A lifecourse study of risk for hyperinsulinaemia, dyslipidaemia and obesity (the central metabolic syndrome) at age 49-51 years

AIMS

Suboptimal maternal nutrition and catch-up growth in early childhood predispose to insulin resistance and other components of metabolic syndrome in later life. A central metabolic syndrome (CMS) has been identified comprising obesity, dyslipidaemia and insulin resistance. This study was designed to investigate determinants of risk for CMS.

METHODS

Persons born in Newcastle in May and June 1947 (n = 358) were followed to 1996-1998. A lifecourse approach was used to estimate the proportion of variance in a summary measure of CMS at age 49-51 years accounted for by factors operating at different stages of life.

RESULTS

After adjustment for other early life variables, childhood catch-up growth in men accounted for significant variation in the CMS score independent of adult lifestyle. In adulthood, exercise level in men and smoking in both genders were independently associated with CMS. Over two-thirds of explained variation in the CMS score in women, and almost half in men, was accounted for exclusively by factors measured in adulthood.

CONCLUSIONS

While risk for CMS in men is compounded by early life disadvantage, promotion of a healthier adult lifestyle and a reduction in the number of people taking up smoking would appear to be the public health interventions most likely to reduce the prevalence of CMS in middle age.

Childhood leukaemia and non-Hodgkin's lymphoma in relation to proximity to railways

We investigated whether living close to railway lines is a risk factor for childhood leukaemia and non-Hodgkin's lymphoma in electoral wards in England and Wales, 1966-1987. The national rail network, 1966-1987, was digitised and the numbers of cases in each ward were related to two measures of environmental exposure to railways: a proximity and a density function, contributions to these functions being weighted by the frequency of use and time in use of each stretch of railway. Poisson regression was used to derive rate ratios in relation to these measures of exposure to railways, both unadjusted and adjusted for population mixing. We found no association between risk of leukaemia and railway proximity (unadjusted rate ratio for trend from the lowest to the median value=1.006, 95% CI: 0.998 - 1.013, P=0.14) and a very small association with railway density, of marginal statistical significance (rate ratio for trend=1.001, 95% CI: 1.000 - 1.003, P=0.05). This effect depended on two deprived, urban wards with high railway density and high population mixing and became nonsignificant (P=0.09) after allowing for population mixing. The very weak association between railway density and risk of childhood leukaemia is likely to be a consequence of the association between population mixing and proximity to railways in very deprived, urban wards.

Regulation of BMP and Activin Signaling in Drosophila

Cytokines of the TGF-beta superfamily act through an evolutionarily conserved signaling pathway to elicit a diverse range of biological responses in vertebrates as well as invertebrates. Drosophila has proved to be a powerful system to unravel the profound complexities underlying the regulation of this superficially simple signaling system for two reasons--the availability of sophisticated genetic tools and the restricted number of core signaling components compared to vertebrates. A BMP signaling pathway in Drosophila that regulates growth, differentiation and morphogenesis of the embryo and the larva has been extensively characterized. This work has provided major insights into how gradients of secreted proteins can be established and maintained in vivo, allowing a single ligand to induce multiple cell fates rather than function as an on-off switch. More recently, an activin signaling pathway has also been delineated that is required for growth and neuronal function during development. This review provides an overview of TGF-beta signaling in Drosophila with emphasis on the extensive modulation of signaling activity both within and outside the cell, that enables ligands to trigger specific and context-dependent effects.

Dose-response effect of walking exercise on weight loss. How much is enough?

OBJECTIVE

Exercise is the cornerstone of behavioral weight loss programs. The total volume of exercise needed to both promote weight loss and elicit health benefits has not been sufficiently investigated. The aim of this study was to examine the effects of two different volumes of walking 'metabolic fitness' exercise prescriptions, in combination with a low-fat, ad libitum diet (LFAL) on weight loss and additional modifiable health-related variables (HRV) in an ethnically diverse sample of overweight premenopausal women.

DESIGN

Clinical 12 week weight loss intervention study with a 5.0-5.8 MJ diet daily with (a). participants walking 30 min, 5 days per week (DEX1), (b). participants walking 60 min, five times per week (DEX2) or (c). a diet only control group (DO).

SUBJECTS

A mixed racial sample (predominantly Hispanic) of 56 subjects (mean BMI=34.26+/-6.61, mean age= 39.45+/-7.34) completed the 12 week program.

MEASUREMENTS

Various body weight, body composition and fat distribution variables, dietary intake and additional HRV such as blood lipids, blood pressure and an estimate of cardiorespiratory fitness at baseline and after 3 months.

RESULTS

All groups showed similar and significant (P<0.001) declines in body weight, percentage body fat, BMI, WHR, fat mass, fat-free mass and diastolic blood pressure following the program. In addition, total cholesterol, triacylglycerol and the TC:HDL ratio displayed a significant time effect (P<0.05). Significant interactions (P<0.05) were found for waist circumference, sagittal diameter, estimated VO(2max) and LDL-C, with both exercise groups showing similar and significantly greater (P<0.05) improvements than DO. Significant interactions (P<0.05) were also observed for several dietary variables.

CONCLUSION

Our study showed no dose-response effect of walking exercise on weight loss over diet alone. Both lower and higher volume metabolic fitness prescriptions resulted in similar and significant beneficial changes in several HRV. This data suggests that 30 min of walking on most days of the week may be as beneficial as 60 min (in combination with diet) in promoting numerous additional healthful outcomes over diet alone following a 12 week weight loss program.

Childhood solid tumours in relation to infections in the community in Cumbria during pregnancy and around the time of birth

In a retrospective cohort study of all 99 976 live births in Cumbria, 1975-1992, we investigated whether higher levels of community infections during the mother's pregnancy and in early life were risk factors for solid tumours (brain/spinal and other tumours), diagnosed 1975-1993 under age 15 years. Logistic regression was used to relate risk to incidence of community infections in three prenatal and two postnatal quarters. There was an increased risk of brain/spinal tumours among children exposed around or soon after birth to higher levels of community infections, in particular measles (OR for trend=2.1, 95%CI : 1.3-3.6, P=0.008) and influenza (OR for exposure=3.3, 95%CI : 1.5-7.4, P=0.005). There was some evidence of an association between exposure to infections around and soon after birth and risk of other tumours, but this may have been a chance finding. The findings are consistent with other recent epidemiological studies suggesting brain tumours may be associated with perinatal exposure to infections.

