Evaluation of the ELOVL4 gene in patients with age-related macular degeneration

Stargardt-like macular degeneration (STGD(3)) and autosomal dominant macular degeneration (adMD) share phenotypic characters with atrophic age-related macular degeneration (AMD). Mutations in a photoreceptor cell-specific factor involved in the elongation of very long chain fatty acids (ELOVL(4)) were shown to be associated with STGD(3), adMD, and pattern dystrophy. We screened 778 patients with AMD and 551 age-matched controls to define the role of sequence variants in the ELOVL(4) gene in age-related macular degeneration. We detected three sequence variants in the non-coding region and eight variants in the coding region. No statistically significant association was observed between sequence variants in the ELOVL(4) gene and susceptibility to AMD. However, for the detection of modest effects of multiple alleles in a complex disease, the analysis of larger cohorts of patients may be required.

Assessment of mutations in the Best macular dystrophy (VMD2) gene in patients with adult-onset foveomacular vitelliform dystrophy, age-related maculopathy, and bull's-eye maculopathy

PURPOSE

To study the presence of Best macular dystrophy (VMD2) gene mutations in patients diagnosed with maculopathies other than classic Best disease and to describe the clinical characteristics of these subjects.

DESIGN

Case-comparison study of phenotype-genotype correlations.

METHODS

Patients with either age-related maculopathy (ARM; n = 259) or maculopathies other than classic Best disease (n = 28) were screened for mutations in the Best gene (VMD2; OMIM 153700). These cases were compared with ethnically similar subjects in the same age range without maculopathy (n = 196). All patients underwent a complete dilated ocular examination, and all affected individuals underwent fundus photography. Phenotype-genotype comparisons were made.

MAIN OUTCOME MEASURES

Presence of mutations in the Best gene (VMD2; OMIM 153700) and the clinical phenotype.

RESULTS

Three of 259 patients (1%) with ARM and 2 of 28 patients (7%) with other maculopathies including 1 of 3 patients with adult-onset foveomacular vitelliform dystrophy and 1 of 5 patients with a bull's eye maculopathy, but none of the controls, were found to possess amino acid-changing variants in the VMD2 gene. These included a man with confluent drusen and retinal pigment epithelial detachments (variant in exon 6; T216I), a man with geographic atrophy and numerous soft drusen (variant in exon 10; L567F), a woman with drusen and retinal pigment epithelial alterations (variant in exon 10; L567F), a woman with drusen and retinal pigment epithelial alterations resembling bull's-eye maculopathy (variant in exon 4; E119Q), and a woman diagnosed with adult-onset foveomacular vitelliform dystrophy (variant in exon 4; A146K).

CONCLUSIONS

Novel mutations in the VMD2 gene were found in patients diagnosed with maculopathies other than classic Best disease. Some cases diagnosed as adult-onset vitelliform foveomacular dystrophy may represent a variant of Best disease with delayed onset. The VMD2 gene does not play a major role in the development of ARM.

The UK version of the Seattle Angina Questionnaire (SAQ-UK): reliability, validity and responsiveness

The study assesses the reliability, validity and responsiveness of the UK version of the Seattle Angina Questionnaire (SAQ-UK). The instrument was anglicised and administered by self-completed postal questionnaire to 959 patients recruited from general practices in the North East of England. A total of 655 (68.3%) patients returned a completed questionnaire. Principal component analysis produced three important dimensions: physical limitations, anginal frequency and perception and treatment satisfaction. Four items that performed poorly were removed from the instrument. The removal of items greatly increased the number of computable scale scores. Estimates of internal reliability for the three dimensions ranged from 0.83-0.92. Estimates of test-retest reliability were above accepted standards. The correlation between the SAQ-UK scores and the SF-12, EuroQol and health transition was evidence for the validity of the instrument. The SAQ-UK produced responsiveness statistics that were comparable to the parent instrument and was more responsive to improvements in health than the generic instruments. The SAQ-UK is recommended as a measure of health outcome for the evaluation of angina management.

Number of non-diabetic drugs: a simple comorbidity indicator for diabetes?

INTRODUCTION

The number of non-diabetic drugs, taken by a patient with diabetes at any one point in time, has been validated in previous studies as a comorbidity indicator.

AIM

The aim of the paper is to examine the relationship between this comorbidity indicator and health status in people with Type 2 diabetes.

METHOD

The analysis presented is from a prospective cohort study of people with Type 2 diabetes before and after commencing insulin therapy, with simultaneous collection of health status, clinical and other comparative data.

RESULTS

Of the 48 people for whom both health status and drug data were available, 26 (54%) were taking at least one non-diabetic drug and 16 (33%) were taking 3 or more non-diabetic drugs, at the baseline assessment. There were no significant relationships between the number of non-diabetic drugs taken, and age, duration of diabetes or baseline HbA1c measurements. However, there were statistically significant relationships between the number of non-diabetic drugs and health status, in terms of depression and physical function.

CONCLUSION

Drug data are routinely recorded in primary care and therefore the number of non-diabetic drugs is a potentially widely available indicator. This indicator could be a useful, simple addition to datasets that not only proxies comorbidity but also relates to patients' physical function and depression status.

Evaluation of the G protein coupled receptor-75 (GPR75) in age related macular degeneration

BACKGROUND

A long term project was initiated to identify and to characterise genes that are expressed exclusively or preferentially in the retina as candidates for a genetic susceptibility to age related macular degeneration (AMD). A transcript represented by a cluster of five human expressed sequence tags (ESTs) derived exclusively from retinal cDNA libraries was identified.

METHODS

Northern blot and RT-PCR analyses confirmed preferential retinal expression of the gene, which encodes a G protein coupled receptor, GPR75. Following isolation of the full length cDNA and determination of the genomic organisation, the coding sequence of GPR75 was screened for mutations in 535 AMD patients and 252 controls from Germany, the United States, and Italy. Employed methods included single stranded conformational polymorphism (SSCP) analysis, denaturing high performance liquid chromatography (DHPLC), and direct sequencing.

