[Complications after spinal analgesia using three different spinal needles: Sprotee, Spinocan and Atraucan]

In this prospective, randomised study 197 patients aged below 40 years received spinal analgesia using one of the following needles: Sprotte G24, Spinocan G27 or Atraucan G26. The incidence of insufficient or failed analgesia and difficulties handling the needles were noted. Patients were interviewed within three weeks after anaesthesia so as to establish the incidence of postoperative complications including post-dural puncture headache (PDPH). Headache was noted in 63 patients of which 33 (16.8%) were of PDPH type. The Sprotte needle caused significantly fewer cases of PDPH (Sprotte: 8.1%; Spinocan: 19.7; Atraucan: 21.7%. p < 0.05). Furthermore a significantly lower incidence of insufficient analgesia was observed with the Sprotte needle (0% versus 12.1% with the Spinocan and 11.6% with the Atraucan, p < 0.05). In conclusion, the Sprotte needle had the best profile with respect to PDPH and successful analgesia. This confirms the importance of the needle tip design.

Extensive regulation compromises the extent to which DNA gyrase controls DNA supercoiling and growth rate of Escherichia coli

As DNA gyrase is the only enzyme to supercoil DNA actively, we address here the question of whether it does play the expected dominant role in controlling the level of DNA supercoiling and growth rate in Escherichia coli. We modulated the expression of DNA gyrase around its wild-type level, and measured the effect on plasmid supercoiling and growth rate. As both the activity and the transcription rate of DNA gyrase are sensitive to DNA supercoiling we distinguish two types of control (with control defined as the percentage change observed on a 1% modulation of a parameter). The first type of control, here named inherent control, quantifies the effect of a sustained modulation of the transcription rate of gyrase. At its wild-type expression level this inherent control exerted by DNA gyrase on growth rate was very low, i.e. c mu/gyrase = 0.05 - 0.00, as was the inherent control on DNA supercoiling, c aLK/gyrase = 0.2. The second type of control, here named global control, quantifies the effect of a change in gyrase activity whilst allowing the cell to respond by readjusting gyrase transcription. Both types of control are linked via the sensitivity of gyrase transcription to DNA supercoiling, as determined from the inherent control by gyrase of the gyrase promoter activity using a chromosomal gyrB:lacZ fusion. As expected, the latter control was negative, but small, i.e. c gyr promoter/gyrase=-0.3. The global control by gyrase of active linking number was 0.1. These results show that although gyrase is an essential enzyme it does not have a high control, on either growth rate or DNA supercoiling. Homeostatic regulation of physiological DNA structure appears to dominate. At low degrees of DNA supercoiling, the control by DNA gyrase and by the other topoisomerases is much stronger.

The need for a veterinary antibiotic policy

The international recognition of the 'stable to table' approach to food safety emphasises the need for appropriate and safe use of antibiotics in animal production. An appropriate use of antibiotics for food animals will preserve the long-term efficacy of existing antibiotics, support animal health and welfare and limit the risk of transfer of antibiotic resistance to humans. Furthermore, it may promote consumer confidence in the veterinary use of antibiotics. In advancing these arguments, the authors of this article argue that there is a need for a visible and operational policy for veterinary use of antibiotics, paying particular attention to the policies that are being developed in Denmark.

Relationships between bone mineral density, serum vitamin D metabolites and calcium:phosphorus intake in healthy perimenopausal women

OBJECTIVES

To determine the relationships between serum vitamin D metabolites, bone mass, and dietary calcium and phosphorus in a cohort of 510 healthy Danish perimenopausal women.

DESIGN

A population-based cross-sectional study.

SUBJECTS

A total of 510 healthy women aged 45-58 years, with amenorrhoea for 3-24 months. None of the women was using hormone replacement therapy.

MEASUREMENTS

Measurements of total bone mineral content and regional bone mineral density were performed by dual-energy X-ray absorptiometry. Analyses of serum levels of 25-OHD and 1,25-(OH)2D, intact PTH, ionized calcium and phosphate, as well as biochemical markers of bone turnover in blood and urine. Assessment of calcium and phosphorus intake using dietary records.

RESULTS

A consistent inverse relationship between serum 1,25-(OH)2D and bone mineral content/ density was found in whole-body mineral content (P = 0.001), spine (P = 0.005) and femoral neck (P<0.05). There was a positive relationship between levels of 1,25-(OH)2D and biochemical bone markers, indicating that high levels of 1,25-(OH)2D are accompanied by increased bone turnover. The dietary calcium:phosphorus ratio was inversely related to serum 1,25-(OH)2D (P = 0.04) and positively related to bone mineral density (P<0.0005). No relationships could be detected between levels of PTH, serum ionized calcium and phosphate, and serum vitamin D metabolites.

CONCLUSION

Within normal physiological range, elevated levels of 1,25-(OH)2D were associated with decreased bone mineral density and content, reduced calcium:phosphorus ratio in the diet and increased bone turnover.

