Methods of consumer involvement in developing healthcare policy and research, clinical practice guidelines and patient information material

BACKGROUND

The importance of consumer involvement in health care is widely recognised. Consumers can be involved in developing healthcare policy and research, clinical practice guidelines and patient information material, through consultations to elicit their views or through collaborative processes. Consultations can be single events, or repeated events, large or small scale. They can involve individuals or groups of consumers to allow debate; the groups may be convened especially for the consultation or be established consumer organisations. They can be organised in different forums and through different media. We anticipated finding few comparative evaluations that reliably evaluated the effects of consumer involvement.

OBJECTIVES

To assess the effects of consumer involvement and compare different methods of involvement in developing healthcare policy and research, clinical practice guidelines, and patient information material.

SEARCH STRATEGY

We searched: the Cochrane Consumers and Communication Review Group's Specialised Register (4 May 2006); the Cochrane Controlled Trials Register (CENTRAL) (The Cochrane Library, Issue 1 2006), MEDLINE (1966 to January Week 2 2006); EMBASE (1980 to Week 03 2006); CINAHL (1982 to December Week 2 2005), PsycINFO (1806 to January Week 3 2006); Sociological Abstracts (1952 to 24 January 2006); and SIGLE (System for Information on Grey Literature in Europe) (1980 to 2003/1). We scanned reference lists from relevant articles and contacted authors.

SELECTION CRITERIA

Randomised and quasi-randomised trials, interrupted time series analyses, and controlled before-after studies assessing methods for involving consumers in developing healthcare policy and research, clinical practice guidelines or patient information material. The outcome measures were: participation or response rates of consumers; consumer views elicited; consumer influence on decisions, healthcare outcomes or resource utilisation; consumers' or professionals' satisfaction with the involvement process or resulting products; impact on the participating consumers; costs.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed their quality and extracted data. We contacted study authors for clarification and to seek missing data. We presented results in a narrative summary and pooled data as appropriate.

MAIN RESULTS

Five randomised controlled trials of moderate or low methodological quality involving 1031 participants were included. There is moderate quality evidence that involving consumers in the development of patient information material results in material that is more relevant, readable and understandable to patients, without affecting their anxiety. This 'consumer-informed' material can also improve patients' knowledge. There is low quality evidence that using consumer interviewers instead of staff interviewers in satisfaction surveys can have a small influence on the survey results. There is very low quality evidence of telephone discussions and face-to-face group meetings engaging consumers better than mailed surveys in order to set priorities for community health goals, and resulting in different priorities being set for these goals.

AUTHORS' CONCLUSIONS

There is little evidence from comparative studies of the effects of consumer involvement in healthcare decisions at the population level. The studies included in this review demonstrate that randomised controlled trials are feasible for providing evidence about the effects of consulting consumers to inform these decisions.

Trophoblast deportation in human pregnancy--its relevance for pre-eclampsia

The maternal syndrome of pre-eclampsia is thought to result from endothelial cell damage caused by a circulating factor derived from the placenta. This study investigates the hypothesis that trophoblast deportation may be part of the process by which this factor enters the maternal circulation. The nature and incidence of trophoblast deportation was studied in uterine vein and peripheral blood taken from normal and pre-eclamptic women at caesarean section. Trophoblasts were enriched using immunomagnetic beads to deplete leucocytes and labelled with trophoblast-specific monoclonal antibodies. Syncytiotrophoblast, cytotrophoblast, cytotrophoblast clumps and anucleate trophoblast cells were found in uterine vein blood. Cytotrophoblast cells were found to be shed less frequently than syncytiotrophoblast and the majority were probably villous in origin. Trophoblasts were found in the uterine vein blood of normal pregnant women with higher levels in pre-eclampsia. However, trophoblasts were rarely found in the peripheral circulation. There was no correlation between trophoblast numbers and either the severity of the disease, the extent of placental pathology or the inhibitory effect of uterine and peripheral vein plasma on endothelial growth in vitro. Thus, it is speculated that increased trophoblast deportation in pre-eclampsia is secondary to the structural and functional changes occurring in the placenta, rather than directly linked with the circulating endothelial cell damaging factor in pre-eclampsia.

An investigation of the prototype validity of the borderline DSM-IV construct

OBJECTIVE

To investigate the prototype validity of the borderline personality disorder (BPD) DSM-IV construct.

