Human Intestinal Dendritic Cells Can Overcome Retinoic Acid Signaling to Generate Proinflammatory CD4 T Cells with Both Gut and Skin Homing Properties

Retinoic acid, produced by intestinal dendritic cells (DCs), promotes T cell trafficking to the intestinal mucosa by upregulating α4β7 integrin and inhibiting the generation of cutaneous leukocyte Ag (CLA) required for skin entry. In the present study, we report that activation of human naive CD4 T cells in an APC-free system generates cells expressing α4β7 alone; in contrast, activation by intestinal DCs that produce retinoic acid and induce high levels of α4β7 also results in CLA expression, generating CLA+α4β7+ "dual tropic" cells, with both gut and skin trafficking potential, that also express high levels of α4β1 integrin. DC generation of CLA+α4β7+ T cells is associated with upregulation of FUT7, a fucosyltransferase involved in CLA generation; requires cell contact; and is enhanced by IL-12/IL-23. The blood CD4+ T cell population contains CLA+α4β7+ cells, which are significantly enriched for cells capable of IFN-γ, IL-17, and TNF-α production compared with conventional CLA-α4β7+ cells. Dual tropic lymphocytes are increased in intestinal tissue from patients with Crohn's disease, and single-cell RNA-sequencing analysis identifies a transcriptionally distinct cluster of FUT7-expressing cells present only in inflamed tissue; expression of genes associated with cell proliferation suggests that these cells are undergoing local activation. The expression of multiple trafficking molecules by CLA+α4β7+ T cells can enable their recruitment by alternative pathways to both skin and gut; they may contribute to both intestinal and cutaneous manifestations of inflammatory bowel disease.

Scale-up of the Internet-based Professional Learning to help teachers promote Activity in Youth (iPLAY) intervention: a hybrid type 3 implementation-effectiveness trial

BACKGROUND

Whole-of-school programs have demonstrated success in improving student physical activity levels, but few have progressed beyond efficacy testing to implementation at-scale. The purpose of our study was to evaluate the scale-up of the 'Internet-based Professional Learning to help teachers promote Activity in Youth' (iPLAY) intervention in primary schools using the RE-AIM framework.

METHODS

We conducted a type 3 hybrid implementation-effectiveness study and collected data between April 2016 and June 2021, in New South Wales (NSW), Australia. RE-AIM was operationalised as: (i) Reach: Number and representativeness of students exposed to iPLAY; (ii) Effectiveness: Impact of iPLAY in a sub-sample of students (n = 5,959); (iii) Adoption: Number and representativeness of schools that received iPLAY; (iv) Implementation: Extent to which the three curricular and three non-curricular components of iPLAY were delivered as intended; (v) Maintenance: Extent to which iPLAY was sustained in schools. We conducted 43 semi-structured interviews with teachers (n = 14), leaders (n = 19), and principals (n = 10) from 18 schools (11 from urban and 7 from rural locations) to determine program maintenance.

RESULTS

Reach: iPLAY reached ~ 31,000 students from a variety of socio-economic strata (35% of students were in the bottom quartile, almost half in the middle two quartiles, and 20% in the top quartile).

EFFECTIVENESS

We observed small positive intervention effects for enjoyment of PE/sport (0.12 units, 95% CI: 0.05 to 0.20, d = 0.17), perceptions of need support from teachers (0.26 units, 95% CI: 0.16 to 0.53, d = 0.40), physical activity participation (0.28 units, 95% CI: 0.10 to 0.47, d = 0.14), and subjective well-being (0.82 units, 95% CI: 0.32 to 1.32, d = 0.12) at 24-months. Adoption: 115 schools received iPLAY.

IMPLEMENTATION

Most schools implemented the curricular (59%) and non-curricular (55%) strategies as intended. Maintenance: Based on our qualitative data, changes in teacher practices and school culture resulting from iPLAY were sustained.

CONCLUSIONS

iPLAY had extensive reach and adoption in NSW primary schools. Most of the schools implemented iPLAY as intended and effectiveness data suggest the positive effects observed in our cluster RCT were sustained when the intervention was delivered at-scale.

TRIAL REGISTRATION

ACTRN12621001132831.