RESULTS

Nine different sequence variations were identified in patients and control individuals. Three of these (-30A>C, 150G>A, and 346G>A) likely represent polymorphic variants. Each of six alterations (-4G>A, N78K, P99L, S108T, T135P, and Q234X) were found once in single AMD patients and were considered variants that could affect the protein function and potentially cause retinal pathology.

CONCLUSION

The presence of six potential pathogenic variants in a cohort of 535 AMD patients alone does not provide statistically significant evidence for the association of sequence variation in GPR75 with genetic predisposition to AMD. However, a possible connection between the variants and age related retinal pathology cannot be discarded. Functional studies are needed to clarify the role of GPR75 in retinal physiology.

Two new genes from the human ATP-binding cassette transporter superfamily, ABCC11 and ABCC12, tandemly duplicated on chromosome 16q12

Several years ago, we initiated a long-term project of cloning new human ATP-binding cassette (ABC) transporters and linking them to various disease phenotypes. As one of the results of this project, we present two new members of the human ABCC subfamily, ABCC11 and ABCC12. These two new human ABC transporters were fully characterized and mapped to the human chromosome 16q12. With the addition of these two genes, the complete human ABCC subfamily has 12 identified members (ABCC1-12), nine from the multidrug resistance-like subgroup, two from the sulfonylurea receptor subgroup, and the CFTR gene. Phylogenetic analysis determined that ABCC11 and ABCC12 are derived by duplication, and are most closely related to the ABCC5 gene. Genetic variation in some ABCC subfamily members is associated with human inherited diseases, including cystic fibrosis (CFTR/ABCC7), Dubin-Johnson syndrome (ABCC2), pseudoxanthoma elasticum (ABCC6) and familial persistent hyperinsulinemic hypoglycemia of infancy (ABCC8). Since ABCC11 and ABCC12 were mapped to a region harboring gene(s) for paroxysmal kinesigenic choreoathetosis, the two genes represent positional candidates for this disorder.

A C-type lectin from the tunicate, Styela plicata, that modulates cellular activity

Previous studies have identified proteins from tunicates (invertebrate members of the Phylum Chordata) that have physicochemical and functional properties similar to those of the inflammatory cytokine, interleukin 1 (IL-1). Here we characterize one of those proteins from the tunicate, Styela plicata, that can stimulate tunicate and mammalian cell proliferation, activate phagocytosis, increase interleukin 2 (IL-2) secretion by mammalian peripheral blood mononuclear cells and enhance IL-2 receptor (IL-2R) expression by mammalian EL-4.IL-2 cells. Partial amino acid sequence data showed that the S. plicata protein resembles three C-type lectins (TC14, TC14-1 and TC14-2) from a closely related tunicate species, Polyandrocarpa misakiensis. Its similarity to carbohydrate recognition domains (CRDs) from P. misakiensis lectins suggests that the S. plicata protein modulates the activities of mammalian immunocompetent cells by interacting with carbohydrate moieties of glycosylated cell surface receptors.

What role do nurses play in Type 2 diabetes care in the community: a Delphi study

OBJECTIVES

To identify the views of nurses on their current and future roles in care in the community for people with Type 2 diabetes.

METHOD

A two-round Delphi study was used to elicit, and assess consensus on opinions from random samples of practice nurses, with a substantial role in the management of diabetes patients and diabetes specialist nurses. Both groups had defined levels of expertise in diabetes care and worked in Great Britain. The study instrument in round one comprised a questionnaire with 10 statement headings inviting opinions on the nursing role in the management and care of people with Type 2 diabetes. In the second round levels of agreement were elicited from responders on collated opinions from round one. The initial questionnaire also included closed questions to obtain a profile of current care delivered.

RESULTS

Responders were 97 practice nurses and 69 diabetes specialist nurses with second round response rates of 93% and 86%, respectively. The 47 themes raised could be grouped under headings of clinical practice, responsibility, communication, knowledge, education/experience, rewards, and patients' roles. Many were common to several statements and both nurse groups. The level of agreement on the themes fed back was high, 85% of the 165 items achieved greater than 80% agreement. Agreement occurred for factors relating to clinical effectiveness, audit, knowledge, education and experience. Dissent occurred both within and between individual nurse groups on issues of responsibility, prescribing, service delivery, resources, and patient factors.

CONCLUSIONS

This Delphi study has identified key areas of consensus on the management of care for people with Type 2 diabetes in the community but also areas in which further work needs to be carried out to understand the differences found. Many of the discordant items relate to the separate roles and associated issues of the two nurse groups.

User satisfaction: measurement and interpretation

Over the past 5 years there has been an increased interest in assessing users' satisfaction with health care services in England. Measuring and interpreting user satisfaction with reproductive and sexual health services can be complex, and efforts have met with varying degrees of success. This paper will summarise the methods that have been used to assess user satisfaction over the past 10 years, describe a different type of approach that has been recently used in England, and provide some suggestions for approaches that may be effective in improving clinical effectiveness in the new millennium.

Diabetes care delivery in the community

Specialist nurses and practice nurses were asked about the future care and management of Type 2 diabetes. Consensus was high on issues such as audit, evidence-based practice, experience and record keeping. There were differences in opinion about nurse prescribing, teamwork, professional responsibility and education/training.

Evidence-based management of groin hernia in primary care--a systematic review

BACKGROUND

National clinical guidelines on the surgical management of groin hernia have been published by the Royal College of Surgeons of England. There is also a need for guidance on the management of pre- and post-hernia repair patients in primary care, in areas such as diagnosis, referral and advice on recuperation.

OBJECTIVE

The purpose of the present study was to determine best practice in primary care aspects of managing groin hernia in adults, by examination of the evidence base.