Presence of erm gene classes in gram-positive bacteria of animal and human origin in Denmark

A classification of the different erm gene classes based on published sequences was performed, and specific primers to detect some of these classes designed. The presence of ermA (Tn554), ermB (class IV) and ermC (class VI) was determined by PCR in a total of 113 enterococcal, 77 streptococcal and 68 staphylococcal erythromycin resistant isolates of animal and human origin. At least one of these genes was detected in 88% of the isolates. Four isolates contained more than one erm gene. ermB dominated among the enterococci (88%) and streptococci (90%) and ermC among staphylococci (75%) with ermA (Tn554) present in some isolates (16%). Variations in the presence of the different genes when comparing staphylococcal isolates of human and animal origin were observed.

Use of antimicrobial growth promoters in food animals and Enterococcus faecium resistance to therapeutic antimicrobial drugs in Europe

Supplementing animal feed with antimicrobial agents to enhance growth has been common practice for more than 30 years and is estimated to constitute more than half the total antimicrobial use worldwide. The potential public health consequences of this use have been debated; however, until recently, clear evidence of a health risk was not available. Accumulating evidence now indicates that the use of the glycopeptide avoparcin as a growth promoter has created in food animals a major reservoir of Enterococcus faecium, which contains the high level glycopeptide resistance determinant vanA, located on the Tn1546 transposon. Furthermore, glycopeptide-resistant strains, as well as resistance determinants, can be transmitted from animals to humans. Two antimicrobial classes expected to provide the future therapeutic options for treatment of infections with vancomycin-resistant enterococci have analogues among the growth promoters, and a huge animal reservoir of resistant E. faecium has already been created, posing a new public health problem.

Internal size variations in Tn1546-like elements due to the presence of IS1216V

In this study, internal size variations in the VanA gene cluster Tn1546, encoding resistance to glycopeptides, is described. Studies of previously uncharacterized size variations of an internal region, encoding the vanX and vanY genes of Tn1546, revealed that these variations were due to the presence of the IS sequence, IS1216V. This IS sequence has previously been found integrated in Tn1546. Integration of the IS1216V element created both deletions and a duplication in a non-essential region of Tn1546. In several isolates, the entire vanY gene was deleted, proving that this gene is non-essential for vancomycin resistance.

Detection of the satA gene and transferability of virginiamycin resistance in Enterococcus faecium from food-animals

The satA gene encoding streptogramin A resistance was detected in virginiamycin-resistant Enterococcus faecium isolates from pigs and broilers. The satA gene was present in 22 of 89 (25%) virginiamycin-resistant E. faecium isolates. It was shown that the satA gene and other gene(s) encoding streptogramin resistance could be transferred between isogenic E. faecium strains at frequencies ranging from 2.3 x 10(-4) to 2.2 x 10(-3) transconjugants per donor.

Molecular analysis of diverse elements mediating VanA glycopeptide resistance in enterococci

Differences were examined among 24 distinct elements mediating VanA-type glycopeptide resistance in enterococci isolated from hospital patients and non-human sources in the UK. The methods used included long-PCR restriction fragment length polymorphism (L-PCR RFLP) analysis and DNA hybridization. All elements had conserved vanRSHAX genes, but variation occurred upstream of vanR and downstream of vanX. Twenty-one VanA elements had significant alterations upstream of vanR in the transposition genes orf1 and orf2: either parts of these genes were absent or they were disrupted by IS1216V or IS3-like insertion sequences. Among VanA elements with alterations downstream of vanX, seven lacked vanY, one lacked both vanY and vanZ, and ten had copies of insertion sequence IS1216V between vanX and vanY. All VanA elements of group D (from geographically and temporally diverse enterococci) were characterized by the presence of an IS1216V/IS3-like/orf1 complex and a point mutation in vanX, both of which were absent from the other 23 groups of VanA elements. This finding is consistent with the dissemination of a stable resistance element. We conclude that L-PCR RFLP analysis, combined with DNA hybridization, merits further development for studying the evolution and epidemiology of VanA resistance elements in enterococci.

Comparison of two endotracheal tube securement techniques on unplanned extubation, oral mucosa, and facial skin integrity

OBJECTIVE

To determine the effect of 2 standard methods (i.e., twill tape versus adhesive tape) of securement on unplanned extubation, oral mucosa, and facial skin integrity of the orally intubated patient.

DESIGN

A prospective, quasi-experimental design was used for the pilot study.

SETTING

The setting for the pilot study included critical care units of 3 community hospitals and 1 veterans' hospital in a midwestern city.

SUBJECTS

A total of 52 orally intubated adult subjects were enrolled in the study from the 4 clinical sites over a 6-month period of time. The participants in the study consisted of 30 men and 22 women. The subjects ranged in age from 22 to 85 years, with a mean age of 62.3 years. The mean length of intubation was 89.6 hours.

OUTCOME MEASURES

The outcome measures of the study were (1) unplanned extubation, (2) oral mucosa status, and (3) facial skin integrity.

INTERVENTIONS

Endotracheal tube securement with either the twill tape or the adhesive tape securement method.