Domain binding and isotype dictate the activity of anti-human OX40 antibodies

BACKGROUND

Previous data suggests that anti-OX40 mAb can elicit anti-tumor effects in mice through deletion of Tregs. However, OX40 also has powerful costimulatory effects on T cells which could evoke therapeutic responses. Human trials with anti-OX40 antibodies have shown that these entities are well tolerated but to date have delivered disappointing clinical responses, indicating that the rules for the optimal use of anti-human OX40 (hOX40) antibodies is not yet fully understood. Changes to timing and dosages may lead to improved outcomes; however, here we focus on addressing the role of agonism versus depleting activity in determining therapeutic outcomes. We investigated a novel panel of anti-hOX40 mAb to understand how these reagents and mechanisms may be optimized for therapeutic benefit.

METHODS

This study examines the binding activity and in vitro activity of a panel of anti-hOX40 antibodies. They were further evaluated in several in vivo models to address how isotype and epitope determine mechanism of action and efficacy of anti-hOX40 mAb.

RESULTS

Binding analysis revealed the antibodies to be high affinity, with epitopes spanning all four cysteine-rich domains of the OX40 extracellular domain. In vivo analysis showed that their activities relate directly to two key properties: (1) isotype-with mIgG1 mAb evoking receptor agonism and CD8+ T-cell expansion and mIgG2a mAb evoking deletion of Treg and (2) epitope-with membrane-proximal mAb delivering more powerful agonism. Intriguingly, both isotypes acted therapeutically in tumor models by engaging these different mechanisms.

CONCLUSION

These findings highlight the significant impact of isotype and epitope on the modulation of anti-hOX40 mAb therapy, and indicate that CD8+ T-cell expansion or Treg depletion might be preferred according to the composition of different tumors. As many of the current clinical trials using OX40 antibodies are now using combination therapies, this understanding of how to manipulate therapeutic activity will be vital in directing new combinations that are more likely to improve efficacy and clinical outcomes.

Asset-based approaches to promote health in place-based communities: when the context matters

Background

In recent years, asset-based approaches (ABAs) to promote health have increasingly been adopted as a strategy to reduce health inequalities between neighbourhoods. However, evidence of impact is still limited due to their complexity. This research aimed to explore what changes ABAs generate, studying two asset-based initiatives that train local lay people to become peer health promoters, implemented in two different settings (Spain and UK).

Methods

A five months ethnography was conducted in each setting between March 2018 and March 2019. Data were collected through 127 hours of observations and interviews with 44 participants (learners, community workers and health professionals). Thematic analysis was performed to explore the impacts of the interventions and their interactions with local contexts.

Results

Preliminary findings indicate that learners' self-confidence, knowledge and skills for addressing local health determinants increased in both settings. However, contextual factors played an important role in supporting or hindering wider impacts in the communities where the initiatives were implemented. Opportunities for working together across sectors and being supported by local institutions were key elements supporting learners to transfer the acquired confidence, skills and knowledge to other settings beyond the time and space of the initiatives. These learners reported volunteering more in their communities, developing new activities, or transferring skills in their workplace to change practice and attitudes.

Conclusions

This study found that ABAs initiatives implemented in communities have the potential to support reduction of inequalities through increasing people's skills, knowledge and self-confidence. However, it is key to work intersectorally to create enabling environments where these acquired capacities can be mobilised, as the context can support or hinder wider changes to occur.

Key messages

Asset-based interventions to promote health increase people knowledge, skills and self-confidence, but it is key to consider how contextual factors can favour or hinder the potential for wider impacts. Community structures and institutional support for joint working influence mobilisation of learners’ acquired confidence, skills and knowledge beyond the formal spaces of asset-based interventions.

Working with Insulin, Carbohydrates, Ketones and Exercise to Manage Diabetes (WICKED): evaluation of a self-management course for young people with Type 1 diabetes

AIMS

To evaluate a 5-day self-management education course for young people with Type 1 diabetes and assess its effects on knowledge, self-efficacy, beliefs, distress, self-management behaviours and HbA_1c .

METHODS

This is an evaluation of a structured education course. Young people (aged 16-24 years) with Type 1 diabetes were recruited from three diabetes centres. In the first centre, participants completed self-report measures of knowledge, self-efficacy, positive and negative outcome expectancies, and hypoglycaemic worries at baseline (n=47) and the end of the course (n=42). In two additional centres, participants completed these and other measures assessing self-management behaviours, cognitive adaptation to diabetes and diabetes distress at baseline (n=32), the end of the course (n=27) and 3-month follow-up (n = 27). HbA_1c levels were recorded at baseline (n=79), 6 months (n=77) and 12 months (n=65).

