Language barriers for primary care access in Europe: a systematic review

Background

A recent increase in migration both inside Europe and from non-European countries has expanded the language profile of many European countries. As a result, there has been a significant increase in barriers to healthcare access experienced by linguistic minority migrants. This systematic review aims to explore language barriers in primary care, focusing on the experiences of linguistic minority migrants living in Europe.

Methods

PubMed, Embase, Scopus and Global Health were searched to identify studies published in English until May 2021. Qualitative and mixed methods studies on either linguistic minority migrants or healthcare workers working with linguistic minority migrants, exploring the impacts of language barriers in a primary care setting published were eligible. The studies were analysed using a Braun and Clarke's thematic analysis approach. Quality of the studies were assessed using the Mixed Methods Appraisal Tool.

Results

16 studies from 14 different European countries were eligible. Participants in the studies included four groups: linguistic minority migrants (n = 11), healthcare workers (n = 10), interpreters (n = 1) and administrative staff (n = 1). Barriers identified included a lack of interpreters, limited cultural competence of practitioners, a lack of practitioner training and knowledge, a lack of accessible information for migrants, difficulties expressing emotions and building patient-practitioner relationships, and risks to women's bodily autonomy resulting from language barriers.

Conclusions

Linguistic minority migrants living in Europe face a number of barriers when accessing primary care. These barriers can risk patient safety, reduce the likelihood of seeking healthcare services, and impact patient experiences of healthcare services. There is a need for improved interpreter services, practitioner training, and information accessibility for both migrants and healthcare staff.

Key messages

• Linguistic minority migrants experience significant barriers to primary healthcare access across Europe.

• There is a need for improved interpreter services, practitioner training, and information accessibility for both migrants and healthcare staff.

Comparison of the Institute for Credentialing Excellence Multi-Organization Survey of Certificants

Introduction/Objective

The Institute for Credentialing Excellence (ICE) conducted a study to measure the value that credential holders place on certification, collecting survey data from a large sample of more than 12,000 credential holders representing six organizations (4 of which were healthcare). In May of 2019, ASCP BOC sent the survey to 47,384 individuals certified within the last 5 years. Of those who received the survey; 2,038 completed the 80 required questions. A comparison of survey data provided an overview of the top five differences in the full survey data (n=9,407) and the data from respondents credentialed by ASCP BOC (n = 2,038 or 22% of full survey respondents) and highlighted the primary reasons individuals pursue certification.

Methods/Case Report

This survey sought to define certificants’ attitudes toward and experiences with certification. Survey questions were grouped by four primary subject areas:

The Value of Certification for Respondents’ Professions

The Value of Certification for Employers

The Value of Certification Outside the U.S. and Canada

The Value of Certification for Certificants

- Responses of themed queries of full survey data and BOC survey data were viewed side by side and averages, standard deviations and medians were calculated. The top 5 items indicating the highest difference from the full survey data results were highlighted.

- Ranked primary motivational factors for the pursuit of certification were viewed side-by-side.

Results (if a Case Study enter NA)

Based on a side-by-side comparison of full survey data and BOC survey data, only minor differences were noted with the exception of the question pertaining to the perceived value of recertification. Both differences and items of agreement were highlighted.

The top 10 reasons for seeking certification were the same amongst both the full survey and ASCP BOC survey respondents, with minor differences in priority order.

Conclusion

With the exception of the question regarding the value of recertification, discrepancies noted were minor. On most questions pertaining to the various benefits of certification, a majority of respondents gave a positive response about certification and its relationship to beneficial outcomes for their professions, employers, or themselves. It is clear that certificants place a high value on certification and believe that certification provides a number of valuable benefits.

Mycobacterium llatzerense lung infection in a liver transplant recipient: case report and review of the literature

Nontuberculous mycobacteria are increasingly encountered pathogens in organ transplant recipients. We report the first case of human disease attributed to Mycobacterium llatzerense that occurred in a liver transplant recipient in the midwestern United States who developed pneumonia and describe the treatment of this patient.