Population mixing and childhood leukaemia and non-Hodgkin's lymphoma in census wards in England and Wales, 1966-87

We found an increased risk of childhood leukaemia with higher levels of inward migration, particularly from outside the region (rate ratio=1.9, 95%CI: 1.2-2.9, P<0.01). This significant effect was observed only in urban areas, although a marked but non-significant effect was seen in affluent, rural areas.

Paternal preconceptional irradiation, population mixing and solid tumors in the children of radiation workers (England)

OBJECTIVE

To investigate whether there was an increased incidence of solid tumors among offspring of male radiation workers at the Sellafield nuclear installation in Cumbria, northwest England and whether paternal preconceptional irradiation was associated with the risk of solid tumors.

METHODS

A cohort study of 266,710 live births in Cumbria, 1950-1991, followed up to age 25 years on the end of 1991.

RESULTS

Children of radiation workers had a non-significantly increased risk of solid tumors (RR= 1.5, 95% CI: 0.9-2.4, p = 0.09), determined largely by an increased risk of cancers excluding leukemias, lymphomas, brain, spinal and gender-specific tumors (RR= 1.9, 95% CI: 1.0-3.3, p = 0.05), which was partly explained by differing patterns of parental migration (adjusted RR= 1.7, 95% Cl: 0.8-3.2, p = 0.50). Within children of radiation workers there was no evidence of an increased risk with increasing paternal preconception dose of external radiation (hazard ratio per 100 mSv for all solid tumors=0.6, 95% CI: 0.1-1.8, p = 0.52).

CONCLUSIONS

Any observed excess of solid tumors in children of radiation workers may be partly explained by population mixing. Fathers' occupational exposure to radiation before conception was not found to be risk factor for solid tumors in their children.

Rapid MR imaging detection of renal cysts: age-based standards

PURPOSE

To establish age-based standards for renal cysts depicted at magnetic resonance (MR) imaging and to compare these standards with existing standards for ultrasonography (US).

MATERIALS AND METHODS

Three radiologists reviewed subsecond T2-weighted single-shot fast spin-echo kidney MR imaging findings in 528 patients (248 men, 280 women) selected from consecutive abdominal MR studies without regard to clinical indication. Age, sex, and number and diameter of cysts were noted. Results were analyzed with nonparametric tests and were compared with published US results.

RESULTS

Men (mean, 2.0; 95% CI: 1.5, 2.5) had more renal cysts than women (mean, 1.2; 95% CI: 0.9, 1.5) (P < .001). Number and diameter of cysts increased with age (P < .001). Of 528 patients, 330 (62.5%) had at least one renal cyst, and 315 (59.7%) had cysts of 10 mm or less. MR imaging findings were comparable to published US criteria for type 1 autosomal dominant polycystic kidney disease (ADPKD) if only cysts larger than 1 cm were considered: Only one subject in the group of 18-29-year-old subjects had at least two renal cysts, and five of 493 subjects aged 30-59 years had at least two cysts in each kidney.

CONCLUSION

Compared with reported US results, MR imaging depicted an increased number of simple renal cysts in healthy individuals because of its increased sensitivity for cysts smaller than 1 cm. If only simple renal cysts larger than 1 cm are considered, US criteria for type 1 ADPKD can be applied to MR imaging.

Implications of childhood obesity for adult health: findings from thousand families cohort study

OBJECTIVE

To determine whether being overweight in childhood increases adult obesity and risk of disease.

DESIGN

Prospective cohort study.

SETTING

City of Newcastle upon Tyne.

PARTICIPANTS

932 members of thousand families 1947 birth cohort, of whom 412 attended for clinical examination age 50.

MAIN OUTCOME MEASURES

Blood pressure; carotid artery intima-media thickness; fibrinogen concentration; total, low density lipoprotein, and high density lipoprotein cholesterol concentrations; triglyceride concentration; fasting insulin and 2 hour glucose concentrations; body mass index; and percentage body fat.

RESULTS

Body mass index at age 9 years was significantly correlated with body mass index age 50 (r=0.24, P<0.001) but not with percentage body fat age 50 (r=0.10, P=0.07). After adult body mass index had been adjusted for, body mass index at age 9 showed a significant inverse association with measures of lipid and glucose metabolism in both sexes and with blood pressure in women. However, after adjustment for adult percentage fat instead of body mass index, only the inverse associations with triglycerides (regression coefficient= -0.21, P<0.01) and total cholesterol (-0.17, P<0.05) in women remained significant.

CONCLUSIONS

Little tracking from childhood overweight to adulthood obesity was found when using a measure of fatness that was independent of build. Only children who were obese at 13 showed an increased risk of obesity as adults. No excess adult health risk from childhood or teenage overweight was found. Being thin in childhood offered no protection against adult fatness, and the thinnest children tended to have the highest adult risk at every level of adult obesity.

The Peterborough Schools Nutrition Project: a multiple intervention programme to improve school-based eating in secondary schools

OBJECTIVE

To evaluate over two years the effectiveness of multiple interventions targeted at lunches in secondary schools with the aim of increasing the consumption of healthier foods by children during the school day.

DESIGN

Controlled comparison study of two intervention schools targeted with multiple interventions to increase both the availability and the number of pupils consuming healthier foods, and one control school with no interventions but with the same observations over a two-year period.

SETTING

Three secondary schools in Peterborough, England.

SUBJECTS

Secondary school children in the three schools taking school lunches between 1996 and 1998.

RESULTS

School Food Groups (SFGs) were set up in both intervention schools. All catering interventions were actioned via the SFGs. Of the food availability targets, only the target to increase the availability of high-fibre bread in both intervention schools was met. The availability of food items at the control school remained stable. The proportion of pupils consuming fruit and vegetables/salad was very low in all schools at baseline. There were positive changes for consumption of fruit and non-fried potato in one intervention school, and for high-fibre bread and non-cream cakes at the other in the short term, but only that for high-fibre bread was close to being sustained at the end of the two years. The dietary consumption target for vegetables/salad was achieved by the final monitoring period in one school.

CONCLUSION

Overall there were no significant changes in school-based eating at the end of the study. Some positive changes were made, with some of the dietary targets being achieved at an early stage but not sustained. Ultimately this study has shown how difficult it is to achieve sustained dietary changes in the eating habits of secondary school children, even with considerable input.

