3D analysis and grading of calcifications from ex vivo human meniscus

OBJECTIVE

Meniscal calcifications are associated with the pathogenesis of knee osteoarthritis (OA). We propose a micro-computed tomography (μCT) based 3D analysis of meniscal calcifications ex vivo, including a new grading system.

METHOD

Human medial and lateral menisci were obtained from 10 patients having total knee replacement for medial compartment OA and 10 deceased donors without knee OA (healthy references). The samples were fixed; one subsection was imaged with μCT, and the adjacent tissue was processed for histological evaluation. Calcifications were examined from the reconstructed 3D μCT images, and a new grading system was developed. To validate the grading system, meniscal calcification volumes (CV_M) were quantitatively analyzed and compared between the calcification grades. Furthermore, we estimated the relationship between histopathological degeneration and the calcification severity.

RESULTS

3D μCT images depict calcifications in every sample, including diminutive calcifications that are not visible in histology. In the new grading system, starting from grade 2, each grade results in a CV_M that is 20.3 times higher (95% CI 13.3-30.5) than in the previous grade. However, there was no apparent difference in CV_M between grades 1 and 2. The calcification grades appear to increase with the increasing histopathological degeneration, although histopathological degeneration is also observed with small calcification grades.

CONCLUSIONS

3D μCT grading of meniscal calcifications is feasible. Interestingly, it seems that there are two patterns of degeneration in the menisci of our sample set: 1) with diminutive calcifications (calcification grades 1-2), and 2) with large to widespread calcifications (calcification grades 3-5).

Silica dust and sarcoidosis in Swedish construction workers

Background

The aetiology of sarcoidosis is not well established. In previous studies, smoking has been negatively associated with sarcoidosis and there are some indications of an association between exposure to silica dust and sarcoidosis.

Aims

To study the risk of sarcoidosis in relation to silica dust exposure.

Methods

A longitudinal cohort of construction workers linked with a registry of Swedish inpatient diagnoses. Workers were designated as exposed or unexposed to silica based on job titles in a job–exposure matrix. The relative risk (RR) was analysed with Poisson regression adjusting for age and smoking.

Results

We identified 371 cases of sarcoidosis among 297 917 male workers. There was an increased risk of sarcoidosis in the medium- to high-exposure group [RR 1.83 (95% confidence interval {CI} 1.14–2.95)]. A stratified analysis according to smoking showed that ever-smoking workers had an increased risk of sarcoidosis if highly exposed to silica dust [RR 2.44 (95% CI 1.37–4.33)] compared to non-exposed ever-smokers. The risk of non-smokers highly exposed to silica was not significantly increased [RR 1.07 (95% CI 0.72–1.58)] compared to non-exposed non-smokers.

Conclusion

The study indicates an increased risk of developing sarcoidosis in ever-smoking men exposed to silica.

A health economic simulation model for the clinical management of osteoporosis

The objective was to estimate the burden of osteoporosis in Sweden based on current clinical practice and the cost-effectiveness of improvements in the management of osteoporosis over the clinical management compared to current clinical practice. Results showed that better compliance to treatment guidelines is associated with better projected outcomes and cost-savings.

INTRODUCTION

The purpose of this study is to estimate the burden of osteoporosis in Sweden based on current clinical practice and the cost-effectiveness of improvements in the management of osteoporosis over the clinical management compared to current clinical practice.

METHODS

The analysis was carried out using a model that simulates the individual patients considered for pharmacological treatment during 1 year and their projected osteoporosis treatment pathway, quality-adjusted life years (QALYs) and costs over their remaining lifetime. All patients regardless of treatment or no treatment were simulated. Information on current management of osteoporosis in terms of patient characteristics and treatment patterns were derived from a Swedish osteoporosis research database based on national registers and patient records. Current (standard) clinical management was compared with alternative scenarios mirroring Swedish treatment guidelines.

RESULTS

The national burden in terms of lost QALYs was estimated at 14,993 QALYs and the total economic cost at €776M. Scenario analyses showed that 382-3864 QALYs could be gained at a cost/QALY ranging from cost-saving to €31368, depending on the scenario. The margin of investment, i.e. the maximum amount that could be invested in the healthcare system to achieve these improvements up to the limit of the willingness to pay/QALY, was estimated at €199M on a population level (€3,634/patient).

CONCLUSIONS

The analysis showed that better compliance to treatment guidelines is associated with better projected outcomes and cost-savings. From a cost-effectiveness perspective, there is also considerable room for investment to achieve these improvements in the management of osteoporosis.

Computed Tomography of Humeral Head Cup Arthroplasties

Computed tomography (CT) was employed to evaluate resurfacing metal cup arthroplasties, in shoulders affected by rheumatoid arthritis. Reconstruction of the information obtained, with the high frequency filter, resulted in an image of the cement and skeletal structures inside the cup. This new application of CT may prove valuable in assessing the complications and results of cup arthroplasties.

Brain Metastases — Comparison of Gadodiamide Injection-Enhanced MR Imaging at Standard and High Dose, Contrast-Enhanced CT and Non-Contrast-Enhanced MR Imaging

The aim was to compare the abilities of contrast-enhanced CT, non-contrast-enhanced MR imaging and contrast-enhanced MR imaging using standard (0.1 mmol/kg b.w.) and high (0.3 mmol/kg b.w.) doses of Gadodiamide injection to detect brain metastases (i.e. blood-brain barrier damage). Sixteen patients with at least 2 metastases found by CT were evaluated by MR imaging using non-contrast-enhanced spin-echo, T1-weighted, T2-weighted sequences, and contrast-enhanced spin-echo T1-weighted sequences at 2 dose levels. Gadodiamide injection was first given at the dose of 0.1 mmol/kg b.w. After imaging, another 0.2 mmol/kg b.w. was given, yielding a cumulative dose of 0.3 mmol/kg b.w. No contrast media-related adverse events were recorded. The images were evaluated openly by one and blindly by 2 investigators and the number of metastases, size, delineation (open study) and diagnostic certainty (blind study) of each individual metastasis noted. High-dose MR imaging showed significantly more and smaller metastases than any other examination, and gave a higher diagnostic certainty. All high-dose images were superior to those with the standard dose MR imaging when compared blindly in pairs. We conclude that spin-echo MR imaging with a high dose of Gadodiamide injection is an efficient way to improve the detection of brain metastases, in particular of small ones.

