CD39+ tumor infiltrating T cells from colorectal cancers exhibit dysfunctional phenotype

Recent studies revealed that CD39 was highly expressed in tumor-specific CD4+ tumor infiltrating lymphocytes (TILs). However, the divergent function of CD39+ T cells remains to be elucidated in colorectal cancer (CRC). In this study, T cells from CRC patients and tumor-bearing mice were isolated to evaluate the function of CD39 in T cells. We found that CD39 was elevated in intratumoral T cells from CRC patients, and negatively correlated with cytokine secretion capacity. T cell activation induced CD39 expression, and CD39+ T cells produced more IFN-γ in response to CRC tumor antigens. In addition, CD39+ T cells in the spleens of tumor-bearing mice exhibited a stronger anti-tumor activity in vitro than CD39- T cells, but there was no significant difference in the anti-tumor activities between CD39- TILs and CD39+ TILs. Moreover, we found that CD39+ T cells expressed higher checkpoint molecules and contained a higher proportion of Treg cells than CD39- T cells, suggesting that CD39+ T cells may be correlated with an immunosuppressive phenotype. And CD39 expression on T cells could convert pro-inflammatory eATP to immunosuppressive eADO. However, both T cells from the vaccinated-wild-type mice and CD39-/- mice could recognize and eliminate tumor cells in vitro, and adoptive transfer of these T cells resulted in tumor growth inhibition in tumor-bearing mice. In conclusion, our study revealed the divergent functions of CD39+ T cells, which were reactive to tumor antigen but exhibited a dysfunctional phenotype.

Brief psychological interventions for psychiatric disorders in young people with long term physical health conditions: A systematic review and meta-analysis

OBJECTIVES

Rates of psychiatric disorders are considerably elevated in young people with long term physical health conditions. Currently few children obtain effective mental health treatments in the context of long term physical health conditions, and ways to improve access to evidence-based mental health interventions are urgently needed. One approach is to deploy briefer, more economical, yet still evidence-based, treatments. The objective of this review was to evaluate the efficacy of brief interventions targeting psychiatric disorders in children and young people with long term physical health conditions.

METHODS

Predefined terms relating to brief psychological interventions for psychiatric disorders in children with long term physical health conditions were used to search relevant databases. A systematic review and meta-analysis was carried out in accordance with the Cochrane guidelines. Two reviewers independently screened titles and abstracts, extracted the data and conducted risk of bias assessments.

RESULTS

A total of 12 randomised controlled trials were found to meet the inclusion criteria of the review. Of those, three studies were suitable for meta-analysis. A large effect size in favour of brief cognitive behavioural therapy for anxiety was found (g = - 0.95, CI -1.49 to -0.041; p < .001) with non-significant moderate-substantial heterogeneity (I² = 58%; p = .09).

CONCLUSION

This review suggests there is preliminary evidence that brief interventions, based on cognitive behavioural principles, may benefit young people with an anxiety disorder in the context of a long term physical health condition. There was insufficient evidence to assess whether this held true for depression and disruptive behaviour.

Folylpolyglutamate synthetase gene transcription is regulated by a multiprotein complex that binds the TEL-AML1 fusion in acute lymphoblastic leukemia

Acute Lymphoblastic Leukemia (ALL) non-random fusions influence clinical outcome and alter the accumulation of MTX-PGs in vivo. Analysis of primary ALL samples uncovered subtype-specific patterns of folate gene expression. Using an FPGS-luciferase reporter gene assay, we determined that E2A-PBX1 and TEL-AML1 expression decreased FPGS transcription. ChIP assays uncovered HDAC1, AML1, mSin3A, E2F, and Rb interactions with the FPGS promoter region. We demonstrate that FPGS expression is epigenetically regulated through binding of selected ALL fusions to a multiprotein complex, which also controls the cell cycle dependence of FPGS expression. This study provides insights into the pharmacogenomics of MTX in ALL subtypes.

Network analysis of primary hepatocyte dedifferentiation using a shotgun proteomics approach

The liver is the major site of xenobiotic metabolism and detoxification. Primary cultures of hepatocytes are a vital tool in the development of new therapeutic agents but their utility is hindered by the rapid loss of phenotype. Hepatocytes cultured in a sandwich of extracellular matrix protein maintain better hepatic function compared with cells cultured as a monolayer but a wide-ranging proteomics study of the differences in cultures has never been performed. We characterize the changing phenotype of rat hepatocytes in primary culture using iTRAQ proteomics and systems biology network analysis of the identified, significantly regulated, proteins. A total of 754 unique proteins were identified from 4 independent experiments. Of these, 413 proteins were common to at least 3 experiments and 328 proteins were identified in all experiments. Both culture systems displayed altered expression of many common proteins. Network analysis showed that the primary functions of these proteins were in metabolic pathways, immune responses and cytoskeleton remodelling. Monolayer cultures uniquely regulate proteins mapping to pathways of oxidative stress and cell migration, whereas sandwich culture affected translation regulation and apoptosis pathways. These experiments provide a detailed proteomics data set to direct further work into maintaining hepatic phenotype using cultured primary hepatocytes and stem cell derived hepatocyte-like cells.

