Systematic review of water fluoridation

OBJECTIVE

To review the safety and efficacy of fluoridation of drinking water.

DESIGN

Search of 25 electronic databases and world wide web. Relevant journals hand searched; further information requested from authors. Inclusion criteria were a predefined hierarchy of evidence and objectives. Study validity was assessed with checklists. Two reviewers independently screened sources, extracted data, and assessed validity.

MAIN OUTCOME MEASURES

Decayed, missing, and filled primary/permanent teeth. Proportion of children without caries. Measure of effect was the difference in change in prevalence of caries from baseline to final examination in fluoridated compared with control areas. For potential adverse effects, all outcomes reported were used.

RESULTS

214 studies were included. The quality of studies was low to moderate. Water fluoridation was associated with an increased proportion of children without caries and a reduction in the number of teeth affected by caries. The range (median) of mean differences in the proportion of children without caries was -5.0% to 64% (14.6%). The range (median) of mean change in decayed, missing, and filled primary/permanent teeth was 0.5 to 4.4 (2.25) teeth. A dose-dependent increase in dental fluorosis was found. At a fluoride level of 1 ppm an estimated 12.5% (95% confidence interval 7.0% to 21.5%) of exposed people would have fluorosis that they would find aesthetically concerning.

CONCLUSIONS

The evidence of a beneficial reduction in caries should be considered together with the increased prevalence of dental fluorosis. There was no clear evidence of other potential adverse effects.

A let-7 microRNA-binding site polymorphism in 3'-untranslated region of KRAS gene predicts response in wild-type KRAS patients with metastatic colorectal cancer treated with cetuximab monotherapy

PURPOSE

recent studies have found that KRAS mutations predict resistance to monoclonal antibodies targeting the epidermal growth factor receptor in metastatic colorectal cancer (mCRC). A polymorphism in a let-7 microRNA complementary site (lcs6) in the KRAS 3' untranslated region (UTR) is associated with an increased cancer risk in non-small-cell lung cancer and reduced overall survival (OS) in oral cancers. We tested the hypothesis whether this polymorphism may be associated with clinical outcome in KRAS wild-type (KRASwt) mCRC patients treated with cetuximab monotherapy.

PATIENTS AND METHODS

the presence of KRAS let-7 lcs6 polymorphism was evaluated in 130 mCRC patients who were enrolled in a phase II study of cetuximab monotherapy (IMCL-0144). Genomic DNA was extracted from dissected formalin-fixed paraffin-embedded tumor tissue, KRAS mutation status and polymorphism were assessed using direct sequencing and PCR restriction fragment length polymorphism technique.

RESULTS

KRAS let-7 lcs6 polymorphism was found to be related to object response rate (ORR) in mCRC patients whose tumors had KRASwt. The 12 KRASwt patients harboring at least a variant G allele (TG or GG) had a 42% ORR compared with a 9% ORR in 55 KRASwt patients with let-7 lcs6 TT genotype (P = 0.02, Fisher's exact test). KRASwt patients with TG/GG genotypes had trend of longer median progression-free survival (3.9 versus 1.3 months) and OS (10.7 versus 6.4 months) compared to those with TT genotypes.

CONCLUSIONS

these results are the first to indicate that the KRAS 3'UTR polymorphism may predict for cetuximab responsiveness in KRASwt mCRC patients, which warrants validation in other clinical trials.

Restricted immunoglobulin VH usage and VDJ combinations in the human response to Haemophilus influenzae type b capsular polysaccharide. Nucleotide sequences of monospecific anti-Haemophilus antibodies and polyspecific antibodies cross-reacting with self antigens

To examine the human antibody repertoire generated against a biologically significant antigen we have obtained sequences of heavy chain variable region genes (IgVH) from 15 monoclonal antibodies specific for the capsular polysaccharide of Haemophilus influenzae type b (Hib PS). All VH segments are members of the VH3 family and 9 of 15 are members of the smaller VH3b subfamily. Restriction is evident by the shared use of certain VDJ joints in independent hybridomas from different subjects. Two hybridomas generated from the same subject demonstrate identical heavy chain variable region gene sequences but differ in isotype and rearrange alternative light chain variable region genes (IgVL), suggesting that in a normal immune response, a single pre-B cell clone may use different light chain rearrangements and give rise to progeny capable of reacting with antigen. Using a polymerase chain reaction assay optimized to detect base pair differences among VH genes we demonstrate that at least a portion of expressed anti-Hib PS VH genes have undergone somatic mutation. Anti-Hib PS heavy chain genes are homologous to VH segments encoding autoantibodies and two hybridomas secrete anti-Hib PS antibody that cross-reacts with self antigens (double-stranded DNA and single-stranded DNA). Comparison of VH regions of self-reactive and monospecific anti-Hib PS Ab demonstrates no consistent structural feature correlating with fine antigen specificity. These data demonstrate significant restriction in VH usage and VDJ recombination in the anti-Hib PS response and confirm that autoantibodies may be elicited during normal immune responses.

