Exploring the perceptions and acceptability of an integrated lifestyle database for public health research and service commissioning: a qualitative study

AIM

Public health lifestyle databases at local authority level are currently poorly aligned across the UK. The integration of lifestyle databases at a regional level could provide a rich resource to support research and help inform public health leads and service commissioners in improving service delivery, facilitating decision-making and developing key public health policies. Prior to its implementation, the acceptability of an integrated lifestyle database should be explored. The aim of this study was to consult with public health stakeholders to explore the acceptability of developing and implementing a regional integrated lifestyle database across four key areas of public health: smoking cessation, diet, physical activity and alcohol consumption.

METHOD

Qualitative interviews were conducted with public health stakeholders recruited from across the East Midlands region of England. All interviews were conducted using video conferencing software and recorded, transcribed, and analysed using the Framework approach. Sixteen public health stakeholders were purposively identified and invited to participate in interviews.

RESULTS

Stakeholders viewed the integrated database as having potential to support research, service development and commissioning decisions. Barriers such as providers' reluctance to reveal their business strategies to rival organisations, cost of setting up and running the proposed database, complex information-sharing and governance were identified.

CONCLUSION

An integrated lifestyle database has the potential to support research and service commissioning regionally. However, several barriers were identified that must be addressed prior to the development and implementation of an integrated database.

Deep learning as a predictive tool for fetal heart pregnancy following time-lapse incubation and blastocyst transfer

STUDY QUESTION

Can a deep learning model predict the probability of pregnancy with fetal heart (FH) from time-lapse videos?

SUMMARY ANSWER

We created a deep learning model named IVY, which was an objective and fully automated system that predicts the probability of FH pregnancy directly from raw time-lapse videos without the need for any manual morphokinetic annotation or blastocyst morphology assessment.

WHAT IS KNOWN ALREADY

The contribution of time-lapse imaging in effective embryo selection is promising. Existing algorithms for the analysis of time-lapse imaging are based on morphology and morphokinetic parameters that require subjective human annotation and thus have intrinsic inter-reader and intra-reader variability. Deep learning offers promise for the automation and standardization of embryo selection.

STUDY DESIGN, SIZE, DURATION

A retrospective analysis of time-lapse videos and clinical outcomes of 10 638 embryos from eight different IVF clinics, across four different countries, between January 2014 and December 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The deep learning model was trained using time-lapse videos with known FH pregnancy outcome to perform a binary classification task of predicting the probability of pregnancy with FH given time-lapse video sequence. The predictive power of the model was measured using the average area under the curve (AUC) of the receiver operating characteristic curve over 5-fold stratified cross-validation.

MAIN RESULTS AND THE ROLE OF CHANCE

The deep learning model was able to predict FH pregnancy from time-lapse videos with an AUC of 0.93 [95% CI 0.92-0.94] in 5-fold stratified cross-validation. A hold-out validation test across eight laboratories showed that the AUC was reproducible, ranging from 0.95 to 0.90 across different laboratories with different culture and laboratory processes.

LIMITATIONS, REASONS FOR CAUTION

This study is a retrospective analysis demonstrating that the deep learning model has a high level of predictability of the likelihood that an embryo will implant. The clinical impacts of these findings are still uncertain. Further studies, including prospective randomized controlled trials, are required to evaluate the clinical significance of this deep learning model. The time-lapse videos collected for training and validation are Day 5 embryos; hence, additional adjustment would need to be made for the model to be used in the context of Day 3 transfer.

WIDER IMPLICATIONS OF THE FINDINGS

The high predictive value for embryo implantation obtained by the deep learning model may improve the effectiveness of previous approaches used for time-lapse imaging in embryo selection. This may improve the prioritization of the most viable embryo for a single embryo transfer. The deep learning model may also prove to be useful in providing the optimal order for subsequent transfers of cryopreserved embryos.

STUDY FUNDING/COMPETING INTEREST(S)

D.T. is the co-owner of Harrison AI that has patented this methodology in association with Virtus Health. P.I. is a shareholder in Virtus Health. S.C., P.I. and D.G. are all either employees or contracted with Virtus Health. D.G. has received grant support from Vitrolife, the manufacturer of the Embryoscope time-lapse imaging used in this study. The equipment and time for this study have been jointly provided by Harrison AI and Virtus Health.

A consensus exercise identifying priorities for research into clinical effectiveness among children's orthopaedic surgeons in the United Kingdom

Aims

High-quality clinical research in children's orthopaedic surgery has lagged behind other surgical subspecialties. This study used a consensus-based approach to identify research priorities for clinical trials in children's orthopaedics.