Proteomic analysis of Nrf2 deficient transgenic mice reveals cellular defence and lipid metabolism as primary Nrf2-dependent pathways in the liver

The transcription factor Nrf2 regulates expression of multiple cellular defence proteins through the antioxidant response element (ARE). Nrf2-deficient mice (Nrf2^−/−) are highly susceptible to xenobiotic-mediated toxicity, but the precise molecular basis of enhanced toxicity is unknown. Oligonucleotide array studies suggest that a wide range of gene products is altered constitutively, however no equivalent proteomics analyses have been conducted. To define the range of Nrf2-regulated proteins at the constitutive level, protein expression profiling of livers from Nrf2^−/− and wild type mice was conducted using both stable isotope labelling (iTRAQ) and gel electrophoresis methods. To establish a robust reproducible list of Nrf2-dependent proteins, three independent groups of mice were analysed. Correlative network analysis (MetaCore) identified two predominant groups of Nrf2-regulated proteins. As expected, one group comprised proteins involved in phase II drug metabolism, which were down-regulated in the absence of Nrf2. Surprisingly, the most profound changes were observed amongst proteins involved in the synthesis and metabolism of fatty acids and other lipids. Importantly, we show here for the first time, that the enzyme ATP-citrate lyase, responsible for acetyl-CoA production, is negatively regulated by Nrf2. This latter finding suggests that Nrf2 is a major regulator of cellular lipid disposition in the liver.

Predicting mortality for patients with exacerbations of COPD and Asthma in the COPD and Asthma Outcome Study (CAOS)

INTRODUCTION

Decisions about the intensity of treatment for patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are influenced by predictions about survival and quality of life. Evidence suggests that these predictions are poorly calibrated and tend to be pessimistic.

AIM

The aim of this study was to develop an outcome prediction model for COPD patients to support treatment decisions.

METHODS

A prospective multi-centre cohort study in Intensive Care Units (ICU) and Respiratory High Dependency Units (RHDU) in the UK recruited patients aged 45 years and older admitted with an exacerbation of obstructive lung disease. Data were collected on patients' characteristics prior to ICU admission, and on their survival and quality of life after 180 days. An outcome prediction model was developed using multivariate logistic regression and bootstrapping.

RESULTS

Ninety-two ICUs (53% of those in the UK) and three RHDUs took part. A total of 832 patients were recruited. Cumulative 180-day mortality was 37.9%. Using data available at the time of admission to the units, a prognostic model was developed which had an estimated area under the receiver operating characteristic curve ('c') of 74.7% after bootstrapping that was more discriminating than the clinicians (P = 0.033) and was well calibrated.

DISCUSSION

This study has produced an outcome prediction model with slightly better discrimination and much better calibration than the participating clinicians. It has the potential to support risk adjustment and clinical decision making about admission to intensive care.

Preference for place of care and place of death in palliative care: are these different questions?

Place of death is at times suggested as an outcome for palliative care services. This study aimed to describe longitudinal preferences for place of care and place of death over time for patients and their caregivers. Longitudinal paired data of patient/caregiver dyads from a prospective unblinded cluster randomised control trial were used. Patients and caregivers were separately asked by the palliative care nurse their preference at that time for place of care and place of death. Longitudinal changes over time for both questions were mapped; patterns of agreement (patient and caregiver; and preference for place of death when last asked and actual placed of death) were analysed with kappa statistics. Seventy-one patient/caregiver dyads were analysed. In longitudinal preferences, preferences for both the place of care (asked a mean of >6 times) and place of death (asked a mean of >4 times) changed for patients (28% and 30% respectively) and caregivers (31% and 30%, respectively). In agreement between patients and caregivers, agreement between preference of place of care and preferred place of death when asked contemporaneously for patients and caregivers was low [56% (kappa 0.33) and 36% (kappa 0.35) respectively]. In preference versus actual place of death, preferences were met for 37.5% of participants for home death; 62.5% for hospital; 76.9% for hospice and 63.6% for aged care facility. This study suggests that there are two conversations: preference for current place of care and preference for care at the time of death. Place of care is not a euphemism for place of death; and further research is needed to delineate these. Patient and caregiver preferences may not change simultaneously. Implications of any mismatch between actual events and preferences need to be explored.