Nurses’ responses to expert patients: The rhetoric and reality of self-management in long-term conditions: A grounded theory study

BACKGROUND

Against the backdrop in the western world of increasing prevalence of chronic disease, active and informed patients and a policy emphasis on self-management, this English study explored health professionals' responses to expert patients.

OBJECTIVES

To:

DESIGN

A grounded theory approach was utilised with two concurrent data strands.

SETTING

A relatively affluent English county including community, primary and secondary care settings.

PARTICIPANTS

Via purposeful and theoretical sampling 100 health professionals (nurses, doctors, physiotherapists) and 100 adults affected by chronic disease participated.

METHODS

Focus groups, interviews and observation.

RESULTS

Nurses were found to be most anxious about expert patients when compared to other professionals, which appeared to be linked with a lack of professional confidence and unfounded fears regarding litigation. However, nurse specialists often provided a negative case for this. As a whole, nurses were most able to meet the emotional needs of patients, but apart from nurse specialists did not articulate this as a skill.

CONCLUSION

Apart from nurse specialists the majority of nurses appeared limited in appropriately facilitating self-management. It is suggested that this is linked to an ongoing nursing culture of patient as passive, an over-emphasis on empirical knowledge and a feeling of vulnerability on the nurses' part towards expert patients. The findings also indicate a rhetoric rather than reality of autonomous nursing roles within the chronic disease management agenda.

A photographic perspective on the origins, form, course and relations of the acetylcholinesterase-containing fibres of the dorsal tegmental pathway in the rat brain

The dorsal tegmental pathway in the rat brain has been studied using acetylcholinesterase (AChe) staining alone, after lesions, and combined with the horseradish-peroxidase (HRP) tracing method. This paper characterises in photographs, diagrams and text the origins, form, extent and relations of its visible AChe-staining fibres in 3 planes. This record should provide a template for further investigations. The pathway largely takes origin from ChAT-containing pedunculopontine (PPTg) and laterodorsal (LDT) nuclei; some non-cholinergic cell groups may also contribute, notably locus coeruleus (LC). It takes the form of a horizontally disposed fan which radiates from the pontomesencephalic area to the forebrain. Its lateral portion is bunched and consists mainly of cholinergic fibres whereas the cholinergic status of its fully unfurled intermediate and partly unfurled medial contingents (which mainly accompany the central tegmental tract) is more doubtful. The changing form and relations of PPTg and LDT are adumbrated including that of the microcellular nucleus (MI) to the former and of Barrington's detrusor nucleus (B) which is unstained, to the latter. Functional overlapping between non-cholinergic and cholinergic nuclei in the peribrachial region are noted and some correlations adduced.

Evidence for a multidimensional self-efficacy for exercise scale

This series of three studies considers the multidimensionality of exercise self-efficacy by examining the psychometric characteristics of an instrument designed to assess three behavioral subdomains: task, scheduling, and coping. In Study 1, exploratory factor analysis revealed the expected factor structure in a sample of 395 students. Confirmatory factor analysis (CFA) confirmed these results in a second sample of 282 students. In Study 2, the generalizability of the factor structure was confirmed with CFA in a randomly selected sample of 470 community adults, and discriminant validity was supported by theoretically consistent distinctions among exercisers and nonexercisers. In Study 3, change in self-efficacy in conjunction with adoption of novel exercise was examined in a sample of 58 women over 12 weeks. Observed changes in the three self-efficacy domains appeared to be relatively independent. Together, the three studies support a multidimensional conceptualization of exercise self-efficacy that can be assessed and appears to be sensitive to change in exercise behavior.

