Standards for the care of people with cystic fibrosis (CF); Planning for a longer life

This is the final of four papers updating standards for the care of people with CF. That this paper "Planning a longer life" was considered necessary, highlights how much CF care has progressed over the past decade. Several factors underpin this progress, notably increased numbers of people with CF with access to CFTR modulator therapy. As the landscape for CF changes, so do the hopes and aspirations of people with CF and their families. This paper reflects the need to consider people with CF not as a "problem" to be solved, but as a success, a potential and a voice to be heard. People with CF and the wider CF community have driven this approach, reflecting many of the topics in this paper. This exercise involved wide stakeholder engagement. People with CF are keen to contribute to research priorities and be involved in all stages of research. People with CF want healthcare professionals to respect them as individuals and consider the impact of our actions on the world around us. Navigating life presents challenges to all, but for people with CF these challenges are heightened and complex. In this paper we highlight the concerns and life moments that impact people with CF, and events that the CF team should aim to support, including the challenges around having a family. People with CF and their care teams must embrace the updated standards outlined in these four papers to enjoy the full potential for a healthier life.

Future therapies for cystic fibrosis

We are currently witnessing transformative change for people with cystic fibrosis with the introduction of small molecule, mutation-specific drugs capable of restoring function of the defective protein, cystic fibrosis transmembrane conductance regulator (CFTR). However, despite being a single gene disorder, there are multiple cystic fibrosis-causing genetic variants; mutation-specific drugs are not suitable for all genetic variants and also do not correct all the multisystem clinical manifestations of the disease. For many, there will remain a need for improved treatments. Those patients with gene variants responsive to CFTR modulators may have found these therapies to be transformational; research is now focusing on safely reducing the burden of symptom-directed treatment. However, modulators are not available in all parts of the globe, an issue which is further widening existing health inequalities. For patients who are not suitable for- or do not have access to- modulator drugs, alternative approaches are progressing through the trials pipeline. There will be challenges encountered in design and implementation of these trials, for which the established global CF infrastructure is a major advantage. Here, the Cystic Fibrosis National Research Strategy Group of the UK NIHR Respiratory Translational Research Collaboration looks to the future of cystic fibrosis therapies and consider priorities for future research and development.

The Impact of Lung Proteases on Snake-Derived Antimicrobial Peptides

Respiratory infections are a leading cause of global morbidity and mortality and are of significant concern for individuals with chronic inflammatory lung diseases. There is an urgent need for novel antimicrobials. Antimicrobial peptides (AMPs) are naturally occurring innate immune response peptides with therapeutic potential. However, therapeutic development has been hindered by issues with stability and cytotoxicity. Availing of direct drug delivery to the affected site, for example the lung, can reduce unwanted systemic side effects and lower the required dose. As cystic fibrosis (CF) and chronic obstructive pulmonary disease (COPD) lungs typically exhibit elevated protease levels, the aim of this study was to assess their impact on snake-derived AMPs. Peptide cleavage was determined using SDS-PAGE and antimicrobial and anti-inflammatory activities of neutrophil elastase (NE)-incubated peptides were assessed using a radial diffusion assay (RDA) and an in vitro LPS-induced inflammation model, respectively. Although the snake-derived AMPs were found to be susceptible to cleavage by lung proteases including NE, several retained their function following NE-incubation. This facilitated the design of novel truncated derivatives that retained functionality following NE incubation. Snake-derived AMPs are tractable candidate treatments for use in environments that feature elevated NE levels, such as the CF airways.

