Opioid analgesia in necrotizing pancreatitis: Incidence and timing of a hidden crisis

BACKGROUND

Rates of opioid usage during necrotizing pancreatitis (NP) disease course are unknown. We hypothesized that a significant number of NP patients were prescribed opioid analgesics chronically.

METHODS

Single institution IRB-approved retrospective study of 230 NP patients treated between 2015 and 2019.

RESULTS

Data were available for 198/230 (86%) patients. 166/198 (84%) were discharged from their index hospitalization with a prescription for an opioid. At the first clinic visit following hospitalization, 110/182 (60%) were using opioids. Six months after disease onset, 72/163 (44%) continued to require opioids. At disease resolution, 38/144 (26%) patients remained on opioid medications. The rate of active opioid prescriptions at six months after disease onset declined throughout the period studied from 68% in 2015 to 39% in 2019.

CONCLUSIONS

Opioid prescriptions are common in NP. Despite decline over time, 1 in 4 patients remain on opioids at disease resolution. These data identify an opportunity to adjust analgesic prescription practice in NP patients.

Enantioselective Synthesis of (-)-10-Hydroxyacutuminine

An enantioselective synthesis of (-)-10-hydroxyacutuminine is reported. Central to our strategy is a photochemical [2+2] cycloaddition that forges two of the quaternary stereocenters present in the acutumine alkaloids. A subsequent retro-aldol/Dieckmann sequence furnishes the spirocyclic cyclopentenone. Efforts to chlorinate the acutumine scaffold at C10 under heterolytic or radical deoxychlorination conditions led to the synthesis of an unexpected cyclopropane-containing pentacycle.

Synthesis and Biological Evaluation of Kibdelone C and Its Simplified Derivatives

Poylcyclic tetrahydroxanthones comprise a large class of cytototoxic natural products. No mechanism of action has been described for any member of the family. We report the synthesis of kibdelone C and several simplified analogs. Both enantiomers of kibdeleone C show low nanomolar cytotoxicity toward multiple human cancer cell lines. Moreover, several simplified derivatives with improved chemical stability display higher activity than the natural product itself. In vitro studies rule out interaction with DNA or inhibition of topoisomerase, both of which are common modes of action for polycyclic aromatic compounds. However, celluar studies reveal that kibdelone C and its simplified derivatives disrupt the actin cytoseketon without directly binding actin or affecting its polymerization in vitro.

Studying the roles of W86, E202, and Y337 in binding of acetylcholine to acetylcholinesterase using a combined molecular dynamics and multiple docking approach

A combined molecular dynamics simulation and multiple ligand docking approach is applied to study the roles of the anionic subsite residues (W86, E202, Y337) in the binding of acetylcholine (ACh) to acetylcholinesterase (AChE). We find that E202 stabilizes docking of ACh via electrostatic interactions. However, we find no significant electrostatic contribution from the aromatic residues. Docking energies of ACh to mutant AChE show a more pronounced effect because of size/shape complementarity. Mutating to smaller residues results in poorer binding, both in terms of docking energy and statistical docking probability. Besides separating out electrostatics by turning off the partial charges from each residue and comparing it with the native, the mutations in this study are W86F, W86A, E202D, E202Q, E202A, Y337F, and Y337A. We also find that all perturbations result in a significant reduction in binding of extended ACh in the catalytically productive orientation. This effect is primarily caused by a small shift in preferred position of the quaternary tail.

Transgender DeKalb: observations of an advocacy campaign

In September 2000, the Community Members Against Discrimination (CMAD), a grassroots LGBT organization in DeKalb, Illinois, convinced their city council to add protection against discrimination on the basis of gender identity and expression. Written as an autoethnography, this essay considers the events of the campaign in terms of queer theory and the study of public argument by isolating a set of episodes that bring the reader closer to the experiences of transgender citizens who act in a public culture. The author also explores his own responsibilities as a scholar of communication, an activist, and a member of the LGBT community.

Meningococcal vaccination for adolescents? An economic evaluation in Victoria

OBJECTIVE

To undertake an economic evaluation of the options for vaccination of adolescents using meningococcal polysaccharide vaccine based on Victorian data.