The Expert Patients Programme: a paradox of patient empowerment and medical dominance

Self-care is seen as a key element in managing resource demand in chronic disease and is also perceived as an empowering right for patients. The Chronic Disease Self-Management Programme developed in the USA has been adopted in a number of countries and in the UK has been as adapted as the Expert Patients Programme. However, despite its potential as a lay-led empowering initiative, the Expert Patients Programme has been criticised as perpetuating the medical model and failing to reach those in most need. This paper revisits a critique of the Expert Patients Programme, and drawing upon a qualitative study seeks to explore whether the Expert Patients Programme enables empowerment or replicates traditional patterns of the patient-professional relationship. A grounded-theory approach was adopted utilising focus groups, in-depth interviews and participant observation. Data were analysed through the constant comparative method and the development of codes and categories. Conducted in the relatively affluent area of the south-east of England, this paper draws on data from 66 individuals with a chronic illness who were knowledgeable, active and informed. The study revealed a number of characteristics common to expert patients that were linked to a systematic, proactive and organised approach to self-management, a clear communication style and the ability to compartmentalise emotion. The study included participant observation of an Expert Patients Programme and a professional-led self-management course. The paradoxical nature of the Expert Patients Programme was revealed, for whilst there was evidence that it reinforced the medical paradigm, there was a concurrent acknowledgement and support for the subjective experience of living with a long-term condition. Furthermore, whilst the policy emphasis has been on individual empowerment within the Expert Patients Programme, there is some evidence that it may be triggering a health consumer movement.

A policy analysis of the Expert Patient in the United Kingdom: self-care as an expression of pastoral power?

The rise in chronic illness and comorbidity in Western society has resulted in an increasing emphasis on self-care initiatives. In the United Kingdom this is exemplified by the Expert Patient policy. This paper discusses the Expert Patient initiative as an example of the State's third way approach to public health. The extent to which this policy challenges conventional power relationships between professional and patient, and fosters equal partnership is examined. In particular, how expert is defined and whether a professional understanding of the term is reconcilable with a patient's expertise is debated. The paper argues that the Expert Patient initiative is unlikely to reconstruct chronic illness and may further complicate the State's responsibility in meeting the needs of those with chronic illness. Issues of power within self-care are explored to illuminate the policy, and this paper argues that the Expert Patient initiative is an example of Foucault's notion of pastoral power. Although the Expert Patient policy focuses on the rights and responsibilities of those with chronic illness, this paper concludes that there is no corresponding strategy to challenge professionals' assumptions toward those with chronic illness.

Vitamin A deficiency alters rat neutrophil function

Previous studies showed a higher percentage of neutrophils from vitamin A deficient rats are hypersegmented and contain lower levels of cathepsin G than the neutrophils from control rats. In this study chemotaxis, phagocytosis and oxidant generation were studied using either isolated neutrophils or neutrophils in whole blood from four dietary groups of rats: 1) vitamin A deficient rats; 2) vitamin A deficient rats that received vitamin A for 16, 8, 4 or 2 d prior to killing; 3) weight-matched rats pair-fed a vitamin A-complete diet; and 4) rats fed nonrestricted, vitamin A complete diet. Chemotaxis towards P. aeruginosa conditioned medium and formylated methinyl leucinyl phenylalanine was significantly lower for neutrophils from vitamin A-deficient rats than for neutrophils from weight-matched pair-fed rats, nonrestricted vitamin A sufficient rats and vitamin A deficient rats that received vitamin A for 16 d prior to killing. No differences in chemotaxis towards activated rat serum were noted among the neutrophils from the four groups of rats. Adhesion of P. aeruginosa organisms, phagocytosis of these organisms and generation of active oxidative molecules were significantly lower in the neutrophils from the vitamin A-deficient rats relative to these functions in the neutrophils from the vitamin A deficient rats that received vitamin A for 16 d, weight-matched rats pair-fed a vitamin A complete diet; and rats fed nonrestricted, vitamin A-complete diet. Eight days after vitamin A administration to vitamin A deficient rats, the ability of the neutrophils to phagocytose P. aeruginosa organisms and to generate active oxidant molecules was restored to the levels observed for weight-matched, pair-fed rats and rats fed nonrestricted, vitamin A complete diet. The elucidated alterations in neutrophil function in vitamin A deficient rats probably contribute to the altered ability of vitamin A deficient rats to fight infections.

