Declining the offer of flexible sigmoidoscopy screening for bowel cancer: a qualitative investigation of the decision-making process

Qualitative methods were used to investigate decision-making among a group of older adults who declined the offer of flexible sigmoidoscopy screening for bowel cancer. Interviews were conducted with 60 people (30 men and 30 women) who either had not responded to the screening letter or who responded saying that they were not interested in participating. The findings suggest that low perceived susceptibility to bowel cancer, in terms of current health status, family history or absence of bowel symptoms. was an important factor in the decision to decline screening. Procedural barriers such as embarrassment, pain/discomfort and perceived unpleasantness of the test were reported as relatively minor, although the test was considered more physically intrusive than other screening tests. Avoidant attitudes emerged as an important theme and were reported by a third of respondents. Distinct patterns of decision-making were also observed and three groups emerged from accounts: (i) forgetting or avoiding making a decision about the test (ii) a confident rejection of the test based on a few salient factors, and (iii) a more careful consideration of the test focusing on issues of susceptibility. The findings are discussed in the context of models of health behaviour and bowel cancer screening participation research.

Clinical and magnetic resonance imaging regression of progressive multifocal leukoencephalopathy in an AIDS patient after intensive antiretroviral therapy

A 36-year-old homosexual man with 6 months of visual symptoms and headaches had right homonymous hemianopia, mild new learning impairment, and alexia with agraphia. The initial brain magnetic resonance imaging (MRI) scan was reported consistent with left occipital infarction. Subsequent MRI demonstrated abnormal demyelination in subcortical white matter and deep parieto-occipital white matter bilaterally, but primarily left. Human immunodeficiency virus testing and cerebrospinal fluid polymerase chain reaction for JC virus DNA were both positive, consistent with progressive multifocal leukoencephalopathy (PML) with AIDS. His clinical status steadily deteriorated, and MRI white matter abnormalities worsened despite high-dose antiretroviral therapy. After the antiretroviral regimen was intensified by the addition of a protease inhibitor, rapid clinical and radiographic improvement occurred with subsequent MRI studies revealing only residual left parieto-occipital encephalomalacia. PML in AIDS patients has been associated with a nearly uniformly poor prognosis until recent reports of improved outcomes after highly active antiretroviral therapy. This patient with PML and AIDS similarly showed a robust clinical and MRI response to intensive antiretroviral combination therapy, which has been maintained for more than 3 years.

Predictors of attendance in the United Kingdom flexible sigmoidoscopy screening trial

OBJECTIVE

To investigate predictors of attendance in the United Kingdom flexible sigmoidoscopy screening trial.

DESIGN

Prospective design in which participants completed a postal questionnaire before being sent their invitation for screening.

SETTING

Welwyn Garden City and Leicester, United Kingdom.

PARTICIPANTS

A total of 2758 patients aged 55 to 64, registered with general practices in the two centres, who (a) expressed interest in having the screening test, (b) completed a postal questionnaire, and (c) were subsequently invited for screening.

MAIN RESULTS

The attendance rate among questionnaire responders was 76.1%. Multiple logistic regression analysis yielded a final model that included nine independent predictors of attendance. Patients with the following characteristics were more likely to attend: men; home owners; non-smokers; those who had regular check ups at the dentist; those with better subjective health; those who minded less about having medical tests; those who said they would definitely rather than probably take up the offer of sigmoidoscopy screening; and those who perceived less barriers and more benefits to having the test.

CONCLUSIONS

The findings are broadly consistent with previous studies of screening participation, although subjective health emerged as an important predictor in this study. There was no evidence for "reverse targeting": attenders were not at lower (or higher) risk for colorectal cancer compared with non-attenders. The findings relating to attitudes and beliefs could be used in efforts to improve attendance, for example by developing information leaflets that address barriers to screening. Other findings could be used to target interventions to subgroups that have relatively low rates of screening participation.

Back to the drawing board? A review of applications of the transtheoretical model to substance use

The transtheoretical model (TTM) is still enormously popular with practitioners, clinicians and many researchers in the addictions field. However, in a recent years a number of commentators have criticized aspects of the model and the research based on it. This paper extends a recent critique of the TTM as applied to smoking cessation to include applications of the model to cessation or reduction of alcohol or drug use. The first section discusses measures of the central construct of stages of change and notes a number of serious problems. Staging algorithms are based on arbitrary time periods and some are logically flawed. In the case of multi-dimensional questionnaires (the URICA, the SOCRATES and the RCQ), the pattern of correlations among the subscales shows that they are not measuring discrete stages of change. The one study to date that has compared the two different methods found low concordance, which is probably due to incompatible stage definitions. In the second section of the paper, the evidence base for the TTM is reviewed. The review is organized by the four research designs that have been used to test predictions from stage models: cross-sectional comparisons of people in different stages; examination of stage sequences; longitudinal prediction of stage transitions; and experimental studies of matched and mismatched interventions. It concludes that current evidence for the model as applied to substance use is meagre and inconsistent. Researchers are urged to develop better stage models.

Beneficiary decisionmaking: the impact of labeling health plan choices

One critical health plan decision concerns choosing an original Medicare plan or a Medicare managed care plan. Evidence suggests that people are confused by the phrase "Original Medicare plan." Using focus group and Q-sort methodology, the authors sought to identify a name for the Medicare fee-for-service (FFS) product. Two key insights were gained. First, participants used the word "Medicare" to name the FFS product. Second, participants did not choose between two plans. Rather, they decided between supplemental insurance and a managed care product. These factors should influence how CMS "brands" not only the FFS product but also the overall Medicare program.

Psychosocial influences on older adults' interest in participating in bowel cancer screening

BACKGROUND

As part of a multicenter, randomized controlled trial of the efficacy of flexible sigmoidoscopy for the prevention of bowel cancer, an investigation of the predictors of screening interest was carried out in a subsample of older adults.

