Cognitive mechanisms and resilience in UK-based general practitioners: cross-sectional findings

BACKGROUND

Being a general practitioner (GP) is a stressful occupation, and the strain GPs are under can have negative effects on their psychological well-being, as well as on the patients' experience of healthcare. Resilience can help buffer against this and is a dynamic process by which one can cope with adversity and stress.

AIMS

This study aimed to identify modifiable cognitive mechanisms related to resilience in GPs, specifically interpretation bias and cognitive reappraisal.

METHODS

One hundred and fourteen GPs completed an online cross-sectional correlational study. This comprised questionnaires assessing resilience, emotional distress, work environment and cognitive mechanisms (emotion regulation), as well as a task assessing interpretation bias.

RESULTS

Resilience of GPs was negatively correlated with measures of emotional distress. Furthermore, resilience was positively correlated with positive interpretation bias (r = 0.60, ρ = 0.60, P < 0.01) and cognitive reappraisal (r = 0.39, ρ = 0.40, P < 0.01). In a hierarchical regression, positive interpretation bias (B = 0.25, SE B = 0.06, β = 0.39, P < 0.01) was a significant independent predictor of resilience when controlling for depression, anxiety and stress.

CONCLUSIONS

This is the first study to establish an association between resilience and positive interpretation bias and cognitive reappraisal in GPs. Future research should use longitudinal designs to determine if they have a causal role in promoting resilience, and importantly whether interventions focusing on these processes may foster resilience in less resilient GPs.

Anaesthetic management of patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei: a retrospective audit

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to improve quality of life and survival rates in patients suffering from pseudomyxoma peritonei. The procedure is long and associated with significant intraoperative blood loss. As such, the anaesthetic management of patients undergoing this procedure can be challenging. The aim of this paper is to describe our perioperative management of pseudomyxoma peritonei patients who received CRS and to report a retrospective audit of our outcomes and complications over a six-year period at a large tertiary centre. A total of 70 patients were included, of whom three (4.3%) had CRS alone, 42 (60.0%) had CRS with HIPEC, and 25 (35.7%) had CRS with HIPEC and early postoperative intraperitoneal chemotherapy. There were no intraoperative deaths. A total of four patients (5.7%) died during their hospital admission. At one-year follow-up, six patients (9.0%) had died, and at the end of the study 15 (22.4%) had died. No statistically significant difference in blood loss was seen between patients who received tranexamic acid (30 patients, 42.9%) and those who did not, but the incidence of deep venous thrombosis was much higher (10/30 versus 1/40). Different intravenous fluid strategies appeared not to influence the incidence of postoperative acute renal failure. Further research is required to evaluate the effects of intraoperative tranexamic acid and different intraoperative fluid strategies on outcomes in patients undergoing CRS with HIPEC.

Abstract P3-07-57: Development of a 6-gene qPCR RUO-validated assay as a predictive biomarker for response of vantictumab (OMP-18R5; anti-frizzled) in HER2- breast cancer patients

Background: We have developed a monoclonal antibody, vantictumab that blocks canonical WNT/β-catenin signaling through binding of five FZD receptors (1, 2, 5, 7, 8). This antibody inhibits the growth of several tumor types, including breast. Vantictumab reduces tumor-initiating cell frequency and exhibits synergistic activity with standard-of-care (SOC) agents (Gurney et al, 2012). To target breast cancer patients most likely to respond to vantictumab, we undertook a predictive biomarker study.

Methods: We have identified a 6-gene Wnt pathway-related signature, FBXW2, CCND2, RHOU, CTBP2, WIF1, and DKK1, based on microarray gene expression data from 8 breast cancer patient derived xenograft (PDX) models with established in vivo response to vantictumab plus SOC. This signature successfully predicted the response of 8 additional and independent PDX breast tumors. We further developed a qPCR Research Use Only (RUO) assay for the 6 genes to be used on FFPE human breast tumor samples. Multiple assays targeting different regions spanning each mRNA transcript were tested and selected based on PCR efficiency, specificity and sensitivity. We compared assay sensitivity under different cDNA synthesis and pre-amplification conditions: random vs. gene-specific priming, number of pre-amplification cycles, pre-amplification reaction volumes, and cDNA synthesis kits. A repeatability study was performed to test assay performance. The pre-amplification and PCR were repeated over three separate days and across two independent labs.

