Perspectives of patients, family members, health professionals and the public on the impact of COVID-19 on mental health

BACKGROUND

The coronavirus (COVID-19) pandemic has seen a global surge in anxiety, depression, post-traumatic stress disorder (PTSD), and stress.

AIMS

This study aimed to describe the perspectives of patients with COVID-19, their family, health professionals, and the general public on the impact of COVID-19 on mental health.

METHODS

A secondary thematic analysis was conducted using data from the COVID-19 COS project. We extracted data on the perceived causes and impact of COVID-19 on mental health from an international survey and seven online consensus workshops.

RESULTS

We identified four themes (with subthemes in parenthesis): anxiety amidst uncertainty (always on high alert, ebb and flow of recovery); anguish of a threatened future (intense frustration of a changed normality, facing loss of livelihood, trauma of ventilation, a troubling prognosis, confronting death); bearing responsibility for transmission (fear of spreading COVID-19 in public; overwhelming guilt of infecting a loved one); and suffering in isolation (severe solitude of quarantine, sick and alone, separation exacerbating grief).

CONCLUSION

We found that the unpredictability of COVID-19, the fear of long-term health consequences, burden of guilt, and suffering in isolation profoundly impacted mental health. Clinical and public health interventions are needed to manage the psychological consequences arising from this pandemic.

Longitudinal evaluation of laboratory-based serological assays for SARS-CoV-2 antibody detection

Serological assays for SARS-CoV-2 infection are now widely available for use in diagnostic laboratories. Limited data are available on the performance characteristics in different settings, and at time periods remote from the initial infection. Validation of the Abbott (Architect SARS-CoV-2 IgG), DiaSorin (Liaison SARS-CoV-2 S1/S2 IgG) and Roche (Cobas Elecsys Anti-SARS-CoV-2) assays was undertaken utilising 217 serum samples from 131 participants up to 7 months following COVID-19 infection. The Abbott and DiaSorin assays were implemented into routine laboratory workflow, with outcomes reported for 2764 clinical specimens. Sensitivity and specificity were concordant with the range reported by the manufacturers for all assays. Sensitivity across the convalescent period was highest for the Roche at 95.2-100% (95% CI 81.0-100%), then the DiaSorin at 88.1-100% (95% CI 76.0-100%), followed by the Abbott 68.2-100% (95% CI 53.4-100%). Sensitivity of the Abbott assay fell from approximately 5 months; on this assay paired serum samples for 45 participants showed a significant drop in the signal-to-cut-off ratio and 10 sero-reversion events. When used in clinical practice, all samples testing positive by both DiaSorin and Abbott assays were confirmed as true positive results. In this low prevalence setting, despite high laboratory specificity, the positive predictive value of a single positive assay was low. Comprehensive validation of serological assays is necessary to determine the optimal assay for each diagnostic setting. In this low prevalence setting we found implementation of two assays with different antibody targets maximised sensitivity and specificity, with confirmatory testing necessary for any sample which was positive in only one assay.

Point of care and intensive care lung ultrasound: A reference guide for practitioners during COVID-19

Objectives

Current events with the recent COVID-19 outbreak are necessitating steep learning curves for the NHS workforce. Ultrasound, although not used in the diagnosis of COVID-19 may be utilised by practitioners at the point of care (POC) or on the intensive care units (ITUs) where rapid assessment of the lung condition may be required. The aim of this article was to review current literature surrounding the use of lung ultrasound in relation to COVID-19 and provide Sonographers with a quick and digestible reference guide for lung pathologies.

Key findings

Ultrasound is being used in Italy and China to help review lung condition during the COVID-19 outbreak however not strictly as a diagnostic tool as Computed Tomography (CT) of the chest and chest radiographs are currently gold standard. Ultrasound is highly sensitive in the detection of multiple lung pathologies which can be demonstrated in conjunction with COVID-19 however to date there are no specific, nor pathognomonic findings which relate to COVID-19 on ultrasound.

Conclusion

Lung ultrasound is highly sensitive and can quickly and accurately review lung condition creating potential to assess for changes or resolution over time, especially in the ITU and POC setting. However it should not be used as a diagnostic tool for COVID-19 due to low specificity in relation to the virus.