Vectors for the expression of tagged proteins in Drosophila

Regulated expression systems have been extremely useful in developmental studies, allowing the expression of specific proteins in defined spatial and temporal patterns. If these proteins are fused to an appropriate molecular tag, then they can be purified or visualized without the need to raise specific antibodies. If the tag is inherently fluorescent, then the proteins can even be visualized directly, in living tissue. We have constructed a series of P element-based transformation vectors for the most widely used expression system in Drosophila, GAL4/UAS. These vectors provide a series of useful tags for antibody detection, protein purification, and/or direct visualization, together with a convenient multiple cloning site into which the cDNA of interest can be inserted.

Seasonality of birth for cancer in Northern England, UK

Environmental factors operating around the time of birth may influence the subsequent development of childhood cancer, particularly leukaemia. Certain factors may vary with season (e.g. infections), and we therefore investigated whether there was any evidence of seasonality of month of birth, based on data from 4199 children diagnosed with cancer under the age of 15 years. We extracted details of (i) children born 1960-95 and diagnosed 1968-95 from two population-based registries, covering the Northern (n = 2053) and Yorkshire (n = 1977) Regional Health Authority and (ii) children born in Cumbria 1950-93 and diagnosed anywhere in the UK before 1994 from a birth cohort database (n = 397). The following diagnostic categories were analysed: 0-14 years--all cancers, leukaemias, acute lymphoblastic leukaemias, central nervous system tumours, all other solid tumours; 1-6 years--leukaemias, acute lymphoblastic leukaemias. Seasonal variation was tested using Walter and Elwood's test, and logistic regression analysis allowing for cyclical variation in month of birth. No evidence of seasonality was present for any group except acute lymphoblastic leukaemia diagnosed among 1- to 6-year-olds. Seasonal trends varied by region: in the Northern and Cumbrian datasets, seasonality patterns were significant and similar (P < 0.05) with a predicted peak in early spring, whereas in Yorkshire there was less strong evidence of seasonality (P = 0.08) with a peak predicted in late summer. These findings suggest that local seasonal environmental factors operating around the time of birth are not associated with the totality of childhood cancer, but possible links with acute lymphoblastic leukaemia are supportive of a hypothesis of an infectious aetiology.

Use trends and geographic variation in neuroimaging: nationwide medicare data for 1993 and 1998

BACKGROUND AND PURPOSE

Powerful tools, including CT and MR imaging, have revolutionized neuroimaging. These are routinely used, but the extent and variation of use has not been studied. Our purposes were to determine the use rates of MR imaging and CT (of spine, brain, or head and neck), myelography, conventional angiography, and MR angiography in diagnosing neurologic disorders; to study trends in use; and to determine regional variations in use.

METHODS

We used the National Part B Medicare Database for 1993 and 1998 to compare rates of use for these procedures in 10 geographic regions.

RESULTS

In 1993 and 1998, respectively, 13,897 and 19,431 (39.8% increase) neuroimaging procedures were performed per 100,000 Medicare beneficiaries nationwide. Use of brain or head and neck CT (30.4%) and MR imaging (43.6%), spinal CT (3.5%) and MR imaging (83.0%), myelography (56.6%), and conventional angiography (24.3%) increased in 1998 versus 1993. Increases in MR angiography were not assessed, because this procedure was not reimbursable in 1993. Regional use of brain or head and neck and spinal CT and MR studies varied considerably; ratios of highest and lowest rates were 1.38-1.56. Use of MR angiography, myelography, and conventional angiography varied three- to fourfold.

CONCLUSION

Use of MR and CT studies of the brain or head and neck and of the spine increased considerably in the Medicare population between 1993 and 1998. Use of conventional invasive procedures such as myelography and angiography increased strikingly, contrary to the expected decline. Regional use varied substantially.

Intraoperative sonographic localization of breast masses: success with specimen sonography and surgical bed sonography to confirm excision

OBJECTIVE

To assess the use of intraoperative sonography for localization of breast masses at excisional biopsy, with specimen and surgical bed sonography to confirm excision.

METHODS

A computer search of the 5-year period from January 1993 through January 1998 revealed 138 consecutive women referred for sonographically guided excisional biopsy of 148 masses; 35 masses were excluded because they had no postoperative mammograms. One hundred thirteen masses constituted the study group. Specimen sonography (n = 60) or surgical bed sonography (n = 53) was performed as the initial evaluation to confirm excision, but ultimately, surgical bed sonography may have been necessary after specimen sonography, and specimen sonography may have been necessary after surgical bed sonography. The miss rates determined by postoperative imaging were calculated for each group and compared with those of mammographically guided needle localization series from the literature.

RESULTS

Follow-up physical examination and mammography showed no residual mass in the region of surgery in any patient. However, follow-up sonography had 1 miss in the initial specimen sonogram group (1 [1.7%] of 60) and 1 miss in the initial surgical bed group (1 [1.9%] of 53). As shown by the Fisher exact test, there was no significant difference between the miss rates of the 2 initial methods of confirming lesion excision or between the miss rates of these initial methods, both groups combined, and 6 mammographic localization series from the literature.

CONCLUSION

Intraoperative breast sonography, using specimen sonography and scanning the surgical bed, has miss rates comparable with those of mammographic needle localization. Follow-up sonography must be performed if there is any doubt of complete excision.

Comparison of unenhanced and contrast-enhanced spiral CT for assessing interval change in patients with colorectal liver metastases

RATIONALE AND OBJECTIVES

The purpose of this study was to determine whether the interval change in hepatic colorectal metastases as assessed with serial computed tomographic (CT) scans without contrast material enhancement differs from that as assessed using serial, portal dominant phase, contrast-enhanced CT scans.

MATERIALS AND METHODS

Unenhanced and contrast-enhanced abdominal CT scans were obtained in 28 patients. Three radiologists separately reviewed serial unenhanced and contrast-enhanced studies to assess the interval change in liver metastases. These radiologists recorded total number of lesions, bidimensional measurements of the largest lesions (as many as three), and overall impressions regarding the interval change (none, worse, or better).