Assessment AT CT of the Rheumatoid Shoulder with Surgical Correlation

Eleven shoulders in 10 patients with rheumatoid arthritis were examined by conventional radiography and CT prior to cup hemiarthroplasty of the humeral head and the results were compared with the surgical findings. There was good agreement between preoperative CT and surgical findings. Humeral head cavities and erosions, with cortical boundaries, could be seen more accurately at CT than at conventional radiography. The HU of their contents corresponded to those of soft tissue, being granulomatous in nature at surgery. In 8 humeral heads CT disclosed large areas of fatty degeneration of bone marrow with HU between − 10 HU and − 76 HU that were not visible on the conventional radiographs. These “fatty cysts” had no cortical boundaries, unlike inflammatory granulomas, but both lesions may influence the surgical approach to hemiarthroplasty.

Degradation and leaching of fluroxypyr after application to railway tracks

Fluroxypyr is an auxin-type herbicide used for postemergent control of broad-leaved weeds in agriculture and in nonagricultural environments such as railways. The overall aim of this study was to assess the potential environmental impact from fluroxypyr application to railway tracks and to elucidate some of the factors that control its environmental fate. In laboratory studies, we examined the degradation of fluroxypyr and the formation of its metabolites fluroxypyr-methoxypyridine (F-MP) and fluroxypyr-pyridinol (F-P) in soil from two Swedish railways. We also investigated the degradation and leaching of fluroxypyr in three different railway plots treated with fluroxypyr (360 g ae ha). The half-life of fluroxypyr in soil samples ranged between 28 and 78 d. An estimated mean 48.6 ± 20% of the fluroxypyr was converted into F-P and 8.0 ± 2% into F-MP. The main metabolite, F-P, was rapidly degraded, with an average half-life of 10 ± 5 d. However, F-MP was not degraded to a significant degree in any sample, resulting in slowly increasing concentrations throughout the experiment. This pattern of relatively rapid degradation of F-P and slow accumulation of F-MP was also observed in the field. The persistent nature of F-MP may be of concern if fluroxypyr is used repeatedly at the same location. Fluroxypyr was detected in the groundwater beneath the track at all three locations studied in concentrations exceeding the EU limit of 0.1 μg L for pesticides in drinking water, and F-P was detected in the groundwater at two of three locations. The most important factor controlling fluroxypyr degradation rate in soil was the soil water content, which modulated microbial activity and presumably also fluroxypyr availability to microorganisms. Our findings imply that fluroxypyr may not be a suitable herbicide for weed control on railway tracks.

Synchronous Pulmonary Metastases from Renal Cell Carcinoma — A Whole Nation Study on Prevalence and Potential Resectability

Background:

At the time of diagnosis, almost one third of patients with renal cell carcinoma (RCC) have metastasis. We studied the prevalence, survival, and potential resectability of synchronous pulmonary metastases (SPMs) in a well-defined cohort of RCCpatients.

Material and Methods:

Aretrospective whole nation study including RCC patients with SPM diagnosed 1970–2005 in Iceland. Imaging studies and histology were reviewed, the TNM system used for staging the primary tumors, and disease-specific survival estimated. Eligibility for SPM removal was evaluated using different criteria from the literature on surgical management of SPM, including solitary SPM and SPMs confined to one lung.

Results:

Altogether, 154 patients (16.9%) had SPMs. In 55 of these patients (35.7%) the lungs were the only site, with detailed information available in 46 cases. Of these 46 patients with SPMs, 15 were unilateral, and of those 11 were solitary. All of these 11 patients were in good physical condition and were deemed eligible for surgical resection; however, only one of them was operated with metastasectomy. Disease-specific survival at five years for patients with solitary SPM was 27.2%, as compared to 12.7%, 7.1%, and 12.0% for patients with unilateral SPMs, all patients with SPMs, and patients with extrapulmonal metastases, respectively (p = 0.33).

Conclusion:

At the time of diagnosis, 16.9% of RCCpatients had SPM. In one in three of these SPM patients metastases were confined to the lungs, while one in five had solitary pulmonary metastases. Although the benefit of pulmonary metastasectomy in RCC is still debated and criteria for resection are not well defined, it appears that many RCC patients with SP Mare potentially eligible for pulmonary metastasectomy.

Caenorhabditis elegans numb inhibits endocytic recycling by binding TAT-1 aminophospholipid translocase

Numb regulates endocytosis in many metazoans, but the mechanism by which it functions is not completely understood. Here we report that the Caenorhabditis elegans Numb ortholog, NUM-1A, a regulator of endocytic recycling, binds the C isoform of transbilayer amphipath transporter-1 (TAT-1), a P4 family adenosine triphosphatase and putative aminophospholipid translocase that is required for proper endocytic trafficking. We demonstrate that TAT-1 is differentially spliced during development and that TAT-1C-specific splicing occurs in the intestine where NUM-1A is known to function. NUM-1A and TAT-1C colocalize in vivo. We have mapped the binding site to an NXXF motif in TAT-1C. This motif is not required for TAT-1C function but is required for NUM-1A's ability to inhibit recycling. We demonstrate that num-1A and tat-1 defects are both suppressed by the loss of the activity of PSSY-1, a phosphatidylserine (PS) synthase. PS is mislocalized in intestinal cells with defects in tat-1 or num-1A function. We propose that NUM-1A inhibits recycling by inhibiting TAT-1C's ability to translocate PS across the membranes of recycling endosomes.

Drinking alcohol during pregnancy: evidence from Canadian Community Health Survey 2007/2008

BACKGROUND

Drinking alcohol during pregnancy may cause many health problems for the child, one of which is fetal alcohol spectrum disorder (FASD). Since FASD is incurable, actions meant to prevent the occurrence of the disability by targeting drinking women become more important. Epidemiological data on drinking among pregnant women, including prevalence and determinants/risk factors, is essential for designing and evaluating prevention programs.

OBJECTIVES

To estimate the prevalence of drinking alcohol during pregnancy and examine the determinants of this behaviour.

METHODS

Using the 2007/8 Canadian Community Health Survey (CCHS) data, we estimated the weighted prevalence of women who drank alcohol during their last pregnancy by provinces. We used a weighted logistic regression to examine associations between drinking patterns, substance abuse behaviours, health-related and socio-demographic characteristics of the women, and the outcome variable.