Implications for practice

The adoption of lung ultrasound to monitor lung condition during the COVID-19 outbreak may reduce the need for serial exposure to ionising radiation on the wards and in turn reduce the number of radiographers required to attend infected wards and bays, protecting both patients and the workforce.

Family impact of childhood neurodevelopmental disability: considering adaptive and maladaptive behaviour

BACKGROUND

The aim of the current study was to identify functional predictors of perceived impact of childhood disability among families of children with neurodevelopmental disorders and disabilities. We first examined the relationship between sub-domains of adaptive and problematic behaviour and perceived family impact. Second, we examined whether the same sub-domains would emerge as significant after controlling for the impact of child diagnosis, including autism spectrum disorder, cerebral palsy and intellectual disability.

METHOD

Caregivers of 216 children and adolescents (M = 8.17 years) with neurodevelopmental disorder and disability completed measures of children's practical, conceptual and social skills (i.e. adaptive behaviour), behaviour problems and positive and negative family impact.

RESULTS

Indices of child adaptive and problematic behaviour were only significantly associated with perceived negative family impact. Children's practical and social skills, as well as emotional symptoms, emerged as significant predictors of perceived negative family impact, with emotional symptoms accounting for greatest variance. Including diagnosis in our statistical models did not explain additional variance above and beyond these particular sub-domains of child functioning.

CONCLUSIONS

The study findings suggest that it is not children's most impaired domains of functioning that are perceived as significantly impactful by the family. The findings highlight the importance of devoting consideration to the ways in which the functional limitations experienced by children with chronic developmental health conditions similarly impact family life and well-being, regardless of disorder designation.

Patient costs during tuberculosis treatment in Bangladesh and Tanzania: the potential of shorter regimens

OBJECTIVE

To estimate the costs incurred by patients during the intensive and continuation phases of the current 6-month tuberculosis (TB) regimen in Bangladesh and Tanzania, and thus identify potential benefits to patients of a shorter, 4-month treatment regimen.

DESIGN

The validated Stop TB patient cost questionnaire was adapted and used in interviews with 190 patients in the continuation phase of treatment with current regimens.

RESULTS

In both countries, overall patient costs were lower during 2 months of the continuation phase (US$74 in Tanzania and US$56 in Bangladesh) than during the 2 months of the intensive phase of treatment (US$150 and US$111, respectively). However, continuation phase patient costs still represented 89% and 77% of the 2-month average national income in the respective countries. Direct travel costs in some settings were kept low by local delivery system features such as community treatment observation. Lost productivity and costs for supplementary foods remained significant.

CONCLUSIONS

Although it is not a straightforward exercise to determine the exact magnitude of likely savings, a shorter regimen would reduce out-of-pocket expenses incurred by patients in the most recent 2 months of the continuation phase and allow an earlier return to productive activities.

Implications of the current tuberculosis treatment landscape for future regimen change

BACKGROUND

The current tuberculosis (TB) treatment landscape has been studied extensively, but researchers rarely consider how it creates challenges or opportunities for future regimen change.

METHODS

In 166 stakeholder interviews in the TB high-burden countries (HBCs), we investigated areas of first-line TB treatment and control that would affect, and be affected by, a future TB regimen change. Responses were compared with existing standardized data.

RESULTS

Public sector regimens are converging towards a single standard, which facilitates comparison with a single control arm from clinical trials. However, final product design is challenging if the goal is fixed-dose combinations and patient kits, whose current widespread use addresses continuing weaknesses in drug management. Any product must address broad groups, as relatively low levels of drug susceptibility testing (DST) do not allow for individualized therapy. Finally, the protection of new drugs from the development of resistance will be challenging, as the implementation of directly observed therapy and public-private mix programs is incomplete, and substantial private sectors have been identified as early adopters of these drugs.

CONCLUSIONS

Health systems for TB treatment and control must be improved not only to allow better implementation of current treatments but also to set the stage for implementation of new, improved TB regimens.