METHODOLOGY

Cost-effectiveness and cost-benefit analyses of three options for vaccination were undertaken for hypothetical populations aged 15-19 years. Baseline analyses assumed a single year of programme implementation and vaccine protection of 5 years. Sensitivity analyses of key variables were performed. Outcomes included the number of people vaccinated, cases averted, life years saved and disability adjusted life years (DALY) averted. Lost earnings avoided were included as a measure of vaccination benefit in cost-benefit analyses.

RESULTS

Vaccination of people in Years 10-12 (secondary school) and first year university within a defined population with a high rate of disease was the most cost-effective option. Excluding direct cost savings and compared with no vaccination, this resulted in a discounted cost per DALY avoided of $17646 and benefits exceeding costs in discounted terms. The 'break-even' incidence rate for this option in the cost-benefit analysis was 11.9/100000.

CONCLUSIONS

Economic evidence favours the use of vaccination within well-defined populations with a high rate of disease.

Should programmes for community-level meningococcal vaccination be considered in Australia? An economic evaluation

BACKGROUND

Disease due to serogroup C Neisseria meningitidis is life-threatening and potentially preventable by vaccination. In 1999, the UK instigated mass vaccination after a sustained increase in serogroup C meningococcal disease. In the same year, Victoria, Australia experienced a similar change in disease epidemiology. It is timely to undertake an economic evaluation of options for community vaccination in Australia based on local data.

METHODS

Cost-effectiveness and cost-benefit analyses of three options for use of polysaccharide vaccine were undertaken for a hypothetical population aged 15--19 years. Baseline analyses assumed 5 years' duration of vaccine protection following a single year of programme implementation. Sensitivity analyses of key variables were performed, including vaccine coverage and effectiveness, case fatality rate and the discount rate. Outcomes included the number of people vaccinated, cases averted, life-years saved and disability-adjusted life-years (DALY) averted. Cost-benefit analysis used lost earnings avoided as a measure of vaccination benefit.

RESULTS

Vaccination of people aged 15--19 years in a defined population with a high rate of disease was the most cost-effective option. Compared with no vaccination and assuming 5 years' duration of protection and exclusion of direct cost savings, this resulted in a discounted cost per life-year saved of $23,623, a cost per DALY avoided of $21,097 and benefits exceeding costs in discounted terms. The 'break-even' incidence rate for this option with exclusion of direct cost savings was 14.0/100,000.

CONCLUSIONS

Community use of polysaccharide vaccination may be cost effective in Australia under certain conditions. Economic evidence favours use of vaccination in well-defined populations with a high rate of disease. Policy decision-making also requires consideration of non-economic factors, including feasibility of implementation and risk perception by the community.

Deficiency of Src homology 2-containing phosphatase 1 results in abnormalities in murine neutrophil function: studies in motheaten mice

Neutrophils, an essential component of the innate immune system, are regulated in part by signaling pathways involving protein tyrosine phosphorylation. While protein tyrosine kinase functions in regulating neutrophil behavior have been extensively investigated, little is known about the role for specific protein tyrosine phosphatases (PTP) in modulating neutrophil signaling cascades. A key role for Src homology 2 domain-containing phosphatase 1 (SHP-1), a PTP, in neutrophil physiology is, however, implied by the overexpansion and inappropriate activation of granulocyte populations in SHP-1-deficient motheaten (me/me) and motheaten viable (me(v)/me(v)) mice. To directly investigate the importance of SHP-1 to phagocytic cell function, bone marrow neutrophils were isolated from both me/me and me(v)/me(v) mice and examined with respect to their responses to various stimuli. The results of these studies revealed that both quiescent and activated neutrophils from motheaten mice manifested enhanced tyrosine phosphorylation of cellular proteins in the 60- to 80-kDa range relative to that detected in wild-type congenic control neutrophils. MOTHEATEN: neutrophils also demonstrated increased oxidant production, surface expression of CD18, and adhesion to protein-coated plastic. Chemotaxis, however, was severely diminished in the SHP-deficient neutrophils relative to control neutrophils, which was possibly attributable to a combination of defective deadhesion and altered actin assembly. Taken together, these results indicate a significant role for SHP-1 in modulating the tyrosine phosphorylation-dependent signaling pathways that regulate neutrophil microbicidal functions.