The impact of private-sector provision on equitable utilisation of coronary revascularisation in London

OBJECTIVE

To investigate the impact of including private-sector data on assessments of equity of coronary revascularisation provision using NHS data only.

DESIGN

Analyses of hospital episodes statistics and private-sector data by age, sex and primary care trust (PCT) of residence. For each PCT, the share of London's total population and revascularisations (all admissions, NHS-funded, and privately-funded admissions) were calculated. Gini coefficients were derived to provide an index of inequality across subpopulations, with parametric bootstrapping to estimate confidence intervals.

SETTING

London.

PARTICIPANTS

London residents undergoing coronary revascularisation April 2001-December 2003.

INTERVENTION

Coronary artery bypass graft or angioplasty.

MAIN OUTCOME MEASURES

Directly standardised revascularisation rates, Gini coefficients.

RESULTS

NHS-funded age-standardised revascularisation rates varied from 95.2 to 193.9 per 100,000 and privately funded procedures from 7.6 to 57.6. Although the age distribution did not vary by funding, the proportion of revascularisations among women that were privately funded (11.0%) was lower than among men (17.0%). Privately funded rates were highest in PCTs with the lowest death rates (p = 0.053). NHS-funded admission rates were not related to deprivation nor age-standardised deaths rates from coronary heart disease. Privately funded admission rates were lower in more deprived PCTs. NHS provision was significantly more egalitarian (Gini coefficient 0.12) than the private sector (0.35). Including all procedures was significantly less equal (0.13) than NHS-funded care alone.

CONCLUSION

Private provision exacerbates geographical inequalities. Those responsible for commissioning care for defined populations must have access to consistent data on provision of treatment wherever it takes place.

An experimental study of determinants of the extent of disagreement within clinical guideline development groups

OBJECTIVE

To assess the effect of design features and clinical and social cues on the extent of disagreement among participants in a formal consensus development process.

METHODS

Factorial design involving 16 groups consisting of 135 general practitioners (GPs) and 42 mental health professionals from England. The groups rated the appropriateness of four mental health interventions for three conditions (chronic back pain, irritable bowel syndrome, and chronic fatigue syndrome) in the context of various clinical and social cues. The groups differed in three design features: provision of a systematic literature review (versus not provided), group composition (mixed versus GP only), and assumptions about the healthcare resources available (realistic versus idealistic). Disagreement was measured using the mean absolute deviation from a group's median rating for a scenario.

RESULTS

None of the design features significantly affected the extent of disagreement within groups (all p>0.3). Disagreement did differ between treatments (closer consensus for cognitive behavioural therapy and behavioural therapy than for brief psychodynamic intervention therapy and antidepressants) and cues (closer consensus for depressed patients and patients willing to try any treatment).

CONCLUSION

In terms of the extent of disagreement in the groups in this study, formal consensus development was a robust technique in that the results were not dependent on the way it was conducted.

The parathyroid hormone-related protein receptor is expressed in breast cancer bone metastases and promotes autocrine proliferation in breast carcinoma cells

Overproduction of parathyroid hormone-related protein (PTHRP) occurs in a high proportion of primary breast cancers (PBC) and is strongly implicated in their metastatic spread to bone. Although the PTHRP-receptor (PTHRP-R) is often coexpressed with PTHRP in PBC, its role in regulating breast cancer cell proliferation and metastases to bone remains unclear. The aims of this study were to determine the expression of the PTHRP-R in breast cancer bone metastases (BM) and to investigate the effects of PTHRP-R overexpression on breast cancer cell proliferation. PTHRP-R expression occurred in 85% (11 out of 13) of BM compared with 58% (39 out of 67) of PBC. Median expression was higher (P<0.05) in BM compared with PBC. PTHRP increased cAMP accumulation and DNA synthesis in MCF-7 cells stably overexpressing the PTHRP-R (MCF-7(WTR)) but not in MCF-7(VEC) control cells. The increase in DNA synthesis was mimicked by the cAMP pathway activator forskolin. The receptor antagonist PTHRP(7-34) reduced DNA synthesis in MCF-7(WTR) cells, but not MCF-7(VEC) cells, indicating that receptor overexpression promotes autocrine PTHRP activity. MCF-7(WTR) cells showed increased mitogenic responsiveness to fetal calf serum and reduced doubling times. PTHRP induced weak activation of ERK1 and ERK2 and potentiated their activation by serum growth factors. Collectively these results show that the PTHRP-R is frequently expressed in breast cancer BM and indicate that receptor overexpression drives proliferation via autocrine signals that are mediated via cAMP and ERK pathways.