RESULTS

Among the 84 judgments (28 patients x 3 radiologists), comparisons of unenhanced and contrast-enhanced CT studies were concordant in 60 assessments (71%). Nineteen (23%) showed mild disagreement. Of these, contrast-enhanced CT studies demonstrated disease stability when unenhanced CT studies demonstrated otherwise in 11 judgments, whereas unenhanced CT studies demonstrated stability when contrast-enhanced CT studies demonstrated otherwise in eight assessments. Furthermore, of the five marked disagreements, two resulted from a conclusion of interval improvement on unenhanced CT studies and a conclusion of interval worsening on contrast-enhanced CT studies, whereas three demonstrated the opposite. Neither set of serial CT studies systematically resulted in under- or overestimation of disease progression (McNemar Q test, P < .25).

CONCLUSION

The authors found no consistent pattern to demonstrate that serial unenhanced or contrast-enhanced CT studies resulted in over- or underestimation of disease progression.

How complete and accurate are cancer registrations notified by the National Health Service Central Register for England and Wales?

STUDY OBJECTIVE

To assess the completeness and accuracy of notification of cancers by the National Health Service Central Register (NHSCR) for England and Wales.

DESIGN

Comparison of 720 cancer registrations ascertained from NHSCR up to May 1999 with those ascertained for the same cohort from six other sources and a pathology review of the NHSCR cancer registrations.

PARTICIPANTS

People born in Cumbria, north west England, 1950-89, and diagnosed with cancer throughout the UK, 1971-1989.

MAIN RESULTS

Cancer diagnoses notified by NHSCR differed substantially from those determined by this pathology review for 47 of the 688 notified cases reviewed (7%; 95% CI 5%, 9%). Over one third of these discrepancies were attributable to failures in data capture or coding by the cancer registration system and almost half to changes in diagnosis; 26 of the 47 discrepant cases were reclassified as non-malignant and 21 as malignancies but with a substantially different diagnosis. The 694 confirmed malignancies represented 94% (95%CI 92%, 95%) of the 740 cancers ascertained from all sources.

CONCLUSIONS

It is estimated that the cancer registration system missed at least 10% (95%CI 6%, 15%) of all incident cases of malignant disease. Without additional ascertainment from multiple sources and diagnostic review, it would be incautious to use NHSCR cancer registrations as the sole basis of an epidemiological study.

Thyroid cancer in children and young adults in the North of England. Is increasing incidence related to the Chernobyl accident?

Population-based data on thyroid carcinomas was obtained from the Northern Region Young Person's Malignant Disease Registry to analyse the incidence of thyroid cancers in young people (<25 years) in the North of England for the period 1968 and 1997 and to assess if changes in incidence were consistent with the spatial and temporal distribution of the fallout from the Chernobyl nuclear accident. We compared incidence rates for differentiated (papillary or follicular) thyroid carcinomas 1968-1986 with those for 1987-1997. There were 75 cases of thyroid carcinoma diagnosed over the study period, of which 63 were differentiated carcinoma and 12 were medullary carcinoma. There were 26 young adults (15-24 years) diagnosed with differentiated thyroid carcinoma in the 19-year period 1968-1986 and 30 in the subsequent 11 years 1987-1997, Age standardised rate (ASR) 3.0 versus 6.5, respectively (rate ratio 2.2, 95% confidence interval (CI): 1.3-3.6). There were three children (aged <15 years) diagnosed with differentiated carcinoma in the period 1968-1986 and four in the period 1987-1997, ASR 0.2 versus 0.6 (rate ratio 2.7, 95% CI: 0.6-12.1). Regression models showed a significant increase in the incidence of thyroid cancer after the Chernobyl accident (P=0.002). In Cumbria, the area receiving the heaviest fallout in the UK, the increase in incidence was much greater (rate ratio 12.19, 95% CI 1.5-101.2). These temporal and spatial changes in incidence are consistent with a causal association with the Chernobyl accident although a greater effect in the younger rather than the older age group would have been anticipated. However, factors including improvements in ascertainment and earlier detection of tumours may also have contributed to the increasing incidence. Further collaborative international studies are needed to investigate changes in the incidence of thyroid cancer in children and young adults.

The origins of height fear: an evaluation of neoconditioning explanations

The present research sought to establish a reliable and valid instrument for assessing the relevance of neoconditioning factors (e.g. latent inhibition, UCS inflation/revaluation, prior fear levels, prior expectancies of harm, fear and pain levels experienced during supposed learning events), in the development of human fear. Fifty-four undergraduate height-fearful students completed the new origins instrument (OQ-II), while 54 matched controls completed a modified version (OQM-II) that examined their prior experiences with heights. In general, few differences between groups were found. Height-fearful and control subjects did not differ on trait anxiety, the frequency of negative encounters with heights, the age at which these events had occurred, prior fear levels, prior expectancies of harm, or reports of UCS inflation/revaluation procedures. However, in a finding directly opposite to that expected from a conditioning account, the mean fear and pain scores reported by subjects who had experienced direct conditioning events were significantly higher in the non-fearful group than in the height-fearful group. These findings are discussed in terms of associative and non-associative models of fear.

Childhood cancer registrations in the developing world: still more boys than girls

It has been shown previously that in many developing countries the reported incidence of childhood cancer for boys is substantially higher than for girls and that this difference is related to economic development of the country under study. The aim of the present study was to investigate the relationship between the sex ratio of children registered with malignant diseases and national economic development. Sex ratios for childhood cancer registration were obtained for populations within 53 countries from the second volume of the International Incidence of Childhood Cancer (range boys:girls 1.09-2.05). Demographic, economic and health data for the corresponding countries were obtained from published statistics and used to determine the extent to which sex ratios were associated with national economic status. The ratio of boys:girls registered with childhood cancer increased with decreasing gross domestic product and with increasing infant mortality, suggesting that boys are increasingly more likely than girls to be registered with increasing economic disadvantage. Combining these results with childhood cancer registration data from northern England suggests that little of the predominance of boys reaching a specialist centre can be explained by differences between boys and girls in early deaths from the disease. The previously observed differences in the childhood cancer registration sex ratio in developing countries still exist. Hence, international differences in the incidence of childhood cancer should be interpreted cautiously as they may not necessarily reflect only differences in the underlying occurrence of disease

A self-administered instrument for assessing therapeutic approaches of drug-user treatment counselors

In this article we describe the development and psychometric properties of a self-administered instrument for assessing drug-user treatment counselors' therapeutic approaches such as psychodynamic or interpersonal, cognitive-behavioral, family systems or dynamics, 12-step, and case management. We generated an initial pool of items corresponding to these five approaches and modified them based on expert ratings. We developed three sets of items. The first concerned the beliefs underlying each therapeutic approach. The second and third concerned the practices of each applicable approach within individual and group counseling, respectively. With the exception of case management, an approach that originated within social work and which is only applicable to individual counseling, the other four approaches are applicable, at least theoretically, to both individual and group counseling. Additionally, we included items that describe techniques used exclusively with groups (i.e., group techniques). Finally, we included some items that are not associated with any of the traditional approaches but which reflect the practical approach that drug-user treatment programs often take to both individual and group counseling (i.e., practical counseling). The initial instrument consisted of 17 subscales with a total of 76 items. This instrument was administered to 226 counselors from 45 drug-user treatment programs in Los Angeles County. Based on this data, we further refined these scales using confirmatory factor analysis to ensure both construct validity and discriminant validity. The final instrument consisted of 14 subscales with a total of 48 items.