Alpha-1 proteinase inhibitor levels in keratoconus

The levels of alpha 1-proteinase inhibitor (alpha 1-antitrypsin) in keratoconus, normal human, and other diseased corneas were examined. Using an immunoperoxidase technique, the presence of this inhibitor was demonstrated in the epithelium, stroma and endothelium of all corneal sections. Compared with normal human controls, the staining intensity in the epithelium and stromal lamellae of keratoconus corneas was markedly reduced. Such a reduction was not seen in either scarred or other diseased corneas. Extracts of keratoconus and normal human corneas were subsequently analyzed for alpha 1-proteinase inhibitor by a dot blot assay using a monoclonal antibody against the inhibitor and a 125I-labelled secondary antibody. In agreement with the immunohistochemical findings, the alpha 1-proteinase inhibitor level found in the epithelium of keratoconus corneas was approximately one-fourth of that found in normal human controls. In addition, the stromal extracts of keratoconus corneas contained about one-sixth the inhibitor level of that in normal human extracts. These results lend further support to the hypothesis that degradation processes may be aberrant in keratoconus.

Immunoglobulin light chain variable region gene sequences for human antibodies to Haemophilus influenzae type b capsular polysaccharide are dominated by a limited number of V kappa and V lambda segments and VJ combinations

The immune repertoire to Haemophilus influenzae type b capsular polysaccharide (Hib PS) appears to be dominated by certain light chain variable region genes (IgVL). In order to examine the molecular basis underlying light chain bias, IgVL genes have been cloned from a panel of heterohybridomas secreting human anti-Hib PS (antibody) (anti-Hib PS Ab). One hybridoma, representative of the predominant serum clonotype of anti-Hib PS Ab in older children and adults following immunization or Hib infection, uses a V kappa II segment identical to the germline gene A2, and a JK3 segment. A second kappa hybridoma uses a member of the V kappa I family and a JK4 segment. Four lambda antibodies, all cross-reactive with the structurally related antigen Escherichia coli K100 PS, use V lambda VII segments which are 96-98% homologous to one another, and may originate from a single germline gene. Two additional lambda antibodies, not K100-cross-reactive, are encoded by members of the V lambda II family. All lambda antibodies use highly homologous J lambda 2 or J lambda 3 segments. The VJ joints of all lambda antibodies and the V kappa II-encoded antibody are notable for the presence of an arginine codon, suggesting an important role in antigen binding. Although more complex than heavy chain variable region gene usage, a significant portion of serum anti-Hib PS Ab is likely to be encoded by a limited number of V kappa and V lambda segments and VJ combinations, which may be selectively expressed during development, or following antigen exposure.

The UK Expert Patients Program: lessons learned and implications for cancer survivors' self-care support programs

Globally, the enablement of self-care is increasingly being recognised as an essential component of chronic disease management. Within the UK a key self-care policy initiative is the Expert Patients Program. Developed from the Chronic Disease Self-Management Program, this is a 6 week self-management education program for people with different chronic diseases, facilitated by lay volunteers. As an example of a major public health initiative designed to enhance self-management in long-term conditions, this paper draws on evaluations of the EPP and CDSMP and analyzes the implications for the development of similar programs for cancer survivors. There are a number of evaluations of the CDSMP which suggest significant improvement in participants' chronic disease management self-efficacy and some evidence of healthcare utilization reduction. However, whilst the national evaluation of the EPP demonstrated similar improvements in self-efficacy and health status, there was no significant effect on healthcare utilization. Trials of such programs need to be treated with some caution as participants are often not typical of the general population, and as a complex intervention effectiveness is inherently difficult to assess. Qualitative evaluations revealed that the EPP's strength was derived mainly through peer support and learning. Nevertheless, a number of contextual problems were identified including recruitment, clinicians' lack of engagement with the program and inflexible course materials. Lay-led self-care support programs such as the EPP have a significantly positive effect on self-efficacy which could be of benefit to cancer survivors. However, a number of lessons should be learned from the EPP when developing similar initiatives for cancer survivors.

Optimization of single-cell gel electrophoresis (SCGE) for quantitative analysis of neuronal DNA damage

Neuronal death can be induced by DNA-damaging agents and occurs by apoptosis involving a specific signal-transduction pathway. However, to our knowledge, methods for the quantitative determination of DNA damage in individual neurons have not yet been described. Here we optimize the single-cell gel electrophoresis (SCGE) or "comet"-assay to measure DNA damage within individual neurons growing in dissociated cell culture. In addition, we have written a macro for the NIH Image program to determine the tail moment of individual comets. We have calibrated this method using gamma-irradiated (0-16 Gy) cerebral cortical neurons from the rat central nervous system. Neuronal DNA damage (in the form of DNA strand breaks) occurs in a linear, dose-dependent manner, which can be quantitatively determined in vitro using the SCGE assay. These data demonstrate that the SCGE assay is an effective method to measure DNA damage in individual neurons and may be highly useful for the study of neuronal DNA damage formation, repair and apoptosis.