RESULTS

There were statistically significant increases in self-report knowledge, self-efficacy, positive outcome expectancies and self-management behaviours, and a statistically significant decrease in negative outcome expectances, between baseline and the end of the course. There were also statistically significant increases in self-report knowledge, self-efficacy, self-management behaviours and cognitive adaptation to diabetes between baseline and 3-month follow-up. Compared with baseline, HbA_1c levels decreased by a mean (sd) of 5.44 (19.93) mmol/mol (0.48%) at 6 months (P=0.019), and by 5.98 (23.32) mmol/mol (0.54%) at 12 months (P =0.043).

DISCUSSION

The results indicate the potential benefits of a self-management course designed to address the developmental needs and challenges faced by young people with Type 1 diabetes. Further studies with larger numbers and appropriate controls are required to confirm these initial findings.

Experiences of self-management among young adults with Type 1 diabetes in the context of a structured education programme: a qualitative study

AIMS

To explore the experiences of young adults with regard to self-management of Type 1 diabetes in the context of a structured education programme.

METHODS

Qualitative interviews and focus groups were conducted with young adults attending a structured education course promoting a flexible and self-directed format. Participants attending the structured education courses were recruited using purposive sampling to acquire a broad mix of participants based on age and equal numbers of young men and women. Fifteen interviews were conducted 12 weeks after each course, whilst seven focus groups and observations of the course delivery were conducted at two course sites and were led by nurse/dietitian educators representing two different diabetes centres (paediatric and adult). The interview and focus group data were audio recorded and transcribed, coded, and analysed thematically to identify similarities and differences.

RESULTS

The analysis revealed three themes, 'we're in it together', 'tacit benefits' and 'transitions beyond the structured education programme'. The findings show that structured education programmes can facilitate reflective critical thinking and greater engagement with diabetes self-management if they: a) foster maximal learning from fellow participants to decrease feelings of isolation, b) maximize engagement during the course by delivering the content in a flexible manner, and c) recognize the social and emotional needs of young adults.

CONCLUSION

Structured education courses can result in improved critical thinking and engagement with diabetes self-management by empowering young adults through a flexible and self-directed learning style that encourages peer group discussion.

Hydrogen Sulfide Reduces Myeloid-Derived Suppressor Cell-Mediated Inflammatory Response in a Model of Helicobacter hepaticus-Induced Colitis

Chronic inflammation contributes to tumor initiation in colitis-associated colorectal cancer (CRC). Indeed, inflammatory bowel disease (IBD) patients show an increased risk of developing CRC. Cancer immune evasion is a major issue in CRC and preclinical and clinical evidence has defined a critical role for myeloid-derived suppressor cells (MDSCs) that contribute to tumor growth and progression by suppressing T-cells and modulating innate immune responses. MDSCs comprise a heterogeneous population of immature myeloid cells that can be distinct in two subtypes: CD11b⁺Ly6G⁺Ly6C^low with granulocytic phenotype (G-MDSCs) and CD11b⁺Ly6G⁻Ly6C^high with monocytic phenotype (M-MDSCs). Hydrogen sulfide (H₂S) is an endogenous gaseous signaling molecule that regulates various physiological and pathophysiological functions. In particular, several studies support its anti-inflammatory activity in experimental colitis and ulcer. However, the role of the H₂S pathway in innate immune-mediated IBD has not yet been elucidated. To better define a possible link between MDSCs and H₂S pathway in colitis-associated CRC development, we used an innate immune-mediated IBD model induced by infection with the bacterium Helicobacter hepaticus (Hh), closely resembling human IBD. Here, we demonstrated an involvement of MDSCs in colitis development. A significant time-dependent increase of both G-MDSCs and M-MDSCs was observed in the colon and in the spleen of Hh-infected mice. Following, we observed that chronic oral administration of the H₂S donor DATS reduced colon inflammation by limiting the recruitment of G-MDSCs in the colon of Hh-infected mice. Thus, we identify the metabolic pathway l-cysteine/H₂S as a possible new player in the immunosuppressive mechanism responsible for the MDSCs-promoted colitis-associated cancer development.