Specificity of natural and artificial substrates for human Cdc25A

Cdc25A is a dual-specific protein phosphatase involved in the regulation of the kinase activity of Cdk-cyclin complexes in the eukaryotic cell cycle. To understand the mechanism of this important regulator, we have generated highly purified biochemical reagents to determine the kinetic constants for human Cdc25A with respect to a set of peptidic, artificial, and natural substrates. Cdc25A and its catalytic domain (dN25A) demonstrate very similar kinetics toward the artificial substrates p-nitrophenyl phosphate (k(cat)/K(m) = 15-25 M(-1) s(-1)) and 3-O-methylfluorescein phosphate (k(cat)/K(m) = 1.1-1.3 x 10(4) M(-1) s(-1)). Phospho-peptide substrates exhibit extremely low second-order rate constants and a flat specificity profile toward Cdc25A and dN25A (k(cat)/K(m) = 1 to 10 M(-1) s(-1)). In contrast to peptidic substrates, Cdc25A and dN25A are highly active phosphatases toward the natural substrate, T14- and Y15-bis-phosphorylated Cdk2/CycA complex (Cdk2-pTpY/CycA) with k(cat)/K(m) values of 1.0-1.1 x 10(6) M(-1) s(-1). In the context of the Cdk2-pTpY/CycA complex, phospho-threonine is preferred over phospho-tyrosine by more than 10-fold. The highly homologous catalytic domain of Cdc25c is essentially inactive toward Cdk2-pTpY/CycA. Taken together these data indicate that a significant degree of the specificity of Cdc25 toward its Cdk substrate resides within the catalytic domain itself and yet is in a region(s) that is outside the phosphate binding site of the enzyme.

A new look at the accelerating universe

We show that the cosmological model having zero cosmological constant, but containing the vacuum energy of a simple quantized free scalar field of low mass (VCDM model), agrees with the cosmic microwave background radiation (CMBR) and supernova (SNe-Ia) data at least as well as the classical cosmological model with a small nonzero cosmological constant. We also show that in the VCDM model the ratio of vacuum pressure to vacuum energy density is less than -1. We display the VCDM results for a set of parameters that give a very good fit to the CMBR power spectrum, and show that the same parameters also give a good fit to the SNe-Ia data.

Neuroblastoma: changing incidence and survival in young people aged 0-24 years. A report from the North of England Young Persons' Malignant Disease Registry

BACKGROUND AND PROCEDURE

Population based data for neuroblastoma in children and young adults under 25 years at diagnosis were ascertained from the Northern Region Young Persons' Malignant Disease Registry for the period 1968-1995. Age-standardised incidence rates were calculated (ASR) and changes in incidence and survival were investigated. Over the study period 144 patients were registered, of these 136 were children under 15 years at diagnosis (median age: 2.2 years, ASR: 8.6 cases per million children per year), and 8 were 15-24 years (ASR 0.6).

RESULTS AND CONCLUSIONS

Incidence of childhood neuroblastoma in the North of England increased significantly over time; ASRs were 5.8 for 1968-1981 and 9.5 for 1982-1995 (rate ratio: 1.6, 95%; CI 1.2-2.3). The increase in incidence was seen in both infants and older children, and in both low stage and advanced disease. Overall 5 year survival was 15% for 1968-1981 and 40% for 1982-1995 (P < 0.0001). Significant improvements in survival were documented across different stage and age-groups, including those over 1 with stage 4 disease (0% versus 18%, P < 0.0001). Further research is needed to investigate the reasons for the increasing incidence of neuroblastoma.

A common variant in BRCA2 is associated with both breast cancer risk and prenatal viability

Inherited mutations in the gene BRCA2 predispose carriers to early onset breast cancer, but such mutations account for fewer than 2% of all cases in East Anglia. It is likely that low penetrance alleles explain the greater part of inherited susceptibility to breast cancer; polymorphic variants in strongly predisposing genes, such as BRCA2, are candidates for this role. BRCA2 is thought to be involved in DNA double strand break-repair. Few mice in which Brca2 is truncated survive to birth; of those that do, most are male, smaller than their normal littermates and have high cancer incidence. Here we show that a common human polymorphism (N372H) in exon 10 of BRCA2 confers an increased risk of breast cancer: the HH homozygotes have a 1.31-fold (95% CI, 1.07-1.61) greater risk than the NN group. Moreover, in normal female controls of all ages there is a significant deficiency of homozygotes compared with that expected from Hardy-Weinberg equilibrium, whereas in males there is an excess of homozygotes: the HH group has an estimated fitness of 0.82 in females and 1.38 in males. Therefore, this variant of BRCA2 appears also to affect fetal survival in a sex-dependent manner.

Three-dimensional multiplanar transvaginal ultrasound of the cervix in pregnancy

OBJECTIVES

To develop a standard technique for using three-dimensional ultrasound (3D US) to study and evaluate the cervix in pregnant women at high risk for premature delivery, comparing the findings on 3D US with those on conventional two-dimensional ultrasound (2D US).

STUDY DESIGN

Twenty-one pregnant women at high risk for premature delivery had a total of 37 transvaginal 2D and 3D US examinations of the cervix between 11 and 32 weeks' gestation. A 3D US vaginal probe (5.0-8.0 MHz, Voluson 530D, Medison, Pleasanton, CA, USA) was used. Measurements made from the 2D and 3D US were compared.