The sensitivity to change over time of the Bristol Activities of Daily Living Scale in Alzheimer's disease

Activities of daily living scales can be a useful tool in assessing change in people with dementia, either as the disease progresses or in response to treatment. However, little data exist as to the sensitivity to change of instruments used. The Bristol Activities of Daily Living Scale was developed with assistance from the carers of community dwelling people with dementia to be completed by such people and has been shown to have internal consistency as well as face and construct validity. This study aimed to analyse the sensitivity to change of the Bristol Activities of Daily Living Scale in people with Alzheimer's disease receiving anticholinesterase medication. Using the Clinician's Global Rating of Change as a gold standard for change, differences between Bristol Activities of Daily Living Scale scores before and after medication were compared with change in Mini-Mental State Examination, Alzheimer's Disease Assessment Scale - Cognitive and the Nurses Observation Scale for Geriatric Patients, in 61 older adults receiving anticholinesterase medication for Alzheimer's disease. Both the Bristol Activities of Daily Living Scale and the Nurses Observation Scale for Geriatric Patients are sensitive and specific in predicting improvement or stability as measured by the clinician's global rating of change. However, unlike the Nurses Observation Scale for Geriatric Patients, change over time in the Bristol Activities of Daily Living Scale significantly correlates with change in the Mini-Mental State Examination and the Alzheimer's Disease Assessment Scale - Cognitive. The Bristol Activities of Daily Living Scale is sensitive to change in activities of daily living and shows the expected and desirable relationship with measures of cognition.

Role and location of NAD malic enzyme in thermogenic tissues of Araceae

This work was done to discover how those nonphotosynthetic tissues of the Araceae that become thermogenic release, as CO2, carbon recently fixed by phosphoenolpyruvate carboxylase. Extracts of clubs of the spadix of Arum maculatum showed no activity for phosphoenolpyruvate carboxykinase and low activities of NADP malic enzyme. NAD malic enzyme activity in the above extracts and in those of thermogenic tissues of other Araceae was appreciable. Analysis of homogenates of clubs of Typhonium giraldii by differential centrifugation and sucrose gradients showed that NAD malic enzyme was confined to mitochondria. Centrifugation of mitochondria after freezing and thawing left all the NAD malic enzyme in the supernatant. NAD malic enzyme in isolated, intact mitochondria was completely latent, and was completely protected from exogenous trypsin. The responses of this latency and protection to different concentrations of Triton X-100 suggested that none of the NAD malic enzyme was accessible from either the outside or the intermembrane space of the mitochondria. Treatment of excised clubs of A. maculatum with 2-N-butylmalonate largely prevented the development of the rapid respiration responsible for thermogenesis, and severely inhibited dark fixation of 14CO2. The conclusion is that in mature clubs of the Araceae phosphoenolpyruvate is converted to malate in the cytosol by phosphoenolpyruvate carboxylase and NAD malate dehydrogenase, and that this malate then enters the mitochondrial matrix where it is converted to pyruvate by NAD malic enzyme.

Possible resolution of a paradox concerning the use of p-chlorophenylalanine and 5-hydroxytryptophan: evidence for a mode of action involving adrenaline in manipulating the surge of luteinizing hormone in rats

Various functions involving the central nervous system can be manipulated by the sequential administration of p-chlorophenylalanine and 5-hydroxytryptophan, compounds which respectively inhibit and restore the synthesis of 5-hydroxytryptamine in the brain. An involvement of 5-hydroxytryptamine in the control of a particular function has been considered established when the effect of p-chlorophenylalanine on that function can be overcome by treatment with 5-hydroxytryptophan. This assumption is not, however, invariably substantiated when the functional consequences of other methods of depleting 5-hydroxytryptamine are considered; studies on the control of the daily surge of luteinizing hormone in oestrogen-treated ovariectomized rats present such a paradox. The surge can be prevented by p-chlorophenylalanine and restored by 5-hydroxytryptophan. Nevertheless, neurotoxin-induced lesions of the 5-hydroxytryptamine projections from the raphe nuclei are compatible with a normal occurrence of the surge. We have therefore examined the effects of p-chlorophenylalanine and 5-hydroxytryptophan on hypothalamic monoamines in oestrogen-treated ovariectomized rats and find that the drugs respectively suppress and elevate the concentration of adrenaline in addition to that of 5-hydroxytryptamine. Phenylethanolamine N-methyltransferase, the enzyme responsible for converting noradrenaline to adrenaline, is shown to be inhibited in vivo by p-chlorophenylalanine and in vitro by its metabolite, p-chlorophenylethylamine. The reciprocal effects of p-chlorophenylalanine and 5-hydroxytryptophan on the concentration of adrenaline are of particular interest since drugs which inhibit adrenaline synthesis can block the luteinizing hormone surge. It is proposed that when the 5-hydroxytryptophan-reversible effects of treatment with p-chlorophenylalanine are not reproduced by other procedures which deplete 5-hydroxytryptamine, the significant action of these compounds may involve adrenaline.