RESULTS

There were two main findings of this study. One was that the 2007/8 prevalence of drinking alcohol during pregnancy in ON, BC, and Canada was estimated at 5.4%, 7.2%, and 5.8%, respectively. The other was that the use of general practitioners (GP) or family physicians (FP) associated with a decreased risk of drinking alcohol during pregnancy.

DISCUSSION

The results suggest that interventions that involve GP or FP and that increase the use of GP or FP by pregnant women can be effective in reducing drinking alcohol during pregnancy.

Costs of fetal alcohol spectrum disorder in Alberta, Canada

BACKGROUND

Although many programs targeting fetal alcohol spectrum disorder (FASD) are implemented, the province of Alberta is still lacking information on costs of FASD.

OBJECTIVES

To estimate the costs of FASD in Alberta based on available US and Canadian research on costs of FASD, and Alberta data.

METHODS

Two types of costs were estimated. The annual long-term economic cost of FASD, which referred to a projected amount of money incurred by lives of the cohort of children born with FASD each year, was estimated by multiplying the lifetime cost of caring for each child born with FASD with the number of children born with FASD each year. The annual short-term economic cost of FASD, which referred to the amount of money incurred by people who are presently living with FASD, was estimated by using a FASD cost calculator online at http://www.online-clinic.com. Both were societal costs adjusted to 2008 Canadian dollars.

RESULTS

The annual long-term economic cost from the disorders rose from $130 to $400 million each year for the Alberta economy. The annual short-term economic cost for FASD in Alberta was from $48 to $143 million, and the daily cost for FASD in Alberta was from $105 to $316 thousand.

CONCLUSION

These numbers suggest a need for a provincial FASD prevention strategy. The costs of FASD can be used to evaluate the benefits of prevention programs to society.

Adenocarcinoma of the prostate in Iceland: a population-based study of stage, Gleason grade, treatment and long-term survival in males diagnosed between 1983 and 1987

OBJECTIVE

To investigate adenocarcinoma of the prostate in a single population with an extended follow-up period.

MATERIAL AND METHODS

Using the Icelandic Cancer Registry, we identified all Icelandic men diagnosed with prostate cancer between 1983 and 1987. Disease stage, initial treatment and follow-up information were obtained from hospital records and death certificates. A critical evaluation was made of the accuracy of the death certificates regarding prostate cancer. All available histology information was reviewed and graded according to the Gleason grading system.

RESULTS

A total of 414 men were diagnosed with adenocarcinoma of the prostate. Of these, 370 were alive at the time of diagnosis and stage could be determined. Four stage groups were defined: focal incidental (n=50); localized (n=164); local advanced (n=32); and metastatic disease (n=124). The mean age at diagnosis was 74.4 years (range 53-94 years). The combined Gleason score was 2-5 in 89, 6-7 in 117, 8-10 in 117 and unknown in 47 cases. The median follow-up period for the group was 6.15 years (range 0.3-19.8 years). Thirty men received treatment with curative intent: radiation therapy, n=20; and radical prostatectomy, n=10. A total of 334 patients died during the follow-up period, of whom 168 (50%) died of prostate cancer. Prostate cancer-specific survival at 10 and 15 years was 100% and 90.6%, respectively for focal incidental cancer; 73.1% and 60.8% for men with localized disease; 23.4% and 11.7% for local advanced disease; and 6.81% and 5.45% for metastatic disease. A Cox multivariate analysis showed age, stage and Gleason score to be independent predictors of prostate cancer death. A total of 104 patients with localized disease and a Gleason score of <or=7 received deferred treatment. The cause-specific survival for this group was 95.6%, 86.5% and 79.2% at 5, 10 and 15 years, respectively. Death certificates were judged to be accurate with regard to prostate cancer in nearly all instances (96%).

CONCLUSIONS

During an extended follow-up period, half of all patients with prostate cancer died from the disease. Males with localized disease and a favorable tumor grade fared well with deferred treatment. However, a higher stage and grade were associated with substantial prostate cancer mortality. Death certificates were accurate as far as prostate cancer was concerned.

Familial risk of prostate cancer in Iceland

OBJECTIVE

To estimate the risk of prostate and other types of cancer among relatives of Icelandic men diagnosed with prostate cancer over a 5-year period.

PATIENTS AND METHODS

The risk ratio (RR) was used to estimate the risk among relatives of 371 patients with prostate cancer, all of whom lived in Iceland and were diagnosed when alive over a 5-year interval (1983-7). Information on cancer incidence was obtained from the population-based Icelandic Cancer Registry, and information on families from a comprehensive genealogical database covering the population of Iceland.

RESULTS

First-degree male relatives were at a 1.7-fold greater age-adjusted risk of prostate cancer (1832 men; 95% confidence interval, CI, 1.28-2.34). The risk was independent of proband's age at diagnosis. First-degree male relatives of patients who died from prostate cancer were at a statistically significantly greater risk of the disease (784 men; RR 2.17; 95% CI 1.34-3.53) and relatives of patients with incidental disease (T1a) were at a greater risk but not statistically significant so (261; RR 1.86; 95% CI 0.75-4.58). Female first-degree relatives were not at greater risk of breast cancer. The risk of kidney cancer was higher in first- and second-degree female relatives, with an RR (n, CI) of 2.50 (1780, 1.10-5.66) and 2.67 (5534, 1.04-6.81), respectively. The risk of kidney cancer was not statistically significantly greater in male relatives.

CONCLUSION

Family history is a risk factor for prostate cancer in Icelandic men. The risk is potentially higher for relatives of patients who die from the disease. Female relatives are not at greater risk of breast cancer but they may be at greater risk of kidney cancer.

Elimination of stabilised hyaluronan from the knee joint in healthy men

OBJECTIVE

To investigate the elimination of stabilised hyaluronan following intra-articular injection into the knee joint.

DESIGN

This was a single-centre, single-dose study in healthy human volunteers.

PARTICIPANTS

Six healthy men, aged 28 to 47 (mean 38) years, were enrolled in the study.

METHODS

Subjects received a single intra-articular injection (3ml; 20 mg/ml) of (131)I-labelled non-animal stabilised hyaluronic acid (NASHA). Radioactivity in the knee, blood, urine and over the liver was measured with gamma counters for 3 weeks post-injection; magnetic resonance and gamma camera imaging of the knee were also performed at 24 hours post-injection. Radioactivity uptake data were tested for conformity of fit to different mathematical models.