Results: Our results showed that cDNA synthesis by gene-specific priming followed by 18 cycles of pre-amplification performed the best and the assay is robust with minimal starting FFPE RNA input. The results of the repeatability study were consistent among the different days and the different labs (&lt;5% CV). Using the 6-gene qPCR RUO assay, the signature score from the microarray data was further refined using 12 PDX HER2- breast tumors with known in vivo response to vantictumab with SOC. The prevalence of the 6-gene signature was established using ∼100 HER2- breast cancer samples.

Conclusions: A robust 6-gene RUO-validated assay was developed as a predictive biomarker for vantictumab in HER2- breast cancer. The assay is currently being evaluated in a Phase 1b study of vantictumab with paclitaxel in HER2- breast cancer.

Citation Format: Zhang C, O'Young G, Wikstrom K, Davison T, Yeung P, Cattaruzza F, Yen W-C, Hoey T, Lewicki J, Rachmann R, Kerr P, Hill L, Eason R, McErlean S, Liu Y, Kapoun AM. Development of a 6-gene qPCR RUO-validated assay as a predictive biomarker for response of vantictumab (OMP-18R5; anti-frizzled) in HER2- breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-07-57.

One cancer destroys another: short report of a myeloid sarcoma causing ischaemic necrosis of an adenocarcinoma

We present a highly unusual case and histological images of a patient who underwent complete resection of a perforated caecal adenocarcinoma caused by angiodestruction of the proximal vasculature by a distinct acute myeloid infiltrate. Both tumours were removed in their entirety at one visit to theatre and the patient remains well and in remission 18 months later.

Identification of subtypes in colorectal cancer and their prognostic values

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Background: The discovery and widespread acceptance of molecular subtypes in breast cancer has changed the way that this disease is viewed. Similarly, we have focussed on stage II colorectal cancer where 20–25% of patients are at risk of recurrent disease following surgery. There are currently several types of colorectal cancer recognised by histopathological methods, however, little has been published regarding disease classification at a molecular level. Methods: We have taken an unbiased approach to the molecular classification of colorectal cancer. Using a colorectal cancer disease specific microarray platform we have performed expression profiling and bioinformatic analysis of 500 formalin fixed and paraffin embedded (FFPE) stage II colorectal cancer samples, in order to identify and characterise molecular subtypes. Results: We have identified molecular subtypes for colorectal cancer. One of these subtypes is enriched with tumours with microsatellite instability (MSI) that are predominantly proximal, mucinous and poorly differentiated. It is notable that while MSI is generally accepted to be associated with a good prognosis, we have found both good and poor prognosis patients within this subtype. A second subtype contains tumors with a low CpG island methylator phenotype. Another subtype is defined by an expression pattern consistent with activation of tumor suppressors. The remaining subtypes are newly identified. Conclusions: We have identified molecular subtypes in colorectal cancer. We will present how knowledge about these subtypes may affect patient management and may be used to guide the development of novel therapeutic strategies.

[Table: see text]

Neutron production from feedback controlled thermal cycling of a pyroelectric crystal

The LLNL Crystal Driven Neutron Source is operational and has produced record ion currents of approximately 10 nA and neutron output of 1.9(+/-0.3)x10(5) per thermal cycle using a crystal heating rate of 0.2 degrees C/s from 10 to 110 degrees C. A 3 cm diameter by 1 cm thick LiTaO(3) crystal with a socket secured field emitter tip is thermally cycled with feedback control for ionization and acceleration of deuterons onto a deuterated target to produce D-D fusion neutrons. The entire crystal and temperature system is mounted on a bellows which allows movement of the crystal along the beam axis and is completely contained on a single small vacuum flange. The modular crystal assembly permitted experimental flexibility. Operationally, flashover breakdowns along the side of the crystal and poor emitter tip characteristics can limit the neutron source. The experimental neutron results extend earlier published work by increasing the ion current and pulse length significantly to achieve a factor-of-two higher neutron output per thermal cycle. These findings are reviewed along with details of the instrument.

Focal segmental glomerulosclerosis and Guillain-Barre syndrome associated with Campylobacter enteritis

Previous reports have noted an association between membranous nephropathy and focal segmental glomerulosclerosis with Guillain-Barre syndrome. We report a case of Campylobacter enteritis, which was complicated by both focal segmental glomerulosclerosis of the collapsing variety and Guillain-Barre syndrome, and propose that Campylobacter may be the common link between the glomerular disease and Guillain-Barre syndrome. We also briefly review previous reports of kidney disease associated with Campylobacter infection.