METHOD

Patients (n = 930) from the Norwegian Network of Psychotherapeutic Day Hospitals. Exploratory/confirmatory factor analyses, correlation and reliability statistics, chi-square, and frequency distributions.

RESULTS

Number of BPD criteria showed no distinct threshold between No-BPD and BPD patients among whom 136 different combinations of criteria occurred. Both factor analyses supported that one component/latent variable accounted for the variance of the BPD criteria, showing a high convergent and discriminant validity. The criterion of unstable relationships displayed the highest diagnostic efficiency, and that of chronic feelings of emptiness the lowest.

CONCLUSION

The prototype theoretical model for BPD fitted the data well and appeared to be satisfactory described by the current criteria. The emptiness criterion needs a more appropriate definition and the hierarchy of the criteria in DSM-IV should be revised.

Macromolecular prodrugs. XVI. Colon-targeted delivery--comparison of the rate of release of naproxen from dextran ester prodrugs in homogenates of various segments of the pig gastrointestinal (GI) tract

We have determined initial rates of naproxen formation from dextran-naproxen ester prodrugs incubated in homogenates of various segments of the pig GI tract. Drug liberation proceeded 15-17 times faster in cecum and colon homogenates than in aqueous pH 7.4 buffer or homogenates of the small intestine. The degree of conjugate substitution did not affect the liberation rates, whereas enhanced drug activation was observed with decreasing molecular size of the carrier dextran. During incubation in colon homogenates the average molecular weight of the dextran prodrugs decreased. The mechanism of drug activation from the prodrugs may therefore involve an initial depolymerization step of the dextran chains by dextranases secreted from bacteria in the pig colon. The generated small fragments then serve as substrates for esterases and other hydrolases.

Induction of Purkinje fiber differentiation by coronary arterialization

A synchronized heart beat is controlled by pacemaking impulses conducted through Purkinje fibers. In chicks, these impulse-conducting cells are recruited during embryogenesis from myocytes in direct association with developing coronary arteries. In culture, the vascular cytokine endothelin converts embryonic myocytes to Purkinje cells, implying that selection of conduction phenotype may be mediated by an instructive cue from arteries. To investigate this hypothesis, coronary arterial development in the chicken embryo was either inhibited by neural crest ablation or activated by ectopic expression of fibroblast growth factor (FGF). Ablation of cardiac neural crest resulted in approximately 70% reductions (P < 0.01) in the density of intramural coronary arteries and associated Purkinje fibers. Activation of coronary arterial branching was induced by retrovirus-mediated overexpression of FGF. At sites of FGF-induced hypervascularization, ectopic Purkinje fibers differentiated adjacent to newly induced coronary arteries. Our data indicate the necessity and sufficiency of developing arterial bed for converting a juxtaposed myocyte into a Purkinje fiber cell and provide evidence for an inductive function for arteriogenesis in heart development distinct from its role in establishing coronary blood circulation.

What is the problem with medically unexplained symptoms for GPs? A meta-synthesis of qualitative studies

OBJECTIVE

To gain a deeper understanding of challenges faced by GPs when managing patients with MUS.

METHODS

We used meta-ethnography to synthesize qualitative studies on GPs' perception and management of MUS.

RESULTS

The problem with MUS for GPs is the epistemological incongruence between dominant disease models and the reality of meeting patients suffering from persistent illness. GPs have used flexible approaches to manage the situation, yet patients and doctors have had parallel negative experiences of being stuck, untrustworthy and helpless. In the face of cognitive incongruence, GPs have strived to achieve relational congruence with their patients. This has led to parallel positive experiences of mutual trust and validation. With more experience, some GPs seem to overcome the incongruences, and later studies point towards a reframing of the MUS problem.

CONCLUSION

For GPs, the challenge with MUS is most importantly at an epistemological level. Hence, a full reframing of the problem of MUS for GPs (and for patients) implies broad changes in basic medical knowledge and education.

PRACTICE IMPLICATIONS

Short-term: Improve management of patients with MUS by transferring experience-based, reality-adjusted knowledge from senior GPs to juniors. Long-term: Work towards new models of disease that integrate knowledge from all relevant disciplines.

Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation

BACKGROUND

The prevalence of type 2 diabetes is increasing rapidly, particularly among younger age groups. Estimates suggest that people with diabetes die, on average, 6 years earlier than people without diabetes. We aimed to provide reliable estimates of the associations between age at diagnosis of diabetes and all-cause mortality, cause-specific mortality, and reductions in life expectancy.

METHODS

For this observational study, we conducted a combined analysis of individual-participant data from 19 high-income countries using two large-scale data sources: the Emerging Risk Factors Collaboration (96 cohorts, median baseline years 1961-2007, median latest follow-up years 1980-2013) and the UK Biobank (median baseline year 2006, median latest follow-up year 2020). We calculated age-adjusted and sex-adjusted hazard ratios (HRs) for all-cause mortality according to age at diagnosis of diabetes using data from 1 515 718 participants, in whom deaths were recorded during 23·1 million person-years of follow-up. We estimated cumulative survival by applying age-specific HRs to age-specific death rates from 2015 for the USA and the EU.

FINDINGS

For participants with diabetes, we observed a linear dose-response association between earlier age at diagnosis and higher risk of all-cause mortality compared with participants without diabetes. HRs were 2·69 (95% CI 2·43-2·97) when diagnosed at 30-39 years, 2·26 (2·08-2·45) at 40-49 years, 1·84 (1·72-1·97) at 50-59 years, 1·57 (1·47-1·67) at 60-69 years, and 1·39 (1·29-1·51) at 70 years and older. HRs per decade of earlier diagnosis were similar for men and women. Using death rates from the USA, a 50-year-old individual with diabetes died on average 14 years earlier when diagnosed aged 30 years, 10 years earlier when diagnosed aged 40 years, or 6 years earlier when diagnosed aged 50 years than an individual without diabetes. Using EU death rates, the corresponding estimates were 13, 9, or 5 years earlier.

INTERPRETATION

Every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes and to intensify the treatment of risk factors among young adults diagnosed with diabetes.

FUNDING

British Heart Foundation, Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

First-in-human study of pbi-05204, an oleander-derived inhibitor of akt, fgf-2, nf-κΒ and p70s6k, in patients with advanced solid tumors

BACKGROUND

PBI-05204, a Nerium oleander extract (NOE) containing the cardiac glycoside oleandrin, inhibits the α-3 subunit of Na-K ATPase, as well as FGF-2 export, Akt and p70S6K, hence attenuating mTOR activity. This first-in-human study determined the safety, pharmacokinetics (PK) and pharmacodynamics (PD) of PBI-05204 in patients with advanced cancer. Methods Forty-six patients received PBI-05204 by mouth for 21 of 28 days (3 + 3 trial design). Dose was escalated 100% using an accelerated titration design until grade 2 toxicity was observed. Plasma PK and mTOR effector (p70S6K and pS6) protein expressions were evaluated. Results Dose-limiting toxicities (grade 3 proteinuria, fatigue) were observed at dose level 8 (0.3383 mg/kg/day). Common possible drug-related adverse were fatigue (26 patients, 56.5%), nausea (19 patients, 41.3%) and diarrhea (15 patients, 32.6 %). Electrocardiogram monitoring revealed grade 1 atrioventricular block (N = 10 patients) and grade 2 supraventricular tachycardia (N = 1). The MTD was DL7 (0.2255 mg/kg) where no toxicity of grade ≥ 3 was observed in seven patients treated. Seven patients (15%) had stable disease > 4 months. Mean peak oleandrin concentrations up to 2 ng/mL were achieved, with area under the curves 6.6 to 25.5 μg/L*hr and a half-life range of 5-13 h. There was an average 10% and 35% reduction in the phosphorylation of Akt and pS6 in PBMC samples in 36 and 32 patients, respectively, tested between predose and 21 days of treatment. Conclusions PBI-05204 was well tolerated in heavily pretreated patients with advanced solid tumors. The recommended Phase II dose is 0.2255 mg/kg/day.