METHOD

The aim of the study was to establish the predictive power of the Health Belief Model (HBM) and to evaluate the contribution of HBM elements in mediating the effect of other demographic and health variables which have been found to be associated with screening interest and participation. A total of 5,099 participants were sent a postal questionnaire which examined screening interest, attitudes toward screen ing (benefits and barriers), perceived bowel cancer risk, bowel cancer worry, bowel symptoms, health status, state anxiety, and optimism. A total of 3,648 questionnaires were returned completed, giving a response rate of 71.5%.

RESULTS

The results showed that threat, barriers, and benefits explained 47% of the variance in interest. Demographic and health variables were also associated with screening interest, although most of their effect was mediated by the HBM constructs.

DISCUSSION

This community study in older adults showed a high level of interest in participating in screening. The large sample size provided the opportunity to test the value of the HBM model and to examine mediation of demographic and health variables. The HBM proved to be a good model of screening interest. These results further our understanding of the decision processes in participating in cancer screening and point to directions to increase the level of participation in community samples.

Acceptability of flexible sigmoidoscopy screening in older adults in the United Kingdom

OBJECTIVES

To assess the acceptability of bowel cancer screening using flexible sigmoidoscopy (FS).

SETTING

Adults aged 55 to 64 recruited from general practices in Welwyn Garden City and Leicester, which were the pilot and start up centres of a multicentred randomised controlled trial of FS screening (the ICRF/MRC Flexible Sigmoidoscopy Screening Trial).

METHODS

Screenees (n=4422) were sent a three month follow up questionnaire that included measures of satisfaction with information given before the test, facilities at the test unit, attitudes of the staff, and explanation of the results. Measures of pain, embarrassment, feelings of being "in control" during the test, willingness to encourage others to have the test, and gladness to have participated were also included. In addition, semistructured telephone interviews were conducted with 60 screenees, stratified by screening outcome and gender.

RESULTS

The follow up questionnaire was completed by 94% of screenees. Responses indicated a high level of satisfaction with the procedure: 99% were satisfied with the information given before the test, the facilities, the attitudes of the staff, and the explanation of their results; 91% reported only mild or no pain; 97% reported little or no embarrassment; and 99% were glad they had the test. Satisfaction ratings varied little by gender or outcome group. The quantitative results were reinforced by the qualitative data, which also revealed high acceptability.

CONCLUSION

In the context of a clinical trial with dedicated trial staff, FS is a well tolerated procedure. There are high levels of satisfaction with service provision and positive attitudes towards the programme.

Single blind, randomised trial of efficacy and acceptability of oral picolax versus self administered phosphate enema in bowel preparation for flexible sigmoidoscopy screening

OBJECTIVE

To compare the acceptability and efficacy of two methods of self administered bowel preparation for flexible sigmoidoscopy screening: a single phosphate enema and a single sachet of Picolax.

DESIGN

Single blind, randomised trial.

SETTING

Endoscopy units of two general hospitals.

PARTICIPANTS

1442 men and women aged 55-64 years who had agreed to be screened by flexible sigmoidoscopy. MAIN OUTCOME MESURESs: Attendance rates, compliance with allocated preparations, adverse effects, quality of bowel preparation, procedure time, and yield of neoplasia.

RESULTS

Compliance with the enema was higher than with the Picolax (608 (84%) v 566 (79%); difference 6%, 95% confidence interval 2% to 10%). Almost half of those who refused Picolax used an enema at home. Wind, incontinence, and sleep disturbance were more frequent in the Picolax group than the enema group; bottom soreness was more frequent in the enema group. Around 30% (187) found the diet restriction required by Picolax difficult; 78% (471) found the enema easy to administer. The quality of preparation was better with the enema; the proportion of procedures complete to the descending colon was greater and the mean duration of the procedure was shorter. There was no significant difference in polyp detection rates.

CONCLUSION

A single phosphate enema self administered around one hour before leaving home is a more acceptable and effective method of preparing the distal bowel for flexible sigmoidoscopy than Picolax.

Participants in the Program of All-Inclusive Care for the Elderly (PACE) demonstration: developing disease-impairment-disability profiles

The Program of All-Inclusive Care for the Elderly (PACE) builds on On Lok's community-based care and financing model for disabled elderly people who are state certified as eligible for nursing home care. Yet PACE's diverse population has not been fully described. We obtained data for a complete cross-section of PACE participants from early 1997 (N = 2,917). Using grade-of-membership analysis, we classified participants on the basis of their specific diseases, impairments, and disabilities. The classification was reviewed by a physician panel to produce clinical profiles, which were then validated against participants' PACE tenure, demographics, supports, and health. Cognitive impairment, incontinence, and activities of daily living disabilities were influential in producing eight types, which correspond predictably to responses in tenure (the more disabled, ill types likely to be in PACE longer), demographics, health, and informal support.

Liver allotransplantation after extracorporeal hepatic support with transgenic (hCD55/hCD59) porcine livers: clinical results and lack of pig-to-human transmission of the porcine endogenous retrovirus

BACKGROUND

Whole organ extracorporeal perfusion of a genetically modified humanized (transgenic) pig liver has been proposed as a technology that may sustain patients with severe liver failure while awaiting human liver transplantation.

METHODS

We report on two cases of successful extracorporeal perfusion of a transgenic pig liver in patients awaiting transplantation for fulminant hepatic failure. The pig livers used were transgenic for human CD55 (decay-accelerating factor) and human CD59. These transgenic modifications are designed to reduce or eliminate the hyperacute rejection inherent in pig-to-primate xenotransplants. We also report on the results of serial surveillance testing for presence of the porcine endogenous retrovirus (PoERV) in these two patients.

RESULTS

Extracorporeal perfusion in two patients was performed for 6.5 and 10 hr, respectively, followed by the successful transplantation of a human liver and resultant healthy patients (18 and 5 months later as of this writing). The porcine livers showed evidence of synthetic and secretory function (decreasing protime and bilirubin, bile production). Serial polymerase chain reaction analysis of these patients' peripheral blood mononuclear cells has failed to show presence of PoERV DNA sequences.