Methods

A modified Delphi technique was used, which involved an initial scoping survey, a two-round Delphi process and an expert panel formed of members of the British Society of Children's Orthopaedic Surgery. The survey was conducted amongst orthopaedic surgeons treating children in the United Kingdom and Ireland.

Results

A total of 86 clinicians contributed to both rounds of the Delphi process, scoring priorities from one (low priority) to five (high priority). Elective topics were ranked higher than those relating to trauma, with the top ten elective research questions scoring higher than the top question for trauma. Ten elective, and five trauma research priorities were identified, with the three highest ranked questions relating to the treatment of slipped capital femoral epiphysis (mean score 4.6/ 5), Perthes' disease (4.5) and bone infection (4.5).

Conclusion

This consensus-based research agenda will guide surgeons, academics and funders to improve the evidence in children's orthopaedic surgery and encourage the development of multicentre clinical trials. Cite this article: Bone Joint J 2018;100-B:680-4.

Abstract PD2-13: Benefits to breast screening beyond mortality reduction

Background

The value of population-based mammographic screening has been questioned by those who believe that the reduction in mortality from earlier diagnosis is outweighed by harms including overdiagnosis and overtreatment. Much of these commentaries assume that all Early-Stage Breast Cancer (ESBC) is treated the same way after diagnosis; with extensive therapies including surgery, radiotherapy and chemotherapy being standard.

Intensity of treatment received is rarely mentioned in the debate. We hypothesised that those diagnosed through a screening program (Active Screeners (AS)) would receive less extensive surgical treatment and less intense adjuvant therapies than those not recently screened (NRS). If demonstrated, these differences would form an important component of the debate over the role of mammographic screening.

Methods

Retrospective analysis of a consecutive cohort of female patients aged 50-69 and managed for ESBC (invasive or DCIS) during 2007-2013 within a large metropolitan Breast Service, diagnosed either via a population screening program (AS) or outside of the program (NRS). Data on patient characteristics, symptoms, mode of detection, tumour pathology, surgical intervention and adjuvant treatment recommendations were derived from prospectively collected Multi-Disciplinary Meeting (MDM) records. Patients with metastatic disease or prior treatment for breast cancer were excluded.

Results

791 cases were identified (569 with screen-detected cancer, 53 with interval cancers and 169 cancers diagnosed in women not recently screened). Invasive cancers in the AS group were much smaller than in the NRS group – mean 17mm versus 26mm. The AS group had lower grade invasive cancer – grade 1, 2 and 3 were 27%, 42%, 31% - compared with 10%, 39% and 52% in the NRS group. The AS group were more likely to have ER+ve cancers (88% vs 80%) and less likely to have nodal involvement (26% vs 48%). For invasive breast cancer, the NRS group were more than twice as likely to undergo mastectomy than cancers in the AS group (35% vs 16%). Axillary dissections were more common in the NRS than the AS group (43% vs 19%). Adjuvant chemotherapy was recommended more frequently for the NRS group compared to the AS group (65% vs 37%), as was post mastectomy radiotherapy (58% vs 39%). Endocrine therapy was less often recommended to the NRS group (86% versus 77%).

Conclusion

Women diagnosed with early stage breast cancer who are participating in a population based screening program are less likely to receive mastectomy and/or axillary dissection, less likely to receive adjuvant chemotherapy and less likely to receive post-mastectomy radiotherapy. These differences in treatment intensity should be considered in the debate surrounding mammographic screening.

Citation Format: Elder KJ, Nickson C, Cooke S, Machalek D, Rose A, Mou A, Collins JP, Park A, De Boer R, Phillips C, Pridmore V, Farrugia H, Mann GB. Benefits to breast screening beyond mortality reduction [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD2-13.

A comparison of ketamine sedation and general anaesthesia for manipulation of paediatric forearm fractures

The purpose of the study was to compare the use of ketamine sedation and general anaesthesia for manipulation of paediatric wrist and forearm fractures. A retrospective analysis was performed of patients under 16 years treated at our centre between October 2014 and October 2015. Exclusion criteria were open fractures and fractures with complete displacement. Outcomes measured were fracture reduction, the quality of the cast, fracture redisplacement, further surgical intervention and use of theatre time. 66 children were manipulated over the study period; 31 received ketamine sedation and 35 general anaesthesia. No statistically significant difference was found in the rate of re-intervention (p=0.48), quality of reduction (p=0.39), quality of cast (p=0.14 and p=0.21), or redisplacement (p=0.87). Those undergoing general anaesthesia used on average 50 minutes of theatre time and one third required an overnight admission. We conclude that ketamine sedation achieves comparable treatment outcomes to general anaesthesia whilst using fewer resources.