Gemcitabine versus gemcitabine plus dalteparin thromboprophylaxis in pancreatic cancer

BACKGROUND

Annualised figures show an up to 7-fold higher incidence of vascular thromboembolism (VTE) in patients with advanced pancreatic cancer (APC) compared to other common malignancies. Concurrent VTE has been shown to confer a worse overall prognosis in APC.

METHODS

One hundred and twenty three APC patients were randomised to receive either gemcitabine 1000 mg/m(2) or the same with weight-adjusted dalteparin (WAD) for 12 weeks. Primary end-point was the reduction of all-type VTE during the study period. NCT00462852, ISRCTN: 76464767.

FINDINGS

The incidence of all-type VTE during the WAD treatment period (<100 days from randomisation) was reduced from 23% to 3.4% (p = 0.002), with a risk ratio (RR)of 0.145, 95% confidence interval (CI) (0.035-0.612) and an 85% risk reduction. All-type VTE throughout the whole follow-up period was reduced from 28% to 12% (p = 0.039), RR = 0.419, 95% CI (0.187-0.935) and a 58% risk reduction. Lethal VTE <100 days was seen only in the control arm, 8.3% compared to 0% (p = 0.057), RR = 0.092, 95% CI (0.005-1.635).

INTERPRETATION

Weight adjusted dalteparin used as primary prophylaxis for 12 weeks is safe and produces a highly significant reduction of all-type VTE during the prophylaxis period. The benefit is maintained after dalteparin withdrawal although decreases with time.

Tuberculosis regimen change in high-burden countries

BACKGROUND

Experience with past tuberculosis (TB) regimen changes can guide future regimen changes.

METHODS

To explore the process, major players and procedural success factors for recent public sector TB regimen changes, we conducted 166 interviews of country stakeholders in 21 of the 22 TB high-burden countries (HBCs).

RESULTS

Stakeholders described 40 distinct regimen changes for drug-susceptible TB. Once countries committed to considering a change, the average timing was ∼1 year for decision-making and ∼2 years for roll-out. Stakeholders more often cited concerns that were program-based (e.g., logistics and cost) rather than patient-focused (e.g., side effects), and patient representatives were seldom part of decision making. Decision-making bodies in higher-income HBCs had more formalized procedures and fewer international participants. Pilot studies focused on logistics were more common than effectiveness studies, and the evidence base was often felt to be insufficient. Once implementation started, weaknesses in drug management were often exposed, with additional complications if local manufacturing was required. Best practices for regimen change included early engagement of budgeting staff, procurement staff, regulators and manufacturers.

CONCLUSIONS

Future decision makers will benefit from strengthened decision-making bodies, patient input, early and comprehensive planning, and regimens and evidence that address local, practical implementation issues.

Schizophrenia is associated with an increase in cortical microRNA biogenesis

MicroRNA expression profiling and quantitative reverse transcription-PCR analysis of the superior temporal gyrus and the dorsolateral prefrontal cortex revealed a significant schizophrenia-associated increase in global microRNA expression. This change was associated with an elevation of primary microRNA processing and corresponded with an increase in the microprocessor component DGCR8. The biological implications for this extensive increase in gene silencing are profound, and were exemplified by members of the miR-15 family and other related microRNA, which were significantly upregulated in both brain regions. This functionally convergent influence is overrepresented in pathways involved in synaptic plasticity and includes many genes and pathways associated with schizophrenia, some of which were substantiated in vitro by reporter gene assay. Given the magnitude of microRNA changes and their wide sphere of influence, this phenomenon could represent an important dimension in the pathogenesis of schizophrenia.

The Leicester Risk Assessment score for detecting undiagnosed Type 2 diabetes and impaired glucose regulation for use in a multiethnic UK setting

AIMS

Risk assessment scores identify those at high risk of impaired glucose regulation and Type 2 diabetes mellitus. To date no risk assessment scores that can be completed by a lay person have been developed and validated specifically for multiethnic populations in the UK.