RESULTS

With use of multiple analysis of variances (MANOVA) and repeated analyses of variances (ANOVAs), there were no significant differences by time or type of endotracheal tube securement method on oral mucosa or facial skin integrity. A chi-square analysis demonstrated no significant association between the 2 types of endotracheal tube securement when comparing their efficacy in preventing unplanned extubation.

CONCLUSION

The findings of this pilot study demonstrated both methods of endotracheal tube securement to be comparable in preventing unplanned extubation and in maintaining oral mucosa status and facial skin integrity.

Vitamin D receptor alleles do not predict bone mineral density or bone loss in Danish perimenopausal women

A BsmI restriction enzyme polymorphism in the vitamin D receptor (VDR) gene has been reported to be associated with bone mineral density (BMD) and bone turnover. However, findings in other studies suggest the presence of considerable interaction by race, body size, and environmental factors. Therefore, we VDR BsmI genotyped 200 healthy perimenopausal Danish white women (mean age 50.8 years, mean calcium intake 900 mg/day) in a comprehensive, longitudinal, community-based population study. Bone loss was assessed by dual-energy X-ray absorptiometry (DXA) using cross-calibrated Hologic QDR-1000W and QDR-2000 densitometers, with a mean follow-up period of 4 years (range 1-5 years). Despite a distribution of genotypes similar to that of other white populations (28% bb, 49% Bb, 23% BB), VDR genotypes were not associated with lumbar or femoral baseline BMD, subsequent bone loss rates, or biochemical markers of bone metabolism (bone-specific alkaline phosphatase, urinary hydroxyproline, and serum osteocalcin). Controlling for body size, calcium intake, and serum levels of 25-hydroxyvitamin D3 [25(OH)D3] did not alter this finding. The possible existence of a threshold effect was subsequently investigated by restricting analysis to women with low serum 25(OH)D3 levels or low calcium intake. VDR BsmI genotypes showed no significant impact on bone density or bone loss in healthy Danish early postmenopausal women, even when allowance was made for calcium intake, serum 25(OH)D3, and body size.

Characterisation of integrons and antibiotic resistance genes in Danish multiresistant Salmonella enterica Typhimurium DT104

The presence and genetic content of integrons was investigated in eight Salmonella enteritica Typhimurium DT104 isolates from different pig herds in Denmark. Two different integrons were identified using PCR and sequencing. Each of the integrons carried a single resistance cassette in addition to the sull and qacE delta 1 genes characteristic of integrons. The first integron encoded the ant (3")-1a gene that specified resistance to spectinomycin and streptomycin. The second contained the pse-1 beta-lactamase gene. All the multiresistant strains contained both integrons. The presence of these two integrons did not account for the total phenotypic resistance of all the isolates and does not exclude the presence of other mobile DNA elements.

Molecular analysis of Tn1546 in Enterococcus faecium isolated from animals and humans

The internal areas and the position of integration of the glycopeptide resistance element Tn1546 were characterized by using PCR fragment length polymorphism, sequencing, and DNA hybridization techniques with 38 high-level vancomycin-resistant Enterococcus faecium isolates of human and animal origins from Europe and the United States. Only minor variations in the coding regions within Tn1546 were found, suggesting high genetic stability. The isolates originated from broilers (n = 5), a chicken (n = 1), a duck (n = 1), a turkey (n = 1), pigs (n = 8), a pony (n = 1), and humans (n = 23). A total of 13 different types were defined based on a single-nucleotide difference in the vanX gene, the presence of insertion sequences, and hybridization patterns. For some types more than one isolate were found. For type 1, 10 isolates of both human and animal origins were found. All were indistinguishable from the reference strain, BM4147. For type 2, 11 isolates of human and animal origins were found. Six human isolates from England were all of type 3. Two human isolates from the United States, indistinguishable from each other, were type 9. These results showed that vancomycin-resistant E. faecium of animal and human origins can contain indistinguishable genetic elements coding for vancomycin resistance, indicating either horizontal gene transfer between E. faecium organisms of human and animal origins or the existence of a common reservoir for glycopeptide resistance.

Improving compliance with hormonal replacement therapy in primary osteoporosis prevention

OBJECTIVES

To evaluate whether introduction of treatment alternatives would improve compliance with hormonal replacement therapy (HRT) as primary osteoporosis prevention in women not tolerating the first line osteoporosis prevention schedule.

MATERIAL AND METHODS

Follow-up in four hospitals participating in the Danish Osteoporosis Prevention Study. A total of 706 peri- and postmenopausal women aged 45-57 years between 3 and 24 months from last menstrual bleeding took part, 489 women were randomised to HRT and 217 received HRT by personal choice. A total of 135 (19%) women were hysterectomised. HRT was given as oral or transdermal oestradiol supplemented with progestogen. If the initial treatment allocation was not acceptable several alternatives were available in a pragmatic approach.