Zoonoses and Communicable Diseases Common to Man aqnd Animals. Third Edition. Pedro N Acha and Boris Szyfres. A Review by Peter Kerr

THE three volumes of this book set out to cover the common and not so common zoonotic diseases. As the title implies, in many cases, for example actinomycosis, the diseases covered are common to humans and animals rather than being transmitted from animals to man. Volume 1 covers bacterial and mycotic diseases, volume 2, chlamydial, rickettsial and viral diseases and volume 3 deals with parasitic diseases. Each disease is dealt with systematically under the headings of: Etiology, Geographic Distribution, Occurrence in man, Occurrence in animals, Disease in man, Disease in animals, Source of infection and mode of transmission, Role of animals in the epidemiology of the disease, Diagnosis, and Control. This is followed by a bibliography. The style makes it easy to gain a quick overview or refresher on any particular disease that is covered. However, it does not lend itself to differential diagnosis based on clinical signs or symptoms. This means that the books are probably more useful for students, clinicians, epidemiologists, researchers and public health workers needing a quick update on a particular disease than for the diagnostician in the field or clinic.

Sequence mapping of the Californian MSW strain of Myxoma virus

Partial sequence mapping of the MSW Californian strain of Myxoma virus was performed by cloning EcoRI and SalI restriction fragments of viral DNA and sequencing the ends of these. In this way, regions of 74 MSW open reading frames were sequenced and mapped onto the complete genome sequences of the related leporipoxviruses South American Myxoma virus and Rabbit fibroma virus to form a partial map of the MSW strain. In general, gene locations and sequences were conserved between the three viruses. However the Californian Myxoma virus was more closely related to South American myxoma virus than to Rabbit fibroma virus based on sequence comparisons and the presence of three genes that have been lost from the Rabbit fibroma virus genome. Compared to the other two viruses, the main difference found in the MSW genome was that the terminal inverted repeats were extended with the duplication of 5 complete open reading frames (M151R, M152R, M153R, M154L, M156R) and partial duplication of one open reading frame (M150R). This rearrangement was associated with the loss of the majority of the M009L open reading frame. Three known virulence genes, including the serine proteinase inhibitor (SERPIN) genes M151R and M152R and leukemia associated protein (LAP) gene M153R, and the potential virulence gene M156R are now present in two copies.

Family-focused case management: a case study of an innovative demonstration program

Using results from a formative evaluation, the paper describes family-focused case management (FFCM). FFCM is an innovative community mental health service designed to support both consumers/survivors and their families. The formative evaluation used a multi-informant, multi-method approach to describe FFCM services and assess their quality. Focus groups with program stakeholders produced a "program-logic model" and identified minimum standards for FFCM. Service activities and outcomes defined in the program-logic model were typical of those offered to consumers/survivors in intensive case management programs, but were supplemented with support being offered to their families. Monitoring of service activities showed that the case manager had regular contact with families and offered them a mix of direct and indirect services that corresponded, in most cases, to defined program standards. Interviews with 14 family members and 8 consumers/survivors receiving FFCM services revealed high levels of satisfaction with most aspects of the program. Overall, evaluation findings suggest that intensive case management can be expanded to include providing support to families. Future directions for developing FFCM are discussed.

Fixation location effects on fixation durations during reading: an inverted optimal viewing position effect

Previous research has found that words are identified most quickly when the eyes are near their center (the Optimal Viewing Position effect). A study was conducted to determine whether this same phenomenon is observed during reading, as revealed by a relationship between fixation position in a word and the duration of the fixation. An analysis of three large existing corpora of eye movement data, two from adults and one from children, showed a surprising inverted Optimal Viewing Position curve: mean fixation duration is greatest, rather than lowest, when the eyes were at the centers of words. From this phenomenon, we suggest an alternative explanation to the fixation duration trade-off effect in word refixations [O'Regan & Lévy-Schoen, Attention and performance XII: the psychology of reading (1987)]; the phenomenon also contradicts expectations of both oculomotor and cognitive theories of eye movement control. Attempts to test alternative explanations led to the discovery of another phenomenon, the Saccade Distance effect: mean fixation durations vary with the distance of the prior fixation from the currently-fixated word, being longer with greater distances. The durations of fixations in reading are complexly determined, with influences both from language and perceptual/oculomotor levels.