METHODS

We used data on 6186 subjects aged 40-75 years from a multiethnic UK screening study (73% white European, 22% South Asian). All participants were given a 75 g oral glucose tolerance test. We developed logistic regression models for predicting current impaired glucose regulation (impaired fasting glycaemia/impaired glucose tolerance) or Type 2 diabetes mellitus using data from anthropometric measurements and self-reported questionnaires. Using the best-fitting model, we developed the Leicester Risk Assessment score. We externally validated the score using data from 3171 subjects aged 40-75 years from a separate screening study.

RESULTS

The components of the final model are age, ethnicity [white European vs. other (predominantly South Asian)], sex, first degree family history of diabetes, antihypertensive therapy or history of hypertension, waist circumference and body mass index. The score ranges from 0 to 47. Validating this model using the data from the second screening study gave an area under the receiver operator characteristic curve of 72% (95% confidence interval, 69-74%). A cut point of 16 had a sensitivity of 81% and a specificity of 45%.

CONCLUSIONS

The Leicester Risk Assessment score can be used to identify those at high risk of impaired glucose regulation and Type 2 diabetes mellitus in UK multiethnic populations. The score is simple (seven questions) and non-invasive.

A single center experience with high-dose (HD) IL-2 treatment for patients with advanced melanoma and pilot investigation of a novel gene expression signature as a predictor of response

9003

Background: HD IL-2 remains one of two FDA-approved therapies for the treatment of patients (pts) with advanced melanoma. Initial studies conducted 15–20 years ago reported 16% response rate with 8% of pts achieving durable responses. The toxicity of HD IL-2 limits its application to pts treated in specialized centers. We present the clinical outcome of pts treated over a recent 2 year period with HD IL-2 at a single institution and an associated retrospective pilot study evaluating the predictive value of a novel tumor gene expression signature. Methods: Clinical and radiological data were collected and analyzed on 49 consecutive pts treated with HD IL-2 at Beth Israel Deaconess Medical Center from 10/05 - 10/07. Response was evaluated via RECIST. Formalin-fixed paraffin embedded tumor was obtained on consenting pts and classified as either Class 1, defined by melanocyte-specific genes including MITF, or Class 2, represented by immune genes, using the DNA-mediated Annealing, Selection, and Ligation (DASL) technique. Two-sided Fisher's Exact test was used to compare the proportion of responses for pts in the two classes. Results: Clinical response occurred in 16 of the 49 pts (32.6%), with 5 pts (10.2%) having a CR. Two other pts had stable disease > 12 mos; 3 pts who progressed after response had resection to NED. 10 pts remain disease/progression free at a minimum of 16 mos following treatment. 28 pts (including 13 of 16 responders) had sufficient tumor for DASL analysis. Among the 21 categorized as Class 1, 7 (33%) were responders. Of the 7 classified as Class 2, 6 (86%) were responders. This difference in response was statistically significant (p = 0.0286). Conclusions: The overall and CR rates in a contemporary series of pts with metastatic melanoma treated with HD IL-2 are twice that reported in initial studies suggesting some treatment selection on clinical grounds since the 1990s. Pts with tumors expressing an immune signature by DASL appeared more likely to respond. This finding requires prospective validation, but suggests immune-related gene expression might contribute to IL-2 responsiveness.

[Table: see text]

Quality of life measurements and bronchodilator responsiveness in prescribing nebulizer therapy in COPD

Nebulized bronchodilators are widely regarded as the optimal treatment for maintenance therapy in patients with severe chronic obstructive pulmonary disease (COPD). The aim of the study was to assess whether detailed physiological, functional and quality of life-related measurements can assist in determining the requirement for nebulized bronchodilator therapy in patients with moderate to severe COPD. This was an unblinded, randomized, crossover study that compared intermediate (120mcg ipratropium bromide and 600mcg of salbutamol using metered dose inhaler (MDI) and spacer) and high dose (nebulized 500 mcg ipratropium bromide and 2.5 mg salbutamol) bronchodilator therapy, on physiological, functional and quality of life-related measurements in patients with COPD. A total of 25 patients (12 female), mean (SD) age 68 (7) years, FEV1 45 (10) % predicted completed the study. There was no statistically significant difference between the treatments in the pre- and post-bronchodilator lung function values, six-minute walk distance, breathlessness score or quality of life questionnaires. Fifteen patients preferred bronchodilator therapy with nebulizer and 10 with MDI and spacer. In 20 patients at least one positive response in quality of life score, lung function or six-minute walk, was observed on the preferred treatment.