RESULTS

Compliance with first treatment schedule was lower in women with intact uterus (at 5 years: 48.3 +/- 2.4% compliance) than in hysterectomised (64.7 +/- 5.8%, P < 0.001 in a Cox analysis) but did not differ after the introduction of HRT alternatives (67.0 +/- 2.9 vs 77.8 +/- 5.9, P = 0.12). Compliance decreased with increasing age at treatment start (RR = 1.11, P < 0.001) in women with intact uterus but not in hysterectomised women (P = 0.96). Headache/migraine was more frequent among women with intact uterus on oral sequential oestrogen plus progestogen than among hysterectomised women receiving oral continuous oestrogen (RR = 11.3, P < 0.01).

CONCLUSIONS

It seems possible to maintain a high HRT compliance by a pragmatic approach including offering alternative HRT formulations to women not tolerating the primary HRT. Further research into long-term compliance with HRT and cost-benefit is warranted.

Bone mass and risk factors for bone loss in perimenopausal Danish women

OBJECTIVES

To determine risk factors for low bone mass at menopause and risk factors for subsequent bone loss in the following period.

DESIGN

A cross-sectional study and a 2-year prospective follow-up.

SETTING

The catchment area of Sundby Hospital in Copenhagen.

SUBJECTS

Four hundred and thirty-three women aged 45-58 years, with amenorrhea for 3-24 months, of whom 87 were followed for a 2-year period.

MEASUREMENTS

Registration of life-style and anthropometric variables, reproductive history, and family history of fractures. Total body bone mineral content (BMC) was measured with dual energy X-ray absorptiometry.

RESULTS

By means of multiple regression analysis height, body weight, and length of reproductive period were found to be positively related to whole body BMC (P < 0.001), whilst a negative relationship was found to age (P < 0.001), smoking (P < 0.001), and family history of fractures (P < 0.005). In the longitudinal study, only body weight at the inclusion (P = 0.005) and subsequent changes in body weight and fat mass (P < 0.001) were related to the changes in bone mass.

CONCLUSION

The most significant predictors for bone loss were changes in body weight and fat mass. Hence, weight loss is a risk factor for bone loss in the early postmenopausal period, whereas weight gain seems to preserve bone.

Characterisation of integrons and antibiotic resistance genes in Danish multiresistant Salmonella enterica Typhimurium DT104

The presence and genetic content of integrons was investigated in eight Salmonella enterica Typhimurium DT104 isolates from different pig herds in Denmark. Two different integrons were identified using PCR and sequencing. Each of the integrons carried a single resistance cassette in addition to the sul1 and qacE delta 1 genes characteristic of integrons. The first integron encoded the ant (3")-Ia gene that specified resistance to spectinomycin and streptomycin. The second contained the pse-1 beta-lactamase gene. All the multiresistant strains contained both integrons. The presence of these two integrons did not account for the total phenotypic resistance of all the isolates and does not exclude the presence of other mobile DNA elements.

Site of osteodensitometry in perimenopausal women: correlation and limits of agreement between anatomic regions

Because the bone mineral density (BMD) in different anatomic regions is heterogenous the number of women who fulfill the World Health Organization definition of osteopenia or osteoporosis increases with the number of regions examined. The purpose of this study was to investigate the agreement between measurements of the spine, femur, forearm, and whole body following menopause. Two thousand and five healthy, perimenopausal women, mean age 50.6 years, were studied using Hologic QDR-1000/W and QDR-2000 densitometers. Though the BMD of different anatomic regions were correlated (r = 0.40-0.77, p < 0.01), the variability in each patient regarding T and Z scores between regions was considerable. For example, despite a high correlation (r = 0.67, p < 0.01) and no systematic difference between the T scores for total femoral and lumbar BMD, the limits of agreement (mean difference +/- 2 SD) for the comparison were -1.89 to 1.87. Femoral neck T scores were 0.5 SD lower than those of the other regions, confirming reports that the young adult reference for this measurement is disproportionally high. The prevalence of osteoporosis was 1.2% when femur total BMD was considered alone and 5.9% when lumbar and ultradistal forearm results were included. However, as many as 7.9% showed osteoporosis of the femoral neck when the Hologic T score was used, compared with 0.7% using National Health and Nutrition Examination Survey (NHANES) values. The choice of anatomic region and availability of appropriate young adult reference data has considerable impact on the apparent prevalence of osteoporosis. Given the heterogeneity between regions, a combination of spinal and femoral densitometry should be used in diagnosing osteoporosis, though this increases the prevalence of osteoporosis by 50% or more in perimenopausal women.

Studies of the impact of a liver glucokinase promoter variant on glucose tolerance and insulin sensitivity index

Because a frequently occurring nucleotide substitution at position -258 in the liver glucokinase promoter has been reported to be associated with impaired promoter activity, we have examined in Danish Caucasians whether this variant is associated with alterations in glucose tolerance and/or the insulin sensitivity index (Si). Among 246 Danish Caucasian patients with noninsulin-dependent diabetes mellitus, the allelic frequency of the -258 promoter variant was 15.2% (95% confidence interval: 12.0-18.4%) vs. 16.5% (13.2-19.8%) among 242 matched control subjects. In the control group, the glucokinase variant was not related to serum insulin or plasma glucose levels before or during an oral glucose tolerance test. Neither was the gene variant among 380 young, healthy subjects associated with altered Si or altered insulin secretion after an i.v. glucose load. We conclude that in Danish Caucasians, the -258 glucokinase promoter variant has no impact on glucose tolerance, whole-body Si, or insulin secretion.