CONCLUSIONS

The CD55/CD59 transgenic porcine liver appears capable of safely "bridging" a patient to liver transplantation. Human PoERV infection from these livers has yet to be demonstrated.

A comparative test of the theory of reasoned action and the theory of planned behavior in the prediction of condom use intentions in a national sample of English young people

Based on the theories of reasoned action (TRA) and planned behavior (TPB), predictors of condom use intentions were investigated in 949 young people (16-24 years of age) from a national survey conducted in England. Contrary to expectations, the TPB did not perform significantly better than the TRA, even among women. Measures of past behavior were the best predictors of intentions and attenuated the effects of attitude and subjective norm. There was only weak evidence for the multiplicative assumption underlying the TRA and TPB. Although the TRA components were not the strongest predictors, the beliefs on which they are based are potentially amenable to change through information-based intervention programs. A number of practical suggestions for developing intervention strategies are offered.

Ovine genomic urocortin: cloning, pharmacologic characterization, and distribution of central mRNA

Urocortin (Ucn), the newest member of the corticotropin-releasing factor (CRF) family of peptides, has been demonstrated to have significant physiologic and behavioral effects following its peripheral and central administration, respectively. In order to assess the differences in Ucn across species, an 18-kb sheep genomic DNA fragment encoding urocortin was isolated by the hybridization screening of a lambda phage library with a probe generated from rat urocortin (rUcn) cDNA. The sheep clone contains a region that is 84% and 88% homologous to the coding region of rUcn and human Ucn (hUcn), respectively and encodes an ovine Ucn (oUcn) that is predicted to be identical to the rat peptide. Competitive binding assays demonstrated oUcn to have a high affinity (Ki=0.1 nM) for the sheep CRF-binding protein (CRF-BP) and localization studies by in situ hybridization have shown that the distribution of oUcn messenger RNA in sheep brain shares with that of rUcn in rat brain a predominant locus of expression in the Edinger-Westphal nucleus of the midbrain, though some secondary sites of expression reported in rat are not conserved. These findings demonstrate that, even across diverse species, Ucn is highly conserved with respect to its structure and pharmacology unlike CRF where significant amino acid substitutions between the rat/human and sheep peptides may underlie differences in neuroendocrine regulation.

Factors predicting delayed presentation of symptomatic breast cancer: a systematic review

BACKGROUND

Delayed presentation of symptomatic breast cancer is associated with lower survival. Understanding of the factors that influence delay is important for the development of strategies to shorten delays. We did a systematic review to assess the quality and strength of evidence on risk factors for delays by patients and providers.

METHODS

We generated hypotheses about the relation between each putative risk factor and delay, against which we tested studies. We did searches to identify papers containing original data related to risk factors for delays by patients (n=86) and providers (n=28). We critically appraised the papers for inclusion in the review according to predefined criteria. The small number of studies of adequate quality did not allow formal meta-analysis. We therefore assigned strength of evidence according to a combination of the number and size of studies supporting, not supporting, or refuting the hypotheses.

FINDINGS

Most studies were deemed to be of poor quality and were excluded. Among 23 studies of adequate quality, however, there was strong evidence for an association between older age and delay by patients, and strong evidence that marital status was unrelated to delays by patients. Younger age and presentation with a breast symptom other than a lump were strong risk factors for delays by providers. Moderate evidence was shown for several other factors.

INTERPRETATION

The strength of the current evidence is inadequate to inform the development of specific strategies to shorten delays by patients or providers. Clarification of the findings of this review through a major programme of primary research is urgently required.

A comparative test of the theory of reasoned action and the theory of planned behavior in the prediction of condom use intentions in a national sample of English young people

Based on the theories of reasoned action (TRA) and planned behavior (TPB), predictors of condom use intentions were investigated in 949 young people (16-24 years of age) from a national survey conducted in England. Contrary to expectations, the TPB did not perform significantly better than the TRA, even among women. Measures of past behavior were the best predictors of intentions and attenuated the effects of attitude and subjective norm. There was only weak evidence for the multiplicative assumption underlying the TRA and TPB. Although the TRA components were not the strongest predictors, the beliefs on which they are based are potentially amenable to change through information-based intervention programs. A number of practical suggestions for developing intervention strategies are offered.

Ectopic expression of the CRF-binding protein: minor impact on HPA axis regulation but induction of sexually dimorphic weight gain

Corticotrophin-releasing factor (CRF) and urocortin possess a high-affinity binding protein. Although the CRF binding protein (BP) can sequester these ligands and inhibit their activity, the endogenous activity of this protein is not understood. Therefore, transgenic mouse lines that over-express the CRF-BP were created. The transgene was constructed by ligating rat CRF-BP cDNA (1.1 kb) between a mouse metallothionein-I promoter (1.8 kb) and a nonfunctional human growth hormone gene sequence (2.1 kb) in a modified pBR322 plasmid and microinjecting the transgene into C57BL/6 x SJL hybrid ova. The transgene was expressed in 50% in both male and female progeny. All transgenic lines were maintained by crossing transgenic animals with wild-type C57BL/6 mates. Reverse-transcriptase (RT) PCR of the CRF-BP transgene showed that it is widely expressed not only in the brain and pituitary, but also peripheral tissues including the liver, kidney and spleen. Transgenic animals of both sexes showed significant increases in weight gain as established by analysis of variance; however, the weight gain profiles for each sex were distinct. High levels of circulating CRF-BP were detected in the transgenic animals, but the basal ACTH and corticosterone levels were not significantly decreased compared to wild-type littermates. The hypothalamopituitary-adrenal (HPA) axis was stimulated by systemic inflammation induced with lipopolysaccharide (LPS). An expected increase in transgene expression was observed and was accompanied by a significant attenuation of ACTH secretion at 3 h after LPS injection in the transgenic males but not the females. These data suggest that HPA axis regulation is significantly affected only with very high circulating levels of CRF-BP. Moreover, this work supports previous studies that implicate CRF and urocortin in the regulation of appetite and the binding protein expression may play a sexually dimorphic role in regulating this and other responses.