A novel deletion partly removing the AVP gene causes autosomal recessive inheritance of early-onset neurohypophyseal diabetes insipidus

Familial neurohypophyseal diabetes insipidus (FNDI) typically presents with age-dependent penetrance and autosomal dominant inheritance caused by missense variations in one allele of the AVP gene encoding the arginine vasopressin (AVP) prohormone. We present the molecular genetic characteristics underlying an unusual form of FNDI occurring with very early onset and seemingly autosomal recessive inheritance. By DNA amplification and sequencing, we identified a novel variant allele of the AVP gene carrying a 10,396 base pair deletion involving the majority of the AVP gene as well as its regulatory sequences in the intergenic region between the AVP and the OXT gene, encoding the oxytocin prohormone. We found two chromosomes carrying the deletion in affected family members and one in unaffected family members suspected to transmit the deleted allele. Whole-genome array analysis confirmed the results and excluded the presence of any additional major pathogenic abnormalities. The deletion is predicted to abolish the transcription of the AVP gene, thus the fact that family members heterozygous for the deletion remain healthy argues, in general, against haploinsufficiency as the pathogenic mechanism FNDI. Accordingly, our data is strong support to the prevailing idea that dominant inheritance of FNDI is due to a dominant-negative effect exerted by variant AVP prohormone.

Reprinted article "Neovascularisation is the principal cause of varicose vein recurrence: results of a randomised trial of stripping the long saphenous vein"

OBJECTIVES

To determine whether routine stripping of the long saphenous vein reduces recurrence after varicose vein surgery.

DESIGN

Randomised controlled trial. All operations done by a consultant vascular surgeon. Two year follow-up.

MATERIALS AND METHODS

One hundred patients with primary long saphenous varicose veins (133 legs) were randomised. Two year follow-up in 81 patients (113 legs) with questionnaire, clinical examination and Duplex scanning.

RESULTS

Some 89% remained satisfied with the results of their surgery, though 35% had recurrent veins on clinical examination. Recurrence was reduced from 43 to 25% in patients who had their long saphenous vein stripped (p = 0.04, χ(2)). Neovascularisation (serpentine tributaries arising from the ligated saphenofemoral junction) was detected in 52% of limbs and was the commonest cause of recurrence. Most tributaries were less than 3 mm in diameter and only caused recurrence if the long saphenous vein or a major thigh vein was intact. Twelve patients had tributaries greater than 3 mm diameter and all had recurrent varicose veins.

CONCLUSIONS

Recurrence is common after varicose vein surgery and in this study was caused principally by neovascularisation at the ligated saphenofemoral junction. Clinical recurrence is reduced by routine stripping of the long saphenous vein.

An investigation of patients' motivations for their participation in genetics-related research

DESIGN

Qualitative interview study.

PARTICIPANTS

Fifty-nine patients with a family history of cancer who attend a regional cancer genetics clinic in the UK were interviewed about their current and previous research experiences.

FINDINGS

Interviewees gave a range of explanations for research participation. These were categorised as (a) social--research participation benefits the wider society by progressing science and improving treatment for everyone; (b) familial--research participation may improve healthcare and benefit current or future generations of the participant's family; and (c) personal--research participation provides therapeutic or non-therapeutic benefits for oneself.

CONCLUSIONS

We discuss the distinction drawn between motives for research participation focused upon self (personal) and others (familial/social), and observe that personal, social and familial motives can be seen as interdependent. For example, research participation that is undertaken to benefit others, particularly relatives, may also offer a number of personal benefits for self, such as enabling participants to feel that they have discharged their social or familial obligations. We argue for the need to move away from simple, static, individualised notions of research participation to a more complex, dynamic and inherently social account.

Healthcare professionals' and researchers' understanding of cancer genetics activities: a qualitative interview study

AIMS

To describe individuals' perceptions of the activities that take place within the cancer genetics clinic, the relationships between these activities and how these relationships are sustained.

DESIGN

Qualitative interview study.

PARTICIPANTS

Forty individuals involved in carrying out cancer genetics research in either a clinical (n = 28) or research-only (n = 12) capacity in the UK.

FINDINGS

Interviewees perceive research and clinical practice in the subspecialty of cancer genetics as interdependent. The boundary between research and clinical practice is described as vague or blurred, and this ambiguity is regarded as being sustained by a range of methodological, ethical and economic factors. The implications of these findings for the "therapeutic misconception" are explored. It is argued that while research participation is seen as having therapeutic benefit for individual patients, the interviewees are not labouring under any misconceptions about the relationship between research and clinical care. It is suggested that concepts such as the "therapeutic misconception" may have less relevance in highly technological specialities that are characterised by a developing evidence base.