Development of a core outcome set for trials investigating the long-term management of bronchiectasis

Heterogeneity in outcomes measured in trials limits accurate comparison of bronchiectasis studies. A core outcome set (COS) is an agreed, standardized set of outcomes that should be measured in trials for specific clinical areas. A COS for bronchiectasis could encourage consistency in future studies. An overview of systematic reviews and qualitative study on outcome selection in bronchiectasis informed an initial list of outcomes. A Delphi panel (n = 86) rated the importance of each outcome from 1 to 9 in 3 sequential questionnaires, as a means to achieve consensus: 1–3 = ‘of limited importance’; 4–6 = ‘important, but not critical’; and 7–9 = ‘critical’. Outcomes rated ‘critical’ by ≥70% of the panel were added to the COS. Eighty-two participants responded to the first questionnaire. Attrition between each questionnaire was 5%. After 3 rounds of questioning, 18 outcomes exceeded the threshold for consensus and were included in the COS. This study has achieved consensus on 18 outcomes that should be measured in trials of interventions for bronchiectasis. Selection of the highest ranked outcomes may represent a pragmatic means for comparison. Further research is required to condense the number of outcomes selected and to determine its relevance to interventions.

Preliminary evidence for neural responsiveness to infants in mothers with schizophrenia and the implications for healthy parenting

Schizophrenia is a severe mental illness that may significantly affect maternal sensitive behaviour. Neural correlates of maternal behaviour represent a potentially valuable means of differentiating objectively between healthy mothers expressing variations in maternal sensitivity. As mothers with schizophrenia (MWS) show deficits in behavioural responses to infants compared to healthy mothers, we explored whether maternal brain responses to infant stimuli would be significantly reduced in MWS. We also examined whether differences in maternal behaviour between healthy and ill mothers (during play interactions with own infant) were associated with differences in brain activation to infant stimuli. We found no evidence of differential 'maternal brain' responses or 'maternal behavioural' responses in 11 new MWS compared to 20 healthy new mums; neither were neural responses to infants linked to behavioural or cognitive aspects of the mother's relationship with her infant in MWS. These preliminary findings suggest maternal sensitivity differences between MWS and healthy mothers, suggested in previous studies, may be reversible in stable treated MWS.

Chronic lung disease in common variable immune deficiency (CVID): A pathophysiological role for microbial and non-B cell immune factors

One of the most common and most severe forms of primary antibody deficiency encountered in the clinical setting is a heterogeneous group of syndromes termed common variable immune deficiency (CVID). This disorder is characterized by reduced immunoglobulin production and increased susceptibility to infection, particularly of the respiratory tract. Infection and subsequent immunological/inflammatory processes may contribute to the development of pulmonary complications such as bronchiectasis and interstitial lung disease. Immunoglobulin replacement and/or antibiotic therapy, to prevent infection, are routinely prescribed treatments. However, chronic lung disease, the major cause of morbidity and mortality in this patient cohort, may still progress. This clinical progression suggests that pathogens recalcitrant to currently prescribed treatments and other immunological defects may be contributing to the development of pulmonary disease. This review describes the potential role of microbiological and non-B cell immunological factors, including T-cells, neutrophils, complement, toll like receptors, and antimicrobial peptides, in the pathogenicity of chronic lung disease in patients with CVID.

State-dependent changes in hippocampal grey matter in depression

Reduced hippocampal volume has been reported in depression and may be involved in the aetiology of depressive symptoms and vulnerability to depressive relapse. Neuroplasticity following antidepressant drug treatment in the hippocampus has been demonstrated in animal models but adaptive changes after such treatment have not been shown in humans. In this study, we determined whether grey matter loss in the hippocampus in depression (1) is present in medication-free depressed (2) changes in response to antidepressant treatment and (3) is present as a stable trait in medication-free remitted patients. Sixty-four medication-free unipolar depressed patients: 39 currently depressed and 25 in remission, and 66 healthy controls (HC) underwent structural magnetic resonance imaging in a cross-sectional and longitudinal design. Thirty-two currently depressed participants were then treated with the antidepressant citalopram for 8 weeks. Adherence to treatment was evaluated by measuring plasma citalopram concentration. We measured regional variation in grey matter concentration by using voxel-based morphometry-Diffeomorphic Anatomical Registration Through Exponentiated Lie algebra. Patients with current depression had bilaterally reduced grey matter in the hippocampus compared with HC and untreated patients in stable remission with the latter groups not differing. An increase in grey matter was observed in the hippocampus following treatment with citalopram in currently depressed patients. Grey matter reduction in the hippocampus appears specific to the depressed state and is a potential biomarker for a depressive episode.