Prodrugs as drug delivery systems IV: N-Mannich bases as potential novel prodrugs for amides, ureides, amines, and other NH-acidic compounds

The hydrolysis kinetics of a series of N-Mannich bases of carboxamides, thioamides, and other NH-acidic compounds were studied to assess their suitability as prodrugs for various drugs. The pH-rate profiles for the compounds were determined at 37 degrees and were accounted for by assuming the spontaneous decomposition of both free and protonated Mannich bases. The reaction rate for the free base increased sharply with increasing steric effects of the amine component of the N-Mannich bases and also with increasing acidity of the amide component. N-Mannich bases may be potentially useful prodrugs for NH-acidic compounds such as various amides, and ureides and for amines.

Macromolecular prodrugs. XV. Colon-targeted delivery--bioavailability of naproxen from orally administered dextran-naproxen ester prodrugs varying in molecular size in the pig

The bioavailability of naproxen after oral administration of aqueous solutions of various dextran-naproxen ester prodrugs in pigs was determined. The dextran prodrugs employed ranged in molecular weight from 10,000 to 500,000. As calculated relative to an equivalent oral dose of parent naproxen, the absorption fractions of all the derivatives were close to 100%. Only small interindividual variation of naproxen bioavailability was observed. The naproxen plasma profiles for all the administered prodrugs exhibited a characteristic lag time of naproxen appearance in the blood (2-3 hr). Compared to administration of the prodrugs alone, coadministration of excess of the parent dextran further delayed the absorption of naproxen from the GI tract. The results of the present study demonstrate the potential of dextran prodrugs for colon site-specific delivery of drugs containing a carboxylic acid functional group.

Prodrugs as drug delivery systems XXV: Hydrolysis of oxazolidines--a potential new prodrug type

The hydrolysis kinetics of several oxazolidines derived from (-)-ephedrine and various aldehydes and ketones were studied to assess their suitability as prodrug forms for beta-amino alcohols and/or carbonyl-containing compounds. The oxazolidines were found to undergo a facile and complete hydrolysis in the pH range of 1-11 at 37 degrees. The hydrolysis rates were subject to general acid-base catalysis by buffer substances and depended strongly on pH. Most oxazolidines showed sigmoidal pH-rate profiles with maximum rates at pH greater than 7-7.5. At pH 7.40 and 37 degrees the following half-lives of hydrolysis for the various ephedrine oxazolidines were found: 5 sec (formaldehyde), 18 sec (propionaldehyde), 5 min (benzaldehyde), 5 sec (salicylaldehyde), 30 min (pivalaldehyde), 4 min (acetone), and 6 min (cyclohexanone). The reaction rates in neutral and basic solutions were shown to decrease with increasing steric effects of the substituents derived from the carbonyl component and to decrease with increasing basicity of the oxazolidines. The oxazolidines are weaker bases (pKa 5.2-6.9) than the parent beta-amino alcohol and more lipophilic at physiological pH. It is suggested that oxazolidines can be considered as potentially useful prodrug candidates for drugs containing a beta-amino alcohol moiety or carbonyl groups.

C-terminal peptide of thrombospondin-1 induces platelet aggregation through the Fc receptor gamma-chain-associated signaling pathway and by agglutination

A peptide from the C-terminal domain of thrombospondin-1 (Arg-Phe-Tyr-Val-Val-Met-Trp-Lys; known as 4N1-1) has been reported to induce platelet aggregation and to bind to the integrin-associated protein (IAP), which is also known as CD47. In this study, it was discovered that 4N1-1 or its derivative peptide, 4N1K, induces rapid phosphorylation of the Fc receptor (FcR) gamma chain, Syk, SLP-76, and phospholipase C gamma2 in human platelets. A specific inhibitor of Src family kinases, 4-amino-4-(4-methylphenyl)-7-(t-butyl) pyrazola[3,4-d]pyrimidine, prevented phosphorylation of these proteins, abolished platelet secretion, and reduced aggregation by approximately 50%. A similar inhibition of aggregation to 4N1-1 was obtained in the presence of Arg-Gly-Asp-Ser in mouse platelets deficient in FcR gamma chain or SLP-76 and in patients with type I Glanzmann thrombasthenia. These results show that 4N1-1 signals through a pathway similar to that used by the collagen receptor glycoprotein (GP) VI. The alphaIIbbeta3-independent aggregation induced by 4N1-1 was also observed in fixed platelets and platelets from patients with Bernard-Soulier syndrome, which are deficient in GPIbalpha. Surprisingly, the ability of 4N1-1 to stimulate aggregation and tyrosine phosphorylation was not altered in platelets pretreated with anti-IAP antibodies and in IAP-deficient mice. These results show that the C-terminal peptide of thrombospondin induces platelet aggregation through the FcR gamma-chain signaling pathway and through agglutination. The latter pathway is independent of signaling events and does not use GPIbalpha or alphaIIbbeta3. Neither of these pathways is mediated by IAP.