Demography and dog-human relationships of the dog population in Zimbabwean communal lands

Dogs are Zimbabwe's primary vector for rabies, and the majority live in communal lands (traditional agropastoralist rural areas). In 1994, a household questionnaire survey was conducted to provide baseline data on the demography and dog-human relationships of the dogs in the communal lands. The survey showed that all the dogs were owned, and there was no evidence of a feral population. They were unrestricted and semi-dependent on people. The numbers of dogs per capita varied little in each communal land, resulting in higher dog densities in communal lands with higher human densities, and indicating that people were not intolerant of dogs at higher densities. The population turnover was rapid: the life expectancy of the dogs was 1.1 years, the mean age 2.0 years, and 71.8 per cent died in their first year. The population was heavily skewed towards juveniles, with 40.8 per cent aged less than 12 months. Despite the high juvenile mortality, the population was growing by 6.52 per cent per annum. It was estimated that in 1994 there were 1.36 million dogs in communal lands.

Phagosomal maturation, acidification, and inhibition of bacterial growth in nonphagocytic cells transfected with FcgammaRIIA receptors

Phagocytosis and killing of microbial pathogens by professional phagocytes is an essential component of the innate immune response. Recently, heterologous transfection of individual receptors into nonmyeloid cells has been used successfully to elucidate the early steps that signal phagosome formation. It is unclear, however, whether the vacuoles formed by such transfected cells are bona fide phagosomes, capable of fusion with endomembranes, of luminal acidification, and of controlling the growth of microorganisms. The aim of the current study was to determine whether COS-1 and Chinese hamster ovary cells, rendered phagocytic by expression of human FcgammaRIIA receptors, express the cellular machinery required to support phagosomal maturation. Immunolocalization studies demonstrated that early endosomes, as well as late endosomes and/or lysosomes, fuse sequentially with phagosomes in the transfectants. Microfluorescence ratio imaging of particles labeled with pH-sensitive dyes revealed that maturation of the phagosome was accompanied by luminal acidification. The drop in pH, which attained levels comparable to those reported in professional phagocytes, was prevented by inhibitors of vacuolar-type H(+)-ATPases. Optimal phagosomal acidification required elevation of cytosolic [Ca(2+)], suggesting that it results from fusion of endomembranes bearing proton pumps. Moreover, the transfected cells effectively internalized live bacteria. Opsonization was essential for bacterial internalization, implying that it occurred by FcgammaRIIA-mediated phagocytosis, as opposed to invasion. Uptake into phagolysosomes was associated with inhibition of bacterial growth, due at least in part to the low intraphagosomal pH. These studies indicate that the biochemical events that follow receptor-mediated particle internalization in cells transfected with FcgammaRIIA receptors closely resemble the process of phagosomal maturation in neutrophils and macrophages. FcgammaRIIA-transfected cells can, therefore, be used as a model for the study of additional aspects of phagocyte biology.

The short-term financial costs of abnormal Pap smears to women and government in Australia

Using data collected from a private Canberra colposcopy service, we examined the direct costs, to women and government, of the gynaecological care of women with cervical cytological abnormalities and determine the potential savings of implementing the Commonwealth recommendations for the clinical care of women with screen-detected abnormalities. We performed a case note audit of 502 women who first attended a gynaecologist because of an abnormal Pap smear between 1 January 1989 and 30 April 1990. The smear resulting in their referral--their presenting smear--was categorised as No CIN (showing no evidence of cervical intraepithelial neoplasia), CIN 1, CIN 2 and CIN 3. The average costs to government (p for trend < 0.001) and women (p for trend = 0.006) increase as the presenting smear increases in severity; the median costs to government (p for trend < 0.001) and women (p for trend < 0.001) also rose with increasing cytological severity. Treatment of CIN 1 and No CIN accounted for half the costs incurred by government and women. Although costs increase with increasing severity of cytological abnormality, adherence to new Australian guidelines for the gynaecological care of women with screen-detected cervical abnormalities could result in substantial short-term savings to government and women.