Complete IGF Signaling Blockade by the Dual-Kinase Inhibitor, BMS-754807, Is Sufficient To Overcome Tamoxifen and Letrozole Resistance In Vitro and In Vivo

Resistance to hormonal therapy is a clinically unmet need in breast cancer. IGF signaling has been identified as a major mechanism of resistance to hormonal therapy in breast cancer. As components of the IGF signaling pathway are expressed in most breast cancers, the development of IGF-1R monoclonal antibody (mAb) and tyrosine kinase inhibitors (TKI) are active areas of clinical investigations. A key distinction between the mAb and TKIs are their differences in their ability to inhibit the Insulin Receptor (InsR). While targeting the InsR with TKIs may have a theoretical liability of hyperglycemia, targeting only the IGF-1R may have the theoretical liability of incompletely blocking IGF signaling. As InsR isoform A expression, which can transduce IGF-II-mediated proliferation, is higher in breast cancers compared to normal breast tissue, we investigated whether IGF-1R or IGF-1R/InsR inhibition was sufficient for overcoming resistance to hormonal therapy. To determine the optimal combination strategies for clinical investigations, we tested the hypothesis that IGF signaling inhibition could overcome primary (or de novo/intrinsic) and secondary (or acquired/selected) resistance to hormonal therapy. For these studies, we used either hormone therapy-naïve or hormone therapy-resistant variants of the breast cancer model, MCF-7/AC-1, which has been engineered to stably express full-length human aromatase. We employed and compared a novel, potent dual kinase inhibitor of the IGF-1R and InsR, BMS-754807, which is currently in early clinical investigations, with the IGF-1R antibody mAb391. BMS-754807 has been shown to induce apoptosis more potently than mAb391 in Rh41 human rhabdomyosarcoma cells. In vitro, BMS-754807 demonstrated profound synergy in combination with tamoxifen and letrozole (median effect combination index <0.1). In vivo, BMS-754807 enhanced the anti-tumor activity of tamoxifen and letrozole in hormone-naïve tumors and induced regression of tumors resistant to tamoxifen or letrozole when combined with letrozole. This activity was not observed with mAb therapy, which resulted in greater up-regulation of InsR-A and erbB receptor expression and activation. This suggested a greater susceptibility to resistance pathways with mAb therapy. Dual IGF-1R/InsR blockade alone or in combination was tolerated by the animals and has no significant change in glucose homeostasis. Gene expression profiling experiments to compare the difference between the effects of tamoxifen in combination with BMS-754807 and with mAb revealed alternative pathway signaling is one of the potential mechanisms of resistance.In summary, combined hormonal therapy with BMS-754807 overcomes primary and secondary resistance to tamoxifen and letrozole and was well tolerated. IGF-1R blockade with a mAb alone is insufficient to overcome resistance and induces InsR over-expression. Thus, IGF signaling through either InsR or IGF-1R may be a major mechanism of resistance to hormonal therapy. These data suggest that blockade of IGF-1 and IGF-II from activation of IGF-1R and InsR, with agents such as BMS-754807 have promise in extending the benefits of hormonal therapy in breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 402.

Positive consequences of head and neck cancer: key correlates of finding benefit

The identification of positive outcomes from adversity has been commonly termed benefit finding. This cross-sectional questionnaire study aimed to identify the extent to which benefit finding occurs among head and neck cancer (HNC) patients and what factors are associated. HNC patients treated 6 months to 10 years previously (n = 76), completed the following measures: the LOT-R, HADS, the Brief COPE, and a measure of benefit finding. Moderate to high levels of benefit finding were reported. Optimism and positive reappraisal were positively associated with benefit finding, with optimism acting independently of positive reappraisal coping. These findings have implications for the development of interventions to maximize positive psychological outcomes after treatment.

Alpha-plutonium's polycrystalline elastic moduli over its full temperature range

alpha-plutonium's volume-corrected polycrystal elastic moduli were measured between 18 K and the upper limit of its occurrence, near 400 K. The two independent moduli for a polycrystal-bulk and shear-behave smoothly, indicating no phase transition. Both moduli show the same 50% increase on cooling, an order of magnitude larger than in other metals. The Debye temperature obtained from low-temperature elastic moduli, 207 K, significantly exceeds most previous estimates. The Gruneisen parameter gamma=5.3, obtained from the temperature dependence of the bulk modulus, is intermediate among previous estimates using other approaches, alpha-plutonium's Poisson ratio nu is low: 0.18, nearly temperature independent, and its small decrease on warming opposes usual behavior. The high gamma, large but equal bulk modulus and shear modulus fractional stiffening on cooling, and near-temperature-invariant nu are attributed to a single mechanism: 5-f electron localization-delocalization.