RESULTS

Elimination of (131)I-labelled NASHA from the knee was characterised by a fast initial phase and a slow late phase, and conformed to a three-exponential-function model with elimination half-lives of 1.5 hours, 1.5 days and 4 weeks. Radioactivity distribution within the knee joint was homogenous, and no local leakage was observed. Hepatic radioactivity uptake was low, but significantly above background levels, for the first 2 days post-injection, before declining to background levels. Visual imaging indicated an increase in intra-articular fluid volume at 24 hours post-injection.

CONCLUSIONS

The elimination kinetics of (131)I-labelled NASHA from the human knee joint were described by three distinct phases, with half-times of 1.5 hours, 1.5 days and 4 weeks. Most likely, the last value reflects the true half-life of NASHA following intra-articular injection since the labelling method used causes minimal modification of hyaluronan.

Model for time dependency of cytotoxic effect of CHS 828 in vitro suggests two different mechanisms of action

CHS 828 is a novel drug belonging to the cyanoguanidines. It has shown promising anticancer activity in many preclinical systems and is currently in early clinical trials. Our aim in this study was to assess the growth inhibitory effect of CHS 828 in comparison with paclitaxel, etoposide, and topotecan as a function of concentration and time. U937 GTB, RPMI 8226/S, MDA 231, primary cells from chronic lymphocytic leukemia, and normal mononuclear cells were exposed to CHS 828 and U937 GTB cells were exposed to paclitaxel, etoposide, and topotecan in 18 concentrations for times ranging from 1 to 72 h. Cell survival was measured after 72-h incubation by using the fluorometric microculture cytotoxicity assay. Nonlinear mixed effect modeling was used to model the concentration-effect curves with a modified Hill equation. Patterns of change of drug potency (IC(50)), slope of the concentration-effect curves, and plateau with time were studied. The log IC(50) for CHS 828 decreased with log time in a sigmoid manner for all cell types tested. Although very steep at short and long incubation, the concentration-effect curves became shallow at intermediate times. The log IC(50) for etoposide and topotecan was decreased with log time in a sigmoid manner. The log IC(50) for paclitaxel decreased linearly with log time. The information obtained from modeling the cytotoxic effect of CHS 828 and changes of IC(50) and slope parameters with exposure time suggests a heterogeneous cell response to CHS 828. This could indicate two distinct mechanisms of induction of cell death.

Activity of CHS 828 in primary cultures of human hematological and solid tumors in vitro

CHS 828 is a pyridyl cyanoguanidine that has shown promising preclinical anticancer activity against various experimental tumor models and is presently being tested in a phase II trial in man. In the present study the fluorometric microculture cytotoxicity assay was used for in vitro evaluation of CHS 828 activity in primary cell cultures from hematological and solid tumors. In total, 156 samples from various diagnoses were tested with 72-h continuous drug exposure. CHS 828 showed high relative in vitro activity against tumor cells from chronic lymphocytic leukemia as well as from acute leukemia and high-grade lymphoma. Activity was also observed in several solid tumor cell samples, although the group as a whole appeared less responsive. CHS 828 was significantly more active against hematological malignancies compared to normal lymphocytes. Correlation analysis with standard drugs revealed low to moderate correlation coefficients. The results show that CHS 828 has potent antitumor activity against primary cultures of human tumor cells from patients and might have a unique mechanism of action.

MRI staging using gadodiamide for soft-tissue tumors of the head and neck region. Results from a phase II trial and a 5-year clinical follow-up

In order to document the safety, tolerability and efficacy of gadodiamide outside CNS, an open, non-drug comparative study was performed in patients with tumors of the head and neck region. Fifty adult patients were included and 48 patients received the contrast medium. The examinations were performed on a 1.5 T imager using transverse, non-enhanced T1- and PD-/T2-weighted conventional spin-echo sequences, followed by a contrast-enhanced transverse T1-weighted sequence. Post-contrast images provided more diagnostic information compared to unenhanced images in 33 of 48 patients (69%). This information was of significant help in four and of moderate help in 14 cases. Post-contrast images compared to non-enhanced T1-weighted showed improvement in lesion delineation for 29 of the 43 patients where a lesion was observed. Only in two patients was the diagnostic information lower post-contrast. A comparison between all pre-contrast images versus contrast medium enhanced showed post-contrast images to give more diagnostic information in 14 and less in nine patients. No patient experienced discomfort in relation to gadodiamide injection. Only one adverse event occurred which was described as thirst, being of moderate intensity. The 5-year clinical outcome was analyzed and compared with the pre-operative staging. The case-books of all patients were reviewed and in 44 patients all information could be found. Of those, 18 were still alive, one with active disease (AAD) and 17 with no evidence of disease (NED). Two of those four patients, where information was incomplete, showed NED and two had died. This trial showed that contrast-enhancement using gadodiamide for evaluation of soft tissue tumors in the head and neck region was safe and provided statistically significant more diagnostic information compared with unenhanced images. MRI, when compared with palpation/inspection, changed tumor staging in approximately 30% of all cases.

Health technology assessment and screening in Sweden

OBJECTIVES

To describe health technology assessment (HTA) and policies concerning three screening procedures in Sweden.

METHODS

The main source of information was reports from the Swedish Council for Technology Assessment in Health Care (SBU) and other governmental reports, supplemented by the professional literature.

RESULTS

Prevention is emphasized in the healthcare services of Sweden. Specifically, screening is encouraged and supported when it is deemed beneficial. Sweden has a strong orientation toward evidence-based health care and HTA. Since its inauguration in 1987, SBU has fostered the use of HTA in making policy and clinical decisions in Sweden. Government policy in Sweden is to encourage services that are beneficial and cost-effective and discourages services that are not. Screening is no exception to this general rule. The three cases examined in this paper-mammography screening, PSA screening, and routine ultrasound screening in pregnancy-have all been formally assessed in Sweden. Assessments have been an integral part of policy making concerning these and other preventive measures. Mammography screening has been widely implemented. However, as in other countries, screening is often carried out in an opportunistic fashion, so that PSA screening, in particular, is carried out more in Sweden than can be justified by the evidence.

CONCLUSIONS

Mammography screening is promoted and is completely available to the target group. PSA screening is discouraged, but not with complete success. Ultrasound in pregnancy is widely used, not because of good evidence of impact on mortality and morbidity among newborns, but because it increases the detection rate of congenitally malformed fetuses and because of evidence of positive effects on the management and planning of deliveries, as well as because of psychological and ethical implications of the technology. HTA is an important part of health policy making in Sweden.