RESULTS

Of the 37 cervical length measurements in 3D US sagittal plane, seven were shorter and three were longer than on 2D US (varying by 5-15 mm) indicating that the true mid-sagittal plane was not obtained in ten (27%) of the 37 2D US examinations. Of 21 examinations showing funneling, funneling was seen on both 2D and 3D US in 15, but was seen only on 3D US in six. There was a significant (P < 0.05) difference between funnel width as measured in the coronal 3D plane versus 2D US, as well as between funnel width in the coronal 3D US plane versus sagittal 3D US plane (P < 0.05). The cerclage was seen in its entirety in nine of 10 examinations; the 3D US axial plane was most valuable for imaging the cerclage.

CONCLUSIONS

3D US appears to offer a more complete assessment of the cervix than 2D US. Multiplanar correlation shows that the standard 2D US sagittal view may under- or over-estimate cervical length. Our preliminary data suggest that 3D US has the potential to improve our understanding of cervical morphology.

Identification of maverick, a novel member of the TGF-beta superfamily in Drosophila

The transforming growth factor-beta (TGF-beta) superfamily of structurally related ligands regulates essential signaling pathways that control many aspects of cell behavior in organisms across the phylogenetic spectrum. Here we report the identification of maverick (mav), a gene that encodes a new member of the TGF-beta superfamily in Drosophila. Phylogenetic analysis and sequence comparison suggest that Mav cannot be easily assigned to any one sub-family, since it is equally related to BMP, activin and TGF-beta ligands. mav maps to the fourth chromosome and is expressed throughout development. In situ hybridization experiments reveal the presence of maternally derived mav transcript in precellular blastoderm embryos. Later in development, mav is expressed in a dynamic pattern in the developing gut, both in endodermal and visceral mesodermal cells. In adult females, high levels of mav mRNA are present in late stage egg chambers.

Vitamin D receptor gene start codon polymorphism (FokI) and bone mineral density in healthy male subjects

OBJECTIVE

The genetic factors determining peak bone mineral density (BMD) in men are not well characterized. Recent studies have investigated the relationship between the start codon polymorphism (SCP) of the vitamin D receptor (VDR) gene and BMD in different populations. We have now examined the relationship between SCP of the VDR gene and BMD in a group of healthy Caucasian men from the north-east of England.

SUBJECTS

Ninety-six healthy men (median age 50, range 40.0-77.0 years).

MEASUREMENTS

Analysis of the FokI genotypes of SCP of the VDR and measurements of BMD at the femoral neck and lumbar spine were performed.

RESULTS

FF, Ff and ff VDR FokI genotypes were found to have the highest, intermediate and the lowest lumbar spine BMD, respectively (Mean +/- SD, for FF 1.07 +/- 0.14, Ff 1.05 +/- 0.16 and ff 0.95 +/- 0.10 g/cm2). There was a significant difference in spine BMD between FF and ff genotypes (P < 0.05, analysis of variance [ANOVA]), but no such difference was apparent between Ff and ff (P > 0.05, ANOVA). Interestingly, there was no association between FokI polymorphism and femoral neck BMD (Mean +/- SD, for FF 0.85 +/- 0.12, Ff 0.87 +/- 0.15 and ff 0.83 +/- 0.15 g/cm2). The distribution of FokI VDR genotypes approached Hardy-Weinberg equilibrium and was similar to that reported for women from different ethnic groups, as the prevalence of FF and ff genotypes was 44% and 16%, respectively.

CONCLUSION

The study shows that in this population of healthy men there is a weak association between lumbar spine bone mineral density and FokI restriction fragment length polymorphism at the translation initiation site of the vitamin D receptor gene.

Role of emergency medicine physicians in US performed in patients in the emergency department: how substantial is their participation?

PURPOSE

To determine the extent to which emergency medicine physicians have assumed responsibility for performing and interpreting ultrasonographic (US) studies in emergency departments (EDs) in the United States.

MATERIALS AND METHODS

The national 1997 Medicare Part B database was searched by using standard US procedure codes, location codes, and physician specialty codes. The authors determined how many US studies were performed in EDs and what percentage of those studies were performed by emergency medicine physicians, radiologists, or other physicians.

RESULTS

During 1997, 234,820 ED US studies within nine major examination categories were performed in Medicare patients nationwide. Emergency medicine physicians performed 1,551 (0.7%) of these studies. When echocardiographic examinations were excluded, emergency medicine physicians performed 458 (0.2%) of the remaining total of 196,158 studies.

CONCLUSION

Although emergency medicine physicians have claimed to be actively involved in ED US on a broad scale, the data reveal that their involvement in 1997 was minimal. This raises doubt as to whether they can properly train their residents to perform US or maintain their own competence at acceptable levels.

Incidence and survival for cancer in children and young adults in the North of England, 1968-1995: a report from the Northern Region Young Persons' Malignant Disease Registry

The Northern Region Young Persons' Malignant Disease Registry records information on young people under 25 years old diagnosed with cancer in the Northern Region of England. Incidence and survival rates were calculated for children and young adults diagnosed with cancer between 1968 and 1995. There were 2099 (M:F 1.28:1) children (age 0-14 years) and 2217 (M:F 1.23:1) young adults (15-24 years) diagnosed with a first cancer between 1968 and 1995. The age-standardized rate (ASR) for childhood cancer was 121 per million 0 to 14 year-olds per year. For young adults the ASR was 175 per million 15 to 24 year-olds, per year. Incidence of childhood cancer increased over time at a rate of 12 extra cases per million children, per decade (P < 0.001). In young adults incidence rates increased by 16 extra cases per million 15 to 24 year-olds, per decade (P < 0.001). For childhood cancer 5-year survival was 42% for those diagnosed 1968-1977, 57% for 1978-1987 and 71% (95% CI 67-75) for 1988-1995. Survival for young adults over the three periods was 45%, 62% and 73% (95% CI 70-78) respectively. The cumulative risk of developing cancer before the age of 25 is 1 in 285. Over the 28-year period there were significant improvements in survival and modest increases in incidence in both children and young adults.

Prevertebral soft tissue swelling following trauma: usefulness following tube placement

OBJECTIVE

Prevertebral soft tissue swelling (PVSTS) is an important marker of spinal trauma. In patients with missed or occult cervical fractures, it may be the only indication of serious injury. It has been anecdotally suggested that PVSTS is not useful following placement of a nasogastric (NGT) or endotracheal (ETT) tube because of possible iatrogenic trauma and/or soft tissue compression. Consequently, we investigated trauma patients for evidence of PVSTS, comparing radiographs performed before and after placement of NGTs and/or ETTs.