Determination and classification of the problems experienced by hearing-impaired elderly people

The aim of this study was to determine whether participation restrictions and contextual factors could be elicited in an elderly hearing-impaired population using an open-ended questionnaire. The study also tested the value of the World Health Organization's ICF in the classification of the problems experienced by the elderly hearing-impaired. To this end, we administered the 'Life Effects Questionnaire', in which the subjects were asked to list the effects of their hearing loss on their lives. With this approach, significantly more participation restrictions, environmental factors and personal factors were elicited than with a traditional approach. ICF proved useful in classifying these, but the Activity and Participation Scales had a major weakness in terms of non-communication-related hearing problems. Furthermore, a high proportion of the responses came into the personal factors, for which a formal classification does not exist within ICF. This highlights a significant need in that classification.

A comparison of a monoclonal antibody-based sandwich ELISA and immunomagnetic bead selective enrichment for the detection of Escherichia coli O157 from bovine faeces

AIMS

To compare a recently developed monoclonal antibody (MAb) based sandwich ELISA (sELISA) with an immunomagnetic separation (IMS) method for the detection of Escherichia coli O157 in bovine faeces.

METHODS AND RESULTS

Faecal samples from 345 cattle were obtained from eight farms in Northern Ireland, in which human disease due to E. coli O157 had occurred. Both assays detected E. coli O157 on five of the farms and the phage-type of the majority of the bovine strains were the same as the corresponding human isolates. Similar numbers of the organism were detected by the two methods, 59 by the sELISA and 53 by the IMS procedure, 39 of the positive samples being common to both. Twenty samples were sELISA positive/IMS negative.

CONCLUSIONS

If the IMS is regarded as the gold standard, then the sELISA is less sensitive and less specific, but under the conditions used sELISA positive results were obtained from all positive farms, and the sELISA gave a presumptive positive a day earlier than the IMS method.

SIGNIFICANCE AND IMPACT OF THE STUDY

The sELISA has the potential to be used as a rapid method for screening large numbers of samples for E. coli O157, but further work is required to determine its specificity.

A cost-minimization analysis of the societal costs of realtime teledermatology compared with conventional care: results from a randomized controlled trial in New Zealand

A randomized controlled trial was carried out to measure the societal costs of realtime teledermatology compared with those of conventional hospital care in New Zealand. Two rural health centres were linked to a specialist hospital via ISDN at 128 kbit/s. Over 10 months, 203 patients were referred for a specialist dermatological consultation and 26 were followed up, giving a total of 229 consultations. Fifty-four per cent were randomized to the teledermatology consultation and 46% to the conventional hospital consultation. A cost-minimization analysis was used to calculate the total costs of both types of dermatological consultation. The total cost of the 123 teledermatology consultations was NZ$34,346 and the total cost of the 106 conventional hospital consultations was NZ$30,081. The average societal cost of the teledermatology consultation was therefore NZ$279.23 compared with NZ$283.79 for the conventional hospital consultation. The marginal cost of seeing an additional patient was NZ$135 via teledermatology and NZ$284 via conventional hospital appointment. From a societal viewpoint, and assuming an equal outcome, teledermatology was a more cost-efficient use of resources than conventional hospital care.

Genetic variation in Australian isolates of myxoma virus: an evolutionary and epidemiological study

Myxoma virus and the European rabbit have been coevolving in Australia since the introduction of the Standard Laboratory Strain (SLS) of myxoma virus as a biological control agent for rabbits in 1950. To examine the degree of genetic variation that has occurred in the virus between 1950 and 1995 and to find genetic markers to use for epidemiological studies, we have examined 37 recent field isolates of myxoma virus for restriction fragment length polymorphisms (RFLPs) by comparision with the progenitor SLS released in 1950. Fifteen RFLPs in Australian isolates have been identified and characterized by mapping and partial DNA sequence analysis. The RFLPs that are most common are deletion and insertion events in regions of tandem repeats. Some of these RFLPs have been investigated by using polymerase chain reaction to identify them in archival tissue samples. In epidemiological studies we characterized two polymorphisms which occur in the Lausanne strain of myxoma virus (widely introduced into Australia from the 1970s) but not in SLS and showed that all of the viruses we isolated were derived from the SLS.

New complexities for BRCA1 and BRCA2

A large number of diverse functions have been attributed to the BRCA1 and BRCA2 breast cancer susceptibility genes. Here we review recent progress in the field.