METHOD

A systematic review of the available evidence was carried out, searching the major electronic databases: Medline, the Cochrane Library, Embase, Assia, Helmis, Cinahl and Psyclit. Key search terms were hern$, inguinal, femoral, groin, truss$, with searches limited to human adult subjects and the English language.

RESULTS

Robust research on groin hernia is concerned almost exclusively with the in-patient surgical management of patients undergoing primary elective hernia repair. The areas with which this review was concerned, principally diagnosis, referral and advice about return to work, are areas in which it is more difficult to conduct robustly designed studies. Perhaps because of this, the evidence base on the non-surgical aspects of management is of poor methodological quality, being based primarily on expert opinion, reviews of clinical practice and experience, surveys, descriptive case studies and clinical audits.

CONCLUSIONS

As the research in this area is generally of poor quality, strong conclusions are precluded, but it is possible to define best practice in some areas of care. In relation to diagnosis, GPs should distinguish correctly between a femoral and inguinal hernia because of the increased risks of strangulation and incarceration associated with the former. Due to clinical inaccuracy, the identification of whether a hernia is direct or indirect is not a good basis on which to base decision making regarding referral for elective repair. The risks associated with surgical repair are those of the normal range found for any procedure. Decisions about the fitness of patients for surgery in this instance are not procedure specific, and therefore the decisions about elective repair especially in older patients should be considered in terms of quality of life and patient choice rather than increased risks with surgical repair. Further research is required to address the gap in the evidence for the management of groin hernia within the primary care sector.

Sub-Doppler resolution limited Lamb-dip spectroscopy of NO with a quantum cascade distributed feedback laser

A quantum cascade distributed feedback laser operating at 5.2 microm is used to obtain sub-Doppler resolution limited saturation features in a Lamb-dip experiment on the R(13.5)1/2 and R(13.5)3/2 transitions of NO. The dips appear as transmission spikes with full widths of ~ 4.3 MHz. At this resolution the 73 MHz _-doubling of the R(13.5)3/2 line, which is normally obscured by the 130 MHz Doppler broadening, is easily resolved.

The efficacy of spinal cord stimulation for chronic pain

A prospective study was undertaken to evaluate the efficacy of spinal cord stimulation (SCS) in the management of chronic pain syndrome. The study included all patients who underwent this procedure at the Royal Melbourne Hospital and the Melbourne Private Hospital over a period of two years. A total of 29 patients were managed by the end of June 1996. These patients were carefully screened by a neurosurgeon (JVR) and a psychiatrist. Of these, 26 patients had a follow up evaluation at the end of August 1996. From the group of 29 patients, four patients failed to obtain any relief during the trial phase of the procedure and thus did not have the stimulator implanted permanently. From the 25 patients who proceeded to have the stimulator implanted, 11 patients had a variable beneficial response, three patients found it to be of marginal benefit, six had no benefit, three patients initially had a good response but subsequently gained no benefit whilst two patients were uncertain of its benefit. It thus appears that SCS was of benefit in 50% of our carefully selected patients with chronic pain syndromes.

Effectiveness of screening and monitoring tests for diabetic retinopathy--a systematic review

AIMS

To determine which screening and monitoring tests for diabetic retinopathy are most effective and under what circumstances.

METHODS

A systematic review of the English language literature, published from 1983 to April 1999.

RESULTS

Available studies are generally limited in their ability to answer the important questions on the effectiveness of tests for early detection of diabetic retinopathy. No randomized controlled trials were identified although primary studies exist for two screening tests: ophthalmoscopy, either direct or indirect, and retinal photography, using either mydriasis or non-mydriasis. Retinal photography under mydriasis appears to be the most effective test, with the majority reporting levels of sensitivity in excess of 80%. However effectiveness is compromised when photographs are ungradable. Ophthalmoscopy can also reach acceptable standards of sensitivity and specificity.

CONCLUSION

Based on an assessment of available cohort studies, the most effective strategy for testing is the use of mydriatic retinal photography with the additional use of ophthalmoscopy for cases where photographs are ungradable. This does not exclude the use of ophthalmoscopy alone for opportunistic case finding but there is evidence of considerable variation in effectiveness of this test.

Patient-assessed measures of health outcome in asthma: a comparison of four approaches

The study compares the psychometric properties of four different approaches to patient-assessed health outcomes in asthma, including the Asthma Quality of Life Questionnaire (AQLQ), Newcastle Asthma Symptoms Questionnaire (NASQ), SF-12 and EuroQol. The instruments were administered by means of a self-completed postal questionnaire to 394 patients recruited from general practices in the North East of England. Patients completed a follow-up questionnaire at 6 months. The levels of missing data were assessed and instrument scores compared using correlational analysis. Scores were related to self-reports of smoking behaviour, socioeconomic status and health transition. Responsiveness was assessed using standardized response means. Two hundred and thirty-five patients took part in the study giving a response rate of 59.6%. There was a relatively large amount of missing data for the individualized section of the AQLQ. Correlational analysis provided evidence of convergent validity between the specific instruments; the largest correlation was found between NASQ scores and the asthma symptoms scale of the AQLQ (r = 0.84). The NASQ was found to be the most powerful at discriminating between smokers and non-smokers. All four instruments were linearly related to self-reported asthma transition (P<0.05); the specific instruments having the strongest association. The specific instruments showed good levels of responsiveness with the NASQ producing a large SRM of 0.82. SRMs for the AQLQ were of a moderate to large size (0.32-0.77) and the SRMs for the SF-12 and EuroQol were of a small size. The two specific instruments are capable of greater levels of discrimination between groups of patients and are more responsive to changes in health than the generic SF-12 and EuroQol. The greater responsiveness of the NASQ is probably due to its focus being restricted to symptoms of asthma compared to the broader focus of the AQLQ domains. The NASQ has a strong relationship with the AQLQ and is a more practical instrument that is more acceptable to patients. However, the AQLQ does measure broader patient concerns. The SF-12 and EuroQol have greater potential to capture side-effects and have wider scope for application in economic evaluation.