Uptake, yield of neoplasia, and adverse effects of flexible sigmoidoscopy screening

BACKGROUND

A multicentre randomised controlled trial to evaluate screening by "once only" flexible sigmoidoscopy (FS) for prevention of bowel cancer is in progress.

AIMS

To pilot the trial protocol examining rates of attendance, yield of neoplasia, and adverse effects.

SUBJECTS

A total of 3540 subjects aged 55-64 years in Welwyn Garden City (WGC) and 19,706 in Leicester (LE).

METHODS

Subjects responding positively to an "interest in screening" questionnaire were randomised to invitation for screening or control arms. Small polyps were removed during screening. Colonoscopy was undertaken for high risk polyps (more than two adenomas, size at least 1 cm, villous histology, severe dysplasia, or malignancy). The remainder were discharged.

RESULTS

In WGC and LE respectively, 59% and 61% indicated an interest in screening, of which 74% and 75% attended. Adenomas were detected in 10% and 9%, respectively, and cancers in 7 per 1000 (in both centres), 55% at Dukes's stage A. The colonoscopy referral rate was 6% in both centres. Mild, short lived bleeding occurred in 3%. One person died following surgery.

CONCLUSIONS

Compliance rates, yield of adenomas, and referral rate for colonoscopy were as expected, but cancer detection rates were higher. Adverse effects following sigmoidoscopy or colonoscopy were mild and transient, but there was one postoperative death. A randomised trial is necessary to evaluate fully the risks and benefits of this intervention.

The first extracellular domain of corticotropin releasing factor-R1 contains major binding determinants for urocortin and astressin

The CRF receptors are members of a 7-transmembrane receptor family that includes GH-releasing hormone (GRF), calcitonin, vasoactive intestinal peptide (VIP), secretin, and PTH receptors. To determine the structural features of the CRF receptor that may influence ligand recognition, a series of mutant receptors was analyzed for binding to astressin, a CRF antagonist, and to urocortin, a CRF agonist. Mutant receptors included chimeras between the CRF-R1 and GRF-R or Activin IIB-R, a single membrane spanning receptor serine/threonine kinase. Binding to the mutant receptors was assessed using 125I-[DTyr1] astressin (Ast*) and 125I-[Tyr0]-rat urocortin (Ucn*). There was no binding to a chimeric receptor in which the first extracellular domain (E1c) (i.e. the N-terminal region) of the CRF-R1 was replaced by that of the GRF-R. The complementary chimera in which E1 domain of the GRF-R was replaced by that of the CRF-R1 bound astressin and urocortin with Ki values approximately 10 nM, compared with inhibitory binding dissociation constant (Ki) values of approximately 2-4 nM for the wild-type CRF-R1. The chimera in which E1 of the activin IIB receptor was replaced by E1 of the CRF-R1 bound astressin with a Ki approximately 4 nM. A chimera in which both the first and fourth extracellular domains of the CRF-R1 replaced the corresponding domains of the GRF-R bound astressin with Ki approximately 4 nM and urocortin with a Ki approximately 2 nM. A chimera in which all four extracellular domains of the CRF receptor replaced those of the GRF-R bound astressin and urocortin with Ki values approximately 4 nM and approximately 1 nM, respectively. In conclusion, the major determinants for high affinity binding of CRF agonists and antagonists to CRF-R1 are found in the first extracellular domain of the receptor.

Histologic-radiologic correlation of mammographically detected microcalcification in stereotactic core biopsies

Core biopsy is an alternative technique to surgical excision for assessment of nonpalpable mammographically detected suspicious lesions. The pattern of radiologic calcification is often considered to have diagnostic importance. The aim of this study was to correlate radiologic and histologic features of calcification, with respect to appearance, distribution, and size, to determine the significance, if any, of different radiologic patterns of calcification. Core biopsy samples from 124 women who had 129 mammographically suspicious areas of calcification were examined. Core biopsy samples (five cores per procedure) were obtained stereotactically using a 14-gauge needle in an automated Biopty (Bard Australia, Chatswood, NSW, Australia) gun. In 30 lesions no histologic calcification was found. In the others, there was a poor correlation between radiology and histology with respect to the appearance and distribution of calcification. In a subgroup of 53 women, radiographs of biopsy cores were available to allow correlation with the size of histologic calcification. Calcification of <100 microm assessed histologically was not visible on core biopsy specimen radiographs and may not represent the calcification seen mammographically. Thus, radiography of core biopsy samples and histologic measurement of the size of calcification in core biopsy specimens is useful to reduce false-negative diagnoses in which a biopsy has been performed to evaluate mammographically suspicious calcifications.

Stereotactic large-gauge core biopsy: its role in the diagnosis of non-palpable mammographic abnormalities presenting to a screening service

A retrospective study of large-gauge core biopsy (LGCB) of 206 non-palpable mammographic abnormalities detected at routine screening in a community-based clinic accredited with the Australian National Program for the Early Detection of Breast cancer, was performed to ascertain the role of LGCB as an alternative to diagnostic surgical biopsy within such a programme. Of the 51 malignancies diagnosed by LGCB and proceeding to treatment, no false-positives were found and agreement as to the presence, or otherwise, of invasion between core and open biopsy was 95%. Once malignancy was established by LGCB, one-stage treatment was possible in 74.5% of cases. A total of 114 lesions were considered to be benign and returned to routine screening. One interval cancer subsequently developed in this group. Incongruity between the pathological diagnosis from core biopsy and the mammographic image occurred in 29 cases, representing potential mistargeting in 14.1% of cases. Four cancers were discovered in this group when the patients subsequently proceeded to surgical biopsy, making an overall false-negative rate of 2.4%. No core biopsy sample was considered inadequate for pathological assessment and no lesion proved inaccessible to targeting. There was no long-term morbidity. We believe that LGCB is a safe, reliable and cheaper alternative to diagnostic surgical biopsy, but a close correlation of pathology and mammography is required to avoid the erroneous return of women to routine recall.