Non-inferiority trial between two dry-powder inhalers containing fluticasone/salmeterol in asthmatic patients

Asthma is an increasing pathology with poor compliance. Achievement of control is possible but under intensive treatment. In this setting, fluticasone/salmeterol association delivered by dry powder inhalers is a valuable and proved option. A prospective, parallel, open-label, phase IV, multicentre non-inferiority study was conducted to determine therapeutic similarity between 2 different inhalers: Generic DPI and Diskus®, which both deliver a fluticasone/salmeterol association (CAS 80474-14-2/CAS 89365-50-4). A 103 uncontrolled asthmatic patients were randomly assigned in 2 groups, Generic (G) and Diskus® (D), and received the association for 18 weeks through the appropriate device. They were evaluated according to Asthma Quality of Life Questionnaire and GINA/NIH guidelines. To demonstrate non-inferiority, the estimation of the Relative Risk between the Global Score Rate per group with its 95% confidence interval was calculated and compared against a non-inferiority margin obtained from a previous study. The Global Score Rate was 82% for G Group and 83% for D Group. The RR was 1.0124 (95% CI: 0.847-1.210). The margin set at 0.832 was not reached by the lower 95% CI (z=-2.097; p=0.018) pointing out non-inferiority. The results have demonstrated non-inferiority between groups. Thus, the 2 products are therapeutically similar.

Interaction between a history of depression and rumination on neural response to emotional faces

BACKGROUND

Both past depressive episodes and the personality trait of depressive rumination are strong risk factors for future depression. Depression is associated with abnormal emotional processing, which may be a neurobiological marker for vulnerability to depression. A consistent picture has yet to emerge as to how a history of depression and the tendency to ruminate influence emotional processing. The aim of this study was to investigate the relationship between rumination, past depression and neural responses when processing face emotions.

METHOD

The Ruminative Responses Scale (RRS) was completed by 30 remitted depressives and 37 controls who underwent functional magnetic resonance imaging (fMRI) scanning while viewing happy, sad, fearful and neutral faces.

RESULTS

The remitted depressives showed overall reductions in neural responses to negative emotions relative to the controls. However, in the remitted depressives, but not the controls, RRS scores were correlated with increased neural responses to negative emotions and decreased responses to happiness in limbic regions.

CONCLUSIONS

Automatic emotion processing biases and rumination seem to be correlated to aspects of vulnerability to depression. However, remission from depression may be maintained by a general suppression of limbic responsiveness to negative emotion.

Self-reported Rumination as Trait Marker for Depression: Evidence from Functional Neuroimaging

Background:

Research using fMRI indicates that sustained limbic activity is linked to processing negative words and self-reported rumination in currently depressed individuals. It is unknown whether this is also present in remitted depressed individuals. We tested the hypothesis that a tendency to ruminate constitutes a trait for depression by using a standard covert fMRI emotional task face in previously and never depressed volunteers and postulated that high rumination scores would correlate with activity in brain areas previously associated with depression.

Methods:

37 controls (25 female) and 30 remitted depressed (RD, 22 female) were enrolled. Volunteers completed the Ruminative Responses Scale (RRS) and underwent fMRI scanning using a standard covert fMRI emotional task faces. Significance level was set at p < 0.05 (FWE).

Results:

With RRS score controlled for RD showed reduced subcortical and limbic activity to sad and fearful faces compared to controls. Correlations between RRS scores and neural activity in all participants and control participants alone were very limited. However, in RD, RRS score was negatively correlated with neural response to happy faces and positively correlated with neural response to sad and fearful faces, in cortical and limbic regions associated with depression (hippocampus, thalamus, caudate, insula and cingulate gyrus).