Radiofrequency tissue reduction of the palate in patients with moderate sleep-disordered breathing

OBJECTIVE

Radiofrequency volumetric reduction of the palate has been advocated as a treatment for mild sleep-disordered breathing (SDB). Our study examines the efficacy of this procedure on patients with mostly moderate SDB.

DESIGN

Prospective, nonrandomized, consecutive series.

SETTING

St. Boniface Hospital, Sleep Disorders Centre, University of Manitoba, Winnipeg.

METHOD

Twelve patients with polysomnographically proven moderate SDB were given a total of 2400 to 3600 joules of radiofrequency energy to their soft palate over two to three treatments. Follow-up examined the effect of treatment on subjective and objective parameters including the Epworth Sleepiness Scale, loudness of snoring, Apnea-Hypopnea Index (AHI), and Arousal Index.

RESULTS

Two of 12 patients had a good objective response to treatment in that their AHI dropped by more than 50% and to a value of less than 20. However, none of the patients claimed to have a satisfactory subjective response. There was a slight reduction in the mean AHI from 31.2+/-5.1 to 25.3+/-4.2 (p < .05), but no clinically significant difference was found between pre- and post-treatment groups with respect to other sleep parameters. There was no improvement in daytime sleepiness or snoring.

CONCLUSIONS

Radiofrequency tissue ablation of redundant soft palate tissues lacks clinical efficacy in patients with moderate SDB.

Development of a monoclonal sandwich ELISA for the detection of animal and human Escherichia coli O157 strains

AIMS

Production of a monoclonal antibody (MAb) to Escherichia coli O157 to develop a rapid test using a sandwich ELISA (sELISA) format.

METHODS AND RESULTS

A MAb (7A6) was developed to the long-chain lipopolysaccharide of E. coli O157. A sELISA developed with the MAb reacted with 28 bovine and seven human enterohaemorrhagic E. coli (EHEC) O157 strains and also with two enterotoxigenic E. coli O157 strains. Cross-reaction to a rabbit diarrhoeal E.coli O15, Citrobacter freundii, Salmonella urbana and Vibrio cholerae O1 Inaba was detected.

CONCLUSION

A MAb-based sELISA to detect E. coli O157 was produced. Its application to field samples is required to fully determine its prospective use for the detection of EHEC O157, to evaluate the non-specific interference of the cross-reacting strains.

SIGNIFICANCE AND IMPACT OF THE STUDY

The assay produced is not wholly specific to EHEC O157, but has the potential to be used as a rapid method for screening large numbers of samples for E. coli O157.

Auditory disablements: an update

In 1999, the World Health Organization issued a document (Beta-2 ICIDH-2) that outlines proposed revisions to the original International Classification of Impairments, Disabilities, and Handicaps. The document, issued for trial purposes, is significant in that it redefines the theoretical context in which audiological research into hearing disability has operated since 1980 and will develop in the future. The purpose of this article is threefold. First, it provides an introductory descriptive overview of the primary disablement dimensions outlined in the Beta-2 version of the ICIDH-2 framework. Second, in discussing the implications of the revised framework for audiology, the article highlights particular classification issues that require clarification if the framework is to be applied effectively in audiological research and practice. Third, the article evaluates the revised framework in the context of recent conceptual developments in audiological research and raises a number of issues for further discussion and investigation. The article concludes that the Beta-2 ICIDH-2 represents a significant advance on the original ICIDH classification framework on three counts. First, much of the rationale underpinning the revised framework, particularly its redefinition of the primary disablement dimensions, is consistent with recent conceptual developments in audiological research into hearing disablements. Second, the framework offers specific pointers for the development of current audiological research and practice. One potential line of enquiry focuses attention on specific ICIDH-2 dimensions that are currently under-represented in audiological literature, namely, the participation and contextual factors dimensions. Another potential line of enquiry focuses attention on issues pertaining to the measurement of function, specifically the inclusion of "positive" outcome indicators in assessment. Finally, the publication of the revised ICIDH-2 framework offers a standard frame of reference from which to conduct larger debates in the audiological literature about the nature and purpose of audiological rehabilitation and the influence of the ecological perspective on the rehabilitative process.