Crossover between channeling and pinning at twin boundaries in YBa2Cu3O7 thin films

The critical current (Jc) of highly twinned YBa2Cu3O7 films has been measured as a function of temperature, magnetic field, and angle. For much of the parameter space we observe a strong suppression of Jc for fields in the twin boundary (TB) directions; this is quantitatively modeled as flux-cutting-mediated vortex channeling. For certain temperatures and fields a crossover occurs to a regime in which channeling is blocked and the TBs act as planar pinning centers so that TB pinning enhances the overall Jc. In this regime, intrinsic pinning along the TBs is comparable to that between the twins.

Cereal genes similar to Snf2 define a new subfamily that includes human and mouse genes

Genes from the SNF2 family play important roles in transcriptional regulation, maintenance of chromosome integrity and DNA repair. This study describes the molecular cloning and characterization of cereal genes from this family. The predicted proteins exhibit a novel C-terminal domain that defines a new subfamily designated SNF2P that includes human and mouse proteins. Comparison between genomic and cDNA sequences showed that cereal Snf2P genes consisted of 17 exons, including one only 8 bp long. Two barley alleles differed by the presence of a 7.7-kb non-LTR retrotransposon in intron 6. An alternative annotation of the orthologous Arabidopsis gene would improve its similarity with the other members of the subfamily. Intron 2 was not spliced out in approximately half of the rice Snf2P mRNAs present in leaves, resulting in a premature stop codon. Transcripts from the barley and wheat Snf2P genes were found in apexes, leaves, sheaths, roots and spikes. The Snf2P genes exist as single copies on wheat chromosome arm 5A(m)L and in the colinear regions on barley chromosome arm 4HL and rice chromosome 3. High-density genetic mapping and RT-PCR suggest that Snf2P is not a candidate gene for the tightly linked vernalization gene Vrn2.

Estrogen status correlates with the calcium content of coronary atherosclerotic plaques in women

BACKGROUND

Coronary artery calcium, a radiographic marker for atherosclerosis and a predictor of coronary heart disease (CHD), is less extensive in women than in men of the same age. The role of estrogen in the pathogenesis of coronary artery calcification is unknown. We examined the association of estrogen status with extent of calcification and atherosclerotic plaque in coronary arteries of deceased women.

METHODS

Coronary arteries were obtained at autopsy from 56 white women age 18--98 yr, 46 postmenopausal and 10 premenopausal. Exclusion criteria included patients with coronary stents, coronary artery bypass surgery, and medical-legal cases. Medical records were reviewed for demographics, CHD risk factors, menstrual status, and use of estrogen replacement therapy. Contact microradiography of coronary arteries assessed true calcium content and atherosclerotic plaque area was analyzed histologically.

RESULTS

The coronary arteries from estrogen-treated postmenopausal women had lower mean coronary calcium content (P = 0.002), mean plaque area (P < 0.0001), and calcium-to-plaque area ratio (P = 0.004) than those from untreated menopausal women. Estrogen status, age, diabetes, and hypertension predicted calcium and plaque area by univariate analysis. After controlling for these CHD risk factors, estrogen status remained an independent predictor of both calcium (P = 0.014) and plaque area (P = 0.001) in all women. Mean calcium area (P < 0.05) but not plaque area (P = 0.44) was significantly greater in women treated with estrogen replacement therapy than in premenopausal women. Coronary calcium (P < 0.007) and plaque area (P < 0.03) varied significantly with age in untreated postmenopausal women, but not in the estrogen-treated or premenopausal women (P = 0.33).

CONCLUSIONS

Estrogen status is associated with coronary calcium and plaque area independent of age and CHD risk factors. Estrogen may modulate the calcium content of atherosclerotic plaques, as well as plaque area and may slow the progression of atherosclerosis in women.

Transmission of Mycobacterium tuberculosis through casual contact with an infectious case

BACKGROUND

An ongoing restriction fragment length polymorphism study of Mycobacterium tuberculosis isolates from tuberculosis cases showed an identical 12-band IS6110 pattern unique to 3 unrelated patients (Patients A-C) diagnosed as having tuberculosis within a 9-month period.