Prevention of coronary heart disease through treatment of infection with Chlamydia pneumoniae? Estimation of possible effectiveness and costs

Evidence has been accumulating for a link between Chlamydia pneumoniae and coronary heart disease (CHD). A spreadsheet model was used to estimate the impact of different strategies for screening and treating C. pneumoniae on the incidence of myocardial infarction and cardiac mortality over a 1-year post-intervention period. It was found that screening would potentially be most cost-effective in men aged over 35 with a history of myocardial infarction (around ł2,000 per life-year saved). Cost-effectiveness would be inferior in those with established heart disease but no history of myocardial infarction (MI), and poor for people at elevated risk of CHD. If causality of the association were proven, the cost-effectiveness of treating C. pneumoniae in post-MI patients would compare favourably with, for example, statins for treating hypercholesterolaemia.

The application of dialectical behavior therapy for patients with borderline personality disorder on inpatient units

Inpatient treatment of individuals with borderline personality disorder (BPD) is typically fraught with difficulty and failure. Patients and staff often become entangled in intense negative therapeutic spirals that obliterate the potential for focused, realistic, and effective treatment interventions. We describe an inpatient treatment approach to BPD patients which is an application of Dialectical Behavior Therapy (DBT), a cognitive-behavioral therapy for patients with BPD which has been shown to be effective in reducing suicidal behavior, hospitalization, and treatment dropout and improving interpersonal functioning and anger management. The inpatient DBT staff creates a validating treatment milieu and focuses on orienting and educating new patients and identifying and prioritizing their treatment targets. Inpatient DBT treatment techniques include contingency management procedures, skills training and coaching, behavioral analysis, structured response protocols to suicidal and egregious behaviors on the unit, and consultation team meetings for DBT staff.

Conditions for which onset or hospital admission is potentially preventable by timely and effective ambulatory care

OBJECTIVES

To identify, using a consensus development process, a list of common conditions likely to be ambulatory care sensitive (ACS); i.e. conditions for which practicable improvements in access to timely and effective ambulatory care in the English National Health Service would either reduce the incidence of the condition or avoid substantial proportions of current hospital admissions.

METHODS

Three panels of clinicians each reviewed about a third of an initial list of 174 conditions commonly recorded as hospital discharge diagnoses for residents of the North West Thames Region. For each condition, panellists estimated the proportion of cases currently admitted to hospital for which, given timely and effective ambulatory care: onset of disease could have been prevented; admission for existing disease could have been prevented; admission, once indicated, should take place within 48 hours. After an introductory meeting to discuss and clarify the task, panel members completed three rounds of a questionnaire, with postal feedback between each round, and a second meeting to discuss interim results before the final round. Seventeen general practitioners (GPs) and 17 hospital specialists working in the region comprised the panels.

RESULTS

The panels considered that for 30 of the 174 conditions at least 70% of admissions to hospital could be avoided, either by prevention of disease onset or timely and effective ambulatory care, though predominantly through the latter. For each of a further 66 conditions, 50-69% of admissions could be prevented. Within-panel agreement between hospital specialists and GPs was generally good, although the GPs tended to give slightly higher scores for avoidability of admissions than the specialists. There was marked convergence of scores in succeeding rounds.

CONCLUSIONS

Although a consensus-based list of ACS conditions cannot be definitive, the clear view of the panels was that the scope for avoiding admission through better ambulatory care is very substantial.

Mutation analysis of interleukin-5 in an asthmatic cohort

Interleukin-5 (IL-5) is a potential candidate gene in the pathogenesis of asthma, as it is the main cytokine controlling eosinophil activity and eosinophils are pivotal in the development of airway inflammation. Mutation detection studies were performed on the IL-5 gene and the alpha-chain of its receptor in 30 asthmatic and 30 nonasthmatic subjects. Single-strand conformational polymorphism (SSCP) and heteroduplex analysis (HA) did not reveal any change from the reported normal sequence in all 4 exons of IL-5 as well as the promoter and 3'-untranslated regions of the gene. No SSCP variations were seen within the complete coding sequence of the IL-5 receptor alpha-chain. Mutations of the IL-5 gene coding region, its promoter and receptor are unlikely to be common causes of an inherited predisposition to asthma.

Technique for identification of submicron metal particulate from implants in histological specimens

Metal implants are being used with increasing frequency for the treatment of many diseases in the field of orthopedics, cardiology, cardiovascular surgery, and otolaryngology. Unfortunately, metals can be a source of submicron particles, which may have adverse effects on tissues. This article describes a technique that uses backscattered electron imaging and energy dispersive X-ray microanalysis, which have the capacity to perform both quantitative and qualitative analysis. The particles can be characterized by size, shape, amount, and composition. Although this technique can be used near the implant interface, it is particularly helpful in tissues a great distance from the implant site with a low concentration of metal debris. In addition, the sensitivity and specificity of this technique can be adjusted to the investigator's needs.