Moving home: costs associated with different models of accommodation for adults with learning disabilities

This paper reports on variation in the cost and social outcomes of provision for clients with learning disabilities, resettled across different models of community accommodation; identifying personal and service-related characteristics influential on such variation. The study was conducted to inform the community reprovisioning strategy associated with the phased closure of the Gogarburn and Tornaveen learning disability hospitals in the Lothian region, Scotland. Total mean service costs, quality of life and community integration outcome data were collected and compared. Total mean service costs ranged between pound16 438 and pound74 097 per year (mean pound42 023; SD = pound16 712). Cost estimates varied by age and dependency group, with costs for elderly clients comparatively low. Overall, there was an inverse relationship between total mean costs and size of accommodation. There was no evidence of a direct relationship between costs and changes in social outcomes. Services with the lowest mean costs were, however, associated with the smallest increases in social outcomes. The most expensive services did not realise proportionally greater gains in social outcomes. The paper concludes that clients generally benefited from the transition from hospital to community accommodation. However, some experienced better outcomes than others. In the absence of a clear link between levels and type of resource use and social outcomes, it is difficult to identify which service features are more or less efficacious in achieving positive outcomes. Broader evaluation perspectives, embracing a fuller range of costs and benefits, will be required to unpack exactly what it is about different models of community care provision that leads to positive outcomes, or otherwise, for learning disability clients. A more sound evidence base is required before effective strategies can be designed to ensure that key policy outcomes are realised and social integration truly achieved.

Carotid artery intima-medial thickness is increased in chronic renal failure

1. Chronic renal failure (CRF) is associated with rapidly progressive atherosclerotic vascular disease. In the present study, carotid arterial intima-medial thickness (IMT) was assessed in a large cohort of patients with CRF and matched controls and related to risk factors. 2. A total of 159 subjects with CRF (serum creatinine > or =0.40 mmol/L) aged > 50 years (mean (+/-SD) 63.8+/-7.7 years) and 159 healthy controls matched for age, sex and smoking status were studied. 3. The IMT was determined using B-mode ultrasound measurements of the far wall of both common carotid arteries and presented as the mean IMT. Fasting plasma homocysteine (tHcy) was measured in the CRF group. 4. Intima-medial thickness was significantly greater in CRF patients than controls (0.89+/-0.17 vs 0.73+/-0.13 mm, respectively) after matching for age, sex and smoking status. Heart rate and pulse pressure were also significantly increased. The tHcy was increased two-fold in the CRF group (27.7+/-11.3 micromol/L; normal < 13.0 micromol/L) and did not correlate with carotid IMT. 5. Compared with controls after adjusting for traditional risk factors, patients with CRF exhibit significantly increased IMT.

Comparing two nursing outcomes reporting initiatives

Nursing has increasingly found itself in the position of having to show that it makes a positive and important impact on health care. Two initiatives have surfaced that have potential for indicating the contribution of nursing to health care. One of these is the American Nurses Association's Report Card for Acute Care. The other is the Nursing Intervention Project's information system model. In this article, these initiatives are analyzed in terms of their content and potential for providing a framework for the assessment and evaluation of the quality of nursing care services. Recommendations for policy changes are made for the collection of data to ensure that standards of excellence are met during this most challenging era of accountability.

Patient cost-benefits of realtime teledermatology--a comparison of data from Northern Ireland and New Zealand

As part of a randomized controlled trial of the costs and benefits of realtime teledermatology in comparison with conventional face-to-face appointments, patients were asked to complete a questionnaire at the end of their consultation. One hundred and nine patients took part in an initial teledermatology consultation and 94 in a face-to-face consultation. The proportion of patients followed up by the dermatologist was almost the same after teledermatology (24%) as after a hospital appointment (26%) and for similar reasons. Two hundred and three questionnaires were completed after the first visit and a further 20 after subsequent visits. Patients seen by teledermatology at their own health centre travelled an average of 12 km, whereas those who attended a conventional clinic travelled an average of 271 km. The telemedicine group spent an average of 51 min attending the appointment compared with 4.3 h for those seen at the hospital. The results of the present study, as in a similar study conducted in Northern Ireland, show that the economic benefits of teledermatology favour the patient rather than the health-care system.