Conclusion:

The results suggest that reduced limbic activity is associated with remission, possibly as a maintenance mechanism. However, within the remitted group the more ruminative participants show greater response in these areas to negative stimuli, and less to positive stimuli. This could be a neurobiological marker for risk of relapse

Self-reported Rumination as Trait Marker for Depression: Evidence from Functional Neuroimaging

Background:

Research using fMRI indicates that sustained limbic activity is linked to processing negative words and self-reported rumination in currently depressed individuals. It is unknown whether this is also present in remitted depressed individuals. We tested the hypothesis that a tendency to ruminate constitutes a trait for depression by using a standard covert fMRI emotional task face in previously and never depressed volunteers and postulated that high rumination scores would correlate with activity in brain areas previously associated with depression.

Methods:

37 controls (25 female) and 30 remitted depressed (RD, 22 female) were enrolled. Volunteers completed the Ruminative Responses Scale (RRS) and underwent fMRI scanning using a standard covert fMRI emotional task faces. Significance level was set at p < 0.05 (FWE).

Results:

With RRS score controlled for RD showed reduced subcortical and limbic activity to sad and fearful faces compared to controls. Correlations between RRS scores and neural activity in all participants and control participants alone were very limited. However, in RD, RRS score was negatively correlated with neural response to happy faces and positively correlated with neural response to sad and fearful faces, in cortical and limbic regions associated with depression (hippocampus, thalamus, caudate, insula and cingulate gyrus).

Conclusion:

The results suggest that reduced limbic activity is associated with remission, possibly as a maintenance mechanism. However, within the remitted group the more ruminative participants show greater response in these areas to negative stimuli, and less to positive stimuli. This could be a neurobiological marker for risk of relapse.

In situ transmissiometer measurements for real-time monitoring of dust discharge during orchard nut harvesting

Rapid assessments of operating conditions and field preparation on dust discharge from nut harvesters are needed to guide improved equipment design and grower practices for dust reduction. An industrial opacity sensor, typically used for industrial stack monitoring, was adapted for use on a nut harvester to measure relative dust intensity during nut pick-up operations in almond orchards. Due to the high volume of discharge air and the presence of large debris such as leaves, additional components were coupled with the sensor to enable subsampling of the air. Pre-harvest windrow preparation conditions were evaluated. Results indicated that relative dust intensity decreased by 32% during harvest activities after windrow preparation with proper nut sweeper adjustment. Conventional harvesting results indicated that under typical operating conditions, reducing the separation fan speed could reduce relative dust intensity by 54%. Ground speed also had a strong effect; reducing speed from 4.8 to 2.4 km h(-1) reduced opacity of discharged air by 50%. The measurement system was also mounted on a separate vehicle and used as a tool for comparing modifications in harvest machine designs where direct measurement of discharge may not be feasible due to mechanical constraints. A comparison between a conventional harvester and one modification in the harvester design found that the machine modification decreased relative dust intensity by 73%. The measurement tools described in this work can be used to provide rapid feedback on harvester operating conditions, orchard cultural practices, and machine design modifications.

Assessing the Prognostic Significance of Transrectal Ultrasound Extracapsular Extension in Prostate Cancer

AIMS

To determine the prognostic value of transrectal ultrasound (TRUS)-detected extraprostatic disease for prostate cancer in patients receiving radical external-beam radiation therapy (EBRT).

MATERIALS AND METHODS

A chart review of 181 patients treated with radical EBRT for prostate cancer was conducted. All patients underwent TRUS assessment by one radiologist. The median radiation dose delivered to the prostate was 66 Gy (range 53-70 Gy) in 33 fractions (range 20-39 fractions). Median follow-up time for all patients was 6.5 years. Sixty-four (35%) out of 181 patients were found to have extracapsular disease on TRUS. Clinical relapse was defined as the first occurrence of either salvage hormonal therapy administration by the treating oncologist or clinical, radiological, and/or pathologic evidence of recurrent or progressive disease. In terms of biochemical failure, two prognostic variable analyses were carried out using both the American Society for Therapeutic Radiology and Oncology (ASTRO) consensus guidelines and the Houston definition of biochemical failure. The primary end point for the prognostic variable analyses was time to first clinical or biochemical failure (CBF).

