Comparison of the costs of fine-needle aspiration and open surgical biopsy as methods for obtaining a pathologic diagnosis

BACKGROUND

A pathologic diagnosis is usually required to determine definitive management for a palpable lesion. In this era of cost control, fine-needle aspiration (FNA) provides a low-cost alternative to open excisional biopsy. Using a broad range of cases collected over 20 years, the authors of this study sought to quantify the savings resulting from the use of FNA on superficial palpable lesions to obtain a pathologic diagnosis.

METHODS

12,452 cases collected by the cytopathology service at the Medical College of Virginia during the period 1972-1991 were used to produce a profile of case type, diagnosis, and indication for surgery. Charge-based cost estimations or Relative Value Units were calculated using the 1995 Physicians' Fee Reference or published Medicare participant fees. The charges for the FNA procedure and open surgical biopsy were compared, and all other biopsy-related costs were omitted.

RESULTS

FNA provided a sufficient pathologic diagnosis to obviate open surgical biopsy in 63-85% of the cases. Estimation of cost savings on the basis of the distribution of cases and indications for surgery suggested a savings of $250,000 to $750,000 per 1000 FNA performed, or approximately 5500 Relative Value Units.

CONCLUSIONS

This study quantifies the substantial savings that result from obtaining a pathologic diagnosis by the FNA procedure rather than open surgical biopsy.

Activation and repression of Drosophila alcohol dehydrogenase distal transcription by two steroid hormone receptor superfamily members binding to a common response element

Developmental activation of the Drosophila alcohol dehydrogenase (Adh) distal promoter is controlled by the Adh adult enhancer (AAE). Within this 150 bp, complex enhancer is a small (12 bp) positive cis-acting element that is required for high levels of distal transcription in adult flies and ADH-expressing tissue culture cells. We previously reported that the steroid receptor superfamily member FTZ-F1 binds to this site. We have identified a second steroid receptor superfamily member, DHR39, which also binds to this site. DHR39 is expressed throughout development in transcripts of several sizes. In situ hybridization to embryos has shown that DHR39 RNA is found primarily in the central nervous system, and not in embryonic tissues that express ADH. FTZ-F1 RNA, however, shows temporal-specific patterns similar to those of the distal promoter. FTZ-F1 and DHR39 have identical amino acids in the 'P-box' of the DNA binding domain, suggesting that they have identical DNA recognition characteristics. By electrophoretic mobility shift analysis we show that a DHR39 fusion protein binds specifically to two FTZ-F1 binding sites. By over expressing the full length DHR39 protein in a transient co-transfection assay we have shown that it represses distal Adh expression in a dosage- and binding site-dependent manner. Over expression of an alternative DHR39 open reading frame that lacks part of the putative ligand binding domain does not alter Adh expression. In contrast, over expression of FTZ-F1 specifically activates distal Adh expression.

Molecular determinants of differential ligand sensitivities of insect ecdysteroid receptors

The functional receptor for insect ecdysteroid hormones is a heterodimer consisting of two nuclear hormone receptors, ecdysteroid receptor (EcR) and the retinoid X receptor homologue Ultraspiracle (USP). Although ecdysone is commonly thought to be a hormone precursor and 20-hydroxyecdysone (20E), the physiologically active steroid, little is known about the relative activity of ecdysteroids in various arthropods. As a step toward characterization of potential differential ligand recognition, we have analyzed the activities of various ecdysteroids using gel mobility shift assays and transfection assays in Schneider-2 (S2) cells. Ecdysone showed little activation of the Drosophila melanogaster receptor complex (DmEcR-USP). In contrast, this steroid functioned as a potent ligand for the mosquito Aedes aegypti receptor complex (AaEcR-USP), significantly enhancing DNA binding and transactivating a reporter gene in S2 cells. The mosquito receptor also displayed higher hormone-independent DNA binding activity than the Drosophila receptor. Subunit-swapping experiments indicated that the EcR protein, not the USP protein, was responsible for ligand specificity. Using domain-swapping techniques, we made a series of Aedes and Drosophila EcR chimeric constructs. Differential ligand responsiveness was mapped near the C terminus of the ligand binding domain, within the identity box previously implicated in the dimerization specificity of nuclear receptors. This region includes helices 9 and 10, as determined by comparison with available crystal structures obtained from other nuclear receptors. Site-directed mutagenesis revealed that Phe529 in Aedes EcR, corresponding to Tyr611 in Drosophila EcR, was most critical for ligand specificity and hormone-independent DNA binding activity. These results demonstrated that ecdysone could function as a bona fide ligand in a species-specific manner.