Chromosomal insertion of the entire Escherichia coli lactose operon, into two strains of Pseudomonas, using a modified mini-Tn5 delivery system

A 12-kb PstI fragment including the entire E. coli lactose operon (lacIPOZYA) was inserted in one copy into the chromosome of Pseudomonas putida, Pseudomonas fluorescens and an E. coli strain with lac- phenotype. This was made possible by improvements of an already existing mini-Tn5 transposon delivery system (de Lorenzo et al., 1990; Herrero et al., 1990), which integrates cloned DNA fragments at random sites on the chromosome of the recipient bacteria in single copies. This has resulted in: (a) the making of two useful low copy-number cloning vectors both with extensive multi-cloning regions flanked by NotI sites needed in the mini-Tn5 delivery system; (b) the generation of E. coli nonlysogenic strains expressing the pi protein thus being capable of maintaining and delivering R6K-based mini-Tn5 vectors to other E. coli strains; (c) the successful insertion of the E. coli lactose operon into the P. fluorescens chromosome giving P. fluorescens the ability to grow on lactose; (d) evidence from Southern blotting that contradicts the assumption that the mini-Tn5 delivery system always creates one-copy inserts. These improvements allow insertion of large DNA fragments encoding highly expressed proteins into the chromosome of a large variety of Gram-negative bacteria including E. coli.

[Postoperative nausea and vomiting]

Postoperative nausea and vomiting (PONV) is still a problem and is very discomforting for the patients. As surgery done on out-patient basis becomes more frequent, PONV will represent an important factor in the length of recovery room stay, and is in this way an economic problem. Based on the literature from 1985-1995 factors associated with increased risk, prevention and treatment of PONV are discussed in view of the physiological mechanisms. The conclusion is that PONV is a complex problem. It demands an individual evaluation with a careful preoperative visit including planning of both preanaesthetic and anaesthetic agents. Furthermore, a proper anaesthetic treatment of the per- and postoperative course is of high importance. Patients at high risk of PONV should be identified and given prophylactic antiemetics.

Procollagen type I N-terminal propeptide (PINP) as an indicator of type I collagen metabolism: ELISA development, reference interval, and hypovitaminosis D induced hyperparathyroidism

A sandwich enzyme-linked immunosorbent assay (ELISA) for quantification of the N-terminal propeptide of human procollagen type I (PINP) utilizing purified alpha 1-chain specific rabbit antibodies is described. The ELISA measured the content of the alpha 1-chain of PINP independent of the molecular form of the molecule. A parallelism was found between amniotic fluid (calibrator), normal and patient serum, and purified PINP (alpha 1), as well as the high and low molecular weight forms of PINP (alpha 1). The concentration of PINP in the calibrator (second trimester amniotic fluid) was determined to 25 micrograms/mL and the detection limit was 62 pg/mL measured in amniotic fluid, and 41 pg/mL measured in serum. The interassay coefficients of variation were 4.6% (low control) and 5.3% (high control), and the corresponding intraassay parameters were 2.9% and 4.9%. Recovery studies revealed an accuracy between 93% and 105%. The normal range (n = 57) for PINP was 56 ng/mL (median) the 10th and 90th centiles being 30 and 82 ng/mL, respectively. Patients with hyperparathyroidism due to hypovitaminosis D had median serum level of 168 ng/mL with a 10th centile of 44 ng/mL and a 90th centile of 450 ng/mL, these values being significantly different from the normal range (p < 0.001). The PINP-ELISA was superior to commercially available assays for PICP and osteocalcin in separation between healthy controls and patients with osteomalaci.

[Mammographic screening in the municipality of Copenhagen. Results of the first screening round]

The aim of the study was to evaluate the results from the prevalence round of the mammography screening programme in the Municipality of Copenhagen. All women who by 1 April 1991 were 50-69 years old, and who lived in the Municipality of Copenhagen, were during the period 1 April 1991-24 April 1993 offered a mammography. Those with suspect findings were recalled for further examination and possible biopsy. Women with breast cancer were offered treatment according to the standard national protocols (DBCCG). The participation rate was 71% (30,416/43,087). Among these 2043 (6.7%) were re-examined and 592 (1.9%) underwent surgical biopsy. Breast cancer was revealed in 359 (1.2%) women, of whom 88% had an invasive breast cancer. Prevalence of breast cancer increased significantly with increasing age. The positive predictive value for breast cancer among those re-examined was 18% and for those who had a surgical biopsy 61%. Among women with an invasive breast cancer 41% had a tumour of 10 mm or less, 80% had negative lymph node status and 56% had breast conserving surgery. During the following 12 months 14 women with a normal mammogram at the screening round developed breast cancer giving a sensitivity of 96%. It is concluded that the first mammography screening in Denmark showed the highest breast cancer prevalence published so far. A possible explanation could be a high sensitivity of the screening method, indicated by a relatively high frequency of small cancers. The screening programme was fully comparable with international standards.