Volumetric changes following barrier regeneration procedures for the surgical management of grade II molar furcation defects in baboons: II. Bone, cementum, epithelium, and connective tissue

In Part I, a computer imaging technique was used to measure the volumetric fill that occurred in surgically created grade II molar furcation defects after they had been treated using the principles of guided tissue regeneration. In Part II, the volumetric fill for each of the specific tissues comprising the defect fill (epithelium, connective tissue, bone, and cementum) was compared. The histologic material consisted of defects treated using one of three types of surgical treatment as well as untreated control sites. All volumetric measurements were expressed as a percentage of the original surgically created defect size, with 100% indicating complete healing of the defect. The results indicate that none of the defects achieved complete healing. Teeth receiving flap debridement had the most overall defect fill (79.50% comprised of 17.13% bone, 35.81% connective tissue, 37.35% epithelium, and 9.71% cementum). Teeth that received a biodegradable barrier showed a mean overall defect fill of 74.98% (7.41% bone, 47.13% connective tissue, 36.20% epithelium, and 9.26% cementum. Sites treated with an exclusion barrier showed 70.75% overall fill (9.63% bone, 40.89% connective tissue, 39.00% epithelium, and 10.48% cementum). The untreated control teeth showed a mean overall fill of 78.70% (5.56% bone, 59.11% connective tissue, 31.06% epithelium, and 4.27% cementum). No significant differences were found among teeth within the same animal and between treatment and controls. The following conclusions were drawn: (1) connective tissue comprised nearly one half of the total fill of the surgically created defects; (2) the percentage of new bone growth was significantly lower than anticipated; and (3) no significant differences were found among the treatment modalities and the untreated control sites for each of the specific tissue types.

Importance of MEK in neutrophil microbicidal responsiveness

Exposure of neutrophils to inflammatory stimuli such as the chemoattractant FMLP leads to activation of responses including cell motility, the oxidative burst, and secretion of proteolytic enzymes. A signaling cascade involving sequential activation of Raf-1, mitogen-activated protein kinase (MEK), and extracellular signal regulated kinase (ERK) is also rapidly activated after agonist exposure. The temporal relationship between these events suggests that the kinases may be involved in triggering the effector functions, but direct evidence of a causal relationship is lacking. To assess the role of the MEK/ERK pathway in the activation of neutrophil responses, we studied the effects of PD098059, a potent and selective inhibitor of MEK. Preincubation of human neutrophils with 50 microM PD098059 almost completely (>90%) inhibited the FMLP-induced activation of MEK-1 and MEK-2, the isoforms expressed by neutrophils. This dose of PD098059 virtually abrogated chemoattractant-induced tyrosine phosphorylation and activation of ERK-1 and ERK-2, implying that MEKs are the predominant upstream activators of these mitogen-activated protein kinases. Pretreatment of neutrophils with the MEK antagonist inhibited the oxidative burst substantially and phagocytosis only moderately. In addition, PD098059 antagonized the delay of apoptosis induced by exposure to granulocyte-macrophage CSF. However, the effects of PD098059 were selective, as it failed to inhibit other responses, including chemoattractant-induced exocytosis of primary and secondary granules, polymerization of F-actin, chemotaxis, or activation of phospholipase A2. We conclude that MEK and ERK contribute to the activation of the oxidative burst and phagocytosis, and participate in cytokine regulation of apoptosis.

Volumetric changes following barrier regeneration procedures for the surgical management of grade II molar furcation defects in baboons: I. Overall defect fill

A computer imaging technique has been advocated for measuring the volumetric fill in furcation defects. Histologic material for this investigation was obtained from an animal study using five adult baboons (Papio anubis). The photographed histology was converted into digitized electronic information, and a computer calculated the overall volume of defect fill for the treated and the untreated control sites. All volumetric measurements were expressed as a percentage of the original surgically created defect size, with 100% indicating complete healing of the defect. The results indicate that none of the defects achieved complete healing. Teeth that had received flap debridement had the most overall defect fill (79.50%). Teeth that received a biodegradable barrier (Epi-Guide) showed a mean overall defect fill of 74.98%, while sites treated with an exclusion barrier (Gore-Tex) showed 70.75% overall fill. The untreated control teeth showed a mean overall fill of 78.70%. A variety of statistical tests revealed no significant differences among teeth within the same animal and between treatments and controls. The following conclusions were drawn: (1) digital imaging technology is a useful research tool for determining the volume of defect fill in surgically created grade II molar periodontal furcation defects in the baboon model; and (2) no significant differences were found among the treatment modalities and the untreated control sites.

A cost-effectiveness analysis of directly observed therapy vs self-administered therapy for treatment of tuberculosis

STUDY OBJECTIVES

To compare the costs and effectiveness of directly observed therapy (DOT) vs self-administered therapy (SAT) for the treatment of active tuberculosis.

DESIGN

Decision analysis.