Activin A, corticotropin-releasing factor and prostaglandin F2 alpha increase immunoreactive oxytocin release from cultured human placental cells

The aim of the present study was to investigate the presence of the immunoreactive oxytocin in human placental extracts and putative factors regulating the release of immunoreactive oxytocin from cultured human placental cells. Fresh placental tissue was collected from pregnant women at term and dissected of membranes (n = 5). Presence of immunoreactive oxytocin in trophoblast tissue was evaluated by a specific radio-immunoassay after acidic extraction and high-pressure liquid chromatography. In a second set of experiments, primary cultures of placental cells were performed and, 48-72 h after dissociation, the effect of arginine vasopressin, corticotropin-releasing factor, neuropeptide Y, activin A, inhibin A, noradrenaline or prostaglandins on immunoreactive oxytocin level in culture medium was investigated. The presence of immunoreactive oxytocin was shown in the acidic extract of trophoblast at term, and in the culture medium of human placental cells, and it was identical to the native peptide. The addition of corticotropin-releasing factor or arginine vasopressin, but not of neuropeptide Y, increased the release of immunoreactive oxytocin three- to fourfold from placental cells, with a dose-dependent effect (P < 0.01). A significantly increased release of immunoreactive oxytocin was shown in presence of noradrenaline (P < 0.01), which was reversed by prazosin, an antagonist of alpha-adrenergic receptors. Recombinant human activin A (P < 0.01), but not inhibin A, stimulated the release of immunoreactive oxytocin three- to fourfold from placental cells. Prostaglandin F2 alpha was a potent secretagogue of immunoreactive oxytocin, whereas a partial or no effect was observed when prostaglandin E2 or prostaglandin I2 was added. Thus, the present findings showed that human placenta contains immunoreactive oxytocin, and that its release from cultured placental cells is regulated by neurohormones, growth factors or prostaglandins.

Histological precision of stereotactic core biopsy in diagnosis of malignant and premalignant breast lesions

The reliability of stereotactic core biopsy in the diagnosis of malignant and premalignant breast lesions was assessed in comparison to excision biopsy in patients with non-palpable suspicious breast lesions detected in a mammography breast screening programme. Fifty-two cases of malignancy and nine of atypical ductal hyperplasia were diagnosed on the programme during the two year period July 1993 to June 1995; two patients did not have excision biopsy. Stereotactic core biopsies and representative sections from 59 excision specimens from the same patients were assessed "blind' by one pathologist. All 51 cancers diagnosed on stereotactic core biopsy were confirmed to be malignant on excision biopsy. There was 96% concordance between stereotactic core biopsy and excision biopsy for the diagnosis of invasive or in situ cancer, and 78% concordance for the type of cancer. The stereotactic core biopsy and excision biopsy diagnoses were: invasive ductal carcinomas (39 on stereotactic core biopsy vs. 33 on excision biopsy), mucinous carcinomas (1 vs. 2), invasive lobular carcinomas (3 vs, 8), and in situ carcinomas (8 vs. 8), two of which had invasive cancer present only in the stereotactic core biopsy. Of the nine cases of atypical ductal hyperplasia diagnosed on stereotactic core biopsy, eight had an excision biopsy, six showed low nuclear grade in situ or invasive cancer, one had a 3 mm focus of high grade invasive ductal cancer and one was atypical ductal hyperplasia. In the invasive ductal carcinoma group stereotactic core biopsy underestimated tumour grade: In nine cases (31%) the cancer at excision was of a higher grade. Stereotactic core biopsy is a reliable alternative to excision biopsy in the diagnosis of breast cancer, however, stereotactic core biopsy may underestimate tumour grade in invasive ductal carcinoma and may not differentiate between invasive ductal carcinoma and lobular carcinoma. It is recommended that the diagnosis of atypical ductal hyperplasia on stereotactic core biopsy be followed by excision biopsy, as stereotactic core biopsy underestimates the presence of cancer in this group.

Diagnostic accuracy of stereotactic core biopsy in a mammographic breast cancer screening programme

Stereotactic core biopsy was performed on 200 women for 206 mammographically suspicious non-palpable lesions detected over a period of 2 years as part of the Australian national programme for early detection of breast cancer. This study aimed to assess the reliability of stereotactic core biopsy in this context and to develop a protocol for the evaluation of stereotactic core biopsy in mammographically detected non-palpable breast lesions. Fifty-one of 52 malignant lesions found by stereotactic core biopsy were confirmed by excision biopsy (one women declined excision). Nine (4.5%) women had atypical ductal hyperplasia on stereotactic core biopsy; at excision, six were low grade carcinomas (in situ or invasive carcinomas), one was a 3 mm focus of grade 3 invasive duct carcinoma, one was atypical ductal hyperplasia, and one patient refused excision biopsy. In 29 (14.5%) women the histology of the stereotactic core biopsy was considered not to correlate with the radiological abnormality, and excision biopsy was advised: in four of these women carcinomas were found. One hundred and ten (55%) women had 116 benign lesions on stereotactic core biopsy: on follow-up, one of these patients has been found to have a carcinoma. Core biopsy number and sequence were analysed demonstrating that no particular biopsy was more diagnostic than any other, and that the diagnostic yield of three cores was statistically equal to that of five cores. The procedure was well-tolerated and there were few complications. Thus, stereotactic core biopsy is an accurate and safe method for diagnosis of mammographically detected non-palpable breast lesions, and we believe it is the diagnostic technique of choice in breast cancer screening programmes. However, a stereotactic core biopsy diagnosis of atypical ductal hyperplasia requires excision biopsy since a diagnosis of low grade intraduct carcinoma cannot be excluded. Furthermore, if tissue obtained by stereotactic core biopsy does not correlate with the mammographic abnormality, excision biopsy should be performed.