Reconstructive urology in the nordic countries--a hospital questionnaire survey

A hospital survey of adult reconstructive urologic surgery in the Nordic countries is presented. The response rate was 80% and included most general hospitals and university clinics. Despite similarities between the healthcare systems of the various countries several differences were found. Cystectomy was performed in a large number of institutions in all countries except Denmark. The annual number of orthotopic bladder substitutions per institution was calculated as three to four (range of medians for each country) and the number of continent cutaneous diversions as two to seven. Open urethral procedures were performed more frequently in Sweden than in the other countries. Surgery for penile curvature and implantation of three-component prostheses for erectile dysfunction was more commonly performed in Denmark and Iceland compared to Sweden.

Local recurrence of rectal cancer: MR imaging before and after oral superparamagnetic particles vs contrast-enhanced computed tomography

The aim of this study was to compare three imaging strategies for the diagnosis of local recurrence of rectal cancer: (a) MR imaging; (b) MR imaging after administration of enteral superparamagnetic particles (Ferristene); and (c) contrast-enhanced CT. Seventeen patients with previous surgery for rectal cancer were examined, 12 patients with local tumour recurrence in the pelvis and 5 patients with postoperative changes. Pelvic multi-coil MR imaging before and after oral administration of superparamagnetic contrast medium [Abdoscan (Ferristene USAN), Nycomed-Amersham, Lidingö, Sweden] as well as abdominal and pelvic CT was performed in all patients. The examinations were independently evaluated by three different radiologists. The general effect of the oral MR contrast medium, the delineation of normal and pathological structures as well as confidence in the diagnosis were registered on a visual analog scale (VAS). The diagnosis according to MR before and after oral contrast medium, and CT, was compared, in 16 patients, with the final diagnosis which was verified by biopsy (n = 3), surgery (n = 6), clinical follow-up (n = 4) and by follow-up with MR or CT (n = 3). No significant improvement in MR image quality was found after enteral contrast medium. The post-contrast MR diagnosis was not changed in any of the patients. The diagnosis on MR correlated with the final diagnosis in 12 of 16 patients (sensitivity 91%, accuracy 62%) and the diagnosis on CT in 11 of 16 patients (sensitivity 82 %, accuracy 56 %). The radiologists' "confidence" in the diagnosis and the degree of accordance with the final diagnosis did not score higher on MR after than before oral contrast administration; however, the accordance with the final diagnosis scored better on MR than on CT. No advantages of orally administered superparamagnetic contrast medium were observed in the examined patient group. Magnetic resonance is preferable to CT in diagnosing local tumour recurrence.

Determination of drug effect on tumour cells, host animal toxicity and drug pharmacokinetics in a hollow-fibre model in rats

PURPOSE

Based on the previously published hollow-fibre assay mainly used for early in vivo anticancer drug screening, we wanted to develop an extended hollow-fibre model in which antitumour activity, haematological toxicity and pharmacokinetics could be studied in the same animal.

METHOD

The breast cancer cell lines MDA-MB-231 and MCF-7 were cultured in semipermeable hollow fibres. The fibres were implanted subcutaneously into immunocompetent male Sprague Dawley rats, and the rats were treated with 5-fluorouracil (5-FU, 125 mg/kg), epirubicin (EPI, 10 mg/kg) or cyclophosphamide (CP, 120 mg/kg) intraperitoneally, the new cyanoguanidine CHS 828 (375 mg/kg or 75 mg/kg x 5) orally, or vehicle only. After 6 days the fibres were retrieved and the cell density was evaluated. Haematological parameters were monitored and two to four samples per animal were drawn to determine the pharmacokinetic parameters in NONMEM.

RESULTS

Drug treatment had generally low effects on the tumour cells. Of the standard drugs (5-FU, EPI and CP), only CP exerted a statistically significant antiproliferative effect. CHS 828 had only a minor effect as a single dose, but divided into five daily doses had a pronounced effect on both cell lines. 5-FU, EPI and CP all caused a marked decrease in leucocytes, platelets and haemoglobin, while CHS 828 did not seem to affect these parameters. The pharmacokinetics of 5-FU and EPI were in accordance with previously established pharmacokinetic models. The pharmacokinetics of CP and CHS 828 were both described by one-compartment models.

CONCLUSIONS

This study illustrates the possibility of measuring antitumour effect, haematological toxicity and pharmacokinetics in the same animal using the hollow-fibre model.

In vivo activity of CHS 828 on hollow-fibre cultures of primary human tumour cells from patients

Fresh human tumour cells from patients with ovarian cancer and chronic lymphocytic leukaemia were cultured in semipermeable hollow fibres. The fibres were implanted on immunocompetent rats, which were treated with the cyanoguanidine N-(4-chlorophenoxyhexyl)-N'-cyano-N"-4-pyridylguanidine (CHS 828). CHS 828 showed high antitumour activity against all eight tumour samples; the fibres from control animals had a mean net growth of 73% while CHS 828 treatment induced a 37% mean reduction of cell density, without observable haematological toxicity. The results show a feasibility of using tumour cells directly from patients in the hollow-fibre rat model.

Temporal effects of the novel antitumour pyridyl cyanoguanidine (CHS 828) on human lymphoma cells

CHS 828, a novel pyridyl cyanoguanidine, has shown potent antitumour activity both in vitro and in vivo and is currently undergoing phase I evaluation in humans in collaboration with the European Organization for Research and Treatment of Cancer (EORTC). Here we study the temporal effects of CHS 828 on cytotoxicity, protein and DNA synthesis, cellular morphology and ultra structure using the lymphoma cell line U-937 GTB as the primary tumour model. In vitro analysis of tumour cell survival in response to CHS 828 revealed a cytotoxic effect progressively increased as a function of exposure time with maximum efficacy observed after 72 h. Activity of CHS 828 on U-937 GTB cells grown in vivo was also found. CHS 828 induced-cell death was dependent on intact protein synthesis and most cells appeared to lose their membrane integrity in the presence of a relatively well preserved nuclear structure. The results indicate that CHS 828 induced active and delayed cell death with a non-apoptotic morphology.