SETTING

We used published rates for failure of therapy, relapse, and acquired multidrug resistance during the initial treatment of drug-susceptible tuberculosis cases using DOT or SAT. We estimated costs of tuberculosis treatment at an urban tuberculosis control program, a municipal hospital, and a hospital specializing in treating drug-resistant tuberculosis.

OUTCOME MEASURES

The average cost per patient to cure drug-susceptible tuberculosis, including the cost of treating failures of initial treatment.

RESULTS

The direct costs of initial therapy with DOT and SAT were similar ($1,206 vs $1,221 per patient, respectively), although DOT was more expensive when patient time costs were included. When the costs of relapse and failure were included in the model, DOT was less expensive than SAT, whether considering outpatient costs only ($1,405 vs $2,314 per patient treated), outpatient plus inpatient costs ($2,785 vs $10,529 per patient treated), or outpatient, inpatient, and patients' time costs ($3,999 vs $12,167 per patient treated). Threshold analysis demonstrated that DOT was less expensive than SAT through a wide range of cost estimates and clinical event rates.

CONCLUSION

Despite its greater initial cost, DOT is a more cost-effective strategy than SAT because it achieves a higher cure rate after initial therapy, and thereby decreases treatment costs associated with failure of therapy and acquired drug resistance. This cost-effectiveness analysis supports the widespread implementation of DOT.

Child Health Surveillance in England and Wales: the good news

Postal surveys were conducted in 1993 among all, or samples of, six groups of providers and managers of pre-school child health surveillance (CHS) in England and Wales. Content analyses were also carried out of strategic policy statements for CHS produced by 54 district health authorities in England and Wales. The surveys aimed to document the views and experiences of CHS providers and managers about the impact of recent changes affecting the structure and operation of CHS, including the publication of Health for All Children, the 1990 Contract for General Practitioners (GPs), the implementation of the National Health Service and Community Care Act 1990, and the changing roles of community doctors and health visitors. Five positive findings from the surveys are discussed: the impact of the first edition of Health for All Children; improvements in the development and use of child health information systems; the beneficial effects of the growing Involvement of GPs in CHS; the developing understanding of, and commitment to, the principle of clinical audit in CHS; and the growing collaboration between providers in the NHS internal market. A separate paper reports the negative findings from the study.

Child Health Surveillance in England and Wales: the bad news

Postal surveys were conducted in 1993 among all, or samples of, six groups of providers and managers of pre-school child health surveillance (CHS) in England and Wales. Content analyses were also carried out of strategic policy statements for CHS produced by 54 district health authorities in England and Wales. The surveys aimed to document the views and experiences of CHS providers and managers about the impact of recent changes affecting the structure and operation of CHS, including the publication of Health for All Children, the 1990 Contract for General Practitioners (GPs), the implementation of the National Health Service and Community Care Act 1990, and the changing roles of community doctors and health visitors. Four adverse findings from the surveys are discussed: fragmentation in the child health service; the unwanted effects of the NHS internal market; the adverse consequences of the changing role of health visitors; and the concerns voiced by the community doctors about the quality of CHS in general practice.

Chemotactic peptide-induced activation of MEK-2, the predominant isoform in human neutrophils. Inhibition by wortmannin

Exposure of neutrophils to a variety of agonists including chemoattractant peptides and cytokines induces degranulation and activation of the oxidative burst which are required for bacterial killing. The signaling pathways regulating these important functions are incompletely characterized. Mitogen-activated protein (MAP) kinases, which include the extracellular signal-regulated kinases (ERKs), are activated rapidly in neutrophils, suggesting that they may regulate cell activation. We found that neutrophils express two isoforms of MAP/ERK kinase (MEK), mixed-function kinases that are responsible for phosphorylation and activation of ERK. Like MEK-1, MEK-2 was found to reside in the cytosol both before and after stimulation. Studies were undertaken to define the relative abundance and functional contribution of MEK-1 and MEK-2 in neutrophils and to characterize the signaling pathways leading to their activation. Although the abundance of the two isoforms was similar, the activity of MEK-2 was at least 3-fold greater than that of MEK-1. A rise in cytosolic [Ca2+] was insufficient for MEK stimulation, and blunting the [Ca2+] change with intracellular chelators failed to prevent receptor-mediated activation of either isoform, implying that cytosolic Ca2+ transients are not necessary. In contrast, both MEK-1 and MEK-2 were activated by exposure of cells to protein kinase C (PKC) agonists. Conversely, PKC antagonists inhibited the chemotactic stimulation of both isoforms, suggesting that PKC was required for their activation. Despite these similarities, clear differences were also found in the pathways leading to activation of the MEK isoforms. In particular, MEK-2 was considerably more sensitive than MEK-1 to the phosphatidylinositol 3-kinase inhibitor wortmannin. Phosphorylation and activation of ERK-1 and ERK-2 were also reduced by this inhibitor. In summary, MEK-2 is stimulated in formyl-methionyl-leucyl-phenylalanine-treated neutrophils, where it appears to be functionally the predominant isoform. The time course and inhibitor sensitivity of MEK-2 activation parallel those of several components of the microbicidal response, suggesting a signaling role of the MEK-ERK pathway.