RESULTS

For time to CBF using the ASTRO consensus guidelines for biochemical failure, univariable analysis revealed that the prostate-specific antigen (PSA) (P = 0.018), clinical T stage (P = 0.002), Gleason score (P = 0.021), adjuvant hormonal therapy (P = 0.032) and TRUS T staging (P = 0.0001) were statistically significant prognostic factors. On multivariable analysis, clinical T stage (P = 0.051) was of borderline statistical significance, whereas PSA (P = 0.036), TRUS T stage (P = 0.0002) and adjuvant hormonal therapy (P = 0.015) were found to be independent prognostic factors. For time to CBF using the Houston definition of biochemical failure, univariable analysis revealed that PSA (P = 0.001), Gleason score (P = 0.026) and prostate volume (P = 0.013) were statistically significant prognostic factors. On multivariable analysis, PSA (P = 0.002), Gleason score (P = 0.012), and adjuvant hormonal therapy (P = 0.041) were found to be independent prognostic factors. TRUS T staging was not found to be independently significant.

CONCLUSIONS

A clear role for TRUS staging as an independent prognostic factor, in the setting of other more established variables, such as Gleason grade, PSA, and digital rectal examination (DRE) T stage, was not confirmed in this study, population.

Safety and efficacy of recombinant alpha(1)-antitrypsin therapy in cystic fibrosis

Neutrophil elastase (NE) is thought to be the most important protease which damages the cystic fibrosis (CF) lung. Attempts have been made to suppress this activity using the plasma-derived inhibitor, alpha(1)-antitrypsin (AAT). In this pilot study, the safety and efficacy of inhaled recombinant human AAT (rAAT) as a treatment for CF were investigated. Thirty-nine patients participated in a prospective, double-blinded, randomized, placebo-controlled phase II trial to examine the effect of rAAT (500, 250, and 125 mg) on sputum NE activity. Sputum myeloperoxidase (MPO), interleukin-8, tumor necrosis factor receptors, sputum and plasma NE/AAT complexes, and safety parameters were also measured. Subjects were randomized to receive nebulized treatment once a day for 4 weeks, followed by 2-4 weeks with no study treatment, and then a 2-week rechallenge phase. Trends toward a reduction in NE activity were observed in patients treated with 500 mg and 250 mg of rAAT compared to placebo. Sputum NE/AAT complex and MPO levels were lower on rAAT compared to placebo. No major adverse events and, in particular, no allergic reactions to rAAT were observed. Although significant differences between rAAT and placebo for sputum NE activity were not observed, some improvements were found for secondary efficacy variables. This study demonstrated that nebulized rAAT is safe and well-tolerated, but has a limited effect on NE activity and other markers of inflammation.

Effect of cystic fibrosis exacerbations on neutrophil function

In cystic fibrosis (CF), inflammation is caused by persistent bacterial infection from Pseudomonas aeruginosa and Burkholderia cenocepacia in the lung and is characterised by the persistent infiltration of massive numbers of neutrophils which leads to lung injury. The aim of this present study was to investigate the effects of CF exacerbations on the reactivity of peripheral blood neutrophils compared to data from a normal healthy control population. Peripheral blood neutrophils were isolated from control subjects and CF patients before and after an exacerbation of their lung disease. Isolated neutrophils were stimulated with N-formyl-methionyl-leucyl-phenylalanine (fMLP) and phorbol 12-myristate 13-acetate (PMA) and the rate of superoxide generation and elastase activity measured and compared with neutrophils from healthy age-matched controls. Neutrophils from CF patients spontaneously generated higher levels of superoxide after resolution of the exacerbation compared to control neutrophils. The stimulated generation of superoxide from control neutrophils was not significantly different from neutrophils isolated from CF patients either before or after resolution of the CF exacerbation. Neutrophils from CF patients spontaneously released more elastase than control neutrophils but released less elastase than control neutrophils in response to fMLP. The stimulated release of elastase from neutrophils was not significantly different before compared to after resolution of the exacerbation. Neutrophils from CF patients displayed a different pattern of response than those from control subjects; however, CF exacerbations did not appear to modulate neutrophil function.