Sulfamyl Radicals Direct Photoredox-Mediated Giese Reactions at Unactivated C(3)-H Bonds

Alcohol-anchored sulfamate esters guide the alkylation of tertiary and secondary aliphatic C(3)-H bonds. The transformation proceeds directly from N-H bonds with a catalytic oxidant, a contrast to prior methods which have required preoxidation of the reactive nitrogen center, or employed stoichiometric amounts of strong oxidants to obtain the sulfamyl radical. These sulfamyl radicals template otherwise rare 1,6-hydrogen-atom transfer (HAT) processes via seven-membered ring transition states to enable C(3)-H functionalization during Giese reactions.

Determinants of rhabdomyolysis in the diabetic state

To evaluate the determinants of rhabdomyolysis in the diabetic state, we compared biochemical and clinical features of diabetic patients with (group 1, 41 patients) and without (group 2, 36 patients) rhabdomyolysis. There was no difference in values for serum potassium, bicarbonate, phosphate and calcium between the two groups. Nineteen patients in group 2 and 21 patients in group 1 were hypokalemic. The mean serum sodium level was higher (p less than 0.001) in group 1 patients (148.8 +/- 2.1 mEq/l) than in group 2 patients (135.0 +/- 1.1 mEq/l). Only 1 patient was hypernatremic in group 2, whereas 24 patients had hypernatremia in group 1. Linear regression of the creatine phosphokinase values versus serum sodium levels suggested a high correlation (p less than 0.001). The mean blood glucose level was higher (p less than 0.05) in group 1 patients (640.8 +/- 80.3 mg/dl) when compared to group 2 patients (436.0 +/- 56.7 mg/dl). There was a linear association (p less than 0.05) between the levels of blood glucose and creatine phosphokinase values in the patients with rhabdomyolysis. The mean serum osmolality was 350.3 +/- 8.2 mosm/kg in group 1 patients as compared to 304.9 +/- 3.6 mosm/kg in group 2 patients (p less than 0.001). There was also a significant correlation (p less than 0.001) between the serum osmolality levels and the serum creatine phosphokinase values in group 1 patients. We conclude that serum sodium, serum osmolality and blood glucose are major determinants for the occurrence of rhabdomyolysis in the diabetic state.

Sulfamate Esters Guide C(3)-Selective Xanthylation of Alkanes

Owing to the pervasiveness of hydroxyl groups in natural isolates, alcohol derivatives are alluring directing groups. Herein, an alcohol-derived sulfamate ester guides the light-initiated xanthylation of primary, secondary, or tertiary centers. This process enables formal directed deuteration, azidation, thiolation, and vinylation reactions.

Synthesis of N-Substituted Sulfamate Esters from Sulfamic Acid Salts by Activation with Triphenylphosphine Ditriflate

A general approach to access sulfamate esters through preparation of sulfamic acid salts, subsequent activation with triphenylphosphine ditriflate, and nucleophilic trapping is disclosed. The method proceeds in modest to excellent yields to incorporate nucleophiles derived from aliphatic alcohols and phenols. This approach can be employed to furnish differentially substituted sulfamides.

Roles of cis-acting elements and chromatin structure in Drosophila alcohol dehydrogenase gene expression

The alcohol dehydrogenase (Adh) gene of D. melanogaster is transcribed from two different promoters during fly development: the distal (adult) and the proximal (embryonic-larval). Certain aspects of Adh gene regulation are represented in Drosophila continuous cell lines. We have used Drosophila tissue culture cells in an in vivo transient expression assay to delimit cis-acting sequences affecting Adh expression, and to investigate the role of chromatin structure in Adh gene regulation. These studies show that positive cis-acting elements of the distal promoter can exist in at least 2 alternative chromatin configurations. There is a close correlation between specific transcriptional activity of the Adh distal promoter and a defined, localized chromatin structural change that indicates altered DNA-protein interactions. Thus, chromatin structure appears to play a role in regulating the accessibility of defined positive cis-acting regulatory sequences of Adh to transcription factors and the transcription machinery.