Characterization of a sheep brain corticotropin releasing factor binding protein

We report here the identification, purification and cDNA cloning of a corticotropin releasing factor (CRF) binding protein(s) (CRF-BP) from sheep brain. Native sheep and rat brain CRF-BP and recombinant rat CRF-BP were shown to be N-glycosylated. Two membrane associated forms of brain CRF-BPs of 33 and 35 kDa were purified from sheep brain homogenates after solubilization in the presence of detergent. N-Terminal sequence analysis revealed that the 35 kDa protein is proteolytically cleaved near the N-terminus giving rise to an 18 amino acid peptide and a 33 kDa CRF-BP. Both the purified 33 and 35 kDa ovine CRF-BPs could be specifically cross linked to ovine [125I]CRF and human [125I]CRF. In contrast, recombinant rat CRF-BP can only be cross-linked to human [125I]CRF. A 1.7 kb cDNA clone (Basil 7) encoding an open reading frame for a 324 amino acid CRF-BP precursor was cloned from a sheep brain lambda gtlO cDNA library and was shown to have 85% and 87% amino acid homology to the rat and human proteins, respectively. Competitive binding analysis of the recombinant sheep CRF-BP (Basil 7) expressed in CHO cells revealed that it binds human and ovine CRF with high affinity. However, the recombinant sheep CRF-BP (Basil 7) had approximately 50-fold higher affinity for human CRF than for the ovine peptide. These data present the first biochemical proof that CRF-BP is in the brain and provides evidence for the existence of different forms of CRF-BP which have evolved across species to regulate CRF.

Nature of ligand affinity and dimerization of corticotrophin-releasing factor-binding protein may be detected by circular dichroism

As the association of corticotrophin-releasing factor (CRF) with its binding protein (BP) to form a dimer complex (CRF2/BP2) appears to be dependent on the nature of the ligand we have compared the circular dichroism difference spectra after association of the BP with ovine (o) CRF, human (h) CRF and the alpha-helical CRF (9-41) antagonist. All three ligands caused a negative change in molar ellipticity above 210 nm, with oCRF having the least and hCRF the greatest effect. Below 210 nm there was a marked divergence of difference spectra, with the reaction with the natural peptides, hCRF and oCRF, resulting in a positive change in ellipticity, whilst that with the antagonist produced a negative change. In view of the BP spectrum indicating predominantly beta-sheet and the peptides showing mainly alpha-helix these results were interpreted as the changes above 210 nm being due to dimerization and below 210 nm to a change in the conformation of ligand on binding. The opposite change in alpha-helicity of the antagonist observed on binding compared with the two natural CRF peptides could have fundamental pharmacological implications.

Urocortin, a mammalian neuropeptide related to fish urotensin I and to corticotropin-releasing factor

Corticotropin-releasing factor (CRF), a peptide first isolated from mammalian brain, is critical in the regulation of the pituitary-adrenal axis, and in complementary stress-related endocrine, autonomic and behavioural responses. Fish urotensin I and amphibian sauvagine were considered to be homologues of CRF until peptides even more closely related to CRF were identified in these same vertebrate classes. We have characterized another mammalian member of the CRF family and have localized its urotensin-like immunoreactivity to, and cloned related complementary DNAs from, a discrete rat midbrain region. The deduced protein encodes a peptide that we name urocortin, which is related to urotensin (63% sequence identity) and CRF (45% sequence identity). Synthetic urocortin evokes secretion of adrenocorticotropic hormone (ACTH) both in vitro and in vivo and binds and activates transfected type-1 CRF receptors, the subtype expressed by pituitary corticotropes. The coincidence of urotensin-like immunoreactivity with type-2 CRF receptors in brain, and our observation that urocortin is more potent than CRF at binding and activating type-2 CRF receptors, as well as at inducing c-Fos (an index of cellular activation) in regions enriched in type-2 CRF receptors, indicate that this new peptide could be an endogenous ligand for type-2 CRF receptors.

Potent, structurally constrained agonists and competitive antagonists of corticotropin-releasing factor

Predictive methods, physicochemical measurements, and structure activity relationship studies suggest that corticotropin-releasing factor (CRF; corticoliberin), its family members, and competitive antagonists (resulting from N-terminal deletions) usually assume an alpha-helical conformation when interacting with the CRF receptor(s). To test this hypothesis further, we have scanned the whole sequence of the CRF antagonist [D-Phe12,Nle21,38]r/hCRF-(12-41) (r/hCRF, rat/human CRF; Nle, norleucine) with an i-(i + 3) bridge consisting of the Glu-Xaa-Xaa-Lys scaffold. We have found astressin [cyclo(30-33)[D-Phe12,Nle21,38,Glu30,Lys33]r/ hCRF(12-41)] to be approximately 30 times more potent than [D-Phe12,Nle21,38]r/hCRF-(12-41), our present standard, and 300 times more potent than the corresponding linear analog in an in vitro pituitary cell culture assay. Astressin has low affinity for the CRF binding protein and high affinity (Ki = 2 nM) for the cloned pituitary receptor. Radioiodinated [D-125I-Tyr12]astressin was found to be a reliable ligand for binding assays. In vivo, astressin is significantly more potent than any previously tested antagonist in reducing hypophyseal corticotropin (ACTH) secretion in stressed or adrenalectomized rats. The cyclo(30-33)[Ac-Pro4,D-Phe12,Nle21,38,Glu30,Lys33++ +]r/hCRF-(4-41) agonist and its linear analog are nearly equipotent, while the antagonist astressin and its linear form vary greatly in their potencies. This suggests that the lactam cyclization reinstates a structural constraint in the antagonists that is normally induced by the N terminus of the agonist.

Does routine screening for breast cancer raise anxiety? Results from a three wave prospective study in England

OBJECTIVE

To investigate whether mammography raises anxiety in routinely screened women who receive a negative result.

DESIGN

Prospective design in which women completed questionnaires at three key points in the breast screening process: at baseline (before being sent their invitation for breast screening), at the screening clinic immediately before or after screening, and at follow up, about nine months after baseline. Information was obtained from non-attenders as well as from attenders.

SETTING

Bromley District Health Authority, served by the South East London Breast Screening Service.