METHODS

In an attempt to identify epidemiologic links between the 3 patients, we performed site visits to the retail business work site of patient A and conducted detailed interviews with all 3 patients and their contacts.

RESULTS

Patient B had visited patient A's work site 3 times during patient A's infectious period, spending no more than 15 minutes each time. Patient C visited patient A's work site on 6 to 10 occasions during this period for no more than 45 minutes at any one time. There were no other epidemiologic links between these 3 cases other than the contact at the store. Contact investigation identified 4 tuberculin skin test conversions among 8 (50%) of patient A's coworkers, 6 positive tests among 15 household contacts (40%), and 8 positive tests among 16 identified customers who were casual contacts (50%). Patient B and patient C were most likely infected by patient A during one of their brief visits to patient A's work site.

CONCLUSIONS

These data demonstrate that some tuberculosis is spread through casual contact not normally pursued in traditional contact investigations and that, in certain situations, M tuberculosis can be transmitted despite minimal duration of exposure. In addition, this outbreak emphasizes the importance of DNA fingerprinting data for identifying unusual transmission in unexpected settings.

Binding of human immunodeficiency virus type 1 gp120 to CXCR4 induces mitochondrial transmembrane depolarization and cytochrome c-mediated apoptosis independently of Fas signaling

Apoptosis of CD4(+) T lymphocytes, induced by contact between human immunodeficiency virus type 1 (HIV-1) envelope glycoprotein (gp120) and its receptors, could contribute to the cell depletion observed in HIV-infected individuals. CXCR4 appears to play an important role in gp120-induced cell death, but the mechanisms involved in this apoptotic process remain poorly understood. To get insight into the signal transduction pathways connecting CXCR4 to apoptosis following gp120 binding, we used different cell lines expressing wild-type CXCR4 and a truncated form of CD4 that binds gp120 but lacks the ability to transduce signals. The present study demonstrates that (i) the interaction of cell-associated gp120 with CXCR4-expressing target cells triggers a rapid dissipation of the mitochondrial transmembrane potential resulting in the cytosolic release of cytochrome c from the mitochondria to cytosol, concurrent with activation of caspase-9 and -3; (ii) this apoptotic process is independent of Fas signaling; and (iii) cooperation with a CD4 signal is not required. In addition, following coculture with cells expressing gp120, a Fas-independent apoptosis involving mitochondria and caspase activation is also observed in primary umbilical cord blood CD4(+) T lymphocytes expressing high levels of CXCR4. Thus, this gp120-mediated apoptotic pathway may contribute to CD4(+) T-cell depletion in AIDS.

Thermal conductance and wettability of xenon on resorcinol-formaldehyde aerogels

We have performed thermal conductivity and adsorption isotherm measurements to investigate the system formed by Xe adsorbed on resorcinol-formaldehyde (RF) aerogel. Below 80 K, the thermal conductivity of the Xe/RF-aerogel system is essentially identical to that of the bare RF aerogel; however, above this temperature the thermal conductivity of the system increases significantly above that of the bare aerogel. Adsorption isotherm measurements indicate that Xe incompletely wets the RF aerogel below Xe's bulk triple point temperature. The thickness of the Xe film that forms on the RF aerogel decreases with decreasing temperature. By 80 K the total amount of Xe present on the aerogel in equilibrium with the saturated vapor pressure is less than the amount needed to form about 1.5 atomic layers of Xe on the substrate. We attribute the observed changes in the thermal conductivity of the Xe/aerogel system to changes in the wettability of the aerogel by the Xe film.

A multi-state outbreak of tuberculosis among members of a highly mobile social network: implications for tuberculosis elimination

SETTING

Baltimore, Maryland.

OBJECTIVE

To describe a tuberculosis (TB) outbreak among a highly mobile population and the efforts required to control it.

DESIGN

Epidemiologic outbreak investigation.