Sociological and behavioural characteristics of perimenopausal women with an express attitude to hormone substitution therapy

OBJECTIVES

The objective of the study is to demonstrate differences in behaviour and in sociological characteristics between women wanting hormone replacement therapy (HRT) and women refusing such treatment.

METHODS

From a study base of 6189 women, 413 perimenopausal women with an express positive or negative attitude towards the use of HRT were interviewed on sociological and behavioural characteristics. Checks against bias were performed by analysis of reluctant participants, identified as women who either did not agree to participate until they received at least one reminder, or who dropped out immediately after the interview.

RESULTS

Women wanting HRT had higher levels of education, were less often childless, and were more frequent solarium users than women refusing this treatment. There were no differences in marital status, employment status, the average tea, coffee, wine and cigarette consumption, sun exposure, frequencies of travels abroad, or number of family cars, summer houses or boats. No difference in present smoking status was demonstrated but the estrogen users were more frequently past or present smokers.

CONCLUSIONS

It is suggested that lack of knowledge of HRT may sometimes be the cause of rejecting it, or may influence on the compliance regarding its use. Familiarity with the use of the health system for other reasons than disease may promote the use of HRT. It is demonstrated that the observed patterns do not originate from self-selection bias.

Construction and behavior of biologically contained bacteria for environmental applications in bioremediation

The survival of microorganisms can be predicted through the use of active biological containment systems. We have constructed contained Pseudomonas putida strains that degrade alkylbenzoates. The modified strain carries a fusion of the Plac promoter to the gef gene, which encodes a killing protein. Expression from Plac is controlled through a regulatory cascade, so that Plac is switched on or off by the absence or presence of alkylbenzoates, respectively. Similar uncontained strains were also constructed and tested as a control. Contained and uncontained strains were genetically stable, and their survival and functionality in soil microcosms were as expected. Both contained and uncontained strains survived well in soils supplemented with alkylaromatics, whereas survival of the contained strain in soil microcosms without methylbenzoates was markedly reduced, in contrast to the control strain, which survived in these soils in the absence of alkylbenzoates. The TOL plasmid was transferred in soils between Pseudomonas strains but was not able to mobilize the elements of the containment system.

Nail abnormalities in nondermatologic patients: prevalence and possible role as diagnostic aids

BACKGROUND

Nail changes have traditionally been used as diagnostic aids. Their usefulness in general and predictive value in particular, however, is not known.

OBJECTIVE

Our purpose was to survey nail changes and to clarify the potential of nail abnormalities to diagnose nondermatologic diseases.

METHODS

The fingernails of 567 patients admitted to general medical and surgical wards were examined. The point prevalence rates were calculated on the basis of a binomial distribution. The results were compared with the diagnosis with logistic regression analysis correcting for age and sex.

RESULTS

The most common findings were absence of lunulae (22.9% [19.5% to 26.6%]), white nails or apparent leukonychia (11.8% [9.3% to 14.8%]), and red lunulae (5.1% [3.5% to 7.3%]). The following significant associations were noted: pulmonary disease and clubbing (odds ratio[OR] = 4.1, 95% confidence interval [CI] = 1.7 to 9.5), hematologic disease and brittle nails (OR = 4.6, 95% CI = 1.6 to 13.7), hematologic disease and Terry nails (OR = 8.7, 95% CI = 2.7 to 27.0), gastrointestinal disease and pincer nails (OR = 33.6, 95% CI = 3.7 to 307.3), and gastrointestinal disease and subjective complaints (OR = 2.7, 95% CI = 1.4 to 5.0).

CONCLUSION

Several significant associations were identified, suggesting that nail abnormalities can be diagnostic clues in the diagnosis of chronic nondermatologic diseases. An association between pincer nails and gastrointestinal disease has not been previously described.

A stochastic killing system for biological containment of Escherichia coli

Bacteria with a stochastic conditional lethal containment system have been constructed. The invertible switch promoter located upstream of the fimA gene from Escherichia coli was inserted as expression cassette in front of the lethal gef gene deleted of its own natural promoter. The resulting fusion was placed on a plasmid and transformed to E. coli. The phenotype connected with the presence of such a plasmid was to reduce the population growth rate with increasing significance as the cell growth rate was reduced. In very fast growing cells, there was no measurable effect on growth rate. When a culture of E. coli harboring the plasmid comprising the containment system is left as stationary cells in suspension without nutrients, viability drops exponentially over a period of several days, in contrast to the control cells, which maintain viability nearly unaffected during the same period of time. Similar results were obtained with a strain in which the killing cassette was inserted in the chromosome. In competition with noncontained cells during growth, the contained cells are always outcompeted. Stochastic killing obtained by the fim-gef fusion is at present relevant only as a containment approach for E. coli, but the model may be mimicked in other organisms by using species-specific stochastic expression systems.