ETV5 is required for continuous spermatogenesis in adult mice and may mediate blood testes barrier function and testicular immune privilege

The transcription factor Ets-variant gene 5 (ETV5) is essential for spermatogonial stem cell (SSC) self-renewal, as the targeted deletion of the Etv5 gene in mice (Etv5(-/-)) results in only the first wave of spermatogenesis. Reciprocal transplants of neonatal germ cells from wild-type (WT) and Etv5(-/-) testes were performed to determine the role of ETV5 in Sertoli cells and germ cells. ETV5 appears to be needed in both cell types for normal spermatogenesis. In addition, Etv5(-/-) recipients displayed increased interstitial inflammation and tubular involution after transplantation. Preliminary studies suggest that the blood-testis barrier (Sertoli-Sertoli tight junctional complex) is abnormal in the Etv5(-/-) mouse.

Meiotic spindle location and identification and its effect on embryonic cleavage plane and early development

BACKGROUND

To examine the relationship between the meiotic spindle, the first cleavage plane and any resulting influence on embryonic development parameters.

METHODS

Sibling oocytes (n = 246) were allocated to either a control [polar body (PB)-aligned] or a treatment (spindle-aligned) microinjection group by use of a random numbers table. Spindles were identified by PolScope((R)) and the early embryo development parameters, and angle of first cleavage plane in relation to a defined animal-vegetal pole were analysed.

RESULTS

Most oocytes (92.7%) had a visible spindle at the time of microinjection; however, 62.6% of first PBs (1PBs) were not located above the spindle (average deviation 37.3 +/- 33.2 degrees; range 0-176.6), with 6.9% of 1PBs in the opposite hemisphere to the spindle. The second PBs (2PBs) can also have an unpredictable deviation from the position of the meiotic spindle (12.5 +/- 16.7 degrees; range 0-91.8). This increased when the 1PB was above the spindle, forming a physical barrier to extrusion (average 24.7 +/- 16.1 degrees; range 7.9-91.8). Embryos developing from the spindle-aligned microinjection group had significantly more blastomeres per embryo (P = 0.044), a higher morphology score per embryo (P = 0.008) and a significantly higher average embryo score parameter (P = 0.003), with more embryos developing without any detectable fragmentation (P < 0.05) than the PB-aligned control group. Non-fragmented embryos undergo meridional cleavage, with a small angle between the spindle location and first cleavage plane (16.4 +/- 14.0 degrees ) compared with embryos with some degree of fragmentation (P = 0.002). This angle increased with the degree of fragmentation, with worst quality embryos having a spindle:cleavage angle of 45.1 +/- 17.7 degrees.

CONCLUSIONS

The 1PB and, to a lesser degree, the 2PB can be unreliable predictors of the exact meiotic spindle location in human oocytes. Embryos from spindle-aligned oocytes have an increase in all measured development parameters over control siblings. When the animal pole is defined as the meiotic spindle location, non-fragmented embryos tend to develop from a meridional cleavage; with the most fragmented embryos developing from a more equatorial initial cleavage plane. This study proposes that the spindle accurately marks the animal pole in human oocytes, and provides evidence linking the meiotic spindle location to the first cleavage plane and resulting early embryo development parameters in human embryos.

The use of automated strain gauge plethysmography in the diagnosis of deep vein thrombosis

The venometer is a nurse- or technician-operated machine that uses automated strain gauge plethysmography to detect deep vein thrombosis (DVT). We compared the venometer with contrast venography to determine its accuracy, and also used it to triage patients between admission with subsequent anticoagulation and out-patient investigation without anticoagulation. We enrolled 307 consecutive patients presenting to the medical admissions unit with suspected DVT, of whom 270 underwent both plethysmography and venography. Plethysmography produced a negative predictive value (NPV) of 97% and a sensitivity of 90% for proximal DVT. It also produced a false negative rate of 10% for proximal DVT, For distal DVT, sensitivity was 66%, specificity 80%, positive predictive value 36% and NPV 93%. We conclude that the automated venometer report is a quick, non-invasive and easy to use initial screening test. However, it is not sufficiently accurate in a medical admissions unit to be a definitive diagnostic test for DVT and may, therefore, be best used in combination with clinical risk assessment and D-dimer assay with more definitive radiological investigations as necessary.