A hollow fiber model for in vitro studies of cytotoxic compounds: activity of the cyanoguanidine CHS 828

The hollow fiber assay is currently used as an in vivo model for anticancer drug screening in nude mice, but it can also be used as an in vitro model. In the current study, an in vitro hollow fiber model was used to study the effect and mode of induced cell death of a new cyanoguanidine, CHS 828. Human leukemia, adenocarcinoma and lymphoma cell lines as well as primary cultures of human tumor cells from patients with chronic lymphocytic leukemia (CLL) and ovarian cancer (OC) and normal human lymphocytes were cultured in semipermeable hollow fibers. The fibers were incubated for 3 or 14 days prior to CHS 828 exposure for 72 h, followed by determination of living cell density by MTT staining. For cell morphology, using harvested cultures on cytospin slides had technical advantages compared to using paraffin sections of the formalin-fixed fibers. CHS 828 showed higher antitumor activity on CLL and normal human lymphocyte cultures compared to OC cultures, and cell lines cultured 3 days were more sensitive than those cultured 14 days. Morphological examination of CHS 828-treated cultures revealed a mixture of apoptosis and necrosis.

Differential activity of topotecan, irinotecan and SN-38 in fresh human tumour cells but not in cell lines

The topoisomerase I inhibitors topotecan irinotecan (CPT-11) and its metabolite SN-38 were studied in a panel of cell lines and in primary tumour cells from patients, using a non-clonogenic cytotoxicity assay. All three substances showed similar activity patterns in the panel of cell lines established to classify the drugs mechanistically. In the patient tumour cells the drugs had different effects. In haematological and ovarian cancer samples, SN-38 was much more potent than topotecan, followed by irinotecan, while in colorectal cancer samples only irinotecan showed substantial activity. This in vitro activity pattern seems to agree with clinical experiences to date. The inactivity of SN-38 in colorectal cancer suggests irinotecan may also have some other role in addition to being a prodrug to SN-38. This study raises questions as to the role and relevance of early preclinical model systems in anticancer drug development, and suggests that important information can be obtained from studies using primary cultures of human tumour cells.

Health technology assessment in Sweden

Sweden has a welfare system that is based on the fundamental principle that all citizens are entitled to good health and medical care, regardless of where they live or what their economic circumstances are. Health and medical care are considered to be public sector responsibilities. However, there is growing interest in establishing more private alternatives to public care. An important characteristic of the Swedish healthcare system is its decentralization, with a major role for county councils. County councils are now merging into larger administrative units (region). The whole Swedish system is in the process of reform, mainly because of perceptions that it was too rigid and had insufficient patient orientation. An important factor in the reforms is that power in the system will be even more decentralized and will have greater public input. This change is seen as calling for increased central follow-up and evaluation of matters such as social, ethical, and economic aspects. Although the state has decentralized control, it still attempts to control the general direction of the system through regulation, subsidy, recommendations, and guidelines. An important actor in the system is the Swedish Council on Technology Assessment in Health Care (SBU). SBU began in 1987 with assessments of health technologies, but its success has recently led policy makers to extend its coverage to dental care. Health technology assessment is increasingly visible to policy makers, who find it useful in decision making.

Evaluation of randomized controlled trials on complementary and alternative medicine

OBJECTIVES

Use of complementary and alternative medicine (CAM) is growing in all Western countries. The goal of this study was to evaluate quality of randomized controlled trials (RCTs) of CAM interventions for specific diagnoses to inform clinical decision making.

METHODS

MEDLINE and related databases were searched for CAM RCTs. Visual review was done of bibliographies, meta-analyses, and CAM journals. Inclusion criteria for review and scoring were blinded RCT, specified diagnosis and intervention, complete study published between January 1, 1966 and July 31, 1998 in an English-language, peer-reviewed journal. Two reviewers independently scored each study.

RESULTS

More than 5,000 trials were found, but only 258 met all study inclusion criteria. The main cause for rejection (> 90%) was that the study was not an RCT or had no blinding. Mean score across 95 diagnosis/intervention categories was 44.7 (S.D. +/- 14.3) on a 100-point scale. Ordinary least-squares regression found date of publication, biostatistician as author or consultant, published in one of five widely read English-language medical journals and diagnosis/intervention category of hypertension/relaxation as significant predictors of higher scores.

CONCLUSIONS

The overall quality of evidence for CAM RCTs is poor but improving slowly over time, about the same as that of biomedicine. Thus, most services are provided without good evidence of benefit.

Characterization and functional analysis of two common human cytochrome P450 1B1 variants

Cytochrome P450 1B1 (CYP1B1) is a human extrahepatic P450 that activates procarinogens, metabolizes 17beta-estradiol, and may well have a role in the pathogenesis of some forms of cancer. Besides rare deleterious mutations reported for the CYP1B1 gene, six single-nucleotide polymorphisms have been reported, of which four cause amino acid exchanges. We have expressed two of the common CYP1B1 alleles in yeast cells and mammalian COS-1 cells in order to functionally characterize the alleles with respect to kinetic properties and protein stability. The CYP1B1.2 variant contains the two linked amino acid substitutions R48G and A119S compared to CYP1B1.1. The kinetic parameters of two structurally unrelated CYP1B1 substrates for the two variants were examined. No kinetic differences were seen of 17beta-estradiol hydroxylation activities between the two CYP1B1 variants and an only minor increase in the apparent Km for ethoxyresorufin was observed for CYP1B1.2. It therefore appears that they have very similar catalytic properties and the substitutions do not appear to alter CYP1B1 catalytic function. The two CYP1B1 variants were similarly stable when expressed in mammalian COS-1 cells, indicating that the substitutions have no effect on protein folding or stability. The combined results indicate that these two CYP1B1 variants show very similar properties with respect to catalytic activities and protein stability and do not alter CYP1B1 function.

Rectal carcinoma: double-contrast MR imaging for preoperative staging

PURPOSE

To evaluate and compare the imaging findings and staging of rectal carcinoma by using conventional magnetic resonance (MR) imaging, MR imaging with an enema of superparamagnetic ferristene-based contrast material, and MR imaging with an enema of ferristene solution plus intravenous injection of gadodiamide.

MATERIALS AND METHODS

Twenty-nine patients (17 women, 12 men; age range, 39-91 years) referred with a diagnosis of rectal carcinoma were examined. Analysis of the rectal wall and staging of the tumor were performed. In all patients, the MR imaging findings were correlated with the histopathologic findings.