Only a proportion of patients with moderate or severe COPD prefer nebulized bronchodilator therapy. This study found that none of the parameters singly or in combination were consistently predictive of patients' preference for nebulized bronchodilator therapy. Therefore, we suggest that clinicians institute a trial of stepping up to an intermediate dose of bronchodilators prior to introducing nebulized therapy. Chronic Respiratory Disease 2008; 5: 13—18

Chemoanticoagulation versus chemotherapy in advanced pancreatic cancer (APC): Results of the interim analysis of the FRAGEM trial

4583

Background: Randomised phase III studies in APC, reveal that many patients (pts) (∼20–25%) die within 3 months from randomisation [(Early Death Burden) (EDB)]. More compared to studies done in other cancers despite pts entered on similar ‘global’ clinical criteria (e.g. 7% in colorectal cancer). We hypothesised that EDB in APC is related to hyper-coagulability. Prevention of veno-thromboembolism (VTE) may result in reduction of EDB. To test this we initiated the randomised phase IIb FRAGEM study. Methods: Upon written informed consent pts with inoperable APC, are eligible for the study (MREC N° 07/02/129, UKCRN 1290). Concurrent VTE or anticoagulant therapy are exclusion criteria. Standard arm pts (arm A) receive gemcitabine 1gr/m2 weekly (Burris schedule). Arm B also receives daily dalteparin injections for 12 weeks at therapeutic dose (CLOT schedule). Primary end point is the reduction of VTE, secondary endpoint the reduction of EDB. To detect a reduction of VTE from around 25% to 5% (odds ratio of 0.158), using a two-group chi-squared test with a two-sided 5% significance level and 80% power, a minimum of 59 pts per treatment group are required. Interim analysis was planned after the first 25 pts entered into arm B to exclude toxicity from dalteparin’s therapeutic, given prophylactically, dose. These results are presented here. Results: 26 pts (50% male, 61% with metastases) in arm A and 25 pts (60% male, 44% with metastases) in arm B have been treated so far. The incidence of VTE in arm A was 31% with 3 pts developing leg deep vein thrombosis (DVT) with pulmonary embolism (PE), 2pts DVT, 1 pt splanchnic vein thrombosis and PE, 1 pt PE without DVT and 1 patient a stroke. No VTE observed in arm B. Haemorrhagic events were 7.5% and 4% in arm A and B respectively. Within the first 12 weeks period 4 pts (15%) in arm A died, 2 from PE (autopsy- confirmed in one ‘sudden death’), 1 from stroke and one from progressive cancer. The VTE related mortality was 37%. In arm B the EDB was 4% as 1 pt died from sepsis. Conclusions: Results of the interim analysis indicate that the dose of dalteparin is safe. They also support our hypothesis that reduction of VTE may result in reduction of the EDB. The trial is on course to achieve its primary endpoint.

No significant financial relationships to disclose.

Vascular endothelial growth factor and soluble Tie-2 receptor in colorectal cancer: associations with disease recurrence

AIMS

A delicate balance exists between pro-angiogenic factors and anti-angiogenic factors to regulate the process of angiogenesis. To investigate the relationship of VEGF-A with other angiogenic factors and to determine their clinical usefulness.

METHODS

Venous blood was obtained from 47 patients with CRC prior to curative resections. VEGF-A, sVEGFR-1, sTie-2 receptor, and TNF-alpha levels in serum were measured concurrently with quantitative ELISA. The median follow-up term for patients without cancer death was 29 months (range 20-35).

RESULTS

Both serum TNF-alpha activity and sVEGFR-1 was detectable in 17% and 74% of CRC patients, respectively. Univariate analysis demonstrated that the disease free survival was significantly associated with the tumour location (P=0.031), T category (P=0.006), TNF-alpha activity (P=0.0008), sTie-2 receptor (P=0.012) and VEGF-A (P<0.00001). From the survival analysis, a higher serum VEGF-A and sTie-2 receptor level is associated with an earlier development of metastases. Using multivariate Cox's regression analysis, the only independent predictors of outcome were sTie-2 receptor (P=0.038) and VEGF-A (P=0.006).