Insulin-like growth factor receptor polymorphism defines clinical outcome in estrogen receptor-positive breast cancer patients treated with tamoxifen

Compelling evidence points to a key role for insulin-like growth factor 1 (IGF1) signaling in breast cancer development and progression. In addition, IGF1 receptor (IGF1R) expression has been correlated and functionally linked with estrogen receptor (ER) signaling. Recent translational studies support a cross talk between IGF1R and ERα at different levels and data suggest enhanced IGF1R signaling as a causative mechanism of tamoxifen (TAM) resistance. We tested whether functional germline variations in the IGF pathway are associated with clinical outcome in ER-positive primary invasive breast cancer patients, who were treated with surgery and adjuvant TAM. Tissue samples of 222 patients with ER+ primary invasive breast cancer, who had undergone surgery at Charing Cross Hospital, London, UK between 1981 and 2003, were analyzed. Genomic DNA was extracted from formalin-fixed, paraffin-embedded tissue samples and six functional IGF1 pathway polymorphisms were analyzed using direct DNA sequencing and PCR-restriction fragment length polymorphism. In multivariable analysis, patients with primary invasive breast cancer carrying IGF1R_rs2016347 G allele had a significantly increased risk of early tumor progression (hazard ratio (HR) 2.01; adjusted P=0.004) and death (HR 1.84; adjusted P=0.023) compared with patients carrying G/T or T/T, independent of established clinicopathological determinants. This association remained significant after adjusting for multiple testing. In addition, we were able to demonstrate that IRS1_rs1801123 and IGFBP3_rs2854744 were significantly associated with lymph node involvement and tumor size, respectively. We provide the first evidence for IGF1R_rs2016347 as an independent prognostic marker for ER+ breast cancer patients treated with TAM and support a rational for combined treatment strategies.

GRP78 promoter polymorphism rs391957 as potential predictor for clinical outcome in gastric and colorectal cancer patients

BACKGROUND

Recently, the analysis of gastric and colorectal tumor specimens determined that 78-kiloDalton glucose-regulated protein (GRP78), an endoplasmic reticulum chaperone, up-regulation serves as an efficient mechanism protecting cells against apoptosis and can confer drug resistance. We tested whether functional polymorphisms within the GRP78 gene are related to clinical outcome in gastric and colorectal cancer (CRC) patients.

PATIENTS AND METHODS

Blood samples of 234 stage II/III CRC patients at the University of Southern California (USC) and formalin-fixed paraffin-embedded tissues of 137 patients with localized gastric adenocarcinoma (GA) at USC and Memorial Sloan-Kettering Cancer Centers were obtained. GRP78 polymorphisms analyzed on germline DNA were correlated with clinical outcome using univariate and multivariate analyses.

RESULTS

GA patients with the combined GRP78 rs391957 C/T and T/T genotype were at higher risk for tumor recurrence and death [hazard ratio (HR) 2.61; P < 0.001 and HR 3.17; P < 0.001, respectively], than those with C/C. These findings were subsequently tested in a CRC cohort where patients with the homozygous T/T genotype were at highest risk for tumor recurrence (HR 2.61; P = 0.015). The results remained significant after adjusting for clinicopathologic determinants.

CONCLUSION

These data provide the first evidence that the GRP78 rs391957 polymorphism can predict clinical outcome in localized GA and locally advanced CRC patients.