DESIGN AND PATIENTS

PVSTS at the C2 and C6 levels was measured on lateral cervical spine radiographs in 102 patients with cervical spine fractures. Measurements were obtained in 66 patients before and after placement of either an NGT (23), ETT (8), or both an NGT and ETT (35). They were also obtained in 36 control patients with fractures and neither an NGT nor ETT, at presentation and after an interval temporally matched to that in the patients with tubes in place.

RESULTS

The group with ETTs showed variable changes to PVSTS (31% increase, 63% decrease, and 6% no change). The group with NGTs also showed variable changes to PVSTS (33% increase, 53% decrease, and 13% no change). The group with ETTs and NGTs similarly showed variable changes to PVSTS (25% increase, 72% decrease, 3% no change). Surprisingly, the control group showed similar temporal changes without tube placement (49% increase, 36% decrease, 13% no change). Analyses using the one-tailed F-test of the ratio of the variance of the tube to non-tube groups and the Mann-Whitney test were performed. No significant difference was found in the prevertebral soft tissues at the C2 level between those with tubes in place and the control subjects. However, at the C6 level there was statistical significance between the groups with NGTs and both NGTs and ETTs versus the non-tube groups. Probability under the F-test for the groups with NGTs and both NGTs and ETTs was 0.001 and 0.005, respectively. Under the Mann-Whitney test, P values for groups with NGTs and both NGTs and ETTs were 0.0002 and 0.0001, respectively.

CONCLUSION

The appearance of PVSTS showed variable and unpredictable changes following ETT, NGT, or combined ETT/NGT placement at the C2 level. This appears to be an artifact of temporal changes. However, at the C6 level, the presence of PVSTS following NGT or ETT and NGT placement (but not ETT placement alone) may be an accurate indirect sign of cervical spine injury.

Individual variation in somatic mutations of the glycophorin-A gene in neonates in relation to pre-natal factors

The frequency of somatic mutations of the glycophorin-A (GPA) gene was measured in red blood cells from a series of newborn babies and related to various epidemiological and lifestyle factors in order to identify those factors that might influence the mutation rate before birth. Although there was substantial variation in the mutation frequencies between individual babies, no specific associations were found with any of the factors explored including smoking, age and social class of the parents, and gender and birth weight of the babies. It is concluded that these factors do not have a substantial effect on the mutational endpoint measured, although this does not necessarily mean that they have no effect on health risk to the offspring. The observed variation in GPA gene mutation frequency must, therefore, be due either to exposure to less obvious external influences or to intrinsic factors.

Applying the principles of infection control to wound care

Human skin in healthy adults is inhospitable organisms. A wound may occur from any accidental or deliberate trauma that breaks the surface of the skin. Once this line of defence is broken there is a risk of infection. All soft tissue injuries, whether chronic, traumatic or surgical, involve the same basic biochemical and cellular processes. This article looks at the risk factors associated with healing of such wounds. The principles of asepsis, wound cleansing agents, choice of dressings and the taking of wound swabs are considered.

Paternal employment in agriculture and childhood kidney cancer

This paper explores the hypothesis that there is an association between risk of childhood kidney cancer and paternal employment in occupations that have potential for exposure to herbicides and/or pesticides. In contrast to a previous study using paternal occupations at the time of the child's death, no significant association was found between such potential paternal exposures (using paternal occupations at the time of the child's birth) and the risk of cancer of the kidney in childhood (OR 0.88, 95% CI 0.20-3.84). In addition, this paper quantifies the extent to which paternal occupational information on death certificates can be used as a proxy for paternal occupation at birth and how such misclassification could affect risk estimates. An example is given showing how a recently reported association between kidney cancer and paternal agricultural employment may have been overestimated as a result of the use of death certificate information.

Additive isotonic regression models in epidemiology

Stone's method for assessing disease risk around a point source through isotonic regression is routinely used in spatial epidemiology. It is useful in situations where the relationship of risk with exposure (distance being commonly used as a surrogate variable) is assumed monotonic but otherwise of unknown form. This paper extends this method to non-spatial epidemiology, where typically two or more risk factors are present. The methodology described is based on the additive isotonic model approach of Bacchetti; versions appropriate to count (Poisson) data and case-control (binomial) data are described. In both cases, adjustment for covariates is incorporated, and a Monte Carlo method of hypothesis testing and interval estimation is presented. The methodology is illustrated through a case-control example concerning the analysis of the possible effect of preconceptional external ionizing radiation doses on the sex ratio at birth among children of fathers working at the Sellafield nuclear installation, Cumbria, U.K.

Can imaging findings help differentiate spinal neuropathic arthropathy from disk space infection? Initial experience

PURPOSE

To determine if radiographic, computed tomographic (CT), and magnetic resonance (MR) imaging findings can help differentiate spinal neuropathic arthropathy from disk space infection.

MATERIALS AND METHODS

Imaging studies in 33 patients were evaluated, including 14 patients with spinal neuropathic arthropathy (12 radiographic, seven CT, and six MR studies) and 19 with disk space infection (13 radiographic, nine CT, and 12 MR studies). Potential imaging discriminators, including endplate sclerosis or erosions, osteophytes, spondylolisthesis, facet involvement (narrowing or erosions), vacuum disk, paraspinal soft-tissue mass, joint disorganization, and osseous joint debris, were recorded, as were MR imaging signal intensity and gadolinium-enhancement characteristics.

RESULTS

The most helpful findings for diagnosis of spinal neuropathic arthropathy were vacuum disk on radiographs and CT images, debris on radiographs and CT and MR images, disorganization on radiographs and CT and MR images, facet involvement on radiographs and CT and MR images, spondylolisthesis on CT and MR images, diffuse signal intensity patterns in vertebral bodies on MR images, and rim enhancement of disks on gadolinium-enhanced MR images. Findings that were not helpful included endplate sclerosis and erosions, osteophytes, paraspinal soft-tissue mass, and decreased disk height.

CONCLUSION

Vacuum disk, facet involvement, vertebral body spondylolisthesis, joint disorganization and debris, and gadolinium-enhancement patterns of vertebral bodies and disks may help differentiate spinal neuropathic arthropathy from infection.