Tuning the performance of organic spintronic devices using x-ray generated traps

X rays produced during electron-beam deposition of metallic electrodes drastically change the performance of organic spintronic devices. The x rays generate traps with an activation energy of ≈0.5  eV in a commonly used organic. These traps lead to a dramatic decrease in spin-diffusion length in organic spin valves. In organic magnetoresistive (OMAR) devices, however, the traps strongly enhance magnetoresistance. OMAR is an intrinsic magnetotransport phenomenon and does not rely on spin injection. We discuss our observations in the framework of currently existing theories.

Use of methylation patterns to determine expansion of stem cell clones in human colon tissue

BACKGROUND & AIMS

It is a challenge to determine the dynamics of stem cells within human epithelial tissues such as colonic crypts. By tracking methylation patterns of nonexpressed genes, we have been able to determine how rapidly individual stem cells became dominant within a human colonic crypt. We also analyzed methylation patterns to study clonal expansion of entire crypts via crypt fission.

METHODS

Colonic mucosa was obtained from 9 patients who received surgery for colorectal cancer. The methylation patterns of Cardiac-specific homeobox, Myoblast determination protein 1, and Biglycan were examined within clonal cell populations, comprising either part of, or multiple adjacent, normal human colonic crypts. Clonality was demonstrated by following cytochrome c oxidase-deficient (CCO⁻) cells that shared an identical somatic point mutation in mitochondrial DNA.

RESULTS

Methylation pattern diversity among CCO⁻ clones that occupied only part of a crypt was proportional to clone size; this allowed us to determine rates of clonal expansion. Analysis indicated a slow rate of niche succession within the crypt. The 2 arms of bifurcating crypts had distinct methylation patterns, indicating that fission can disrupt epigenetic records of crypt ancestry. Adjacent clonal CCO⁻ crypts usually had methylation patterns as dissimilar to one another as methylation patterns of 2 unrelated crypts. Mathematical models indicated that stem cell dynamics and epigenetic drift could account for observed dissimilarities in methylation patterns.

CONCLUSIONS

Methylation patterns can be analyzed to determine the rates of recent clonal expansion of stem cells, but determination of clonality over many decades is restricted by epigenetic drift. We developed a technique to follow changes in intestinal stem cell dynamics in human epithelial tissues that might be used to study premalignant disease.

Protecting the health and safety of female sex workers: the responsibility of all

Research and criminality on the sex industry is often generalised to that of the visible street based market. With wider reference to the indoor sex markets and drawing on key conclusions from Jeal and Salisbury (page 875), this commentary explores the current criminal justice framework that is driving sex work policy and the management of prostitution in the UK. The consequences of a punitive approach in relation to a complex and multi-layered sex industry are assessed in relation to the role of health care workers.

Do bowel cancer patients participate in treatment decision-making? Findings from a qualitative study

The views of bowel cancer patients towards treatment decision-making and the extent to which they participate in this process were investigated. A prospective longitudinal qualitative study was conducted based on 55 new consultations between oncologists and bowel cancer patients and interviews with 37 recently diagnosed patients, 28 of whom were re-interviewed after 6 months. The interview and consultation data were transcribed verbatim and coded. Theoretical comparisons were made between the interviews and themes emerging from the consultation narratives. The analysis revealed that most bowel cancer patients preferred a limited role in the treatment decision-making process, preferring to delegate the responsibility to the clinician. However, they did not always consider themselves as 'passive' participants within the consultation and many felt that they had made the final decision to accept or refuse treatment. The consultation data shows that when a treatment recommendation was not forthcoming from the oncologist, patients became more proactive in the consultation, often taking the initiative to participate. It is concluded that patients who indicate a desire to participate in these types of consultations should be encouraged to do so and oncologists should try to identify those patients who could benefit from a greater role in treatment decision-making.

Assessment of outcomes at alternative medicine cancer clinics: a feasibility study

OBJECTIVE

This pilot study tested the feasibility of performing outcomes and more advanced research regarding cancer patients at two complementary and alternative (CAM) clinics. The primary objectives were to determine the feasibility of (1) obtaining and collecting data from medical records, (2) determining 5-year survival, and (3) comparing 5-year survival to that of conventional treatment. In addition, in this paper we present the barriers and recommend strategies to facilitate high-quality research.