Consensus development methods: a review of best practice in creating clinical guidelines

BACKGROUND

Although there is debate about the appropriate place of guidelines in clinical practice, guidelines can be seen as one way of assisting clinicians in decision-making. Given the likely diversity of opinion that any group of people may display when considering a topic, methods are needed for organising subjective judgements. Three principal methods (Delphi, nominal group technique, consensus development conference) exist which share the common objective of synthesising judgements when a state of uncertainty exists.

OBJECTIVES

To identify the factors that shape and influence the clinical guidelines that emerge from consensus development methods and to make recommendations about best practice in the use of such methods.

METHODS

Five electronic databases were searched: Medline (1966-1996), PsychLIT (1974-1996), Social Science Citation Index (1990-1996), ABI Inform and Sociofile. From the searches and reference lists of articles a total of 177 empirical and review articles were selected for review.

RESULTS

The output from consensus development methods may be affected by: the way the task is set (choice of cues, recognition of contextual cues, the focus of the task, the comprehensiveness of the scenarios); the selection of participants (choice of individuals, degree of homogeneity of the group, their background, their number); the selection and presentation of scientific information (format, extent to which its quality and content is assessed); the way any interaction is structured (number of rating rounds, ensuring equitable participation, physical environment for meetings); and the method of synthesising individual judgements (definition of agreement, rules governing outliers, method of mathematical aggregation).

CONCLUSIONS

Although a considerable amount of research has been carried out, many aspects have not been investigated sufficiently. For the time being at least, advice on those aspects has, therefore, to be based on the user's own commonsense and the experience of those who have used or participated in these methods. Even in the long term, some aspects will not be amenable to scientific study. Meanwhile, adherence to best practice will enhance the validity, reliability and impact of the clinical guidelines produced.

The infant index: a new outcome measure for pre-school children's services

BACKGROUND

The evaluation of community services for preschool children is hampered by the lack of valid and routinely available outcome measures. This study examines the use of data collected by teachers in response to educational legislation to determine whether a routine measure of attainments in primary school is sensitive to factors known to affect mental development.

METHOD

A community child health dataset for the cohort of children born in Sheffield in 1990-1991 was matched with a dataset provided by schools in 1995-1996. The educational data consisted of the Infant Index scores which measure education attainments in reception class pupils.

RESULTS

We matched 4487 children from both datasets, which represented 75 per cent of all children born in the 1990-1991 cohort. Factors which predicted a poor Infant Index included male gender (odds ratio (OR) = 2.1, 95 per cent confidence interval (CI)= 1.8-2.6), low birthweight (OR = 1.4, 95 per cent CI = 1.1-1.9) and lack of breast feeding either by intention to feed (OR = 1.3, 95 per cent CI = 1.1-1.7) or actual feeding practice at one month (OR = 1.5, 95 per cent CI = 1.1-2.0). Other factors associated with a poor outcome for the child were postnatal depression, number of pregnancies, ethnicity, pre-school educational experiences and poor housing.

CONCLUSIONS

Although the results are interesting in themselves, the main significance of our project is in establishing a link between routinely collected health data and routine education data. This could facilitate research in the future thus leading to a considerable saving in the cost of long-term intervention studies.

Threats to applicability of randomised trials: exclusions and selective participation

BACKGROUND

Although the randomised controlled trial (RCT) is regarded as the 'gold standard' in terms of evaluating the effectiveness of interventions, it is susceptible to challenges to its external validity if those participating are unrepresentative of the reference population for whom the intervention in question is intended. In the past, reporting on numbers and types of potential subjects that have been excluded by design, and centres, clinicians or patients that have elected not to participate, has generally been poor, and the threat to inference posed by possible selection bias is unclear.

METHODS

A systematic review was undertaken, based largely on MEDLINE and EMBASE with follow-up of cited references, to assess the extent, nature and importance of excluding potential subjects or the unwillingness of particular centres, clinicians or patients to participate.

RESULTS

RCTs vary widely in the extent to which potential future recipients of treatment are included. The reasons cited for excluding certain categories of patient may be medical or scientific. Medical reasons include a high risk of adverse effects and the belief that benefit will be relatively small or absent (or has already been established) in the groups in question. Scientific reasons include more precise estimates of treatment effect because of a relatively homogeneous sample and the reduction of potential bias by excluding those individuals most likely to be lost to follow-up. Many RCTs have blanket exclusions, such as the elderly, women and ethnic minorities, but reasons for these exclusions are seldom given. Evaluative research is undertaken predominantly in university or teaching centres. Non-randomised studies are more likely than RCTs to include non-teaching centres. The effect of patient non-participation appears to depend on whether the RCT is concerned with treatment of an existing condition or with disease prevention. Participants in treatment trials tend to be more severely ill than those who do not participate. In contrast, those who participate in prevention trials are more likely to have adopted a healthy lifestyle than those who decline. Most evaluative studies fail to document adequately the characteristics of those who, while eligible, do not participate. However, subjects included in RCTs (i.e. eligible and participating) tend to have a different prognosis than patients identified from clinical databases.