Measurement of the inorganic pyrophosphate in tissues of Pisum sativum L

Purified pyrophosphate: fructose 6-phosphate 1-phosphotransferase (EC 2.7.1.90) was used to measure the inorganic pyrophosphate in unfractionated extracts of tissues of Pisum sativum L. The fructose 1,6-bisphosphate produced by the above enzyme was measured by coupling to NADH oxidation via aldolase (EC 4.1.2.13), triosephosphate isomerase (EC 5.3.1.1) and glycerol-3-phosphate dehydrogenase (EC 1.1.1.8). Amounts of pyrophosphate as low as 1 nmol could be measured. The contents of pyrophosphate in the developing embryo of pea, and in the apical 2 cm of the roots, were appreciable; 9.4 and 8.9 nmol g(-1) fresh weight, respectively. The possibility that pyrophosphate acts in vivo as an energy source for pyrophosphate: fructose 6-phosphate 1-phosphotransferase and for UDPglucose pyrophosphorylase (EC 2.7.7.9) is considered.

How unmet are unmet needs post-stroke? A policy analysis of the six-month review

Background

Stroke is the fourth largest cause of death in the UK and a leading cause of death and disability worldwide. Policy recommends reviewing patients at six-months post-stroke to identify unmet needs but lacks evidence of effectiveness. This study explored needs identified by patients, how they were addressed by the six-month review (6MR) and whether or not policy aspirations for the review were substantiated by the data.

Methods

A multiple case study design underpinned by critical realism. Data sources included interviews with 46 patients and 28 professionals across three sites in the South East Coast of England. Patients’ interviews coincided with their reviews of which twenty-nine were observed. Thematic analysis of interviews, observations and policy documents was carried out within and across sites.

Results

There were ‘hotspots’ in the care pathway where patients and carers felt particularly unsupported. Whilst these gaps exacerbated anxiety, they were neither universal nor ameliorated by review. Patients consistently identified unmet needs related to rehabilitation, information/education and support. Stroke nurse specialists focused on investigations, medication and liaising with general practitioners or consultants while the Stroke Association co-ordinator focused on sign-posting to other services and provision of generic information which not all respondents found helpful. The remit of review was more modest than that of policy aspirations.

Conclusions

The review rests on two causal assumptions: that identifying unmet need will lead to its amelioration; and that provision of information will lead to behaviour change and self-management. While there was some evidence to support the former, there was almost none for the latter. The 6MR would benefit from a patient-led approach to its timing and format; a consistent and individualised approach to stroke education and self-management that is embedded across the care pathway; and targeting reviews should be considered.

Long-term conditions. 2: supporting and enabling self-care

This article is the second of a series focusing on long-term conditions. It explores supported self-care identifying that this is the most appropriate approach to managing long-term conditions in 70-80% of patients with a chronic illness. The paper focuses on the Department of Health for England and Wales flagship initiative; the Expert Patient Programme. This lay-led self-management programme for people affected by a physical long-term condition is currently being rolled out by PCTs throughout the NHS and is seen as a key mechanism for empowering individuals and reducing resource demand in long-term conditions. The history, content, current and future models of the Expert Patient Programme will be described and the paper concludes by discussing future challenges for the programme as illuminated by two external evaluations.

Changes in rat corneal matrix metalloproteinases and serine proteinases under vitamin A deficiency

PURPOSE

Vitamin A deficiency alters the transparency of the cornea due to epithelial cell keratinization and increases the susceptibility of the cornea to ulceration. The purpose of this study was to determine the effect of vitamin A deficiency on rat corneal matrix metalloproteinases and serine proteinases.

METHODS

Four dietary groups of male WAG/RijMCW rats were prepared: (1) Vitamin A deficient rats were raised on a casein-based retinoid deficient diet; (2) Retinol repleted rats were raised on the retinoid deficient diet. On the eighty-sixth day on this diet, the rats were fed retinyl palmitate and then given free access to the retinyl palmitate-supplemented control diet; (3) The weight-matched, pair-fed rats were restricted in their intake of the retinyl palmitate-supplemented diet so that their weight gain matched that of the A-rats; (4) The non-restricted rats were given free access to the retinyl palmitate-supplemented diet. The animals were killed at the late plateau stage for weight of the deficiency (102-106 days). Zymography was used to study proteinases in the corneal extracts.