Shunting for normal pressure hydrocephalus (NPH)

BACKGROUND

Since the condition was first described in 1965, the syndrome of normal pressure hydrocephalus (NPH) has conventionally been managed by placement of a cerebrospinal fluid (CSF) shunt.

OBJECTIVES

To determine the effectiveness of shunting procedures in promoting stability or improvement in the neurological symptoms and signs of NPH.

SEARCH STRATEGY

The trials were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 26 June 2001 using the terms 'shunt*' and 'normal pressure hydrocephalus'.

SELECTION CRITERIA

Studies included for analysis were those involving the placement of a CSF shunt for the treatment of NPH as part of a randomized controlled trial.

DATA COLLECTION AND ANALYSIS

No data matching the selection criteria were found.

MAIN RESULTS

No randomized controlled trials of shunt placement versus no shunt were found.

REVIEWER'S CONCLUSIONS

There is no evidence to indicate whether placement of a shunt is effective in the management of NPH.

Oocyte morphology and early zygote cleavage does not appear to be related to intrafollicular concentrations of inhibin-A or -B

PURPOSE

The aim was to investigate the relationship of intrafollicular inhibin dimers A and B with human oocyte morphology and subsequent embryo potential.

METHODS

Sixty-eight oocytes were isolated from 31 women undertaking intracytoplasmic sperm injection (ICSI). Estradiol, progesterone, testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, sex hormone-binding globulin, inhibin-A and inhibin-B was assayed in corresponding follicular fluid.

RESULTS

The mean (+/- SD) concentration for inhibin-A was 9.7 +/- 9.8 ng/ml (range, 1.1-60.0 ng/ml) and for inhibin-B was 269.4 +/- 185.2 ng/ml (range, 33.1-811.0 ng/ml). In a correlation matrix there were no marked relationships (r < 0.556) between inhibin and steroid or gonadotropin concentrations. Similarly, when inhibin concentrations were divided according to whether the oocytes had mature or immature cumulous complexes, were viable or necrotic, were meiotically immature or mature, became fertilized or not, or had different embryo gradings after cleavage, no statistically significant difference could be seen between groupings.

CONCLUSIONS

Because the range of values was large and the data often skewed, neither inhibin dimer has discriminatory power to reflect the potential of the oocyte.

Basic fibroblast growth factor promotes subplate cell survival in explant cultures of embryonic mouse cortex

Subplate neurons form a transient layer immediately below the embryonic cortex and die early in postnatal life. It has been suggested that trophic factors, perhaps coming from cortical afferents, maintain the initial survival of these cells. Later withdrawal of these factors may cause subplate cell death. We tested whether basic fibroblast growth factor (bFGF) has survival-promoting effects on subplate cells in organotypic cultures from the late embryonic mouse cortex. We found that the survival of subplate cells was promoted by adding bFGF to the cultures. By contrast, there was no effect of bFGF on the survival of overlying cortical neurons. These results indicate that bFGF may have a role in the regulation of subplate cell survival and death in vivo.

A universal granulocyte-macrophage colony-stimulating factor-producing bystander cell line for use in the formulation of autologous tumor cell-based vaccines

Irradiated tumor cells transduced with the gene encoding the cytokine GM-CSF have been extensively studied as a vaccine formulation capable of priming systemic antitumor immune responses in the tumor-bearing host. In spite of the therapeutic promise of this vaccine strategy demonstrated in both animal models and early-phase clinical trials, clinical development has been limited by difficulties pertaining to the need to establish in culture the tumor of each patient and to perform individualized gene transfer. To circumvent these issues, we generated an HLA-negative human cell line producing large quantities of human GM-CSF for use as a universal bystander cell to be mixed with unmodified autologous tumor cells in the formulation of a vaccine. This line is easily propagated as a suspension culture in defined, serum-free medium. In a mouse model, we find that vaccination with a mixture of autologous tumor cells and an MHC-negative allogeneic GM-CSF-producing bystander cell primes antitumor immune responses that are equivalent or better than those achieved using autologous tumor cells directly transduced to secrete GM-CSF. This strategy greatly simplifies further clinical development of autologous tumor cell-based vaccines.