The mapping from sound structure to the lexicon in aphasia: evidence from rhyme and repetition priming

Two studies were conducted to explore the hypothesis that Broca's and Wernicke's aphasics have deficits arising from the processes involved in activating the lexicon from phonological form. The first study explored whether phonologically similar lexical entries differing only in their initial consonants show "rhyme priming." Results revealed that Broca's aphasics failed to show facilitation when the target was identical to the prime (i.e. identity priming) and they showed significant inhibition when targets were preceded by rhyming words. Wernicke's aphasics showed a pattern of results similar to that of normal subjects, i.e., identity priming and rhyme priming as well as significantly slower reaction-times in the rhyming condition compared to the identity condition. The second study investigated form-based repetition priming in aphasic patients at a number of intervals including when no other stimuli intervened between repeated stimuli (0 lag) or when 4, 8, or 12 stimuli intervened. Results showed that, unlike old normal subjects who showed repetition priming for both words and nonwords, both Broca's and Wernicke's aphasics showed repetition priming for word targets only. Moreover, in contrast to old normal subjects who showed a greater magnitude of priming at 0 lag for word targets, neither Broca's aphasics or Wernicke's aphasics showed priming at 0 lag. Implications of these findings are considered with respect to the hypotheses that Broca's and Wernicke's aphasics have deficits in the nature of the activation patterns within the lexicon itself and in auditory (working) memory.

New ABCR mutations and clinical phenotype in Italian patients with Stargardt disease

PURPOSE

To assess the mutation spectrum in the ABCR gene and clinical phenotypes in Italian families with autosomal recessive Stargardt disease (STGD1) and fundus flavimaculatus (FFM).

METHODS

Eleven families from southern Italy, including 18 patients with diagnoses of STGD1, were clinically examined. Ophthalmologic examination included kinetic perimetry, electrophysiological studies, and fluorescein angiography. DNA samples of the affected individuals and their family members were analyzed for variants in all 50 exons of the ABCR gene by a combination of single-strand conformation polymorphism analysis and direct sequencing techniques.

RESULTS

TenABCR variants were identified in 16 (73%) of 22 mutant alleles of patients with STGD1. Five mutations of 10 that were found had not been previously described. The majority of variants represent missense amino acid substitutions, and all mutant alleles cosegregate with the disease in the respective families. These ABCR variants were not detected in 170 unaffected control individuals (340 chromosomes) of Italian origin. Clinical evaluation of these families affected by STGD1 showed an unusually high frequency of early age-related macular degeneration (AMD) in parents of patients with STGD1 (8/22; 36%), consistent with the hypothesis that some heterozygous ABCR mutations enhance susceptibility to AMD.

CONCLUSIONS

Patients from southern Italy with Stargardt disease show extensive allelic heterogeneity of the ABCR gene, concordant with previous observations in patients with STGD1 from different ethnic groups. Half the mutations identified in this study had not been previously described in patients with STGD1. Screening of increasingly large numbers of patients would help to determine whether this can be explained by ethnic differences, or is an indicator of extensive allelic heterogeneity of ABCR in STGD1 and other eye diseases. In 6 (55%) of 11 families, the first-degree relatives of patients with STGD1 were diagnosed with early AMD, supporting the previous observation that some STGD1 alleles are also associated with AMD.

Perceptions of good medical practice in the NHS: a survey of senior health professionals

OBJECTIVES

To categorize senior health professionals' experience with poor medical practice in hospitals and in general practice, to describe perceptions which senior NHS staff have of good medical practice, and to describe how problems of poor medical practice are currently managed.

DESIGN

A postal questionnaire survey. The questionnaire sought perceptions of good medical practice, asked participants to characterise deviations from good practice, and to describe experience with managing poor performance at the time of the introduction of the General Medical Council (GMC) performance procedures.

SETTING

A range of NHS settings in the UK: hospital trusts, health authorities/boards, local medical committees, community health councils.

SUBJECTS

Senior health professionals involved in the management of medical professional performance.

MAIN MEASURES

Perceptions of what constitutes good medical practice.

RESULTS

Most respondents considered that persistent problems related to clinical practice (diagnosis, management, and outcome and prescribing) would require local management and, possibly, referral to the GMC performance procedures. Informal mechanisms, including informal discussion, education, training, and work shifting, were the most usual means of handling a doctor whose performance was poor. Many took a less serious view of deficiencies in performance on manner and attitude and communication, although consultation skills rather than technical skills comprised the greatest number of complaints about doctors.

CONCLUSIONS

Senior NHS professionals seem reluctant to consider persistently poor consultation skills in the same critical light as they do persistently poor technical practice. These attitudes may need to change with the implementation of clinical governance and updated guidance from the GMC on what constitutes good medical practice.

Relatives' lived experiences of complementary therapies in a critical care department--a phenomenological study

This phenomenological study examined relatives' lived experiences of complementary therapies in the Department of Critical Care Medicine at Royal Hobart Hospital. Participants in the study, 20 relatives of critically ill patients, were involved in a non-structured, audiotaped interview. Subsequently, transcripts were analysed using a phenomenological transformative process to identify common themes in the text. Study findings suggested four emerging conceptual categories, which with further analysis uncovered the essence of the phenomenon as extending and enriching a caring atmosphere.

A systematic review of foot ulcer in patients with Type 2 diabetes mellitus. II: treatment

AIM

To assess the value of treatments for foot ulcers in patients with Type 2 diabetes mellitus.

METHODS

A systematic review of interventions to treat diabetic foot ulcers.

RESULTS

The evidence base for treating infections and dressing wounds is poor. A number of new and potentially promising treatments are being developed but currently available studies are often small, inadequately powered and use different methods and outcomes.