Preincisional infiltration with bupivacaine in tonsillectomy

OBJECTIVE

To investigate the value of preincisional peritonsillar infiltration of bupivacaine hydrochloride before tonsillectomy under general anesthesia.

DESIGN

Double-blind trial with two groups comparing 0.25% bupivacaine with placebo (normal saline). The patients were followed up for 10 days after surgery.

SETTING

Department of Otolaryngology, University Hospital of Aarhus (Denmark).

PATIENTS

Men and women 18 to 40 years of age referred to our department for bilateral tonsillectomy, but with no sign of acute infection or suspected malignant neoplasm. Twenty-six patients entered the study; five were excluded for failure to complete the postoperative data; and two, one from each group, had postoperative bleeding. Data from 19 patients were analyzed, nine in the bupivacaine group and 10 in the placebo group.

INTERVENTION

One group had 5 mL of 0.25% bupivacaine hydrochloride (Marcaine) infiltrated around each tonsil, the other an identical placebo (normal saline) infiltration.

OUTCOME MEASURES

A visual analogue scale was used as the primary efficacy measure. The daily intake of analgesics and a possible weight loss were registered.

RESULTS

A notably lower score on the visual analogue scale was found in the bupivacaine group.

CONCLUSIONS

Preoperative blocking of nociceptive impulses reduces prolonged postoperative pain, but no reduction in the intake of analgesics was found. Medication was insufficient for the first postoperative days.

How does the thought of cancer arise in a general practice consultation? Interviews with GPs

BACKGROUND

Only a few patients on a GP's list develop cancer each year. To find these cases in the jumble of presented problems is a challenge.

OBJECTIVE

To explore how general practitioners (GPs) come to think of cancer in a clinical encounter.

DESIGN

Qualitative interviews with Norwegian GPs, who were invited to think back on consultations during which the thought of cancer arose. The 11 GPs recounted and reflected on 70 such stories from their practices. A phenomenographic approach enabled the study of variation in GPs' ways of experiencing.

RESULTS

Awareness of cancer could arise in several contexts of attention: (1) Practising basic knowledge: explicit rules and skills, such as alarm symptoms, epidemiology and clinical know-how; (2) Interpersonal awareness: being alert to changes in patients' appearance or behaviour and to cues in their choice of words, on a background of basic knowledge and experience; (3) Intuitive knowing: a tacit feeling of alarm which could be difficult to verbalize, but nevertheless was helpful. Intuition built on the earlier mentioned contexts: basic knowledge, experience, and interpersonal awareness; (4) Fear of cancer: the existential context of awareness could affect the thoughts of both doctor and patient. The challenge could be how not to think about cancer all the time and to find ways to live with insecurity without becoming over-precautious.

CONCLUSION

The thought of cancer arose in the relationship between doctor and patient. The quality of their interaction and the doctor's accuracy in perceiving and interpreting cues were decisive.

Observation of associated near-side and away-side long-range correlations in sqrt[s(NN)]=5.02 TeV proton-lead collisions with the ATLAS detector

Two-particle correlations in relative azimuthal angle (Δø) and pseudorapidity (Δη) are measured in sqrt[s(NN)] = 5.02 TeV p+Pb collisions using the ATLAS detector at the LHC. The measurements are performed using approximately 1 μb(-1) of data as a function of transverse momentum (p(T)) and the transverse energy (ΣE(T)(Pb)) summed over 3.1 < η < 4.9 in the direction of the Pb beam. The correlation function, constructed from charged particles, exhibits a long-range (2 < |Δ η | < 5) "near-side" (Δø ~ 0) correlation that grows rapidly with increasing ΣE(T)(Pb). A long-range "away-side" (Δø ~ π) correlation, obtained by subtracting the expected contributions from recoiling dijets and other sources estimated using events with small ΣE(T)(Pb), is found to match the near-side correlation in magnitude, shape (in Δη and Δø) and ΣE(T)(Pb) dependence. The resultant Δø correlation is approximately symmetric about π/2, and is consistent with a dominant cos2Δø modulation for all ΣE(T)(Pb) ranges and particle p(T).