Identification and removal of polymer- and aggregate-forming proteins in human plasma albumin preparations

The presence of the glycoproteins haptoglobin and hemopexin in human plasma albumin (HPA) solutions were demonstrated to be responsible for the formation of polymers and aggregates during heat treatment for 10 h at 60 degrees C. Apart from haptoglobin and hemopexin three other contaminating proteins were identified as transferrin, Gc-globulin and beta 2-glycoprotein. During heat treatment the antigenicity of haptoglobin and hemopexin changed markedly and more than 90% of the antigens appeared as aggregates in the void volume during the following size chromatography. Without loss of albumin haptoglobin and hemopexin were removed from the HPA preparation by lectin (concanavalin A) affinity chromatography. The haptoglobin- and hemopexin-depleted HPA preparation did not form aggregates or polymers during heat treatment.

Bone loss accompanying voluntary weight loss in obese humans

Dual-energy x-ray absorptiometry was performed in 51 obese patients before and after 15 weeks on a low-calorie diet. Of these patients 39 were scanned 6 months later. Total and regional body bone mineral, fat mass, and fat free mass were measured. In the control group, 9 normal volunteers were scanned with up to 23 kg lard distributed anteriorly, and 9 volunteers were scanned with 15 kg lard posteriorly. The lard was then gradually removed to simulate the fat loss found in the patient group. In the patient group the mean weight loss was 12,273 g, the mean fat loss was 11,014 g, and the mean bone mineral loss was 171.6 g after 15 weeks. Close correlation between the fat loss and the bone loss was found and calculated to be 16.5 g bone mineral per kg fat in the patient group, in contrast with 0.5 g bone mineral per kg fat in the control group. In the control group, 15 kg lard placed posteriorly had no statistically significant effect on the bone measurements. If weight and fat were regained at the scanning time 6 months later, the bone mineral was regained as well. Patients with further weight loss continued to lose bone mineral. One patient lost 754 g bone mineral in 9 months. Her weight loss was 45 kg in that period, and the bone mineral content remained within the range for normal women at her age. Methodologic and pathogenetic problems are discussed. It is concluded that the observed bone loss should be regarded as physiologic normalization accompanying a diet-induced weight loss in the obese.

A substrate-dependent biological containment system for Pseudomonas putida based on the Escherichia coli gef gene

A model substrate-dependent suicide system to biologically contain Pseudomonas putida KT2440 is reported. The system consists of two elements. One element carries a fusion between a synthetic lac promoter (PA1-04/03) and the gef gene, which encodes a killing function. This element is contained within a transposaseless mini-Tn5 transposon so that it can be integrated at random locations on the Pseudomonas chromosome. The second element, harbored by plasmid pCC102, is designed to control the first and bears a fusion between the promoter of the P. putida TOL plasmid-encoded meta-cleavage pathway operon (Pm) and the lacI gene, encoding the Lac repressor, plus xylS2, coding for a positive regulator of Pm. In liquid culture under optimal growth conditions and in sterile and nonsterile soil microcosms, P. putida KT2440 (pWWO) bearing the containment system behaves as designed. In the presence of a XylS effector, such as m-methylbenzoate, the LacI protein is synthesized, preventing the expression of the killing function. In the absence of effectors, expression of the PA1-04/03::gef cassette is no longer prevented and a high rate of cell killing is observed. Fluctuation test analyses revealed that mutants resistant to cell killing arise at a frequency of around 10(-5) to 10(-6) per cell per generation. Mutations are linked to the killing element rather than to the regulatory one. In bacteria bearing two copies of the killing cassette, the rate of appearance of mutants resistant to killing decreased to as low as 10(-8) per cell per generation.

Suicidal genetic elements and their use in biological containment of bacteria

The potential risks of unintentional releases of genetically modified organisms, and the lack of predictable behavior of these in the environment, are the subject of considerable concern. This concern is accentuated in connection with the next phase of gene technology comprising deliberate releases. The possibilities of reducing such potential risks and increasing the predictability of the organisms are discussed for genetically engineered bacteria. Different approaches towards designing disabled strains without seriously reducing their beneficial effects are presented. Principally two types of strain design are discussed: actively contained bacteria based on the introduction of controlled suicide systems, and passively contained strains based on genetic interference with their survival under environmental-stress conditions.

[Allergy to insulin developed during exposure to human insulin]

A case of allergy to human insulin is presented. The allergy developed during treatment with semisynthetic humanised insulin and was verified by a prick-test and RAST analysis.