A novel follicle culture system markedly increases follicle volume, cell number and oestradiol secretion

This study reports a novel, simple method for culture of mouse follicles which results in follicles with cell numbers similar toin vivofully grown follicles. Using this method, follicles (180–240 μm in diameter) were cultured in a 100 μl inverted drop of medium without oil and compared with culture in upright drops with and without a mineral oil overlay. Follicles, isolated from C57BL/6 × CBA/ca crossbred and MF1 inbred mice, were cultured individually at 37 °C in 96-well round-bottomed suspension cell tissue culture plates for 6 days. Follicles grown in the inverted drop culture system reached a markedly higher final diameter (means±s.e.m.; 471 ± 6.0 μm) as compared with the upright with oil (363 ± 2.7 μm) and without oil (358 ± 4.0) systems. There was no significant effect of mouse strain on follicle diameter. Follicular secretion of oestradiol and lactate into the medium was measured on days 2, 4 and 6 of culture. Secretion of oestradiol per follicle on day 6 was 2.49 ± 0.45 ng in the inverted and 0.90 ± 0.17 ng in the upright without oil system (P< 0.001). Follicular secretion of lactate on a per unit of follicle volume basis remained constant in the inverted system over days 2, 4 and 6 and was less (P< 0.001) than secretion in both the upright with and without oil systems. Follicle cell proliferation was markedly increased in the inverted as compared with the upright with oil system; the increases in cell numbers were significant on day 3 (P< 0.01) and on all subsequent days (P< 0.001). These results are discussed in relation to the supply of oxygen to the follicle in culture.

Evaluation of voxel-based registration of 3-D power Doppler ultrasound and 3-D magnetic resonance angiographic images of carotid arteries

Spatial registration and fusion of ultrasound (US) images with other modalities may aid clinical interpretation. We implemented and evaluated on patient data an automated retrospective registration of magnetic resonance angiography (MRA) carotid bifurcation images with 3-D power Doppler ultrasound (PD US) and indirectly with 3-D B-mode US. Volumes were initially thresholded to reduce the uncorrelated noise signals. The registration algorithm subsequently maximized the mutual information measure between the PD US and 3-D MRA via iterative simplex search to find best "rigid body" transformation. We rated the performance of the algorithm visually on (n = 5) clinical MRA and 3-D PD US datasets. We also evaluated quantitatively the effect of thresholding, initial misalignment of the paired volumes and the reproducibility registration. We investigated the effect of image artefacts by simulation experiments. Preregistration misalignments of up to 5 mm in the transaxial plane, up to 10 mm along the axis of the carotids and up to 40 degrees resulted in 107 of 110 successful registrations, with translational and rotational errors of 0.32 mm +/- 0.3 mm and 1.6 +/- 2.1 degrees. The algorithm was not affected by missing arterial segments of up to 8 mm in length. The average registration time was 4 min. We conclude that the algorithm could be applied to 3-D US PD and MRA data for automated multimodality registration of carotid vessels without the use of fiducials.

Oral, water-soluble combined estrogen/calcium preparation for postmenopausal therapy

OBJECTIVES

Estrogen is often prescribed for symptoms and sequelae of ovarian estrogen loss after menopause.