Mutations in the zebrafish unmask shared regulatory pathways controlling the development of catecholaminergic neurons

The mechanism by which pluripotent progenitors give rise to distinct classes of mature neurons in vertebrates is not well understood. To address this issue we undertook a genetic screen for mutations which affect the commitment and differentiation of catecholaminergic (CA) [dopaminergic (DA), noradrenergic (NA), and adrenergic] neurons in the zebrafish, Danio rerio. The identified mutations constitute five complementation groups. motionless and foggy affect the number and differentiation state of hypothalamic DA, telencephalic DA, retinal DA, locus coeruleus (LC) NA, and sympathetic NA neurons. The too few mutation leads to a specific reduction in the number of hypothalamic DA neurons. no soul lacks arch-associated NA cells and has defects in pharyngeal arches, and soulless lacks both arch-associated and LC cell groups. Our analyses suggest that the genes defined by these mutations regulate different steps in the differentiation of multipotent CA progenitors. They further reveal an underlying universal mechanism for the control of CA cell fates, which involve combinatorial usage of regulatory genes.

Failure to collect oocytes in assisted reproductive technology: a retrospective

While there is much information and discussion on pregnancy failure after assisted reproductive technologies, less emphasis is placed on the failure to collect oocytes after apparently successful ovarian stimulation. This retrospective survey reviewed 4973 treatment cycles in order to obtain information about the likelihood of this event. Overall 42 women (43 treatment cycles) failed to have oocytes collected [0.86% of treatments started and 0.92% of women given human chorionic gonadotrophin (HCG)]. However, in only six cases was this failure unexpected (0.1%) with no obvious potential clinical reason (i.e. all six cases had: HCG administered; more than two follicles >15 mm in diameter; oestradiol values >2000 pmol/l; <38 years old; normal body mass index). Indifference concerning uncommon events is fraught with peril, as although rare, the particular outcome may be devastating to the individual, both economically and psychologically. Eighteen of the 42 women did not return for on-going treatment suggesting increased contact by clinic staff may be required when oocyte retrieval is not achieved. These data suggest that the failure to collect oocytes after apparently successful ovarian stimulation is rare and random. The information has proved useful in allaying the fears of couples contemplating assisted reproductive technologies.

A comparison of three procedures for the detection of Bence-Jones proteinuria

A traditional electrophoretic procedure for detection of Bence-Jones proteinuria, employing Amido black stain on 200-fold concentrated urine, has been compared to two procedures employing highly sensitive protein stains not requiring prior urine concentration. All three procedures were carried out on 80 random urine samples screened for Bence-Jones proteinuria and 10 samples were provided by patients attending a myeloma clinic. A new procedure employing modified Coomassie brilliant blue stain on unconcentrated urine showed comparable sensitivity to the established procedure (82% versus 88%, respectively) and specificity (77% versus 74%, respectively), when assessed against immunofixation as a reference method. However, the new method is considerably quicker and cheaper. A second method, employing Gold stain, showed enhanced sensitivity (94% versus 88% for Amido black) but lower specificity (62% versus 74% for Amido black). However, this method is labour intensive and relatively expensive. Our data suggest that the procedure employing modified Coomassie brilliant blue may be a suitable alternative to the traditional procedure commonly used in many clinical laboratories.

Neovascularisation is the principal cause of varicose vein recurrence: results of a randomised trial of stripping the long saphenous vein

OBJECTIVES

To determine whether routine stripping of the long saphenous vein reduces recurrence after varicose vein surgery.

DESIGN

Randomised controlled trial. All operations done by a consultant vascular surgeon. Two year follow-up.

MATERIALS AND METHODS

One hundred patients with primary long saphenous varicose veins (133 legs) were randomised. Two year follow-up in 81 patients (113 legs) with questionnaire, clinical examination and Duplex scanning.

RESULTS

Some 89% remained satisfied with the results of their surgery, though 35% had recurrent veins on clinical examination. Recurrence was reduced from 43 to 25% in patients who had their long saphenous vein stripped (p = 0.04, chi 2). Neovascularisation (serpentine tributaries arising from the ligated saphenofemoral junction) was detected in 52% of limbs and was the commonest cause of recurrence. Most tributaries were less than 3 mm in diameter and only caused recurrence if the long saphenous vein or a major thigh vein was intact. Twelve patients had tributaries greater than 3 mm diameter and all had recurrent varicose veins.

CONCLUSIONS

Recurrence is common after varicose vein surgery and in this study was caused principally by neovascularisation at the ligated saphenofemoral junction. Clinical recurrence is reduced by routine stripping of the long saphenous vein.

Temperature change in cryo-containers during short exposure to ambient temperatures

Times have been defined for the handling of 0.25 ml embryo cryostraws and semen, in either 0.5 ml cryostraws or 1.0 ml cryovials containing 0.5 ml material, before potentially detrimental changes in temperature take place. When handling cryovials the time lag is relatively long, with 78.8 +/- 2.6 s being available to manipulate the vials before -80 degrees C is reached and 335.4 +/- 3. 8 s until the eutectic point (approximately -7 degrees C) is reached. However the situation with cryostraws is less tolerant. Both 0.25 and 0.5 ml versions reach temperatures >-80 degrees C within 40 s, and the eutectic point is reached in 79.0 +/- 2.0 s in 0.25 ml cryostraws. These time/temperature data have proved useful in educating new technicians, as well as clinicians and nurses who may also handle frozen human material, in the need to minimize the ambient temperature exposure time of stored specimens so as to maintain optimal post-thaw viability.