Planning flexible learning to match the needs of consumers: a national survey

The injection of market forces into the National Health Service (NHS) has led to nurse education being viewed as a commodity which educational institutions supply and NHS employers purchase. Conscious of the costs of paying for courses within this new consumer culture, NHS trusts and other health service employers are increasingly looking for cost-effective flexible training to educate their workforce quickly and efficiently. Parallel to this is the accelerated demand for continuing professional development (CPD) brought about by the inception of the UKCC's Post-Registration Education and Practice Project (PREPP). Both registered and enrolled nurses are finding they need professional updating and skills and thus increased access to courses. The increased demand for education and training brought about by these changes cannot be met through traditional methods alone, requiring educational institutions to re-appraise their methods of delivery and introduce more flexible approaches to learning. There is every evidence that this is now the case with open learning, distance learning and flexible approaches to learning ever growing in popularity as providers of nurse education recognize the benefits such approaches offer. The emphasis is on meeting the diverse needs of the health care employers and individuals by providing education that is flexible, learner-centred and customer focused. This paper presents the findings of a national survey to ascertain how providers of flexible education plan educational programmes to meet the needs of their customers. Based on data collected from 120 educational institutions within the higher education, health and social care and private sectors, it highlights: the ways in which flexible learning programmes and courses are delivered; what aspects of flexibility are considered important when designing programmes to meet the needs of prospective customers; and what approaches are used to assess demand for flexible education. The study stresses the need for providers of flexible education to take into account the dual perspectives of those who have a stake in the flexibility of nurse education; NHS employers as funders of students and individual healthcare professionals themselves.

Conserved enhancer and silencer elements responsible for differential Adh transcription in Drosophila cell lines

The distal promoter of Adh is differentially expressed in Drosophila tissue culture cell lines. After transfection with an exogenous Adh gene, there was a specific increase in distal alcohol dehydrogenase (ADH) transcripts in ADH-expressing (ADH+) cells above the levels observed in transfected ADH-nonexpressing (ADH-) cells. We used deletion mutations and a comparative transient-expression assay to identify the cis-acting elements responsible for enhanced Adh distal transcription in ADH+ cells. DNA sequences controlling high levels of distal transcription were localized to a 15-base-pair (bp) region nearly 500 bp upstream of the distal RNA start site. In addition, a 61-bp negative cis-acting element was found upstream from and adjacent to the enhancer. When this silencer element was deleted, distal transcription increased only in the ADH+ cell line. These distant upstream elements must interact with the promoter elements, the Adf-1-binding site and the TATA box, as they only influenced transcription when at least one of these two positive distal promoter elements was present. Internal deletions targeted to the Adf-1-binding site or the TATA box reduced transcription in both cell types but did not affect the transcription initiation site. Distal transcription in transfected ADH- cells appears to be controlled primarily through these promoter elements and does not involve the upstream regulatory elements. Evolutionary conservation in distantly related Drosophila species suggests the importance of these upstream elements in correct developmental and tissue-specific expression of ADH.

The binding site of a steroid hormone receptor-like protein within the Drosophila Adh adult enhancer is required for high levels of tissue-specific alcohol dehydrogenase expression

Developmental and tissue-specific transcription from the Adh distal promoter is regulated in part by the Adh adult enhancer, located 450 to 600 bp upstream from the distal RNA start site. We have characterized four proteins (DEP1 to DEP4), present in Drosophila tissue culture cell nuclear extracts, which bind to this enhancer. DEP1 and DEP2 bind to a positive cis-acting element (-492 to -481) and share nucleotide contacts. A small linker replacement deletion mutation, which disrupts the overlapping DEP1- and DEP2-binding sites, reduces Adh distal transcription in an alcohol dehydrogenase (ADH)-expressing cultured cell line, in the adult fat body (the major tissue of ADH expression), as well as in some but not all adult tissues where ADH is normally expressed. This enhancer element contains an imperfect palindromic sequence similar to steroid hormone receptor superfamily response elements. Binding-site screening of a lambda gt11 expression library has identified the steroid receptor superfamily member fushi tarazu factor 1 (FTZ-F1) as a protein that binds to this site. Anti-FTZ-F1 antibodies have identified DEP1 as FTZ-F1. DEP2 also binds to the FTZ-F1 site from the fushi tarazu zebra element, suggesting that DEP2 may also be a steroid receptor superfamily member. Our results raise the possibility that Adh regulation in certain adult tissues involves a hormone-mediated pathway. Because DEP1 (FTZ-F1) and DEP2 contact some of the same nucleotides within the positive cis element, it is unlikely that they can bind simultaneously. Such alternative binding may play a role in the tissue-specific and developmental transcription of Adh.