METHODS

To assess efficacy and acceptability of a new, highly soluble estrogen-calcium preparation, we formulated a water-soluble powdered combination of estrogen (0.625 mg estrone piperazine sulfate) and calcium (1 g, ions) as the highly soluble glycerophosphate salt (Estrosol). Effects of once-daily administration on bone mineral turnover of Estrosol dissolved in water (n = 11) was compared with 0.625 mg conjugated estrogens (Premarin) + 1 g calcium (Tums 500 Calcium Supplement) (n = 8). All women had had a previous hysterectomy, were between the ages 40 and 75, within 25% of ideal body weight, and had not taken hormonal preparations for at least 3 months. Assessment of bone mineral turnover was by monitoring N-telopeptides and bone specific alkaline phosphatase (BSAP) on 5 occasions: pretreatment and once during each of the 4 months of treatment.

RESULTS

Mean N-telopeptide values decreased (p = .005) in both groups: Estrosol, 29.2% (40 --> 29 mmol bone collagen equivalents (BCE)/mmol creatinine), and Premarin(R) + calcium, 44.8% (33 --> 18 mmol). Mean BSAP values also decreased (p = 0.007) in both groups: Estrosol, 12.6% (12.06 --> 10.54 mg/l), Premarin(R) + calcium, 19.1% (11.57 --> 9.36 mg/l). The difference between groups for both N-telopeptides and BSAP was not significant, although sample size was small. Symptoms (hot flashes, vaginal dryness) improved similarly in both groups. Symptoms during treatment (breast or nipple tenderness, bloating) also were similar in both groups. Both preparations were well-tolerated. There were no changes in CBC, liver function tests, electrolytes or urinalyses in either group .

CONCLUSIONS

This pilot study indicates that the combined, highly water-soluble preparation of estrogen and calcium is effective in reducing bone mineral turnover, acceptable and well-tolerated. Use of this single aqueous preparation may lead to better compliance than using two separate pills.

Multiple focal nodular hyperplasia and steatosis: Atypical imaging characteristics

Focal nodular hyperplasia is a rare, benign condition of the liver. A 28-year-old woman with malignant melanoma, mild liver enzyme abnormalities, steatohepatitis and newly documented hepatic lesions is described. Ultrasound, computed tomography and magnetic resonance imaging suggested only areas of focal fatty sparing but could not eliminate the concern for metastases. A (99m)technetium-labelled sulphur colloid scan, however, revealed areas of increased uptake consistent with multiple focal nodular hyperplasia. This diagnosis was ultimately confirmed with a liver biopsy. The investigation of a patient with a malignancy and expanding hepatic lesions is challenging. This case illustrates the usefulness of the (99m)technetium-labelled sulphur colloid scan in the evaluation of patients with hepatic lesions.

Porphyria: the road not traveled

As our ability to evaluate patients with porphyria expands there have been some inconsistencies that are not easily explained. These inconsistencies are biochemical, enzymatic and genetic in nature. Recent work by others has led me to believe there is another way to look at the problem. I will propose how an evolutionary approach could reconcile these problems. In doing so it will imply that porphyria could potentially affect many more people than currently thought.

"Impact? What impact?" Epidemiological research findings in the public domain: a case study from north-east England

This paper reflects on the dissemination of potentially controversial research evidence about industrial air pollution and health in north-east England. It draws on a participant observation study of the local impact of a four-year epidemiological research programme in Teesside. The difficulties in and obstacles to disseminating research findings are explored. It may thus be described as a study of the impact of a study. We look at institutional resistance (including from the funders of the research) to any evidence indicating adverse health effects from industrial pollution. We also look at the failure of researchers to surmount such resistance and to communicate effectively with those who lived in the vicinity of the major industrial operations. This leads us to consider how conflicting notions of accountability coloured dissemination strategies as well as researchers' judgements. We offer a critique of fashionable and unduly consensual notions of a 'user community', in a context where different 'user communities' had incompatible expectations about the purpose of a piece of research and the significance of the data to emerge from it. The study also highlights the difficulties of disseminating research findings when the topic has the potential to affect economic interests.