Upregulation of glucose-6-phosphate dehydrogenase in response to hepatocellular oxidative stress: studies with diquat

The expression of hepatic glucose-6-phosphate dehydrogenase (G6PDH, E.C. 1.1.1.49) is hypothesized to be modulated by free radicals during oxidative stress. The ability of diquat, a compound known to enhance oxidative stress through generation of reactive oxygen species, to modulate the expression of G6PDH in primary cultures of Fischer-rat hepatocytes was examined. Diquat-treated hepatocytes maintained in a chemically defined medium showed both a time- and concentration-dependent increase in G6PDH enzyme activity. This increase in enzyme activity was accounted for by an increase in both G6PDH mRNA and immunoreactive protein, suggesting control at a pretranslational level. The possibility that diquat increased transcription by transfecting cells with a chimeric gene containing 935 bp of the G6PDH promoter (-878 to +57) linked to the gene for chloramphenicol acetyl-transferase (CAT) was examined. Hepatocytes transiently transfected with this chimera, and subsequently treated with diquat, exhibited an increase in CAT activity. However, hepatocytes transfected with a chimera containing 287 bp of the G6PDH promoter (-230 to +57) exhibited only basal CAT activity in the presence of diquat. These results suggest that regions in the DNA sequences required for diquat-induced expression of G6PDH lie between base pairs -878 and -230 of the G6PDH gene. These findings are suggestive that oxidative stress in hepatocytes increased the expression of G6PDH activity and protein and that the increased expression is controlled at the transcriptional level.

Hyperspermia: the forgotten condition?

The seminal volumes of 4223 men with known periods of abstinence of ejaculation, complete collections and with no dysfunction known to affect production of accessory gland secretions have been examined to define a minimum value for hyperspermia. The 95th percentile of the skewed data distribution was 6.3 ml and of the 229 men with values equal to or greater than this, 113 (49.3%) had sperm concentrations below the World Health Organization accepted minimum 'normal' value of 20 x 10(6)/ml. Basic seminal parameters should not be forgotten when assessing infertile men.

Registration health checks: inverse care in the inner city?

BACKGROUND

Attendance at health checks of patients already registered with a general practitioner is known to be poor, with those in need least likely to attend. Little is known of the efficacy of such checks for newly registered patients.

AIM

This study set out to determine the characteristics of attenders and non-attenders at health checks for patients registering with a general practitioner in east London, and the effect of health checks on motivation to change unhealthy lifestyles.

METHOD

A questionnaire analysis was carried out of patients aged 16 years and over at registration and after a health check in seven east London training practices. Questionnaires asked about personal background and lifestyle including smoking status, alcohol intake, diet, weight, exercise, cervical smear uptake, and motivation to change unhealthy aspects of lifestyle.

RESULTS

Questionnaires were offered to 356 patients registering with the practices, of whom 101 declined or returned inadequate data. Of the remaining 255 patients, 118 (46%) attended a health check with 113 completing a second questionnaire after the check. Non-attenders were significantly more likely than attenders to be of lower social class, unemployed, of African origin and to be heavy smokers. Women who did not attend were significantly less likely than attenders to have had a cervical smear within the last three years. Non-attending mothers were significantly more likely than attending mothers to be single parents. Motivation among attenders to stop smoking and drink less alcohol was increased significantly after the health check.

CONCLUSION

Attendance at registration health checks at these practices was poor and non-attenders tended to be more socially deprived than attenders and had relatively unhealthy lifestyles. Although the health checks increased the attenders' motivation to alter smoking and drinking habits, inviting all new patients to a health check would appear to result in poor targeting of health promotion resources and may widen inequalities in health.

A study of endometrial morphology in women who failed to conceive in a donor insemination programme

OBJECTIVE

To examine the morphology of endometrium in women who failed to conceive after nine or more cycles of donor insemination treatment.

DESIGN

Prospective study.

SETTING

Jessop Hospital for Women, Sheffield.

SUBJECTS

Two groups: twenty-six infertile women and a control group of eight fertile women.

INTERVENTION

Endometrial biopsy specimens were obtained in the mid-luteal phase, timed precisely by the luteinising hormone surge.