CONCLUSIONS

Given the prevalence, morbidity and healthcare costs of diabetic foot disease, it is surprising that available trials provide inadequate evidence to improve upon current empirically based treatment approaches. Substantial effort and resources should be deployed in order to investigate both new and existing treatments in a co-ordinated, systematic and consistent manner, so that a proper evidence base can be established for this important disease area.

A systematic review of foot ulcer in patients with Type 2 diabetes mellitus. I: prevention

AIM

To evaluate the role of preventative strategies in reducing foot ulcers in patients with Type 2 diabetes mellitus, both in the general population and those identified to be at a raised risk.

METHOD

A systematic review of interventions to prevent diabetic foot ulcers.

RESULTS

Available studies are generally unsatisfactory in their ability to answer the important questions relating to prevention. However, where people with diabetes receive well-organized and regular care with rapid referral to appropriate specialist multidisciplinary teams when problems (or their precursors) occur, ulcer morbidity can be substantially reduced.

CONCLUSION

Foot ulcers are common in people with diabetes and are costly in terms of both patient morbidity and the use of healthcare resources. Although it is nearly a decade since the St Vincent Declaration called for a marked reduction in morbidity to be achieved through better patient management, available evidence suggests that the process of care in Britain is still very variable in quality. Foot care for people with diabetes must be organized to provide monitoring, education and referral in a manner acceptable to patients and realistic for local healthcare providers.

The ABCR gene in recessive and dominant Stargardt diseases: a genetic pathway in macular degeneration

Stargardt disease (STGD) is a juvenile-onset macular dystrophy and can be inherited in an autosomal recessive or in an autosomal dominant manner. Genes involved in dominant STDG have been mapped to human chromosomes 13q (STGD2) and 6q (STGD3). Here, we identify a new kindred with dominant STGD and demonstrate genetic linkage to the STGD3 locus. Because of a more severe macular degeneration phenotype of one of the patients in this family, the gene responsible for the recessive STGD1, ABCR, was analyzed for sequence variants in all family members. One allele of the ABCR gene was shown to carry a stop codon-generating mutation (R152X) in three family members, including the one patient who had inherited also the dominant gene. A grandparent of that patient with the same ABCR mutation developed age-related macular degeneration (AMD), consistent with our earlier observation that some variants in the ABCR gene may increase susceptibility to AMD in the heterozygous state. Based on these results, we propose that there is a common genetic pathway in macular degeneration that includes genes for both recessive and dominant STGD.

NHS attitudes to good medical practice

Perceptions of good medical practice among senior NHS staff were collected through a survey. There are differences between the perceived seriousness of poor communication skills and poor technical skills.

Evaluation of the Best disease gene in patients with age-related macular degeneration and other maculopathies

Vitelliform macular dystrophy (VMD2, Best disease, MIM153700) is an early onset, autosomal, dominant macular degeneration characterized by the deposition of lipofuscin-like material within and below the retinal pigment epithelium (RPE); it is associated with degeneration of the RPE and overlying photoreceptors. Recently, we cloned the gene bestrophin, which is responsible for the disease, and identified a number of causative mutations in families with VMD2. Here, we report that the analysis of bestrophin in a collection of 259 age-related macular degeneration (AMD) patients provides evidence that mutations in the Best disease gene do not play a significant role in the predisposition of individuals to AMD. However, our results suggest that, in addition to Best disease, mutations within the bestrophin gene could be responsible for other forms of maculopathy with phenotypic characteristics similar to Best disease and for other diseases not included in the VMD category.

Mutation of a putative mitochondrial iron transporter gene (ABC7) in X-linked sideroblastic anemia and ataxia (XLSA/A)

X-linked sideroblastic anemia and ataxia (XLSA/A) is a recessive disorder characterized by an infantile to early childhood onset of non-progressive cerebellar ataxia and mild anemia with hypochromia and microcytosis. A gene encoding an ATP-binding cassette (ABC) transporter was mapped to Xq13, a region previously shown by linkage analysis to harbor the XLSA/A gene. This gene, ABC7, is an ortholog of the yeast ATM1 gene whose product localizes to the mitochondrial inner membrane and is involved in iron homeostasis. The full-length ABC7 cDNA was cloned and the entire coding region screened for mutations in a kindred in which five male members manifested XLSA/A. An I400M variant was identified in a predicted transmembrane segment of the ABC7 gene in patients with XLSA/A. The mutation was shown to segregate with the disease in the family and was not detected in at least 600 chromosomes of general population controls. Introduction of the corresponding mutation into the Saccharomyces cerevisiae ATM1 gene resulted in a partial loss of function of the yeast Atm1 protein. In addition, the human wild-type ABC7 protein was able to complement ATM1 deletion in yeast. These data indicate that ABC7 is the causal gene of XLSA/A and that XLSA/A is a mitochondrial disease caused by a mutation in the nuclear genome.

Genotype/Phenotype analysis of a photoreceptor-specific ATP-binding cassette transporter gene, ABCR, in Stargardt disease

Mutation scanning and direct DNA sequencing of all 50 exons of ABCR were completed for 150 families segregating recessive Stargardt disease (STGD1). ABCR variations were identified in 173 (57%) disease chromosomes, the majority of which represent missense amino acid substitutions. These ABCR variants were not found in 220 unaffected control individuals (440 chromosomes) but do cosegregate with the disease in these families with STGD1, and many occur in conserved functional domains. Missense amino acid substitutions located in the amino terminal one-third of the protein appear to be associated with earlier onset of the disease and may represent misfolding alleles. The two most common mutant alleles, G1961E and A1038V, each identified in 16 of 173 disease chromosomes, composed 18.5% of mutations identified. G1961E has been associated previously, at a statistically significant level in the heterozygous state, with age-related macular degeneration (AMD). Clinical evaluation of these 150 families with STGD1 revealed a high frequency of AMD in first- and second-degree relatives. These findings support the hypothesis that compound heterozygous ABCR mutations are responsible for STGD1 and that some heterozygous ABCR mutations may enhance susceptibility to AMD.