Comparison of fundamental and wideband harmonic contrast imaging of liver tumors

Wideband harmonic imaging (with phase inversion for improved tissue suppression) was compared to fundamental imaging in vivo. Four woodchucks with naturally occurring liver tumors were injected with Imagent (Alliance Pharmaceutical Corp., San Diego, CA). Randomized combinations of dose (0.05, 0.2 and 0.4 ml/kg) and acoustic output power (AO; 5, 25 and 63% or MI < or = 0.9) were imaged in gray scale using a Sonoline Elegra scanner (Siemens Medical Systems, Issaquah, WA). Tumor vascularity, conspicuity and contrast enhancement were rated by three independent observers. Imagent produced marked tumor enhancement and improved depiction of neovascularity at all dosages and AO settings in both modes. Tumor vascularity and enhancement correlated with mode, dose and AO (P < 0.002). Fundamental imaging produced more enhancement (P < 0.05), but tumor vascularity and conspicuity were best appreciated in harmonic mode (P < 0.05). Under the conditions studied here, the best approach was wideband harmonic imaging with 0.2 ml/kg of Imagent at an AO of 25%.

Parental recall of birth weight: how accurate is it?

OBJECTIVE

To assess the accuracy of parental recall of birth weight in a British population and to investigate whether social class and age of the child significantly influence the accuracy of recalled birth weight.

METHODS

A questionnaire was given to parents whose children were participating in a blood pressure study and the hospital records were retrieved to check the birth weight data.

RESULTS

At the time of the study, the children (n = 649) ranged in age from 6 to 15 years. Seventy five per cent of the recalled birth weights were within 50 g of that recorded in the hospital records. No significant associations were found between the difference in birth weights (recalled birth weight minus hospital record) and social class of the parents or age of the child at time of data collection.

CONCLUSION

This large study shows that parental recall of birth weight is good across the social classes and up to 16 years after delivery. There was no evidence of systematic bias, which would prejudice results of studies on the relation of birth weight to adult hypertension.

Proximity to maternity services and stillbirth risk

A study of all 77 995 live births and 1234 stillbirths to mothers living in West Cumbria from 1950 to 1989 found no significant increase in stillbirth risk with distance of mother's residence from the first or second nearest maternity services, after allowing for year of birth, father's social class, and birth order.

Stillbirth risk with social class and deprivation: no evidence for increasing inequality

The objective of this study was to determine whether inequality in stillbirth risk between social strata has changed over time. Subjects were all 288,869 births in Cumbria, northwest England, 1950-1993 and all 8,039,269 births in England and Wales, 1981-1992. Social class of Cumbrian babies was ascertained from birth registrations. Community deprivation scores were calculated from census data for (i) enumeration districts in Cumbria and (ii) county districts in England and Wales. The relative index of inequality was used to measure inequality of stillbirth risk between social strata. Results indicate inequality in stillbirth risk in Cumbria has fallen significantly since 1966 (P< or =0.02) and was not evident in more recent time periods. In England and Wales, there was significant inequality in stillbirth risk in all time periods and no evidence that this has changed over time. Inequality in stillbirth risk has not increased and in some areas has attenuated in recent years.

Risk of cardiovascular disease measured by carotid intima-media thickness at age 49-51: lifecourse study

OBJECTIVE

To quantify the direct and indirect effects of fetal life, childhood, and adult life on risk of cardiovascular disease at age 49-51 years.

DESIGN

Follow up study of the "Newcastle thousand families" birth cohort established in 1947.

PARTICIPANTS

154 men and 193 women who completed a health and lifestyle questionnaire and attended for clinical examination between October 1996 and December 1998.

MAIN OUTCOME MEASURES

Correlations between mean intima-media thickness of the carotid artery (carotid intima-media thickness) and family history, birth weight, and socioeconomic position around birth; socioeconomic position, growth, illness, and adverse life events in childhood; and adult socioeconomic position, lifestyle, and biological risk markers. Proportions of variance in carotid intima-media thickness that were accounted for by each stage of the lifecourse.

RESULTS

Socioeconomic position at birth and birth weight were negatively associated with carotid intima-media thickness, although only social class at birth in women was a statistically significant covariate independent of adult lifestyle. These early life variables accounted directly for 2.2% of total variance in men and 2.0% in women. More variation in carotid intima-media thickness was explained by adult socioeconomic position and lifestyle, which accounted directly and indirectly for 3.4% of variance in men (95% confidence interval 0.5% to 6.2%) and 7.6% in women (2.1% to 13.0%). Biological risk markers measured in adulthood independently accounted for a further 9.5% of variance in men (2.4% to 14.2%) and 4.9% in women (1.6% to 7.4%).

CONCLUSIONS

Adult lifestyle and biological risk markers were the most important determinants of the cardiovascular health of the study members of the Newcastle thousand families cohort at age 49-51 years. The limited overall effect of early life factors may reflect the postwar birth year of this cohort.

Endometrial polyps: MR imaging features and distinction from endometrial carcinoma

PURPOSE

To determine the magnetic resonance (MR) imaging characteristics of endometrial polyps and the accuracy of MR imaging in distinguishing endometrial polyps from endometrial carcinomas in a case-control study.

MATERIALS AND METHODS

Cross-referencing pathology records with MR studies from two institutions disclosed 35 patients with surgically proved endometrial polyp or carcinoma after controlling for tumor size. All MR examinations were performed at 1.5 T with T2-weighted fast spin-echo sequences in multiple planes. Three independent readers blinded to histologic diagnoses and clinical data scored each image for the presence of several defined findings.

RESULTS

A central fibrous core (low signal intensity on T2-weighted images) and intratumoral cysts (high signal intensity on T2-weighted images) were seen more frequently in endometrial polyps than in carcinomas; myometrial invasion and necrosis showed high predictive value for carcinomas. The readers' responses showed a mean sensitivity of 79%, specificity of 89%, accuracy of 86%, positive predictive value of 82%, and negative predictive value of 88% for diagnosis of carcinoma. The mean area under the receiver operating characteristic curve for the three readers was 0.87 for the diagnosis of carcinoma.

CONCLUSION

MR images can help to distinguish most polyps from endometrial carcinomas on the basis of morphologic features. Accuracy does not appear to be sufficient to obviate biopsy, partly because carcinomas and polyps frequently coexist.