SETTINGS/LOCATION

The Bio-Medical Center in Tijuana, Mexico, and the Livingston Foundation Medical Center in San Diego, California.

SUBJECTS

New patients who were treated for cancer during 1992 at the Livingston Foundation Medical Center and during the first quarter of 1992 at the Bio-Medical Center.

RESULTS

Charts were available for 89.6% of the 307 new patients treated at the Bio-Medical Center; 149 (54%) patients were treated for cancer and 65 (43.6%) cases were confirmed by pathology reports. In contrast, all records were available for 193 new patients treated for cancer at the Livingston Clinic; 152 (78.8%) cases had pathology confirmation. At both clinics, patients were equally divided by gender and were predominantly Caucasian, were married, and were U.S. residents. On average, patients were 51-54 years old and within 1 year of diagnosis for breast, colorectal, lung, or male genital cancer. Most patients (61.1%-63.7%) arrived with distant or regional disease after conventional surgery and/or chemotherapy/radiotherapy. Survival at 5 years was determined for 57.0% at the Bio-Medical Center (11.4% were alive and 45.6% were deceased) and 94.8% at Livingston (14.5% were alive and 80.3% were deceased). The limited number of cases by cancer site prevented comparison to conventional treatment.

CONCLUSIONS

Historical, widespread use of clinics such as these with anecdotal reports of extraordinary survival merit prospective, systematic monitoring of patient outcomes. For data to be meaningful, however, disease status must be pathologically confirmed and patient follow-up improved.

Age-related mitochondrial DNA mutations in the human larynx

OBJECTIVE

To determine whether age-related mitochondrial DNA mutations occur in the human larynx.

STUDY DESIGN

Genetic study of cadaveric larynx specimens.

METHODS

Vocal fold mucosa, thyroarytenoid muscle, and cricoarytenoidjoint tissue were harvested from 13 fresh postmortem larynges (age range, 2 d-82 y). DNA was extracted from each sample, and the polymerase chain reaction (PCR) was used to amplify a target DNA sequence resulting from the common age-associated, 4977-base-pair (bp) mitochondrial DNA deletion. PCR products were visualized by agarose gel electrophoresis. Automated sequencing determined the sequence of identified PCR products.

SUBJECTS

Thirteen cadaveric larynges were obtained through the University of Kentucky Medical Center (Lexington, KY). Specimens from patients with a history of head and neck cancer, previous laryngeal trauma, or surgery were excluded.

RESULTS

Strongly positive bands were identified in samples from three individuals. Weaker bands were seen in samples from four other samples. No band was noted from the two pediatric larynges. Different band patterns were seen among the three different tissue sites in the larynges with positive PCR products, but no consistent pattern was seen. Sequencing of the identified PCR products from selected samples confirmed that they were products of the age-associated, 4977-bp mitochondrial DNA deletion.

CONCLUSIONS

An age-associated mitochondrial DNA deletion was detected in several post-mortem human larynges. Its presence seemed to increase in appearance with age. In the larynges in which the deletion occurred, there were individual regional differences in the occurrence of the deletion, but no consistent pattern was noted across all individuals who carried the deletion.

Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology

PURPOSE

Oncologists are aware that their patients use complementary/alternative medicine (CAM). As cancer incidence rates and survival time increase, use of CAM will likely increase. This study assessed the prevalence and predictors of CAM use in a comprehensive cancer center.

SUBJECTS AND METHODS

Subjects were English-speaking cancer patients at least 18 years of age, attending one of eight outpatient clinics at The University of Texas M.D. Anderson Cancer Center, Houston, TX, between December 1997 and June 1998. After giving written informed consent, participants completed a self-administered questionnaire. Differences between CAM users and nonusers were assessed by chi(2) and univariate logistic regression analysis. A multivariate logistic regression model identified the simultaneous impact of demographic, clinical, and treatment variables on CAM use; P values were two-sided.

RESULTS

Of the 453 participants (response rate, 51.4%), 99.3% had heard of CAM. Of those, 83.3% had used at least one CAM approach. Use was greatest for spiritual practices (80.5%), vitamins and herbs (62.6%), and movement and physical therapies (59.2%) and predicted (P <.001) by sex (female), younger age, indigent pay status, and surgery. After excluding spiritual practices and psychotherapy, 95.8% of participants were aware of CAM and 68.7% of those had used CAM. Use was predicted (P <.0001) by sex (female), education, and chemotherapy.