The rising agenda of physician-assisted suicide: explaining the growth and content of morality policy

Employing theories and methods of agenda-setting analysis, this article explains the rapid rise of physician-assisted suicide (PAS) on the national political agenda based on its status as a morality policy. PAS reached the mass agenda before the professional agenda, probably because PAS is an outgrowth of previous right-to-die policies and Dr. Jack Kevorkian's assisted suicides provided major focusing events. As in other morality policies, competing groups fight for the last word, but PAS has been blocked on most governmental agendas because its image and media tone has been mostly negative and public opinion is divided. Groups in a few generally liberal states have tried to enact policy through referenda when legislators failed to address the issue. We speculate that competing interest groups will become more active and that state courts will become a venue of choice in the future.

A human placenta-specific ATP-binding cassette gene (ABCP) on chromosome 4q22 that is involved in multidrug resistance

We characterized a new human ATP-binding cassette (ABC) transporter gene that is highly expressed in the placenta. The gene, ABCP, produces two transcripts that differ at the 5' end and encode the same 655-amino acid protein. The predicted protein is closely related to the Drosophila white and yeast ADP1 genes and is a member of a subfamily that includes several multidrug resistance transporters. ABCP, white, and ADP1 all have a single ATP-binding domain at the NH2 terminus and a single COOH-terminal set of transmembrane segments. ABCP maps to human chromosome 4q22, between the markers D4S2462 and D4S1557, and the murine gene (Abcp) is located on chromosome 6 28-29 cM from the centromere. ABCP defines a new syntenic segment between human chromosome 4 and mouse chromosome 6. The abundant expression of this gene in the placenta suggests that the protein product has an important role in transport of specific molecule(s) into or out of this tissue.

Stem cell factor enhances the adhesion of AML cells to fibronectin and augments fibronectin-mediated anti-apoptotic and proliferative signals

Acute myeloid leukaemia (AML) cells express the SCF receptor c-kit (CD117) on their cell surface and demonstrate enhanced adhesion to fibronectin (FN) following exposure to stem cell factor (SCF). Increased adhesion occurs within 5 min, is dose dependent, and persists beyond 2 h. Baseline and enhanced adhesion occur through the surface FN receptor very late antigen-5 (VLA-5, CD49e/CD29) which is expressed by AML cells. Unstimulated AML cells exposed to FN undergo less apoptosis than controls (inhibition 22.5 +/- 7.0%, P = 0.02, n = 8). Exposure to SCF alone without FN also inhibits AML cell apoptosis (by 19.0 +/- 7.7% compared to controls, P = 0.06, n = 8). Simultaneous exposure to SCF and FN increases the inhibition of AML cell apoptosis to 37.8 +/- 7.9% (P = 0.005 compared to control, P = 0.04 compared to FN alone, P = 0.06 compared to SCF alone) demonstrating that SCF not only enhances the propensity of AML cells to adhere to FN, but also results in an additive survival benefit following FN contact. Some but not all the reduction in apoptosis is mediated through VLA-5. The combination of SCF and FN also affects proliferation, resulting in a synergistic enhancement of AML cell proliferation in half the cases studied. When normal CD34+ human haemopoietic progenitors were studied, FN had little effect on their apoptosis and failed to enhance the anti-apoptotic effect of SCF. It did, however, synergise with SCF in promoting CD34+ cell proliferation. Exposure of AML cells to SCF and FN, both of which can be found in high concentration in the bone marrow stroma, inhibits apoptosis. Cytokines and extracellular matrix proteins augment each others' effects since SCF enhances adhesion to fibronectin, which in turn augments the survival signal delivered by the cytokine alone. Cytokine and adhesion receptors can combine to affect cell characteristics including proliferation and survival.

Organization of the ABCR gene: analysis of promoter and splice junction sequences

Mutations in the human ABCR gene have been associated with the autosomal recessive Stargardt disease (STGD), retinitis pigmentosa (RP19), and cone-rod dystrophy (CRD) and have also been found in a fraction of age-related macular degeneration (AMD) patients. The ABCR gene is a member of the ATP-binding cassette (ABC) transporter superfamily and encodes a rod photoreceptor-specific membrane protein. The cytogenetic location of the ABCR gene was refined to 1p22.3-1p22.2. The intron/exon structure was determined for the ABCR gene from overlapping genomic clones. ABCR spans over 100kb and comprises 50 exons. Intron/exon splice site sequences are presented for all exons and analyzed for information content (Ri). Nine splice site sequence variants found in STGD and AMD patients are evaluated as potential mutations. The localization of splice sites reveals a high degree of conservation between other members of the ABC1 subfamily, e.g. the mouse Abc1 gene. Analysis of the 870-bp 5' upstream of the transcription start sequence reveals multiple putative photoreceptor-specific regulatory elements including a novel retina-specific transcription factor binding site. These results will be useful in further mutational screening of the ABCR gene in various retinopathies and for determining the substrate and/or function of this photoreceptor-specific ABC transporter.

Haemoglobin Le Lamentin (alpha 20 (B1) His-->Gln) in a British family: identification by electrospray mass spectrometry

The first identification of haemoglobin Le Lamentin (alpha 20 (B1) His-->Gln) in a British patient is described. The patient was a 69 year old asymptomatic white male being screened for diabetes, whose blood was undergoing its first ever analysis for glycated haemoglobin using a Glycomat II analyser. Identification of the haemoglobin variant was by electrospray mass spectrometry.