PARTICIPANTS

Two overlapping samples were used. Sample A comprised 1500 women aged 50-64 who were due to be called for first round screening at a mobile screening unit. Altogether 1021 (68%) returned a usable questionnaire and 795 of these (78%) also provided adequate information at nine month follow up: there were 695 attenders (including 24 women who received false positive results) and 100 non-attenders. Sample B consisted of 868 women who attended the screening unit in a three month period, 732 (84%) of whom provided adequate data. A total of 306 attenders (including 10 who received false positive results) occurred in both samples and provided adequate information on all occasions. The main analyses were based on these 306 women plus the 100 non-attenders. The analysis of retrospective anxiety took advantage of the larger sample size of 695 attenders.

MAIN RESULTS

On average, the women were not unduly anxious at any of the three points in the screening process. Among attenders, there was no difference between anxiety levels immediately before and immediately after screening. Anxiety was lowest at the clinic and highest at baseline but the changes were very small in absolute terms. Anxiety did not predict attendance: there were no differences in anxiety levels between attenders and non-attenders at baseline. As expected, women who received false positive results recalled feeling extremely anxious after they had received the referral letter but their retrospective anxiety was also higher than in the negative screenees at earlier stages in the breast screening process. They also reported having experienced more pain and discomfort during the x ray.

CONCLUSIONS

Anxiety does not seem to be an important problem in routinely screened women who receive a negative result. This finding is very reassuring in relation to a major criticism of breast screening programmes. Thus, apart from maintaining current procedures such as keeping waiting times to a minimum, there seems to be no need to introduce special anxiety reducing interventions into the national programme. On the other hand, the findings for women who received false positive results suggest that there are aspects of the experience of being recalled for assessment after an abnormal mammogram that warrant further attention. The relationship between contemporaneous and retrospective anxiety should also be studied.

Marked changes of arginine vasopressin, oxytocin, and corticotropin-releasing hormone in hypophysial portal plasma after pituitary stalk damage in the rat

Mechanical compression of the pituitary stalk with the help of a blunt stereotaxic knife results in posterior pituitary denervation (PPD) and sprouting proximal to the injury, leading to formation of an ectopic neurohypophysis in the stalk. This provides an experimental model for those cases in which traumatic damage severs the nerve fibers to the neural lobe but does not obliterate the hypophysial-portal circulation. The effect of PPD on the hypophysial-portal concentration profile of putative ACTH secretagogues as well as basal and stimulated ACTH secretion in vitro were investigated at varying times after PPD. The contents of arginine vasopressin (AVP) and oxytocin (OT) in extracts of the stalk median eminence 1 week after PPD were markedly elevated, whereas corticotropin-releasing hormone (CRH) content was unaffected. Levels of these three neuropeptides in hypophysial-portal blood collected under anesthesia from the proximal stump of the transected stalk (or the ectopic neural lobe) were measured at weekly intervals in groups of rats after sham or PPD surgery. Hypophysial-portal AVP levels showed a monotonic increase with time after PPD from a 1.8-fold elevation at 1 week post-PPD to a maximum concentration 6-fold greater than that in sham groups at 4 weeks post-PPD. Portal plasma OT levels also exhibited extreme elevation. In contrast, portal plasma CRH levels showed an initial 72% decline 1 week post-PPD. We suggest that mechanical damage to the pituitary stalk and the subsequent sprouting redirected secretion of AVP and OT from the neural lobe to the pituitary stalk. This caused sustained elevations of portal plasma concentrations of AVP and OT. The resulting tonic exposure to AVP and/or OT may down-regulate anterior pituitary receptors to these neurohypophyseal peptides and indirectly decrease CRH release into the portal circulation.

Distribution of corticotropin-releasing factor receptor mRNA expression in the rat brain and pituitary

Corticotropin-releasing factor (CRF) is a major hypophysiotropic peptide regulating pituitary-adrenal response to stress, and it is also widely expressed in the central nervous system. The recent cloning of cDNAs encoding the human and rat CRF receptors has enabled us to map the distribution of cells expressing CRF receptor mRNA in rat brain and pituitary by in situ hybridization. Receptor expression in the forebrain is dominated by widespread signal throughout all areas of the neo-, olfactory, and hippocampal cortices. Other prominent sites of CRF receptor mRNA expression include subcortical limbic structures in the septal region and amygdala. In the diencephalon, low levels of expression are seen in a few discrete ventral thalamic and medial hypothalamic nuclei. CRF receptor expression in hypothalamic neurosecretory structures, including the paraventricular nucleus and median eminence, is generally low. In the brainstem, certain relay nuclei associated with the somatic (including trigeminal), auditory, vestibular, and visceral sensory systems, constituted prominent sites of CRF receptor mRNA expression. In addition, high levels of this transcript are present in the cerebellar cortex and deep nuclei, along with many precerebellar nuclei. In the pituitary, moderate levels of CRF receptor mRNA expression were detected throughout the intermediate lobe and in a subset of cells in the anterior lobe identified as corticotropes by concurrent immunolabeling. Overall, the central distribution of CRF receptor mRNA expression is similar to, though more expansive than, that of regions reported to bind CRF, and it shows limited overlap with loci expressing CRF-binding protein. Interestingly, CRF receptor mRNA is low or undetectable in several cell groups implicated as central sites of CRF action.

Profound atrophy of the bone marrow reflecting major histocompatibility complex class II-restricted destruction of stem cells by CD4+ cells

The effector functions of CD4+ cells in vivo are presumed to reflect a combination of lymphokine-mediated bystander reactions and direct cytotoxic T lymphocyte activity. To assess the relative importance of these two mechanisms, we studied the effects of transferring small doses of purified unprimed CD4+ cells to lightly irradiated (600 cGy) recipients expressing major histocompatibility complex class II (Ia) differences. Within the first week after transfer, the host marrow was rapidly repopulated with hemopoietic cells. Thereafter, however, the donor CD4+ cells caused massive destruction of hemopoietic cells, both in marrow and spleen. Marrow aplasia did not affect stromal cells and was prevented by coinjecting donor but not host bone marrow. The use of allotypic markers and fluorescence-activated cell sorter analysis indicated that the destructive effects of CD4+ cells were directed selectively to host Ia+ hemopoietic cells, including stem cells; donor hemopoietic cells and Ia- host T cells were spared. No evidence could be found that the ongoing destruction of host cells impaired the capacity of donor stem cells to repopulate marrow, spleen, or thymus. Moreover, CD4+ cells failed to destroy host-type hemopoietic cells from Ia-deficient mice. Tissue destruction by CD4+ cells thus did not seem to reflect a bystander reaction. We conclude that, under defined conditions, CD4+ cells can manifest extremely potent Ia-restricted CTL activity in vivo, probably through recognition of covert Ia expression on stem cells and/or their immediate progeny.