CONCLUSION

In most categories, CAM use was common among outpatients. Given the number of patients combining vitamins and herbs with conventional treatments, the oncology community must improve patient-provider communication, offer reliable information to patients, and initiate research to determine possible drug-herb-vitamin interactions.

The modified Hohmann bunionectomy: a retrospective review

A retrospective review of 35 modified Hohmann bunionectomies is presented with analysis of objective radiographic and subjective patient questionnaire results. Thirty-five modified Hohmann bunionectomies were performed, on 29 patients over a 6-year period with follow-up ranging from 11 months to 5 years and 11 months. The modification involves resection of a triangular wedge from the first metatarsal, to minimize shortening, and utilizes two points of fixation. In total, 88% of those patients responding to our questionnaire had either excellent or good results. The Hohmann bunionectomy is a valuable procedure in alleviating symptoms caused by hallux abductovalgus.

The effects of peripheral vascular disease on gait

This study was designed to determine whether patients with peripheral vascular disease (PVD) have gait abnormalities. A previous study on humans with PVD found no abnormalities whereas significant gait changes were seen with a rat model of PVD. The study population was comprised of 10 controls and 9 subjects with PVD (all male). The PVD group had documented pain in one or both legs while walking. Subjects ranged in age from 55-92 years of age, with a mean age of 69 in the PVD group and 70 in the control group. The GaitMat II system was used to measure both spatial and temporal variables of gait. Subjects walked across the mat, four to six times, at their comfortable walking speed. The PVD group then walked on a treadmill until they experienced moderate claudication pain and felt they had to stop (pain levels between 6 and 8, with maximal pain at level 10). Control group walked on a treadmill for 10 minutes without pain. All subjects repeated the gait tests on the GaitMat H system immediately after treadmill walking. Claudication pain persisted in the PVD group during the second gait test. The PVD group was not different than control group in any of the measured variables on the first test (p values from .35 to .99). Difference scores (post- minus pre-treadmill walking)for PVD group were significantly different than those for control group on 8 of 11 variables (p values <.005). The primary response in PVD subjects was reduced walking speed (1.02+/-0.16 to 0.94+/-0.16 m/s) and reduced step length (0.60+/-0.08 to 0.57+/-0.09 m/s), whereas control subjects increased their speed (1.09+/-0.17 to 1.19+/-0.19 m/s) and step length (0.63+/-0.10 to 0.67+/-0.10 m/s). No asymmetries in gait were measured in either group, either before or after treadmill walking. In conclusion, PVD subjects were not different in gait while rested, but responded to claudication pain by reducing preferred walking speed and step size.

Electroneurography during facial nerve expansion

With the use of tissue-expansion techniques, it is possible to elongate the facial nerve without impairing its function. The rate of expansion is limited by ischemic events imposed by stretching of the nerve and by anatomic characteristics of the nerve segment. In this study, we used various electroneurography techniques to determine the first sign of facial dysfunction during expansion. The main objective of the study was to ascertain test-retest variability of electroneurography techniques. Facial nerves were expanded in 16 cats with the use of a tissue expander secured more deeply to the main trunk. We conducted electroneurography measurements with the use of surface electrodes, temporary needle electrodes, and permanently implanted electrodes. Technique-dependent variations encountered with the surface electrodes made this method unreliable. Using implanted electrodes, we noted gradual worsening of the compound-action potential amplitude with increasing expansion. During acute expansion, reduction in compound-action potential amplitude was correlated with clinically observed deterioration of facial-nerve function. In this study, electroneurography with implanted electrodes was found to be the most reliable predictor of the rate of successful facial nerve expansion.

The management of cervical carcinoma within the south west region of England. Expert Tumour Panel

OBJECTIVE

1. To audit the management of cervical carcinoma in the South West Region with the aim of identifying and addressing deficiencies. 2. To determine whether recent NHS restructuring has affected the provision of cancer care.

DESIGN

Retrospective review of hospital case notes.

SETTING

All hospitals in the South West Region of England.

POPULATION

Three hundred and twenty-four women with a diagnosis of cervical carcinoma: 191 were diagnosed in 1989 and 133 in 1993.