RESULTS

Between June 1998 and January 2000, 20 TB outbreak cases were identified, of which 18 were culture-confirmed. Seventeen isolates of Mycobacterium tuberculosis had an identical 11-band DNA fingerprint; another isolate had one additional band and was considered a match. Two cases were diagnosed in New York City; another patient lived primarily in Atlanta, but was diagnosed in Baltimore. Persons in the outbreak were predominantly young (median age 24 years), black, male, infected with the human immunodeficiency virus (HIV), and gay, transvestite or transsexual. Activities common among many TB cases included attending two nightclubs, membership in one of three social 'Houses', attending balls or pageants in East Coast cities, marijuana use, and prostitution. Community outreach, extended contact tracing, DNA fingerprinting, directly-observed therapy, and expanded use of preventive therapy were utilized to assess and control the outbreak. During the outbreak period the Baltimore City TB rate declined by 10%. However, additional public health personnel were required to control the outbreak, resulting in a 17% increase in TB clinic staff.

CONCLUSION

As TB rates decline, remaining cases are likely to occur in difficult-to-reach populations. Increased resources per case of TB treated will be required to eliminate TB.

General practice. Hit and miss

A survey of practices in a primary care group in outer London found many were poorly prepared for implementing clinical governance. More than half consisted of one doctor, and a quarter of practices were not computerised. Only a third had a staff development plan. Only a minority had sought patients' views about new services. Although three-quarters of practices were using guidelines, few had been trained in the use of protocols and guidelines.

Idiopathic transient osteoporosis: a hidden cause of hip pain

Idiopathic transient osteoporosis must be considered in active young adult and middle-aged patients who have spontaneous joint pain with acute onset. This often debilitating condition most commonly affects the hip; it is then marked by pain that intensifies with weight bearing or hip rotation. The knee, ankle, or foot can also be affected. Delayed diagnosis is common, in part because of a lack of physician familiarity with the condition. Physical exam tests can reproduce pain, and scintigraphy and MRI can help narrow the differential. Treatment is typically supportive and includes pain relief and physical therapy to maximize function. Two case reports illustrate management of the condition.

Use of Dacron as an alternative carrier for evaluating oxidizing sterilants in the AOAC sporicidal test

The AOAC sporicidal method (966.04) recommends the use of porcelain penicylinders and black waxed silk sutures as carriers for demonstrating the sporicidal activity of sterilants. However, the silk carriers are not suitable for evaluating the sporicidal efficacy of oxidizing agents, and an inert polyester material (Dacron) is recommended as an alternative. Dacron provides an equivalent microbial and physical challenge to silk. Microbiologically, both materials demonstrated similar HCI resistance, which is required by the AOAC test, as well as equivalent spore loading and spore wash-off. Electron microscopy showed that both materials present the same braided microstructure, providing an equivalent physical challenge to the test sterilant. Dacron was more consistent than silk, and did not require extraction prior to spore loading. The extraction method for black waxed silk was variable and incomplete, which may compromise the activity of oxidizing sterilants and add to method variability. Silk was also structurally altered in the presence of oxidizing sterilants and increased sterilant degradation. Dacron did not affect the sterilant and was inert in the presence of oxidizing agents. Dacron sutures are proposed as inert alternatives to silk for evaluating the sporicidal efficacy of oxidizing agents.

Effects of physisorption of xenon on the thermal conductivity of resorcinol-formaldehyde aerogels

The effects of adsorption of xenon to the thermal conductivity of a resorcinol-formaldehyde aerogel were investigated in a temperature range from 20 to 120 K. It was found that at temperatures below 75 K, the adsorbed xenon has little effect on the thermal conductivity. Rapid rises of the thermal conductivity develop at temperatures around 75-80 K with magnitudes roughly proportional to the amount of xenon adsorbed. The effect is explained as due to adsorbed xenon atoms that enhance the neck connection between aerogel particles.

Molecular and geographic patterns of tuberculosis transmission after 15 years of directly observed therapy

CONTEXT

Recent studies suggest that one third of tuberculosis cases in urban areas result from recent transmission. Improved tuberculosis control measures such as uniform implementation of directly observed therapy might reduce the proportion of cases resulting from recent transmission.

OBJECTIVE

To determine patterns of tuberculosis transmission in Baltimore, Md, after 15 years of community-based directly observed therapy.

DESIGN

A 30-month (January 1994-June 1996), prospective, city-wide study of all cases of tuberculosis using traditional contact investigations, geographic information systems data, and molecular epidemiologic comparison of Mycobacterium tuberculosis isolates with 2 DNA probes.