The measurement of molar furcation defect fill using digital computer technology--report on a new technique

Recent advances in digital imaging technology have opened up new horizons for dental researchers. This study demonstrates the efficacy of a new technique for measuring regeneration in surgically created molar furcal defects. The investigators evaluated histologic material from a recently completed animal study using five adult baboons. In the animal study, surgically created molar furcation defects were treated using the principles of guided tissue regeneration. From the histologic data of one animal a computer calculated the volume of new bone, connective tissue, epithelium, and cementum as a percentage of the original defect size. The results of this study indicated that digital imaging technology is a useful research tool for determining the volume of defect fill in surgically treated Grade II molar furcation defects in the baboon animal model.

A cost-effectiveness analysis of enalapril maleate in the management of congestive heart failure in Australia

BACKGROUND

This study is motivated by the results of the SOLVD treatment trial (N Engl J Med 1991; 325: 293-302) which demonstrated the clinical efficacy of enalapril in the treatment of congestive heart failure but did not undertake an economic evaluation of enalapril therapy.

AIMS

To undertake a cost-effectiveness analysis of enalapril maleate versus placebo, in conjunction with conventional treatment, in the management of congestive heart failure in Australia.

METHODS

The published results from the SOLVD treatment trial are used to estimate the increase in survival, and the reduction in the number of hospitalisations, arising from the use of enalapril in the management of congestive heart failure. The costs of enalapril therapy are estimated using Australian data on the drug and non-drug costs of enalapril therapy and the costs of hospitalisation.

RESULTS

Enalapril therapy increases mean survival in heart failure patients by 1.68 to 1.80 months. The average additional drug and non-drug cost of enalapril therapy is estimated to be $1890 over a four year period, against which must be offset cost savings from a reduction in hospitalisations of $2060 to $2140. On balance, therefore, enalapril is cost saving, reducing health care costs for a congestive heart failure patient on average by $170 to $250 over a four year period. This value is sensitive to estimates of cost offsets and of improved survival which can result in either a net cost saving with enalapril of approximately $1200 per patient or a net additional cost of up to $3000 per patient (over four years) or greater than $20,000 per life-year saved.

CONCLUSIONS

The addition of enalapril to conventional management of congestive heart failure in Australia should improve survival and may provide a net reduction in treatment costs compared with conventional management alone.

Estimating treatment cost functions for progressive diseases: a multiproduct approach with an application to breast cancer

Using the theory of multiproduct cost functions, a treatment cost function is derived for diseases which progress through a number of stages. The output classes are conceived as the stages at detection of the disease, with the unit of output within each class being the treated case. The derivation clarifies the assumptions underlying various specific functional forms for the treatment cost function. An empirical application to the treatment of breast cancer is provided, producing evidence on an important issue in the economics of screening programs, viz. whether detection of breast cancer at an earlier stage results in treatment cost savings.

The costs of treating breast cancer in Australia and the implications for breast cancer screening

The aim of the study was to determine if there is a relationship between the stage of breast cancer at the time of detection and the costs of treatment and to assess whether any such relationship would have an influence on the cost of a mammographic screening programme. A retrospective analysis of the stage at presentation for primary breast cancer and the treatment costs over the duration of treatment was made. Multiple regression analysis was employed, with treatment cost as the dependent variable and categorical variables to represent stage at detection. A total of 301 women whose treatment for breast cancer commenced at the Royal Brisbane Hospital participated in the study. A statistically significant relationship was found between the stage of disease at the time of detection and subsequent treatment costs; more advanced stages of disease incurred higher treatment costs. This relationship was robust even after taking into account the age of patients, their discharge status, and differences between patients in the duration of treatment. When the effect of earlier detection on treatment cost was assessed in relation to a breast screening programme, cost savings were estimated to be in the range of 8-36% of total screening costs. There are treatment cost savings to be gained from breast cancer screening as a result of the detection of earlier stages of disease. These treatment cost savings should be offset against the cost of a mammographic screening programme.