MAIN OUTCOME MEASURES

Documentation of patient assessment and management.

RESULTS

There was a mean delay of 17 days (range 0-66) from cervical smear to cytology report and 34 days (range 1-380) from general practitioner referral to attendance at a hospital clinic. Overall, 175 women (54%) had evidence of cytological assessment prior to treatment and 137 (42%) had a colposcopic assessment; 49% had cytological assessment and 37% had colposcopy in 1989, compared with 60% and 50%, respectively, in 1993. Excluding 49 cases of micro-invasive carcinoma, 238 case notes (86%) contained evidence of clinical examination; 195 women (71%) had had an examination under anaesthesia, 115 (42%) a chest radiograph, 123 (45%) an intravenous urogram or renal ultrasound, and 92 (33%) cystoscopy. One hundred and forty-seven women (53%) had FIGO staging recorded in the notes. As first line treatment, 69 had conservative surgery (39 for Stage IA), 138 had radiotherapy, and 107 had radical surgery. Ten had radical surgery for Stage IA but eight had a > 3 mm invasion or lymphatic/vascular spread. Thirty-one had Stage IB treated with radiotherapy of whom 14 were younger than 50 years of age. Following radical surgery 30% had evidence of sampling > or = 10 nodes, and 9% had tumour extending to the resection margins.

CONCLUSIONS

Record keeping was inadequate but appeared to indicate inconsistent cytological, clinical, colposcopic and radiological assessment, leading to inappropriate clinical delays and conservative surgery. Radical surgery often appeared inadequate, but poor node sampling rates may also reflect insufficient histopathological preparation or reporting. There was a reduction in the number of new cases of cervical carcinoma diagnosed in 1993, perhaps reflecting an observed increase in cytological surveillance. No other alterations in clinical practice were observed over the four-year period. We feel it is imperative to standardise assessment throughout the region with a minimum clinical and histopathological dataset.

A retrospective study of the investigation and management of muscle-invasive bladder cancer in the South West Region

OBJECTIVE

To evaluate the present management of muscle-invasive bladder cancer in the South West Region and to assess the workload resulting from the rationalization of treatment in specific centres.

METHODS

A retrospective survey was undertaken in all the hospitals in the South West Region, to assess the management of all patients presenting with muscle-invasive bladder cancer in the years 1989 and 1993. Data were collected from histopathology records and hospital in-patients' notes. The optimum standard of assessment and treatment were defined by a panel of specialists in urological tumours. The management of patients was compared against these defined standards.

RESULTS

A total of 186 and 199 patients in 1989 and 1993, respectively, were evaluated. When comparing their assessment against the defined standard, only 69% of patients in 1989 and 58% in 1993 had an intravenous urogram, with 7% and 4%, respectively, having no upper tract imaging (the remainder undergoing ultrasonography). Evidence from an examination under anaesthetic (EUA) was found for 80% of patients in 1989 and 84% of patients in 1993. Only 23% of patients in 1989 and 36% in 1993 were staged by either computed tomography or magnetic resonance imaging. In both 1989 and 1993, 54% of patients had definitive treatment, 31% had an endoscopic follow-up only and 15% had no treatment; there were no differences in age or co-morbidity among these groups. The median time elapsed between referral and diagnosis was 59 days (1989) and 52 days (1993), and the median delay to definitive treatment was 114 and 96 days, respectively.

CONCLUSION

There was insufficient upper tract imaging, poor clinical staging in the EUA and too few investigations for staging. The low rate of definitive treatment may be a consequence of the delays in management, allowing the tumour to progress, and suggesting the need for a more rapid assessment of haematuria.

Good nutrition for the vegetarian mother

A pregnant or nursing vegetarian mother needs to be aware of the need to vary her diet because the nutrients that she would otherwise get from meat or fish are more widely scattered in foods of plant origin. Diets which exclude dairy products require more careful planning. Particular attention needs to be made to the mother's intake of iron, calcium, vitamin B12 and vitamin D. Vegetarian mothers do not show a higher incidence of complications of pregnancy, but there are some links between vegetarians and lower birthweight and earlier labour. On weaning the infant's diet should not be too bulky and should provide adequate vitamin D and B12.