MAIN OUTCOME MEASURE

Morphological study of endometrial biopsy specimens by the use of traditional dating criteria and established morphometric techniques.

RESULTS

Twelve biopsy specimens (42%) were found to be retarded. In addition, morphometric analysis revealed significant differences in the glandular component of the endometrium between the infertile and fertile groups.

CONCLUSION

Endometrial defect leading to implantation failure may be an important underlying cause of failure to conceive after repeated attempts at donor insemination. The endometrium should be investigated in this group of women, and further attempts at donor insemination treatment should be offered only in conjunction with attempts to restore the normality of the endometrium.

The antigenicity and allergenicity of microparticulated proteins: Simplesse

New technologies are allowing the food industry to develop products from standard foods which may not be recognized in its modified form by food allergic patients. One such product, Simplesse, has been formulated by microparticulation of egg white and/or cows' milk proteins and is used as a fat substitute in many fat-laden foods. The purpose of this study was to determine whether the process of microparticulation altered the allergenicity/antigenicity of egg white and cows' milk proteins compared to the starting materials. Soluble protein fractions of Simplesse and its respective starting materials were compared to egg white, cows' milk protein, an ultra-filtered egg white/condensed milk mixture, and/or a whey concentrate by SDS-polyacrylamide gel electrophoresis. In addition, sera from 16 patients with documented egg and/or cows' milk hypersensitivity and two controls who were not allergic to egg or milk were used to assess potential allergenicity/antigenicity of these products by immunoblot (Western blot) analysis. There were heterogeneous IgE and IgG binding patterns to the food fractions among these food allergic patients suggesting differing sensitivity patterns among the individuals tested. However, utilizing both SDS-PAGE and immunoblot analyses, the major allergens in the microparticulated products were the same as those found in the starting materials, egg and cows' milk. In addition, there was no evidence of 'novel' protein fractions in the Simplesse test materials compared to the starting materials.

Control of gene expression in tobacco cells using a bacterial operator-repressor system

We have investigated the efficacy of using the Escherichia coli lac operator-repressor system to control plant gene expression. The lacI gene was modified to allow optimal expression in plant cells and then placed downstream of the cauliflower mosaic virus (CaMV) 35S RNA promoter. This construct was introduced into tobacco plants by leaf disc transformation. Transgenic tobacco plants synthesized significant quantities of LacI protein (up to 0.06% of total soluble protein). We have used the E.coli beta-glucuronidase gene (gus) as the reporter gene by placing it downstream of the maize chlorophyll a/b binding protein (CAB) gene promoter. Lac operators were introduced into several positions within the CAB promoter and operator-free plasmid was used as control. Repression was assessed by comparing the transient expression from CAB-operator-gus reporter constructs in protoplasts expressing lac protein, with that in control cells not expressing the repressor. Repression varied between 10 and 90% with different operator positions. Transient assays were also performed in the presence of the inducer, isopropyl-beta-D-thiogalactoside (IPTG). In lacI protoplasts the presence of IPTG manifested itself in a 4.2-fold relief of repression. The study was extended to show regulation of expression in stable transformants. Tobacco transformants harbouring a CAB-operator-gus reporter construct and the lacI gene were shown to have repressed GUS levels, but in the presence of IPTG, repression was relieved 15-fold. We conclude that the lac repressor can enter the plant cell nucleus, find its cognate operator sequence in the chromatin to form a repressor--operator complex and effectively block transcription of a downstream gene.

Social influences approach to smoking prevention: the effects of videotape delivery with and without same-age peer leader participation

This study tested the hypothesis that cigarette smoking adoption among adolescents could be suppressed by providing school-based videotape instruction for resisting social influences to smoke. The utilization of same-age peer leaders was also varied to test whether their participation in the classroom would enhance program effects. Seventh grade students (N = 540) from one junior high school in Southern California were randomly assigned by classrooms (N = 15) to: (a) videotape instruction, (b) videotape instruction plus peer leader involvement, or (c) survey-only. Seventh grade students (N = 234) in a second junior high school served as a measurement-only control. Assessments were conducted at the beginning and end of the academic year. Results revealed a marked suppression in the onset of both experimental and regular smoking among those students exposed to the pressure resistance training with peer leader involvement. Pressure resistance training without peer leader involvement produced a more variable and less powerful effect on students' smoking behavior. Data collected on students' use of alcohol and marijuana revealed a generalized suppression effect, albeit weaker than for tobacco, among those students exposed to the social resistance training with peer leader involvement. Results provide further encouraging support for the use of peer-led pressure resistance training in preventing adolescent drug use.