RESULTS

Vitamin A deficient and control rat corneas contain multiple matrix metalloproteinases and serine proteinases. The matrix metalloproteinases at 90/92 kDa (gelatinase B) and 66/63/57 kDa (gelatinase A) were significantly decreased in the corneas of the vitamin A deficient rats relative to the control corneas. Corneas from the four groups of rats contained 76, 45, 38, 28 and 22 kDa proteinases that cleaved casein. Only the vitamin A deficient corneas contained a 50 kDa casein cleaving enzyme. The 76, 45, 38 and 28 kDa serine proteinases were significantly lower in the vitamin A deficient corneas. The major 22 kDa enzyme was not altered by the deficiency. All casein cleaving proteinases were inhibited by phenylmethylsulfonyl fluoride and chymostatin except for a minor 76 kDa band. The activity of this band was not altered by inhibitors for the other classes of proteinases, ethylenediaminetetraacetic acid, E-64 or pepstatin. The concentrations of the 61, 52 and 40 kDa plasminogen activators were not altered by the deficiency.

CONCLUSIONS

Alterations in corneal proteinases under vitamin A deficiency conditions may be involved in the characteristic changes observed in the cornea under vitamin A deficiency conditions: decreased exfoliation of epithelial cells, increased levels of keratofibrils in the corneal keratocytes, increased stromal keratocyte degradation and increased susceptibility towards ulceration.

Patient and carer experience of obtaining regular prescribed medication for chronic disease in the English National Health Service: a qualitative study

BACKGROUND

The increasing burden of chronic disease is recognised globally. Within the English National Health Service, patients with chronic disease comprise of half of all consultations in primary care, and 70% of inpatient bed days. The cost of prescribing long-term medications for those with physical chronic diseases is rising and there is a drive to reduce medicine wastage and costs. While current policies in England are focused on the latter, there has been little previous research on patient experience of ordering and obtaining regular medication for their chronic disease. This paper presents findings from England of a qualitative study and survey of patients and their carers' experiences of community and primary care based services for physical chronic diseases. Although not the primary focus of the study, the results highlighted particular issues around service delivery of repeat prescriptions.

METHODS

We conducted 21 qualitative in-depth interviews with 30 patients and family carers' in two Primary Care Trusts in England. Participants were receiving community based care for diabetes, respiratory, neurological or complex co-morbidities, and ranged in age from 39-92 years old. We used a broadly inductive approach to enable themes around patient experience to emerge from the data.

RESULTS

While the study sought to gain an overview of patient experience, the findings suggested that the processes associated with ordering and obtaining regular medication - the repeat prescription, was most frequently described as a recurring hassle of managing a long-term condition. Issues for patients and carers included multiple journeys to the surgery and pharmacy, lack of synchrony and dissatisfaction with the length of prescriptions.

CONCLUSION

Much literature exists around medication waste and cost, which led to encouragement from the NHS in England to reduce dosage units to a 28-day supply. While there has been an acknowledgement that longer supplies may be suitable for people with stable chronic conditions, it appears that there is limited evidence on the impact of shorter length prescriptions on patient and carer experience, adherence and health outcomes. Recent policy documents within England also fail to address possible links between patient experience, adherence and flaws within repeat prescription service delivery.

Retinol is sequestered in the bone marrow of vitamin A-deficient rats

Retinoic acid bound to the nuclear retinoic acid receptor-alpha is required for the differentiation of promyelocytes to mature neutrophils. However, severely vitamin A-deficient rats have normal numbers of neutrophils in the blood and inflamed tissues. This paradox was explored using four dietary groups of rats: 1) vitamin A-deficient rats; 2) vitamin A-deficient rats subsequently receiving vitamin A; 3) weight-matched pair-fed rats; and 4) nonrestricted, vitamin A-complete diet-fed rats. Plasma and liver retinol concentrations of the vitamin A-deficient rats were < 1 % of those of the other three groups. In contrast, the bone marrow retinol concentrations of the vitamin A-deficient rats were fourfold higher than those in the other three groups. The distribution of myeloid-derived cells in the bone marrow was similar in all four groups of rats with the exception of a significantly greater (P < 0.05) occurrence of hypersegmented neutrophils (six or more lobes) in the vitamin A-deficient rats (2. 1 %) relative to the control groups (0-0.1%). The blood of the vitamin A-deficient rats also contained significantly higher numbers (P < 0.01) of hypersegmented neutrophils (67%) relative to those in the control groups (2-7%). The hypersegmentation of the neutrophils in this group of rats was not due to a concurrent deficiency of vitamin B-12 or folate. The importance of bone marrow-derived cells to the survival of the animal is suggested by retinol sequestration in the bone marrow of vitamin A-deficient rats, allowing the differentiation of myeloid cells to neutrophils.