Chemotactic peptides induce phosphorylation and activation of MEK-1 in human neutrophils

Extracellular signal-regulated kinase (Erk) (mitogen-activated protein (MAP) kinase) is rapidly activated when neutrophils are stimulated. Several isoforms of MAP/Erk kinase (MEK), a kinase capable of phosphorylating and activating Erk, have been identified, but their distribution and differential roles in leukocytes are unknown. We studied the effect of chemotactic stimulation on MEK-1, using isoform-specific antibodies. MEK-1 was found to be phosphorylated on serine and threonine residues in unstimulated human neutrophils. Stimulation by the chemotactic peptide formyl-methionyl-leucyl-phenylalanine (fMLP) enhanced serine/threonine phosphorylation of MEK-1, while reducing its electrophoretic mobility. MEK-1 activity, measured as autophosphorylation or as phosphorylation of a glutathione S-transferase-Erk fusion protein, was undetectable in unstimulated cells but became evident after treatment with chemoattractant. Phosphorylation and activation of MEK-1 were rapid and transient, peaking after 1-2 min and returning to base line by 10 min. Experiments using electropermeabilized cells indicated that elevation of cytosolic Ca2+ is not required for activation of MEK-1 by fMLP. Moreover, MEK-1 was not stimulated by either platelet-activating factor or thapsigargin, which increase Ca2+ to levels comparable with those attained in chemoattractant-activated cells. In contrast, activation of MEK-1 was induced by phorbol esters, and the stimulatory effect of fMLP was blocked by an antagonist of protein kinase C. Stimulation of MEK-1 was also blocked by concentrations of erbstatin that prevent the fMLP-induced accumulation of tyrosine-phosphorylated proteins. The data suggest that MEK-1 is largely responsible for the activation of Erk in chemoattractant-stimulated neutrophils and that protein kinase C and/or tyrosine kinases mediate this effect, whereas elevated cytosolic Ca2+ is not essential.

Receptor-mediated activation of multiple serine/threonine kinases in human leukocytes

Activation of the microbicidal response of phagocytes requires cytosolic ATP and is associated with extensive protein phosphorylation, suggesting the involvement of protein kinases in the signal transduction cascade. An in vitro renaturation assay was used to identify the protein kinase(s) activated by chemoattractants in human blood neutrophils. Four distinct kinases were activated by the chemotactic peptide formyl-methionyl-leucyl-phenyl-alanine with molecular masses of 72, 65, 49, and 41 kDa (designated PK72, PK65, PK49, and PK41, respectively). PK72 and PK65 were activated very rapidly (5-15 s), yet transiently. By comparison, PK49 and PK41 responded in a slower, more sustained manner. Treatment of extracts of activated cells with alkaline phosphatase reverted the stimulation of the kinases, suggesting that phosphorylation is the post-translational modification that underlies activation of the kinases. Stimulation of PK72 and PK65 by chemoattractant was independent of calcium and protein kinase C. In contrast, elevation of cytosolic free calcium levels was sufficient and appeared to be necessary for full activation of PK49 and PK41. While phorbol esters can mimic the effects of formyl-methionyl-leucyl-phenylalanine on PK49 and PK41, inhibition of protein kinase C by staurosporine did not prevent the receptor-mediated activation of these kinases. PK41 most likely corresponds to the Erk-1 isoform of mitogen-activated protein (MAP) kinase. Accordingly, PK41 effectively phosphorylated myelin basic protein, known to be a good substrate for Erk-1. The electrophoretic mobility of PK49 is similar to that of MAP kinase-kinase (MAP/Erk kinase). However, immunoprecipitation experiments indicated that PK49 is not MAP/Erk kinase. The identity of this and other kinases remains to be defined, but possible candidates are discussed. In addition to autophosphorylating, PK72, PK65, and PK41 were shown to effectively phosphorylate exogenous substrates. These kinases may therefore play a role in signal transduction during stimulation by chemoattractants.