PATIENTS

One hundred eighty-two patients with culture-positive tuberculosis.

MAIN OUTCOME MEASURES

Proportion of disease defined as recently transmitted based on epidemiologic linkage by traditional contact tracing and molecular linkage by DNA fingerprint analysis of isolates; geographic foci of transmission based on linkage of residences by geographic information systems data.

RESULTS

Of the 182 patients who had isolates of M tuberculosis available, 84 (46%) showed molecular clustering with 58 (32%) defined as being recently transmitted. Only 20 (24%) of 84 cases with clustered DNA fingerprints had epidemiologic evidence of recent contact. Geographic analysis showed significant spatial aggregation of the 20 clustered cases with epidemiologic links (P<.001), occurring in areas of low socioeconomic status and high drug use. The 64 cases with clustered DNA fingerprints but without epidemiologic links shared common risk factors and demographic features with the 20 clustered patients who did have epidemiologic links.

CONCLUSIONS

Recently transmitted tuberculosis accounts for a high proportion of tuberculosis cases in Baltimore. Recently transmitted cases occur in geographically distinct areas of Baltimore, and location-based control efforts may be more effective than contact tracing for the early identification of cases.

Transmission of Mycobacterium tuberculosis by a fiberoptic bronchoscope. Identification by DNA fingerprinting

CONTEXT

An ongoing restriction fragment length polymorphism (RFLP) study of Mycobacterium tuberculosis isolates from tuberculosis (TB) cases revealed an identical 10-banded IS6110 RFLP pattern unique to 2 patients diagnosed as having TB 6 months apart. Their only identifiable link was care at the same hospital.

OBJECTIVE

To determine if nosocomial transmission had occurred.

DESIGN

Traditional and molecular epidemiologic investigation.

MEASUREMENTS

We reviewed medical charts and bronchoscopic records, examined hospital locations visited by both patients, evaluated hospital ventilation systems, and observed cleaning and disinfection of bronchoscopes.

RESULTS

A patient with cough, hoarseness, and fever underwent bronchoscopy and was diagnosed as having TB. A second patient with a mediastinal mass underwent bronchoscopy 2 days later and was diagnosed as having small cell carcinoma. Following 6 months of chemotherapy and radiation therapy, the second patient developed fever and an infiltrate of the right upper lobe of the lung. Bronchoscopic washings revealed acid-fast bacilli and were culture positive for M tuberculosis. Both patients had undergone bronchoscopy with the same instrument in the same operating room with no intervening bronchoscopies. Bronchoscope cleaning and disinfection procedures were inconsistent with national guidelines.

CONCLUSIONS

A contaminated bronchoscope was the most likely source of M tuberculosis transmission between these 2 patients. The RFLP analysis of M tuberculosis isolates was responsible for detecting this nosocomial source of transmission and led to the implementation of public health measures to prevent further spread of infection and disease. This study emphasizes the need for continued vigilance in endoscope cleaning techniques.

A hypervariable region in VP1 of chicken infectious anemia virus mediates rate of spread and cell tropism in tissue culture

Chicken infectious anemia virus (CIAV) is a unique infectious agent with an amino acid composition that has been found to be remarkably conserved even in isolates from different parts of the world. We have characterized field isolates of CIAV which vary significantly in terms of their abilities to replicate in culture, demonstrating a biological difference between isolates. Two sublines of MDCC-MSB1 cells that differ in their abilities to support CIAV were identified. In the MSB1(S) subline the CIA-1 isolate of CIAV was found to be less cytopathogenic than the prototype Cux-1(C) isolate; the MSB1(L) subline, which supports Cux-1(C) replication, was found to be nonpermissive for CIA-1. Alignments of the VP1 sequences of previously examined isolates with those of the field isolates CIA-1 and L-028 and the culture-adapted ConnB isolate revealed a previously unreported hypervariable region spanning amino acid positions 139 to 151. Chimeras of Cux-1(C) and CIA-1 were constructed to examine the potential for this region to affect cytopathogenicity. Transfer of a 316-bp region of Cux-1(C) open reading frame 1 into CIA-1 produced a virus with a cytopathogenic profile typical of Cux-1(C), indicating that one or both of the amino acid differences at positions 139 and 144 affect the rate of replication or the spread of infection. Transfection experiments with additional chimeras indicated that the inability of CIA-1 to replicate in MSB1(L) cells is mediated by a larger region of the genome which contains the hypervariable region in addition to upstream amino acid differences. Analysis of chimeras excluding the entire region of open reading frame 1 suggested the presence of a secondary mediator in the progression of infection in culture that was localized to a region containing a single nucleotide difference which results in amino acid differences in both VP2 (V-153) and the nuclear localization signal of VP3 (C-118). Immunofluorescence assays indicated an increased cytoplasmic distribution of VP3 and a general lack of VP3-associated apoptotic bodies in infections of CIA-1 and chimeras containing V-153 or C-118, as opposed to a primarily nuclear distribution and association with well-formed apoptotic bodies in Cux-1(C)-infected cells.