Anxiety and self-esteem as a function of abstinence time among recovering addicts attending Narcotics Anonymous

Among 200 members of Narcotics Anonymous (NA), those who had been off drugs and in contact with NA for longer tended to have lower trait anxiety and higher self-esteem scores, the relationship in each case being approximately linear. Those abstinent for longer than about three years had levels of anxiety and self-esteem similar to those in a comparison group of 60 students.

Prospective study of predictors of attendance for breast screening in inner London

OBJECTIVE

To investigate the predictors of first-round attendance for breast screening in an inner city area.

DESIGN

Prospective design in which women were interviewed or completed a postal questionnaire before being sent their invitation for breast screening. Sociodemographic factors, health behaviours, and attitudes, beliefs, and intentions were used as predictors of subsequent attendance. A randomised control group was included to assess the effect of being interviewed on attendance.

SETTING

Three neighbouring health districts in inner south east London.

PARTICIPANTS

A total of 3291 women aged 50-64 years who were due to be called for breast screening for the first time. The analysis of predictors was based on a subsample of 1301, reflecting a response rate of 75% to interview and 36% to postal questionnaire.

MAIN RESULTS

Attendance was 42% overall, and 70% in those who gave an interview or returned a questionnaire. There was little evidence for an interview effect on attendance. The main findings from the analysis of predictors are listed below. (These were necessarily based on those women who responded to interview/questionnaire and so may not be generalisable to the full sample.) (1) Sociodemographic factors: Women in rented accommodation were less likely to go for screening but other indicators of social class and education were not predictive of attendance. Age and other risk factors for breast cancer were unrelated to attendance, as was the distance between home and the screening centre. Married or single women were more likely to attend than divorced, separated, or widowed women, and black women had a higher than average attendance rate; however, neither of these relationships was found in the interview sample. (2) Health behaviours: Attenders were less likely to have had a recent breast screen, more likely to have had a cervical smear, more likely to go to the dentist for check ups, and differed from non-attenders with regard to drinking frequency. Exercise, smoking, diet change, and breast self-examination were unrelated to attendance. (3) Attitudes, beliefs, and intentions: The two best predictors were measures of the perceived importance of regular screening for cervical and breast cancer and intentions to go for breast screening. Also predictive were beliefs about the following: the personal consequences of going for breast screening, the effectiveness of breast screening, the chances of getting breast cancer, and the attitudes of significant others (the woman's husband/partner and children). Women who reported a moderate amount of worry about breast cancer were more likely to attend than those at the two extremes.

CONCLUSIONS

Attenders and non-attenders differ in two broad areas: the health related behaviours they engage in and the attitudes, beliefs, and intentions they have towards breast cancer and breast screening. The latter are potentially amenable to change, and though different factors may operate among women who do not respond to questionnaires, the findings offer hope that attendance rates can be improved by targeting the relevant attitudes and beliefs. This could be done by changing the invitation letter and its accompanying literature, through national and local publicity campaigns, and by advice given by GPs, practice nurses, and other health professionals. It is essential that such interventions are properly evaluated, preferably in randomised controlled studies.

Elderly nonrespondents to a mail survey: a telephone follow-up

The most frequently used method to request and collect health-related information has been the mail questionnaire. While self-administered surveys offer a relatively low-cost and convenient method for collecting health data, they have been unpopular among researchers because of concerns about low response rates and nonresponse bias. This study examines differences in demographic and health characteristics between mail survey respondents and nonrespondents who were subsequently interviewed by telephone. Subjects for this study had at least one health care encounter in 1990 from a Medicare-waiver program. The telephone survey was conducted approximately two months after the last wave of a three-wave mailing survey of this urban elderly population. No significant differences were found between telephone and mail respondents for demographic, socioeconomic, quality of life, or perceived oral health characteristics. However, mail respondents were more likely to be dentate and report better perceived general health than were the telephone respondents.

Corticotropin-releasing factor-binding protein is produced by human placenta and intrauterine tissues

CRF circulates in high concentration in pregnant woman. It is produced by the placenta and the other intrauterine tissues (maternal decidua, amnion, and chorion). Recently, a CRF-binding protein (CRF-BP) has been identified and cloned. It binds the circulating CRF, reducing its biological action during pregnancy. Liver is the major source of CRF-BP. The aim of the present study was to evaluate whether human placenta and intrauterine tissues produce CRF-BP. The localization of mRNA and immune CRF-BP by in situ hybridization and immunohistochemistry, respectively, was performed. Antisense and sense riboprobes synthesized from a fragment of human CRF-BP cRNA and a specific rabbit anti-hCRF-BP serum was used. The syncytial layer of placental villi at term intensely expressed CRF-BP mRNA and immunoreactivity, whereas rare positively hybridized cells were observed within the cytotrophoblasts and mesenchymal cells. Large decidual cells, amniotic epithelial cells, and chorionic cytotrophoblast stained positively for CRF-BP mRNA and protein. Control sections collected from the same tissues failed to show any positive localization of sense strand cRNA probe and antiserum preadsorbed with immunogen. Finally, the addition of recombinant CRF-BP to human cultured placental cells significantly decreased CRF-induced ACTH release, with a dose-dependent effect. The present data show that local production of CRF-BP occurs in human trophoblast and intrauterine tissues and may represent one of the major mechanisms used by targets tissues to control CRF activity during pregnancy.