CONCLUSIONS

Narrow inclusion criteria may offer benefits such as increased precision and reduced loss to follow-up, but there are important disadvantages, such as uncertainty about extrapolation of results, which may result in denial of effective treatment to groups who might benefit, and delay in obtaining definitive results because of reduced recruitment rate. Selective participation by teaching centres and sicker patients in treatment RCTs may exaggerate the measured treatment effect. Prevention trials, on the other hand, may underestimate effects as participants have less capacity to benefit.

Partial purification of heparanase activities in Chinese hamster ovary cells: evidence for multiple intracellular heparanases

Heparanases are mammalian endoglycosidases that cleave heparan sulphate glycosaminoglycans from proteoglycan core proteins and degrade them into shorter chains. The enzymes have been proposed to act in a variety of cellular processes, including proteoglycan catabolism, remodelling of basement membranes and release of heparan sulphate-binding ligands from their extracellular storage sites. Additional functions for heparanases may be to generate short heparan sulphate chains that stabilize or activate other proteins. While heparanase activities have been described in a number of tissues and cell lines, it is not known how many different enzymes are responsible for these activities. Our recent studies characterizing the short glycosaminoglycans produced in Chinese hamster ovary (CHO) cells suggested that multiple heparanases are necessary for the formation of the short heparan sulphate chains [Bame and Robson (1997) J. Biol. Chem. 272, 2245-2251]. We examined whether this is the case by purifying heparanase activity from CHO cell homogenates. Based on their ability to bind ion-exchange resins and their elution from gel-filtration columns, four separate heparanase activities were partially purified. All four activities cleave free glycosaminoglycans over a broad pH range of 3.5-6.0 or 6. 5, suggesting that they act in the endosomal/lysosomal pathway. The sizes of the short heparan sulphate chains generated by the partially purified heparanases ranged from 6 to 9 kDa, and for two of the activities the product size is pH-dependent. Three of the four activities degrade proteoglycans as well as the free glycosaminoglycan chain. Interestingly, all four enzymes generate short glycosaminoglycans with a sulphate-rich, modified domain at the non-reducing end of the newly formed chain. Since our previous studies showed that in CHO cells there is also a population of short heparan sulphates with a modified domain at the reducing end of the chain, this suggests that there may be another heparanase in CHO cells that was not purified. Alternatively, our findings suggest that the formation of short heparan sulphate glycosaminoglycans inside CHO cells may be a result of the concerted action of multiple heparanases, and may depend on the proportions of the different enzymes and the environment in which the chains are degraded.

Seasonal variation in mortality in Moscow

BACKGROUND

Seasonal variation in mortality has been investigated in many countries but not, until recently, in Russia. There are some grounds for suspecting that it may differ in Russia from what is seen in western countries. This paper explores patterns of seasonal variation in mortality in Moscow between 1993 and 1995.

METHODS

Analysis was based on individual data on deaths occurring in Moscow between January 1993 and December 1995, grouped by four-week period and by calendar month and on mean monthly temperature in Moscow for the same period. Crude, smoothed and deseasonalized trends were inspected. Auto-correlation functions were estimated and deaths were regressed against temperature.

RESULTS

As in other northern hemisphere countries, there is a winter excess of deaths but this is much smaller than in many western countries. It is restricted to some causes of death, such as ischaemic heart disease and cerebrovascular disease, and is associated with low temperature. In contrast, there is a marked summer increase in deaths among young people, especially from accidents and other deaths associated with alcohol consumption. Over the three-year period studied, there was an initial underlying increase in alcohol-related deaths that subsequently fell, coinciding with a previously observed increase in life expectancy.

CONCLUSIONS

It is possible that the low level of excess winter mortality reflects warmer indoor environments than in the west. The seasonal variation of deaths among young people reinforces evidence of the important role of alcohol in the Russian mortality crisis.

Assessment of the reproducibility of clinical coding in routinely collected hospital activity data: a study in two hospitals

BACKGROUND

The aim of the study was to assess the reproducibility of clinical coding in two National Health Service hospitals within North West Thames region.