Bending strength of Fuji and Ketac glass ionomers after sonication

Glass ionomer cements mixed by conventional methods contain voids that can decrease their overall strength. This study evaluated the effect of sonication on the reduction of air entrapment by measuring the bending strength in glass ionomer cements (Fujj-II and Ketac-fil). Glass ionomer cement was placed in identical-test vials and sonicated for 45s, 10s, or 0s. The bending strengths were measured (0.005 in min-1) after setting times of 1 or 2 weeks. Mean bending strengths (MPa +/- SD) for the 12 treatment both cements (P < 0.001) and sonication times (P < 0.001). The effect of setting time produced minimal increases in bending strength (P < 0.218). The sonication of freshly mixed glass ionomer cements is a possible solution for reducing voids to increase bending strength.

Association of a cGMP-binding activity with nuclei isolated from amoebae of Dictyostelium discoideum and Polysphondylium violaceum

When vegetative and early slug stage amoebae of Dictyostelium discoideum or Polysphondylium violaceum were lysed by filter breakage in a nuclear isolation buffer not containing detergents, substantial levels of a cGMP-binding activity with slow-dissociation kinetics were detected. After fractionation by centrifugation, 50% or more of this binding activity was associated with isolated nuclei. In addition, with Polysphondylium cells, the fraction of stable, nuclear-associated binding activity appeared to increase during cell aggregation. These results support the idea that cGMP might function in the nucleus during early development.

Effect of immune system imagery on secretory IgA

This study was an investigation of the effects of physiologically-oriented mental imagery on immune functioning. College students with normal medical histories were randomly selected to one of three groups. Subjects in Group 1 participated in short educational training on the production of secretory immunoglobulin A. They were then tested on salivary IgA, skin temperature, and the Profile of Mood States (POMS) before and after listening to a 17-minute tape of imagery instructions with specially composed background "entrainment" music designed to enhance imagery. Subjects in Group 2 (placebo controls) listened to the same music but received nor formal training on the immune system. Group 3 acted as a control and subjects were tested before and after 17 minutes of no activity. Treatment groups listened to their tapes at home on a bi-daily basis for six weeks. All groups were again tested at Weeks 3 and 6. Secretory IgA was analyzed using standard radial immunodiffusion techniques. Repeated measures analyses of variance with planned orthogonal contrasts were used to evaluate the data. Significant overall increases (p less than 0.05) were found between pre- and posttests for all three trials. Groups 1 and 2 combined (treatment groups) yielded significantly greater increases in sIgA over Group 3 (control) for all three trials. Group 1 (imagery) was significantly higher than Group 2 (music) in antibody production for Trials 2 and 3. Symptomatology, recorded by subjects at Weeks 3 and 6, was significantly lower for three symptoms (rapid heartbeat, breathing difficulty, and jaw clenching), favoring both treatment groups over the control group.

The economy of time in general practice: an assessment of the influence of list size

A lack of time is one of the major reasons given to account for low quality care provided in general practice. One of the basic assumptions inherent in this explanation is that activities in general practice are shaped by the level of patient demand and general practitioners have little control over their work. The objective of this study is to explore empirically this assumption that general practice is demand led by examining the relationship between list size and the time general practitioners spend at work-related activities. The analysis uses data gathered from a survey carried out on a nationally representative sample of unrestricted principals (N = 1419) living in England and Wales. The results show that list size is statistically significantly associated with each of the different indices of time allocation, although it is only relatively strongly associated with hours spent on surgery consultations and surgery consultation rates. The implications of these findings are discussed and it is suggested that the demand led model provides only a partial explanation for variations in time allocation in general practice.

List sizes and use of time in general practice

The claim that list sizes in general practice should continue to fall towards a national average of 1700 patients rests heavily on the assumption that the extra time available to doctors would be used mainly for longer consultations, resulting in better standards of care. Evidence suggests, however, that the time is more likely to be used to increase rates of consultation in surgeries and home visits and to reduce the length of the working week. A national, random sample of 2104 principals in general practice in England and Wales were questioned about their allocation and use of time. The response rate was 67%, and no large biases in response were detected. The smaller their personal list size the less time general practitioners spent on all aspects of their work and the higher their rates of consultation and home visiting. The effects of further reductions in list sizes would be haphazard, being differentially distributed across the range of list sizes. Longer consultations would probably result, but most of the extra time would probably be used in higher rates of consultation in surgeries and home visits and some would be taken as free time.