Effect of regular consumption of oily fish compared with white fish on chronic plaque psoriasis

The influence of dietary advice on the severity of chronic plaque psoriasis was studied in 18 patients. Medication was standardized in all patients who were advised to eat 170 g white fish daily for a 4 week run-in period. Then the patients were randomized either to continue with the white fish diet or to substitute 170 g oily fish daily for 6 weeks. At the end of this second period the diets were reversed for a further 6 weeks. The oily fish but not the white fish diet led to a modest clinical improvement (11% and 15%, P < 0.01) which was accompanied by a rise in plasma eicosapentaenoic acid (20:5n-3) concentrations. It is concluded that dietary advice to increase the daily intake of oily fish is a useful adjunct in the treatment of psoriasis. The fish that should be recommended include mackerel, sardine, salmon, pilchard, kipper and herring.

The environmental challenge

We now come to the ultimate question of whether we should be optimistic or pessimistic about our environmental future, and indeed our survival. If we believe human beings to be rational and thus ultimately acting in their own self-interest, there is no reason to believe that the environmental challenges confronting us as individuals and as a society are not resolvable in a manner that allows both economic development and a reasonable quality of life for human beings. Indeed, we see, at least in the developed world, recognition of the magnitude of the problems that we face and movements toward solutions. Yet our nemesis is time. Irretrievable seconds are ticking away as we struggle against ignorance and economic self-interest. Our concern must be not whether we will act, but whether we will act in time to forestall environmental catastrophe for our civilization. The ultimate solution to our environmental problems must come from a fundamental change in the self-serving psychology that produced the tragedy of the commons. Self-interest must be sublimated not only to the greater needs of society, but to the needs of our posterity. The tragedy of the commons can only be avoided if our time horizon shifts from the short- to long-term. In addition, there must be a shift in values from obsession with economic development to concern for the quality of human life. These shifts dictate that in the future our economic, political, and social system must be built upon a foundation of "sustainable" growth. This means that "industries (and nations, for that matter) cannot thrive if they sacrifice future quality of life for present economic gain. In the long run, the principles of economic growth and environmental quality reinforce each other." How do we make this esoteric speculation relevant to our job each day as materiel managers in health care delivery organizations? We can do this by first understanding the problems that we confront and how we are a part of these problems. Next, we must assume a leadership role in confronting and resolving these problems. This means being an advocate for the environment and championing initiatives within the institution to resolve problems and advance environmental responsibility. Finally, we must remember that every day, with each purchase order we issue, we vote for or against the environment.

Efficiency experts. Hospitals can improve performance by starting in the human resources department

In our changing economic environment, efficient human resource (HR) management is especially crucial to hospitals. Has the emphasis on HR activities responded to this changing environment? We studied 165 hospitals to determine whether they are making good use of HR. The results of our study show that HR activities remain important during these turbulent times. The emphasis hospitals place on HR activities increased slightly between 1985 and 1986. Performance evaluation ranked the highest in emphasis; job redesign and analysis were also high ranking. These are important mechanisms for improving performance and productivity. Respondents also rated HR activities by importance. Several categories that ranked high in change in emphasis ranked low in importance, and vice versa. One reason for this discrepancy between emphasis and importance is that HR activities that directors consider important may have already received a great deal of emphasis, leaving no room for increase. Also, circumstances may dictate increased emphasis on an activity (e.g., layoffs) even though HR directors consider it unimportant.

Antibiotic prophylaxis in hysterectomy--cefotaxime compared to ampicillin-tinidazole

The role of prophylactic cefotaxime and a combination of ampicillin and tinidazole was assessed in 201 patients undergoing hysterectomy. One hundred and twenty-five patients were evaluated in the abdominal hysterectomy group and 46 patients completed the protocol after vaginal hysterectomy. Patients were allocated randomly to receive either (1) no prophylactic antibiotic, (2) cefotaxime peroperatively for 24 h or (3) ampicillin/tinidazole peroperatively for 24 h. Both cefotaxime and ampicillin/tinidazole reduced the septic complication rate in abdominal and vaginal hysterectomy. Efficacy was most evident in reducing early urinary infections after abdominal hysterectomy (0.001 less than P less than 0.01). Cefotaxime and ampicillin/tinidazole were equally effective and no significant side-effects were demonstrated. Cefotaxime is recommended as a safe and effective agent for hysterectomy prophylaxis.