Resistance patterns of Streptococcus pneumoniae and Haemophilus influenzae isolates recovered in Egypt from children with pneumonia. The Antimicrobial Resistance Surveillance Study Group

Treatment of childhood pneumonia in developing countries requires knowledge of susceptibility patterns for Streptococcus pneumoniae and Haemophilus influenzae. Between October 1991 and April 1993, a surveillance survey of antimicrobial resistance was performed at two fever hospitals in Egypt; nasopharyngeal swab and blood specimens obtained from 1,635 children with pneumonia were cultured for these organisms. Susceptibility testing of these organisms was performed. At least one of these organisms was isolated from nasopharyngeal swab specimens from 73% of the children; 3.7% of blood cultures were positive. For S. pneumoniae strains, 70.9% of nasopharyngeal isolates were calculated to be susceptible to penicillin vs. 77.6% of blood isolates; the percentages of isolates susceptible to co-trimoxazole were 73.0% and 75.0%, respectively. For H. influenzae strains, 93.0% of nasopharyngeal isolates were calculated to be susceptible to ampicillin vs. 100% of blood isolates; the percentages of isolates susceptible to co-trimoxazole were 84.9% and 100%, respectively. Although most S. pneumoniae and H. influenzae strains associated with childhood pneumonia in Cairo were susceptible to penicillins and co-trimoxazole, antimicrobial resistance did not occur.

Screening and genetic counselling for relatives of patients with breast cancer in a family cancer clinic

Family history is the major risk factor in the aetiology of breast cancer. Breast screening is currently available to women from the age of 50 to 64 through the National Breast Screening Programme. There is, however, an equivalent risk of developing breast cancer below 50 for first degree relatives of women diagnosed with breast cancer premenopausally. We have estimated the risk of breast cancer for relatives of women affected at different ages and used these to establish a family cancer clinic offering breast screening based on individual risk. In three years we have seen 851 patients. Compliance for annual radiology was in excess of 83% over this period and of five cancers detected one had a lump at presentation, two developed interval breast lumps, and two were asymptomatic.

Early detection of antibody to human immunodeficiency virus type 1 by using an antigen conjugate immunoassay correlates with the presence of immunoglobulin M antibody

Sequential plasma samples obtained from 16 individuals who seroconverted were tested for the presence of antibody to human immunodeficiency virus type 1 (HIV-1) by an antigen conjugate enzyme immunoassay (EIA) and a conventional antibody conjugate assay. In 11 of these individuals, the antigen conjugate assay detected antibody to HIV-1 2 to 11 days (mean, 5.5 days) earlier than the antibody conjugate assay. In 11 individuals, HIV-1 p24 antigen was detected a median of 6.5 days (range, 3 to 14 days) prior to positivity by the antigen conjugate EIA. Using class-specific probes, we determined the profiles of immunoglobulin M (IgM), IgG, and IgA antibodies for each individual and correlated these profiles with the EIA signals from both assays. In general, the appearance of IgM exhibited a peak at about 1 week postseroconversion, which was followed by gradually declining levels. Absorbance levels for IgG antibody, however, rose steadily and reached a plateau after 3 to 5 weeks. The levels of IgA were generally low and variable. In contrast to the progressive increase in EIA absorbance observed by the antibody conjugate assay, the antigen conjugate assay displayed a rapid early rise in absorbance which generally coincided with the transient expression of IgM antibody. The subsequent gradual increase coincided with rising levels of IgG. Because the configuration of the antigen conjugate EIA allows for an increased sensitivity for IgM compared with that for other classes of immunoglobulins, these results suggest that earlier detection of antibody to HIV-1 is due to the detection of IgM antibody during the early phase of seroconversion.