RESULTS

The contrast material enema caused distention of the rectum and an intraluminal signal void, whereas the gadodiamide injection caused enhancement of the mucosa on T1-weighted images. This enhancement enabled evaluation of the normal rectal wall and differentiation of the mucosa, tunica muscularis, and perirectal space, which was not possible on the nonenhanced images. Double-contrast (ferristene solution plus gadodiamide) MR imaging was superior to imaging with only ferristene-based contrast material and had a sensitivity of 100%, specificity of 70%, and accuracy of 90% in distinguishing tumor stages worse than Dukes A.

CONCLUSION

Double contrast material-enhanced MR imaging enables accurate rectal carcinoma staging, which is not possible at nonenhanced imaging.

CHS 828, a novel pyridyl cyanoguanidine with potent antitumor activity in vitro and in vivo

A new class of recently discovered antineoplastic agents, the pyridyl cyanoguanidines, exert a potent antitumor activity in rodents after oral administration. Optimization in vitro and in vivo has resulted in the selection of the lead candidate CHS 828 (N-(6-chlorophenoxyhexyl)-N'cyano-N"-4-pyridylguanidine). CHS 828 was found to exert potent cytotoxic effects in human breast and lung cancer cell lines, with lesser effects on normal fibroblasts and endothelial cells. In a study using a panel of cell lines with different resistance patterns, the effects of CHS 828 showed a low correlation with the activity patterns of known anticancer agents, and no sensitivity to known mechanisms of multidrug resistance was observed. In nude mice bearing human tumor xenografts, CHS 828, at doses from 20 to 50 mg/kg/day p.o., inhibited the growth of MCF-7 breast cancer tumors and caused regression of NYH small cell lung cancer tumors. Oral administration of CHS 828 once weekly improved efficacy without increasing toxicity. CHS 828 was found to compare favorably with established chemotherapeutic agents such as cyclophosphamide, etoposide, methotrexate, and paclitaxel. In mice with NYH tumors, long-term survival (>6 months) was observed after treatment with CHS 828 was stopped. In conclusion, CHS 828 is an effective new antitumor agent, with a potentially new mechanism of action. CHS 828 is presently being tested in Phase I clinical trials in collaboration with the European Organization for Research and Treatment of Cancer.

Heterologous expression and kinetic characterization of human cytochromes P-450: validation of a pharmaceutical tool for drug metabolism research

Drug metabolism studies in the early phases of drug discovery and development will improve the selection of new chemical entities that will be successful in clinical trials. To meet the expanding demands for these studies on the numerous chemicals generated through combinatorial chemistry, we have heterologously expressed nine human drug-metabolizing cytochromes P-450 (CYPs) in Saccharomyces cerevisiae. The enzymes were characterized using known marker substrates CYP1A1/1A2 (ethoxyresorufin), 2C8 (paclitaxel), 2C9 (diclofenac), 2C19 (S-mephenytoin), 2D6 (bufuralol), 2E1 (chlorzoxazone), and 3A4/3A5 (testosterone). All of the CYPs showed the expected substrate specificity except for chlorzoxazone hydroxylation, which, in addition to CYP2E1 and 1A2, was also catalyzed by CYP1A1 with a high turnover. The apparent Michaelis-Menten parameters obtained for each CYP were within the ranges of those reported in the literature using human liver microsomes and/or recombinant CYPs. The K(m) for CYP2E1-catalyzed chlorzoxazone hydroxylation was, however, much higher (177 microM) than that obtained using liver microsomes (40 microM). CYP-selective inhibitors, alpha-naphthoflavone (CYP1A1/1A2), quercetin (2C8), sulfaphenazole (2C9), quinidine (2D6), and ketoconazole (3A4/3A5) showed significant isoform-selective inhibitory effects. We have shown that ticlopidine is a potent inhibitor of CYP2C19 (IC(50) = 4. 5 microM) and CYP2D6 (IC(50) = 3.5 microM) activities. We have therefore successfully set-up and validated an "in-house" heterologous system for the production of human recombinant CYPs for use in metabolism research.

[Adenocarcinoma of the prostate. Familial risk in Icelandic males.]

OBJECTIVE

To invesigate the familial risk of prostate cancer in Icelandic males.

MATERIAL AND METHODS

In the years 1983 and 1984 a total of 146 Icelandic males were diagnosed with adenocarcinoma of the prostate. Family trees were constructed to the third degree relation (first degree male relatives are father, brother/s, and son/s, et cetera). Relatives with prostate cancer were found using the centralized Icelandic cancer registry. Expected number of cases was calculated from relatives age and the population risk of the disease.

RESULTS

The relative risk of prostate cancer was markedly increased for the first and second degree relatives 1.7 (CI: 1.2-2.3) and 1.5 (CI: 1.1-2.2) respectively. The mean age for the probands was 74 years and there was no significant difference in the cumulative familial risk (first, second and third degree relatives) after dividing the probands into two groups; younger or older than the mean age.

CONCLUSIONS

Risk of prostate cancer is significantly elevated in relatives of Icelandic males diagnosed with the disease. Family history is therefore of value in screening for prostate cancer.

A prospective randomised study (named SVEA) of three methods of delayed breast reconstruction. Study design, patients' preoperative problems and expectations

A randomised study named SVEA to compare three methods for delayed breast reconstruction was initiated in 1994. The methods were: the lateral thoracodorsal flap, the latissimus dorsi flap, and the pedicled transverse rectus abdominis muscle flap. In the present paper we describe the study design, primary endpoints, and inclusion and exclusion criteria. Results from preoperative questionnaires about problems after mastectomy and expectations of the reconstruction are presented. The preoperative questionnaires, completed before randomisation, included a health related quality of life questionnaire, the SF-36, and a questionnaire concerning the impact of breast loss and expectations of the reconstruction. A total of 87 patients have been randomised in SVEA and 30 patients have been followed up outside the randomised study, comprising a reference group. The results from preoperative questionnaires, completed by 106 of the total 117 women, showed that they encountered many problems after mastectomy, primarily about feeling mutilated and being bothered socially. They held high expectations on the breast reconstruction in these areas. The women in the present study did not differ from Swedish women in general regarding health related quality of life, with two exceptions: the study sample scored lower on physical functioning and mental health.

Sick leave and disability pension before and after treatment for obesity: a report from the Swedish Obese Subjects (SOS) study

OBJECTIVES

To analyse sick leave and disability pension among surgically and conventionally treated obese patients.

DESIGN

A prospective study over five years. Differences in sick leave and disability pension were analysed using multiple and logistic regressions. Possible confounding factors were analysed and controlled for.

SETTING

Nine counties in Sweden.