Crown-rump length discordance in the first trimester: a predictor of adverse outcome in twin pregnancies?

OBJECTIVES

To evaluate the usefulness of first-trimester crown-rump length (CRL) discordance in predicting adverse outcome in twin pregnancies.

METHODS

This retrospective study included a large cohort retrieved from local ultrasound databases at 14 obstetric departments in Denmark, comprising all twin pregnancies with two live fetuses scanned between 11 and 14 weeks' gestation during the period 1 January 2004 to 31 December 2006. The association between CRL discordance ≥ 10 % and adverse outcome was evaluated.

RESULTS

Among 1993 twin pregnancies, 1733 were dichorionic (156 (9%) discordant; 1577 (91%) concordant) and 260 were monochorionic (32 (12%) discordant; 228 (88%) concordant). In dichorionic twin pregnancies we found an association between CRL discordance ≥ 10% and preterm delivery before 34 weeks' gestation (P=0.007), birth weight discordance (P=0.001) and mean birth weight (P=0.033). In monochorionic twin pregnancies we found an association between CRL discordance ≥ 10% and birth weight discordance (P=0.02) and mean birth weight (P=0.03). To evaluate CRL discordance as a predictor of fetal loss and preterm delivery before 34 weeks' gestation, receiver-operating characteristics curves were created for each outcome. For CRL discordance ≥ 10% as a predictor of fetal loss and preterm delivery in dichorionic twin pregnancies, sensitivity was 0.17 (95% CI, 0.06-0.28) and 0.14 (95% CI, 0.10-0.18), respectively, and in monochorionic twin pregnancies it was 0.10 (95% CI, 0.03-0.22) and 0.16 (95% CI, 0.06-0.26), respectively.

CONCLUSIONS

CRL discordance in twin pregnancies is associated with, but is not a strong predictor of, adverse outcome.

Search for magnetic monopoles in sqrt[s]=7 TeV pp collisions with the ATLAS detector

This Letter presents a search for magnetic monopoles with the ATLAS detector at the CERN Large Hadron Collider using an integrated luminosity of 2.0  fb(-1) of pp collisions recorded at a center-of-mass energy of sqrt[s]=7  TeV. No event is found in the signal region, leading to an upper limit on the production cross section at 95% confidence level of 1.6/ϵ  fb for Dirac magnetic monopoles with the minimum unit magnetic charge and with mass between 200 GeV and 1500 GeV, where ϵ is the monopole reconstruction efficiency. The efficiency ϵ is high and uniform in the fiducial region given by pseudorapidity |η|<1.37 and transverse kinetic energy 600-700<E(kin)sinθ<1400  GeV. The minimum value of 700 GeV is for monopoles of mass 200 GeV, whereas the minimum value of 600 GeV is applicable for higher mass monopoles. Therefore, the upper limit on the production cross section at 95% confidence level is 2 fb in this fiducial region. Assuming the kinematic distributions from Drell-Yan pair production of spin-1/2 Dirac magnetic monopoles, the efficiency is in the range 1%-10%, leading to an upper limit on the cross section at 95% confidence level that varies from 145 fb to 16 fb for monopoles with mass between 200 GeV and 1200 GeV. This limit is weaker than the fiducial limit because most of these monopoles lie outside the fiducial region.

A doctor close at hand: How GPs view their role in cancer care

OBJECTIVE

To explore GPs' own views on their role in cancer care.

DESIGN

Qualitative study based on semi-structured interviews.

SETTING

Norwegian primary care.

METHODS

The stories of 14 GPs concerning 18 patients were analyzed for core content and abstracted into general ideas, to create a broader sense of the experienced professional role.

RESULTS

The GPs claimed to have an important role in cancer care. In our analysis, three main aspects of GPs' work emerged: first, as a flexible mediator, e.g. between the patient and the clinic, interpreting and translating; second, as an efficient "handyman", solving practical problems locally; and third, as a personal companion for the patient throughout the illness.

CONCLUSION

The interviewed GPs see their place in cancer care as being close to their patients. In their many tasks we found three main aspects: the mediating, the practical, and the personal.