Teaching the theory behind guidelines: the Royal College of General Practitioners Guidelines Skills Course

In the face of a perceived lack of widespread understanding of the theoretical issues underlying the development, dissemination and implementation of clinical guidelines, the Royal College of General Practitioners Guidelines Group developed a 2-day course aimed at teaching the theory in these areas. The course was targeted at potential opinion formers and ran on six occasions. Postal questionnaire assessment of the course revealed high levels of satisfaction with all aspects of the course and high levels of reported use of the knowledge gained. Further developments of the course are discussed.

Measuring outpatient resource use and case mix in ophthalmology in north east England

OBJECTIVES

To test the extent to which two existing ambulatory case mix measures (Ambulatory Visit Groups and Ambulatory Patient Groups) and other variables can explain resource use variations in ophthalmic outpatient visits.

DESIGN

Three week prospective study of three consultant outpatient clinics.

SETTING

One ophthalmic hospital (Sunderland Eye Infirmary, Sunderland, Tyne and Wear) and three outreach clinics (South Tyneside District Hospital, South Shields, Tyne and Wear; Dryburn Hospital, Durham, Co Durham; and Hartlepool General Hospital, Hartlepool, Cleveland).

SUBJECTS

325 patients who visited ophthalmic outpatient clinics.

MAIN OUTCOME MEASURES

Mean consultation time and mean cost distributions by case mix group, analysed by analysis of variance.

RESULTS

Ambulatory case mix measures can explain some of the variation in resource use for outpatient visits, but different measures differ in the extent to which they can do so. Clinicians' behaviour also accounts for a significant amount of such variation. Simpler measures of visit type, without diagnostic or procedure information, do not explain resource use variations.

CONCLUSIONS

Existing measures perform reasonably well, but their data requirements may preclude their introduction in the National Health Service. Caution is required in advocating simpler measures, however. The influence of clinical practice on resource use variations is important; in this study, most differences between clinicians were not attributable to differences in case mix.

The philosophy of clinical practice guidelines: purposes, problems, practicality and implementation

There are a number of technical and professional challenges to the use of clinical practice guidelines in the United Kingdom. Until recently, many guidelines have been consensus-based rather than being explicitly linked to evidence of effectiveness and have also been of variable quality. Moreover, clarity of purpose has been lacking with some guidelines being developed as a means of limiting access to secondary care rather than as a means of assisting clinical decision-making. Implementation of new research into practice and of clinical practice guideline recommendations shares many of the same barriers to changing clinician behaviour. Without local support systems to assist with implementation, including clinical audit programmes and methods of feeding back information on current practice, it is unlikely that guidelines will change practice in the majority of clinicians. Progress on the implementation of guidelines in the British National Health Service is discussed.

On-line processing of filler-gap construction in aphasia

Two experiments were conducted exploring on-line processing of filler-gap construction in aphasia. An auditory-auditory lexical decision paradigm was used to investigate whether Broca's and Wernicke's aphasic patients show, as do normals, reactivation of the filler at the gap site. Experiment I investigated the processing of a number of filler-gap constructions including wh-questions, relative clauses as subject, relative clauses as object, and embedded wh-questions. Broca's aphasics showed reactivation of the filler at the gap site, whereas Wernicke's aphasics did not. Experiment II examined object relative clauses and their processing by Broca's aphasics. In addition, we investigated whether the presence (or absence) of the relative pronoun played any role in on-line processing. Broca's aphasics performed as did normals. In addition, their performance was unaffected by the presence or absence of the relative pronoun. The results of these experiments suggest that Broca's aphasics do not have an impairment in processing or representing thematic relationships of NP arguments to predicates or relating traces to their antecedents.

The inter-rate reliability of a generic measure of severity of illness

BACKGROUND

There has been increasing interest in the development of measures to quantify baseline severity of illness and thus provide a more meaningful interpretation of health outcomes.

OBJECTIVE

We aimed to assess the inter-rater reliability of a generic measure of illness severity, the Duke University Severity of Illness (DUSOI) checklist.

METHODS

Selected general practices and hospital outpatient departments across Tyneside and Humberside in the UK were used as the setting. Thirty-three clinicians were posted copies of the same set of 14 patient records and asked to rate the severity of illness of each patient using the DUSOI. The subjects were 27 GPs, three consultant chest physicians and three diabetologists. The main outcome measures were: (i) intraclass correlation coefficients used to express clinician agreement upon severity scores; and (ii) a 'gold standard', constructed in order to assess clinician agreement upon the health problems identified in the patient record to be considered as constituents of overall severity.

RESULTS

It was found that the degree of inter-rater reliability of severity scoring was satisfactory, with an intraclass correlation coefficient of 0.43. In terms of identification of problems to be rated, there was considerable agreement between raters and a specially compiled 'gold standard' of health problems.

CONCLUSION

The DUSOI has potential use in routine clinical practice, but strategies should be developed in order to maximize the reliability of rating illness severity on such a generic measure.

Mutation of the Stargardt disease gene (ABCR) in age-related macular degeneration

Age-related macular degeneration (AMD) is the leading cause of severe central visual impairment among the elderly and is associated both with environmental factors such as smoking and with genetic factors. Here, 167 unrelated AMD patients were screened for alterations in ABCR, a gene that encodes a retinal rod photoreceptor protein and is defective in Stargardt disease, a common hereditary form of macular dystrophy. Thirteen different AMD-associated alterations, both deletions and amino acid substitutions, were found in one allele of ABCR in 26 patients (16%). Identification of ABCR alterations will permit presymptomatic testing of high-risk individuals and may lead to earlier diagnosis of AMD and to new strategies for prevention and therapy.