METHODS

A retrospective audit was carried out, of clinical coding in hospital episode statistics, involving comparison of the codes assigned by local staff with those assigned by members of an external team unaware of the locally assigned codes. Where local and external coders disagreed, the records were reviewed for a third time by a further independent coder. The subjects were a random sample of 1607 non-maternity, non-psychiatric admissions occurring between 1991 and 1993, stratified for year and type of disease (asthma, diabetes, appendicitis, fractured femur and 'general'--a random selection of any diagnoses). The main outcome measures were the levels of exact agreement between local and external teams over codes for main diagnosis and procedure, and the level of approximate agreement (over the first three characters of the ICD-9 code for diagnosis and the letter and first two digits of the OPCS-4 code for procedure). For disagreements, the outcome measure was the level of agreement between the 'third' coder and the local and external coders.

RESULTS

For the main diagnosis in the 'general' group at hospital A, internal and external coders agreed exactly in 43 per cent of the admissions examined and agreed 'approximately' in 55 per cent (kappa = 0.54). For hospital B the corresponding figures were 60 per cent and 72 per cent (kappa = 0.72). Approximate agreement was higher for the specific diseases considered, particularly for asthma (A: 86 per cent; B: 91 per cent) and fractured femur (A: 84 per cent; B: 89 per cent). For the main procedure at hospital A, there was exact agreement for 58 per cent and approximate agreement for 70 per cent (kappa = 0.66). For hospital B, the corresponding figures were 76 per cent and 83 per cent (kappa = 0.80). In cases of disagreement over the first three digits of the ICD-9 code for main diagnosis, the third coder disagreed with both local and external coders in 53 per cent at hospital A and 38 per cent at hospital B. Agreement was slightly better for discharges in 1992-1993 than in 1991-1992.

CONCLUSIONS

The full clinical codes in NHS hospital episode statistics (HES) data should be treated with caution. The first three characters of ICD-9 codes for diagnoses and the OPCS-4 codes for procedures were more reliable. For some specific conditions such as asthma and fractured femur, reliability of the first three characters is much higher (for example, 86 per cent and 91 per cent for asthma in the two hospitals), but for the full codes can be worse. Secondary diagnoses or comorbidities may be significantly undercoded. A higher level of agreement in 1992-1993 than in 1991-1992 suggests that coding may be improving.

Ethylenediaminetetraacetic acid in ammonium hydroxide for reducing decalcification time

Ethylenediaminetetraacetic acid (EDTA) solution is used to decalcify bone specimens for histological examination. Sodium hydroxide (NaOH) has been used to dissolve EDTA and to bring EDTA solutions to neutral pH. This solution, however, requires several weeks to decalcify bone specimens. We investigated a new decalcification fluid using concentrated ammonium hydroxide (NH4OH) to dissolve EDTA and to adjust the pH to neutral. Decalcification was performed using a magnetic stirrer with and without vacuum, or with a sonic cleaner. Decalcification end point was confirmed using both the weight loss and X-ray methods. After decalcification, specimens were processed through paraffin and sections were stained with hematoxylin and eosin. Decalcification employing NH4OH required an average of six days. Light microscopy indicated good retention of cellular detail.

Day surgery: development of a national comparative audit service

OBJECTIVES

To develop software for hospitals to analyse their own survey data on patients' experiences of day surgery and to create and test the feasibility of a national comparative audit service.

DESIGN

Software development and testing; database analysis.

SETTING

Eleven general hospitals in England.

PATIENTS

1741 day surgery patients undergoing procedures during 1991-2.

MAIN MEASURES

Postoperative symptoms, complications, health and functional status, general satisfaction, and satisfaction with specific aspects of care.

RESULTS

Software for data entry and analysis by hospitals was successfully used at the pilot sites. The overall response rate for the 11 hospitals using the questionnaire was 60%, ranging from 33% to 90% depending on the way the survey was managed. Data from all 11 hospitals were included in the national comparative audit database. Hospitals showed little variation in measures of patients' overall satisfaction (around 85%), but significant differences were apparent for specific aspects such as receiving adequate written information before admission (range 50%-89%), provision of adequate parking facilities (14%-92%) and experiencing a significant amount of postoperative pain (8%-42%). The proportion of day case patients undergoing procedures that could have been performed in outpatient departments varied from 0 to 27% between hospitals. Further comparisons of outcome, in particular measures of effectiveness, must await the development of validated case mix adjustment methods.

CONCLUSION

Establishing a comparative audit database is feasible but several methodological problems remain to be resolved.

Day surgery; development of a questionnaire for eliciting patients' experiences

OBJECTIVE

To develop a single, short, acceptable, and validated postal questionnaire for assessing patients' experiences of the process and outcome of day surgery.

DESIGN

Interviews and review of existing questionnaires; piloting and field testing of draft questionnaires; consistency and validity checks.

SETTING

Four hospitals, in Coventry (two), Swindon, and Milton Keynes.

PATIENTS

373 patients undergoing day surgery in 1990.