An investigation of methods for enriching trophoblast from maternal blood

Trophoblast deportation is known to occur in normal human pregnancy, but it is not yet clear whether these cells routinely enter the maternal peripheral circulation and are available as a source of fetal DNA for non-invasive prenatal diagnosis of genetic disorders. To resolve this issue requires an efficient method of enriching trophoblast from maternal blood combined with a means to confirm its identity. Five different techniques were tested on ten retroplacental blood samples to determine the most sensitive and operator-efficient method. Lysis of red cells alone gave the best recovery of trophoblast but had to be discounted, together with Ficoll density gradient centrifugation, due to the very low purity and the excessive time required. Fluorescence-activated cell sorting (FACS) of pre-enriched trophoblast resulted in the lowest recovery rate (8 per cent) despite a 3250-fold enrichment and a very high purity. Immunomagnetic beads (Dynabeads) coated with anti-CD16 antibody proved to be the best method for the subsequent immunocytochemical characterization of deported trophoblast. However, IO beads coated with anti-CD45 antibody may be more useful for isolating trophoblast for prenatal diagnosis due to the high purity, enrichment (32-fold), and recovery rate (78 per cent) obtained with this method.

Plasma erythropoietin levels in mice during the growth period

Plasma erythropoietin (erythropoiesis stimulating factor(s), ESF), PCV and body weight were measured in normal mice from birth until the age of 70 d. Low but detectable ESF activity was present at birth, following by undetectable levels 12-48 h after birth. Thereafter the ESF level rapidly increased. Peak levels were obtained 15-20 d after birth. During the same phase an increased growth velocity occurred, coincident with decreased PCV levels. A fall to undetectable levels in plasma ESF activity coincided with decelleration of growth 40-50 d after birth. In small litters (four pups per litter) growth velocity and PCV levels were significantly higher than in large litters (16 pups per litter) 8 and 15 d after birth. The plasma ESF activity, however, did not differ between the two groups. Prohibiting suckling for a period of 16 h did not change the plasma ESF level. The hypothesis is put forward that growth directly or indirectly stimulates ESF production.

International standards for neurological classification of spinal cord injury: cases with classification challenges

The International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) is routinely used to determine levels of injury and to classify the severity of the injury. Questions are often posed to the International Standards Committee of the American Spinal Injury Association (ASIA) regarding the classification. The committee felt that disseminating some of the challenging questions posed, as well as the responses, would be of benefit for professionals utilizing the ISNCSCI. Case scenarios that were submitted to the committee are presented with the responses as well as the thought processes considered by the committee members. The importance of this documentation is to clarify some points as well as update the SCI community regarding possible revisions that will be needed in the future based upon some rules that require clarification.

High-performance size-exclusion chromatographic procedure for the determination of fluoresceinyl isothiocyanate dextrans of various molecular masses in biological media

A high-performance size-exclusion chromatographic procedure, using Nucleosil Diol, for the quantitative analysis of fluoresceinyl isothiocyanate dextrans of various molecular masses (10,000-150,000) in biological media was developed. The influence of the molecular mass and the degree of substitution of the conjugates on the chromatographic behaviour are discussed. In addition to quantitation, the molecular mass of the conjugates with degree of substitution below 1.6 could be estimated from the chromatograms. Linear standard calibration curves were obtained at concentrations down to 0.050 micrograms ml-1 in rabbit plasma and urine and homogenates of rabbit liver, lymph node and muscle when the derivative (degree of substitution 0.85) was monitored by fluorescence detection (lambda ex = 493 nm, lambda em = 520 mm). The fluoresceinyl isothiocyanate dextrans were found to be stable for more than three days at 37 degrees in all biological media under investigation. A pH-rate profile for the alkaline hydrolysis of fluoresceinyl isothiocyanate dextrans was constructed. The applicability of the method to pharmacokinetic studies was demonstrated by recording the plasma concentration-time profile of a fluoresceinyl isothiocyanate dextran T-70 conjugate following intravenous injection to a rabbit. In relation to future pharmacokinetic investigations on dextran conjugates, the results reported indicate that labelling of the parent dextran with fluoresceinyl isothiocyanate and monitoring of the fluoresceinyl isothiocyanate dextran conjugate throughout the organism using the described method is a promising development.