Antibodies to CD44 enhance adhesion of normal CD34+ cells and acute myeloblastic but not lymphoblastic leukaemia cells to bone marrow stroma

The role of CD44 in the adhesion of haemopoietic cells to bone marrow stromal layers has not been clearly defined in humans, although its importance in the murine system has been well documented. We have demonstrated that the CD44 antibody, NIH44-1, enhances the adhesion of haemopoietic cells to bone marrow stroma. Normal human CD34+ haemopoietic progenitors and blasts from patients with acute myeloblastic, but not lymphoblastic, leukaemia responded to NIH44-1. All CD44 antibodies tested which bound the same epitope as NIH44-1 also augmented haemopoietic cell adhesion to bone marrow adherent layers; however, antibodies which bound to other CD44 epitopes showed mixed responses. Augmented adhesion was independent of cell metabolism, suggesting that antibody binding resulted in direct activation of the CD44 molecule. However, hyaluronic acid was not the ligand for induced adhesion, nor could we show a role for other CD44 ligands including fibronectin, laminin, collagen or chondroitin sulphate proteoglycan. Similarly, none of the 22 CD44 antibodies tested inhibited the stimulatory effect of the NIH44-1. Expression of CD44 was not sufficient to determine NIH44-1 responsiveness since cell lines and leukaemic cells which failed to respond to NIH44-1 expressed high levels of CD44. Neither CD44 isoforms nor glycosylation patterns could be identified as predictive of response. CD44 antibodies enhanced binding of normal and leukaemic haemopoietic progenitors to bone marrow fibroblasts via an unidentified stromal ligand.

A new self-completion outcome measure for diabetes: is it responsive to change?

Self-completion instruments assessing subjective health are increasingly being used to measure patient outcome. However, there is very little evidence as yet of existing instruments' responsiveness to change. This paper describes a study to evaluate the responsiveness to change of a self-completion instrument for the measurement of clinical outcome in patients with diabetes. A prospective follow-up study of 48 patients with non-insulin-dependent diabetes commencing insulin therapy was carried out, with assessments at baseline (i.e. pre-intervention), 6 weeks and 3 months post-intervention. The outcome measures used were the changes in scores on the self-completion instrument for symptom level, physical function, energy, depression, psychological distress and barriers to activity, HbA1c, non-fasting serum cholesterol and the body mass index (BMI). There were significant improvements in HbA1c and non-fasting serum cholesterol and worsening of the BMI, as expected. The self-completion instrument detected significant improvements in patient-reported symptoms within 6 weeks of the intervention (p < 0.01) and in energy levels (p < 0.05). There is evidence from this study of the self-completion instrument's ability to respond to change and it has potential for use in evaluative studies.

A photoreceptor cell-specific ATP-binding transporter gene (ABCR) is mutated in recessive Stargardt macular dystrophy

Stargardt disease (STGD, also known as fundus flavimaculatus; FFM) is an autosomal recessive retinal disorder characterized by a juvenile-onset macular dystrophy, alterations of the peripheral retina, and subretinal deposition of lipofuscin-like material. A gene encoding an ATP-binding cassette (ABC) transporter was mapped to the 2-cM (centiMorgan) interval at 1p13-p21 previously shown by linkage analysis to harbour the STGD gene. This gene, ABCR, is expressed exclusively and at high levels in the retina, in rod but not cone photoreceptors, as detected by in situ hybridization. Mutational analysis of ABCR in STGD families revealed a total of 19 different mutations including homozygous mutations in two families with consanguineous parentage. These data indicate that ABCR is the causal gene of STGD/FFM.

Effects of Common Estuarine Pollutants on the Immune Reactions of Tunicates

Tunicates are filter-feeding estuarine and marine animals that are frequently exposed to chronic environmental pollution. This study demonstrates that exposure to low-level (i.e., below the threshold of acute lethality) contamination with tributyltin, creosote, and copper can have substantial effects on natural immune reactions in tunicates. Sublethal doses of toxicants administered either in vitro or in vivo profoundly affected phagocytosis, cellular cytotoxicity, and hematopoietic cell proliferation. Effects were not always inhibitory, and responses often varied depending on the route of toxicant administration. The data suggest that pollutants can activate cascades of cellular processes and compensatory mechanisms, as well as directly inhibiting some of the responses tested. Some evidence indicates that toxicants exert their effects by altering the relative frequencies of circulatory hemocytes.

Initial experience with hysteroscopic endometrial resection/ablation using a new specialized tissue aspirating resectoscope

Hysteroscopy is gaining increasing acceptance among surgeons as the initial surgical treatment of choice for managing abnormal uterine bleeding and submucous fibroids. With refinements in electrosurgery and laser ablation instruments, and the development of continuous-flow resectoscopes, hysteroscopic techniques are proving to be cost-effective alternatives to hysterectomy for an ever expanding range of treatment indications.

Continuous real-time monitoring of patient fluid status during hysteroscopic surgery

Although the development of continuous-flow resectoscopes has revolutionized hysteroscopic surgery, the necessity of using electrolyte-free irrigating solutions to distend the uterus has also introduced a risk of serious or fatal clinical complications should a patient absorb an excessive volume of fluid during the operation.

Accuracy and reliability of assessment of severity of illness before and after an educational intervention

Severity-of-illness measurement is considered to be an important factor in the risk adjustment of medical outcomes. However, for those measures that involve a high level of clinical judgment, strategies have to be developed to maximize the consistency of rating severity that can be implemented, especially when rating is based upon medical record review. A group of 25 clinicians were sent the same set of 14 patient records, and requested to use the Duke University Severity of Illness (DUSOI) checklist to rate the severity of patients' illness. Written instructions for the use of this instrument were provided. A short educational intervention was than made by the research team, and the clinicians were sent the same set of records to be rated again. Any improvement in the accuracy and reliability of severity assessment over the two ratings was then studied. The educational intervention resulted in identification of fewer irrelevant health problems. However, it had little impact upon the reliability of severity scoring itself, as measured by the intraclass correlation coefficient. Measuring severity of illness is a conceptually complex procedure. However, given its role in outcome interpretation, it may be worth pursuing strategies aimed at maximizing consistency of clinician rating. There are a number of options, including improved written instructions and more intensive training, that could be implemented.