SUBJECTS

369 surgically treated patients and 371 matched obese controls, included in the Swedish Obese Subjects (SOS) study. At baseline, mean body mass index (BMI) was 42 kg/m2 in surgical patients and 41 kg/m2 in controls. After four years of treatment, weight reduction was 20% among surgical patients while the control patients kept their initial weight.

INTERVENTION

Gastric bariatric surgery.

MEASUREMENTS

Days of sick leave plus disability pension, and days of disability pension.

RESULTS

In the year prior to treatment, adjusted average number of days of sickness due to sick leave plus disability pension was similar in surgical patients and controls. Compared with controls, the surgical group had 35% more days of sickness during the first year after initiation of treatment, but 10-14% fewer days during years 2-3. During year four, days of sickness tended to be lower in the surgical group (P = 0.07). In the sub-group, aged above the median, surgical patients had 14-18% fewer days of sickness than controls, during years 2-3 after initiation of treatment This difference did not occur in the group below median age.

CONCLUSION

Surgical treatment of obesity results in a reduction of sick leave and disability pension, compared to controls, particularly in subjects aged 47-60 y.

Relationship between diagnosis-specific activity of cytotoxic drugs in fresh human tumour cells ex vivo and in the clinic

The aim of this investigation was to evaluate the relationship between the disease-specific activity of cytotoxic drugs in the clinic and in fresh human tumour cells from patients, as detected by a non-clonogenic cytotoxicity assay. The activity of 18 different cytotoxic drugs in fresh human tumour cells ex vivo was analysed in up to 15 samples from each of 13 different diagnoses using the fluorometric microculture cytotoxicity assay (FMCA). For each drug and diagnosis, relative activity indices (RAIs) were calculated, defined as the fraction of samples within the diagnosis having a survival index (SI) less than the median SI for the drug in all tested samples. Clinical response rates for the drug in the same diagnoses were collected from published phase II trials and were compared with the RAIs using Spearman's rank correlation (Rho) and Pearson's correlation coefficient (R). Correlation coefficients could be calculated for 12 drugs. The coefficients varied between 0.02 and 0.92 (Rho) and between 0.07 and 0.91 (R), but for most drugs the correlation between RAI and clinical response rates was good, with Rho > 0.6 and R > 0.7. Weak correlations were observed for cyclophosphamide and vincristine (Rho = 0.32 and 0.16, respectively), which might be due to old clinical data, and for paclitaxel (Rho = 0.02), which perhaps could be explained by in vitro activity of the solvent, Cremophor EL. The 18 drugs were also categorised according to their suggested clinical use in solid or haematological tumours, and were then compared regarding the activity in solid compared with haematological tumours ex vivo, expressed as the ratio between the number of responders among solid and haematological tumours (S/H ratio). The mean ex vivo S/H ratios in the group of drugs registered for use in haematological tumours was only 0.09 and was significantly different (P = 0.05) from the mean S/H ratios for the drugs used in both haematological and solid tumours (0.31) and in solid tumours only (0.47). Furthermore, the FMCA could identify the 50% most and least sensitive diagnoses with respect to clinical phase II activity with 74% (78/106) correct classifications. The results indicate that the relative activity of cytotoxic drugs in different diagnoses may be detected by the FMCA. Thus, 'phase II trials ex vivo' using non-clonogenic cytotoxicity assays might be used to make clinical trials more effective by targeting trials to diagnoses in which a new agent is most likely to be active.

Synergistic interactions of combinations of topotecan with standard drugs in primary cultures of human tumor cells from patients

OBJECTIVE

Combination therapies are important in the treatment of many tumor types. This study was undertaken to find candidates for combination therapy with the novel topoisomerase I inhibitor topotecan.

METHODS

The cytotoxic effect of topotecan alone and in combination with five standard cytotoxic drugs was studied in 27 primary cultures of human tumor cells from patients with various diagnoses using the fluorometric microculture cytotoxicity assay (FMCA). The combinations were analysed according to the multiplicative concept of drug interaction.

RESULTS

The additive model was shown to be a better descriptor than the effect of the most effective agent (Dmax) for all drug combinations tested. Topotecan in combination with cisplatin (CisP) was the drug combination showing synergy in the highest percentage of samples (54%), followed by topotecan in combination with doxorubicin (Dox: 39%), etoposide (P16; 23%), paclitaxel in the formulation Taxol (22%) and cytarabine (AraC; 12%). The high percentage of synergistic interactions was especially pronounced in solid tumors. In 28% of the samples tested, drug sensitivity testing of only single drugs failed to predict response to the drugs in combination.

CONCLUSION

Cisplatin and doxorubicin showed promising effects in combination with topotecan, and clinical trials with these combinations seem warranted. The results also indicate the value of testing drug combinations in in vitro drug sensitivity testing.

International collaboration in health technology assessment: a study of technologies used in management of osteoporosis

A collaborative study was undertaken by members of the International Network of Agencies for Health Technology Assessment (INAHTA). The evidence of the effectiveness of bone density measurement and selected treatments in preventing fractures in later life was reviewed. There was fair evidence that bone density measurement can predict risk of fractures and that hormone replacement therapy and intranasal salmon calcitonin preserve bone mass and decrease the risk of fractures. However, it was estimated that only 1-7% of hip fractures would be prevented if these technologies were used in a screening program for menopausal women. Results of the assessment were endorsed by 13 INAHTA members, disseminated widely and provided input to policy and further work in this area. The project demonstrated the feasibility of international collaborative health technology assessment.

Recommendations for the application of bone density measurement. What can you believe?

This study examined the conclusions of published reports that review the literature and make recommendations about appropriate applications of bone density measurement. It is based on a survey of 22 organizations producing such reports between 1986 and Spring 1995. Overall, the application of bone density measurement for the diagnosis of osteoporosis was supported by 65% of reports, by 44% for the monitoring and follow-up of patients with previously diagnosed disease, and by 59% for monitoring and follow-up of patients receiving treatment that may affect their bone density. A smaller proportion of reports from government and public organizations compared with other types of organizations and a smaller proportion of reports using more rigorous methods supported the applications for bone density measurement identified in the survey. A larger proportion of the reports published after 1990 compared with those published between 1986 and 1990 support the applications of bone density measurement, with the exception of population screening. The results of this survey suggest that there is considerable disagreement about the potential applications of bone density measurement. Publicly funded organisations and those using more rigorous methods tended to be more conservative in their conclusions.