Analysis of formaldehyde-induced Adh mutations in Drosophila by RNA structure mapping and direct sequencing of PCR-amplified genomic DNA

Two formaldehyde-induced mutations at the Drosophila Adh locus (Adhfn45 and Adhfn46) were analyzed by determining RNA structures at different developmental stages, polymerase chain reaction (PCR) amplification of the affected genomic regions, and direct sequencing of the resulting double-stranded DNA fragments. Adhfn46 adults and larvae accumulate abundant ADH-like distal (adult) and proximal (larval) transcripts that are shorter than transcripts in wild-type flies by a lesion located in the second ADH protein-coding exon. Direct sequencing of the amplified DNA region showed that Adhfn46 contains a 69-bp in-frame deletion that removes 23 amino acids near one border of the second exon. Consistent with these findings, we observed a shorter ADHfn46 protein present at only 3% of wild-type levels. In contrast, Adhfn45 adults and larvae accumulate much smaller amounts of ADH-like distal and proximal transcripts. Both RNAs have an identical aberration in RNA splicing of the 65-base intron sequence. Direct sequencing of the amplified mutated DNA region showed that Adhfn45 contains a 21-bp deletion that removed and rearranged DNA at the 5' splice junction of the 65-bp intron. No ADH cross-reacting material is detected in Adhfn45 flies. Direct-repeat sequences (3-11 bp) are present flanking and within the mutated DNA regions. The patterns of DNA deletion and deletion accompanied by sequence addition at the mutant sites suggest a slipped mispairing mechanism during DNA replication or repair that involves local DNA homology.

Practice-led education and development project: developing styles in clinical supervision

This paper is the second installment which reports a study conducted by the authors following successful application to the Yorkshire Regional Health Authority in response to a call for proposals for studies into practice-led education and development. The aim of the project is to pilot and evaluate an approach to leadership development based upon a conceptual model of reflectivity within a learning organization whilst developing and evaluating a model of supervised practice.

Community care: failure of professionals to meet family needs

This paper is based on a 3-year study involving 132 mothers caring for their severely mentally handicapped school children at home. The study shows that many mothers lack awareness of available services. Services are determined by professional perspectives. Many mothers find that available services tend to substitute rather than reinforce their caring capacity. Services are ad hoc and crisis orientated rather than planned and coordinated. Increasing numbers of parents are seeking support through mutual aid and self-help groups.

Defining a model for team leader development

This paper will provide details of a study conducted jointly by the authors following successful application to the Yorkshire Regional Health Authority in response to a call for proposals for studies into 'Practice-Led Education and Development'. The aim of the project was to pilot and evaluate an approach to leadership development based upon a conceptual model of reflectivity within a learning organization whilst developing and evaluating a model of supervised practice.

Directed Photochemically Mediated Nickel-Catalyzed (Hetero)arylation of Aliphatic C-H Bonds

Site-selective functionalization of unactivated C(sp3)-H centers is challenging because of the ubiquity and strength of alkyl C-H bonds. Herein, we disclose a position-selective C(sp3)-C(sp2) cross-coupling reaction. This process engages C(sp3)-H bonds and aryl bromides, utilizing catalytic quantities of a photoredox-capable molecule and a nickel precatalyst. Using this technology, selective C-H functionalization arises owing to a 1,6-hydrogen atom transfer (HAT) process that is guided by a pendant alcohol-anchored sulfamate ester. These transformations proceed directly from N-H bonds, in contrast to previous directed, radical-mediated, C-H arylation processes, which have relied on prior oxidation of the reactive nitrogen center in reactions with nucleophilic arenes. Moreover, these conditions promote arylation at secondary centers in good yields with excellent selectivity.

Submitting a research proposal for ethical approval

1. Research involving human subjects should conform to ethical and moral codes. 2. Special considerations should apply in respect of research in special and vulnerable groups such as children, people with learning disabilities/mental handicap, psychiatric patients and prisoners. 3. Local research ethics committees should protect subjects of research from possible harm. 4. Local research ethics committees should exercise discretion as to the mode of consent appropriate to the nature of the proposed research.

A proper process of scrutiny. Developing a college research base

As the amount of small scale research undertaken by students increases, it is vital that colleges ensure such research is subject to proper scrutiny before approval. This protects human participants, maintains the reputation of research and ensures the knowledge base is not contaminated by improperly conducted projects.