The endoscopic diagnosis of duodenal ulcer disease. A randomized clinical trial of bias and of interobserver variation

In a randomized design we examined whether endoscopists are biased by knowledge of the radiologic diagnosis of duodenal ulcer and deformity of the duodenal bulb when recording the corresponding endoscopic diagnoses. A total of 156 patients had a barium meal and were subsequently randomized into 2 groups. In 74 of the cases the 2 endoscopists knew the result of the X-ray examination when doing the endoscopy; in 82 of the cases they did not. One endoscopist was significantly biased by his knowledge of the radiologic diagnosis of deformity of the duodenal bulb. Neither of the endoscopists was biased by his knowledge of the radiologic diagnosis of duodenal ulcer. In addition, the interobserver variation between the two endoscopists with regard to the endoscopic diagnoses of duodenal ulcer, deformity of the duodenal bulb, and duodenitis was examined. The interobserver variation was expressed by the overall agreement and by the kappa statistics, which adjusts the overall agreement for expected chance agreement. For duodenal ulcer, deformity of the duodenal bulb, and duodenitis, the overall agreements and kappa values were 0.91, 0.78, and 0.75, and 0.54, 0.42, and 0.33, respectively.

Interobserver variation in the radiographic diagnosis of gastric ulcer. Gastroenterologists' guesses as to level of interobserver variation

A total of 156 double contrast barium examinations were independently interpreted by two observers for the presence of gastric ulcer. The observed agreement between the two readings was 93 per cent, and after adjusting for the expected chance agreement a kappa value of 0.73 was obtained. At the first reading 4 ulcers, and at the second reading 8 ulcers were interpreted as malignant. None of these interpretations agreed. In a questionnaire study it was demonstrated that gastroenterologists had a realistic impression of the level of agreement in the radiographic detection of gastric ulcer.

Effect of acupuncture on tension headache and urinary catecholamine excretion

Sixteen patients with tension headaches were treated with acupuncture, needles being inserted in the hand and foot and then electrostimulated. All patients were seen at four 2-h sessions with intervals of 1 week between each. The first two sessions were used for clinical examination only, thus serving as control, while acupuncture was administered during the last two sessions. Urine samples were collected immediately before and after each session and later analyzed for catecholamine content. During the 1-week intervals between sessions, records were kept of headache attacks and medicine intake. Following acupuncture two-thirds of the patients showed reduction in number of headache attacks, and about one half of the patients reduced their use of pain relieving drugs considerably. Urinary excretion of adrenaline and noradrenaline was always higher in samples collected before sessions than after sessions. However, this reduction in catecholamine excretion was significantly greater when acupuncture had been administered.

Mammography directed wire marking of nonpalpable breast lesions. A consecutive biopsy study of 100 patients

Among 665 patients referred for breast complaints, 100 women (15%) had mammographically detected nonpalpable lesions suspected of malignancy. Using a mammography directed hook wire marking, 115 excisional biopsies were carried out. A correct biopsy containing the lesion was obtained in 113 instances. There were 2 failures, due to displacements of the wire in one case and surgical inexperience in another case. Two patients had minor wound complications. Invasive carcinoma was found in 12 and carcinoma in situ in 4 biopsies, i.e., a cancer rate of 16% of patients and 14% of biopsies. The biopsy procedure was simple, time saving, and acceptable of patients. The excisions were small and the cosmetic results excellent. During mammography for control of wire position, and during dressing and surgical manipulations the flexible hooked wire remained as originally placed in all cases but one.

Effect of acupuncture on headache measured by reduction in number of attacks and use of drugs

The experiment was performed in order to study the effect of acupuncture on headache by comparing the number of attacks during a 2-month period after acupuncture with the number of attacks during a similar period before treatment. Twenty-nine students (age: 19-24 years) all suffering from headache filled out questionnaires noting the days with attacks of headache and the amount and type of drugs used for 60 consecutive days. After acupuncture this observation procedure was repeated. One group of 10 students, however, received a placebo treatment instead of acupuncture but followed the identical questionnaire procedure. After 120 days acupuncture was given to this second group without revealing that the first treatment was a placebo. This treatment was again followed by a 60-day observation period. Comparison of the questionnaires before and after acupuncture showed a significant reduction in the number of days with headache. The placebo treatment resulted in a nonsignificant reduction in attacks of headache. A reduction in the amount of drugs used, especially the acetylsalicylate type, was noted following the acupuncture treatment. It is concluded that acupuncture is a relevant therapy for headache with a definite symptomatic effect.

Visual evoked potential in patients with cerebral asthenopia

Cerebral asthenopia is often overlooked as a symptom in diffuse brain lesion. An objective correlate of this symptom has so far never been demonstrated. Averaged visual evoked potential (VEP) in 10 patients with asthenopia was compared with 20 normal subjects. Both eyes and each eye alone were stimulated using bipolar recording in the midline and over each of the occipital lobes. There was no difference of latency of the VEPs in the two groups, but the amplitude of the most prominent component was significantly reduced in the patients. There was also a difference in the two groups regarding habituation and lateralisation. No amplitude difference could be found in the somatosensory evoked potential. The amplitude difference in VEP, as an objective correlate of asthenopia, is probably modal specific and suggests involvement of the visual cortex. VEP is unsuitable as a diagnostic tool due to the great overlap between amplitudes in asthenopic patients and control subjects.

Spinal leptomeningeal carcinosis visualized by amipaque myelography

A case of metastases to the spinal subarachnoidal space from a primary anaplastic pulmonary tumor visualized by Amipaque myelography is reported.