5'-deoxy-5'-methylthioadenosine phosphorylase--V. Acycloadenosine derivatives as inhibitors of the enzyme

Various adenosine acyclonucleoside derivatives were tested as inhibitors of 5'-deoxy-5'-methylthioadenosine (MeSAdo) phosphorylase, an enzyme involved in the salvage of adenine and methionine from MeSAdo. The 2-halogenated derivatives of acyloadenosine [9-(2-hydroxyethoxy-methyl)adenine], including the chloro-, bromo- and iodo-congeners, all inhibited murine Sarcoma 180 (S180) MeSAdo phosphorylase, with Ki values in the range of 10(-6) to 10(-5) M. Halogenated derivatives of 9-(1,3-dihydroxy-2-propoxymethyl)adenine, which more closely resemble the natural substrate, were substantially more potent inhibitors of the enzyme, with Ki values in the range of 2-7 x 10(-7) M. 5'-Methylthio and 5'-halogenated analogs of 2'-deoxy-1',2'-seco-adenosine were weak inhibitors, with Ki values of 10(-4) M or greater. 9-[(1-Hydroxy-3-iodo-2-proxy)methyl]adenine. (HIPA), the derivative with the lowest Ki values among these analogs, was a competitive inhibitor of S180 MeSAdo phosphorylase. In preliminary studies, HIPA inhibited MeSAdo phosphorylase in intact HL-60 human promyelocytic leukemia cells, as it limited the incorporation of [8-14C]MeSAdo into cellular adenine nucleotide pools. In addition, 9-(phosphonoalkyl)adenines, representing potential multisubstrate inhibitors of MeSADo phosphorylase, were synthesized. Of these the heptyl derivative was the most potent inhibitor, with a Ki of 1.5 x 10(-5) M at low (3.5 mM) phosphate concentrations. The inhibitory effects of these analogs could be ablated at high phosphate concentrations (50 mM), suggesting that they interact with the phosphate binding site on the enzyme. Some of these novel MeSAdo phosphorylase inhibitors may have a role in cancer chemotherapy as potentiators of agents that block purine de novo synthesis, e.g. antifolates and 6-methylmercaptopurine ribonucleoside.

Isolation and analysis of nuclear bodies from estrogen-stimulated chick liver

The target cells of most steroid hormones contain prominent structures termed nuclear bodies (NB). Estrogen (ES) responsive tissues have very distinctive NB, whose development has been associated with both the level of ES receptors and their retention times in nuclei. It has been suggested that these NB may be large-scale ES binding centers at transcriptionally hyperstimulated sites. We examined the formation of NB in ES-stimulated rooster liver, after primary induction of vitellogenesis and during subsequent decay of this response. Distinct NB appear 6 h postinduction, initially as compact spheroids with ring-like profiles and later on as more complex morphotypes. Nuclei average 15-17 NB each at peak induction (24-48 h), but this declines again gradually as the hormonal response abates. This transient pattern is paralleled closely by the [3H]ES binding capacity of nuclei in vitro and the calculated number of specific hormone receptors present. There is no direct numerical correspondence, however, between the NB and the ES receptors, either on a one-to-one basis or as some simple ratio. Hence any links between ES binding activity in nuclei and the NB must be both complex and indirect. Nuclear bodies were isolated following lysis of nuclei by sonication and separation of subfractions on discontinuous sucrose gradients. The resultant NB-enriched fraction consisted primarily of protein, with traces of DNA and RNA. Analysis of proteins by sodium dodecyl sulfate-polyacrylamide gel electrophoresis revealed a complex pattern of polypeptides, some apparently unique and probably NB-derived.

Causes of the liability insurance crisis

In this article the reasons for recent dramatic premium increases for liability insurance are explored by examination of available data on industry premiums, losses, and expenses. The suggestions that the premium increases were primarily caused by collusion among insurers, cyclical behavior, or systematic errors in forecasting losses are rejected. Instead, the evidence indicates that the jump in liability insurance premiums is most plausibly due to the growth in the discounted value of expected liability losses.