An intrinsic timer that controls cell-cycle withdrawal in cultured cardiac myocytes

Developing cardiac myocytes divide a limited number of times before they stop and terminally differentiate, but the mechanism that stops their division is unknown. To help study the stopping mechanism, we defined conditions under which embryonic rat cardiac myocytes cultured in serum-free medium proliferate and exit the cell cycle on a schedule that closely resembles that seen in vivo. The culture medium contains FGF-1 and FGF-2, which stimulate cell proliferation, and thyroid hormone, which seems to be necessary for stable cell-cycle exit. Time-lapse video recording shows that the cells within a clone tend to divide a similar number of times before they stop, whereas cells in different clones divide a variable number of times before they stop. Cells cultured at 33 degrees C divide more slowly but stop dividing at around the same time as cells cultured at 37 degrees C, having undergone fewer divisions. Together, these findings suggest that an intrinsic timer helps control when cardiac myocytes withdraw from the cell cycle and that the timer does not operate by simply counting cell divisions. We provide evidence that the cyclin-dependent kinase inhibitors p18 and p27 may be part of the timer and that thyroid hormone may help developing cardiac myocytes stably withdraw from the cell cycle.

Use of a monoclonal antibody against an Escherichia coli O26 surface protein for detection of enteropathogenic and enterohemorrhagic strains

A monoclonal antibody (MAb) was obtained from a mouse immunized with solubilized outer membrane proteins extracted from a bovine enterohemorrhagic strain of Escherichia coli (EHEC), O26. The MAb produced a strong immunoblot reaction at approximately 21 kDa for an O26 strain containing the intimin gene (eae) and verocytotoxin (VT), but not with an O26 eae- and VT-negative strain, or O157 eae- and VT-positive strains. The MAb was used in a sandwich enzyme-linked immunosorbent assay (ELISA) format to screen strains from animal and human sources, and all reactive strains were characterized for the presence of eae and the gene encoding VT factors by PCR. The antigen was detected in a group of strains containing a high proportion of O26, the majority of which were eae positive with or without VT; these were isolated mostly from animal enteritis cases but included a small number of human enteric isolates. Nonreactors included eae-positive (with or without VT) O157 strains and one O26 strain. In a survey of mixed cultures from both animal and human enteric disease, ELISA-positive reactions were obtained from 7.1 to 11.2% of samples from bovine, porcine, ovine, and human sources. The two human O8 and ten animal O26 ELISA-reactive pure strains obtained from these samples contained six eae- and/or VT-positive strains; the other six strains lost their ELISA positivity following storage at -70 degrees C, after which none were found to contain either eae or VT factors. The association of the antigen detected by the MAb with significant enteropathogenic E. coli and EHEC virulence factors in isolates from both animal and human enteric infections indicates a diagnostic potential for the assay developed.

Use of patient-specific estimates in patient evaluation and rehabilitation

For a number of years we have been using open-ended questionnaires in the assessment of hearing disability and handicap, tinnitus complaint behaviour together with shortcomings and benefits of various rehabilitative interventions. More recently we have applied this approach to positive experiences reported by adults who have developed a hearing impairment and to the use of silence or social withdrawal as a communication tactic. In addition, we have asked individuals to rate the magnitude of each of their listed disabilities, handicaps, shortcomings, etc., on a scale to provide a qualitative assessment of each of these elements important to the individual. Such a procedure can be repeated after the intervention to measure changes in such estimates. This approach can thus highlight for the therapist, those elements of the patients' problems which are being well or poorly addressed and hence help them to concentrate their effort on the latter. Results obtained using this technique are presented and discussed.

Ocular manifestations of autosomal recessive Alport syndrome

Ocular abnormalities are common in X-linked Alport syndrome, but they have not been studied in patients with the rarer autosomal recessive disease. We have examined the eyes of a family with autosomal recessive Alport syndrome. Four of the eight offspring of a consanguineous marriage had renal failure and deafness by the age of 20 years. The diagnosis of Alport syndrome was confirmed on the ultrastructural demonstration of a lamellated glomerular basement membrane (GBM) in one affected family member. Autosomal recessive inheritance was suggested by the lack of linkage to the COL4A5/COL4A6 locus, and by linkage to the COL4A3/COL4A4 locus. All four affected family members had anterior lenticonus (or had had a lens replacement for this) and the three who were examined had a dot-and-fleck retinopathy. Neither of the two unaffected offspring who were examined nor the father had these abnormalities. The ocular manifestations of autosomal recessive Alport syndrome are probably identical to those for the X-linked form. Although the mutations in these diseases affect genes for different type IV collagen chains, these chains occur together in the basement membranes of the kidney, eye and ear, and abnormalities in any one may result in the same clinical phenotype.