MAIN MEASURES

Postoperative symptoms, complications, health and functional status, general satisfaction, and satisfaction with specific aspects of care.

RESULTS

Response rates of 50% were obtained on field testing draft questionnaires preoperatively and one week and one month after surgery. 28% of initial non-responders replied on receiving a postal reminder, regardless of whether or not a duplicate questionnaire was sent; a second reminder had little impact. Many patients who expressed overall satisfaction with their care were nevertheless dissatisfied with some specific aspects. Outcome and satisfaction were related to three aspects of case mix; patient's age, sex, and type of operative procedure. The final questionnaire produced as a result of this work included 28 questions with precoded answers plus opportunities to provide qualitative comments. Several factors (only one, shorter questionnaire to complete, fewer categories of nonresponders, and administration locally) suggested that a response rate of at least 65% (with one postal reminder) could be expected.

CONCLUSION

A validated questionnaire for day surgery was developed, which will be used to establish a national comparative database.

Measuring hospital workload in general medicine

The study described here used routine data sources to consider three aspects of hospital workload-volume and case-mix of inpatients; volume of outpatients; and volume of procedures.

Does labour substitution occur in district general hospitals?

A survey of 31 district general hospitals found a large variation in hours of medical and nursing time available per inpatient episode in general medicine and its associated specialties. These differences could not be attributed to case-mix variation or severity. The application of weightings to different grades of nursing and medical staff had little effect on either the rankings of hospitals by staff hours per episode, or the overall degree of variation in staffing levels. The results show no evidence to suggest that hospitals with relatively low levels for one category of staff are compensated by relatively high levels of another. It would appear that those hospitals with high levels for one category of staff are also well provided for the others. This evidence of inequality may reflect historic patterns of resource allocation that recent manpower policies might seek to redress. Studies of the relationship between staffing levels and quality of patient care should be undertaken before adopting a policy of labour redistribution.

What makes outpatient attendance worthwhile for patients?

All patients attending 10 general medical and general surgical outpatient clinics at a provincial teaching hospital were surveyed during a 1-week period. Questionnaires administered and completed by the patients at the time of the visit were used to establish the factors most closely associated with patients feeling that their consultations had been "very worthwhile". These were: consultations lasting more than 10 min, having received advice from a specialist and having been reassured. The study may provide a basis for a process of medical audit in outpatient departments and, thus, more appropriate services.

Infection of IL5 transgenic mice with Mesocestoides corti induces very high levels of IL5 but depressed production of eosinophils

Transgenic mice expressing interleukin 5 (IL5) have been demonstrated to show a lifelong high level eosinophilia. These mice were produced using a construct in which the dominant control region (DCR) of the human CD2 gene was ligated to a 10-kb fragment containing the mouse IL5 gene. The construct allows the expression of the IL5 gene under the control of its own promoter, but the DCR ensures constitutive expression by all T cells. Infection of these transgenic mice with Mesocestoides corti, which is itself a potent inducer of eosinophilia, increases serum IL5 to very high levels. This demonstrates that the transgenes retain inducibility, which is a feature of the endogenous gene. However, despite the high levels of IL5, the numbers of eosinophils in the blood, marrow, and spleen decrease during the period 1-4 weeks after infection. Furthermore, there is a decrease in eosinophil precursors, as assessed by the capacity of bone marrow to produce eosinophils in culture. After this decrease eosinophils return to their previous high levels, although the levels of IL5 remain high. These results suggest that a control mechanism is operating to limit the numbers of eosinophils produced. This control appears to act at the level of the precursor production and may not be directly related to the high levels of IL5.

What will happen to the quality of care with fewer junior doctors? A Delphi study of consultant physicians' views

Hospital medical staffing: achieving a balance proposed a reduction in the number of junior doctors and an expansion in the number of consultant posts. This change was to be subject to the 'safety net'--that the number of staff should not fall below a minimum safe level for 24-hour emergency cover. However, no operational definition of 'safe' was offered. Consultant physicians in one NHS region were interviewed to find out how they thought safety would be affected by a reduction in junior doctor numbers. It emerged that consultants' concerns over reductions in staff covered a wider range of issues than just the clinical effectiveness of care. The interpretation of safety extended to cover general adverse effects on care. A survey, using the Delphi method, revealed that consultant physicians were most concerned over reductions in the humanity of care if numbers of junior staff were reduced. This included such factors as the time spent by patients waiting in outpatient and A&E departments, and the time doctors spend talking to patients. Consultants were less concerned over the effect of reduced staff numbers on the technical efficiency of provision, and least of all on the effectiveness of care. This last point was seen to be a reflection of consultant physicians' confidence in the basic medical knowledge and skill of their junior staff.