CONCLUSIONS

sTie-2 receptor and VEGF-A appear to associate independently with the development of metastases, with VEGF-A being the most powerful predictor of outcome. These data also suggest that measurement of pre-operative sTie-2 receptor and VEGF-A is superior to determining VEGF-A alone with regards to predictive value.

Risk modelling for carotid endarterectomy

Background

A 30-day stroke or death rate of 3–10 per cent has been reported in patients undergoing carotid endarterectomy (CEA). The aim of this study was to identify the risk factors that influenced the outcome and to develop a logistic regression model that can aid in the comparative audit of CEA.

Methods

Some 836 CEAs performed by four vascular surgeons from 1992 to 1999 were analysed. The median age of the population was 69 (range 38–86) years, and the male: female ratio was 1·6. Multiple logistic regression was used to model the effect of 15 risk factors on the 30-day stroke and death rate. The outcome after risk adjustment was compared for four surgeons and two vascular units.

Results

The overall 30-day stroke and death rate was 3·9 per cent. Regression modelling identified heart disease, diabetes and stroke at presentation as significant risk factors. A risk score of 1 was assigned to each of these risk factors to produce a logistic regression equation (where P is the probability of 30-day stroke or death):

ln(P/1 − P) = 0·9294(risk score) − 4·2726.

The observed 30-day stroke and death rate for four vascular surgeons was 3·0, 4·0, 4·2 and 4·3, and for two vascular units was 3·9 and 3·9. Differences between the surgeons and the vascular units were not statistically significant after allowing for risk adjustment using this model.

Conclusion

Multiple logistic regression models can successfully identify patients at higher risk from CEA, and aid in the comparative audit of surgeons and vascular units.

The inhibition of protein phosphatases 1 and 2A: a new target for rational anti-cancer drug design?

Recent investigations in our laboratories have highlighted that the inhibition of the serine/threonine protein phosphatases 1 and 2A (PP1 and PP2A) is an excellent target for the development of novel anti-cancer agents. Using a combination of the known crystal structure of PP1 and the modelled structure of PP2A, we have rationally designed a new class of protein phosphatase inhibitors, cantharimides, which exhibit broad-spectrum anti-cancer activity. Synthetic modifications of the simplest known PP1 and PP2A inhibitor, norcantharidin, has led to the development of potent PP1 and PP2A inhibitors.

Cantharimides: a new class of modified cantharidin analogues inhibiting protein phosphatases 1 and 2A

Cantharidin and its analogues have been of considerable interest as potent inhibitors of the serine/threonine protein phosphatases 1 and 2A (PP1 and PP2A). However, limited modifications to the parent compounds is tolerated. As part of an on-going study we have developed a new series of cantharidin analogues, the cantharimides. Inhibition studies indicate that cantharimides possessing a D- or L-histidine, are more potent inhibitors of PP1 and PP2A (PP1 IC(50)=3.22+/-0.7 microM; PP2A IC(50)=0.81+/-0.1 microM and PP1 IC(50)=2.82+/-0.6 microM; PP2A IC(50)=1.35+/-0.3 microM, respectively) than norcantharidin (PP1 IC(50)=5.31+/-0.76 microM; PP2A IC(50)=2.9+/-1.04 microM) and essentially equipotent with cantharidin (PP1 IC(50)=3.6+/-0.42 microM; PP2A IC(50)=0.36+/-0.08 microM). Cantharimides with non-polar or acidic amino acid residues are only poor inhibitors of PP1 and PP2A.

The Challenging Behaviour Scale (CBS): development of a scale for staff caring for older people in residential and nursing homes

OBJECTIVES

A review of behavioural rating scales identified the need for a measure of resident behaviours that staff in care homes for older people find difficult to manage. A 25-item, broad-based rating scale, the Challenging Behaviour Scale (CBS), was developed to meet this need and its psychometric properties were examined.

DESIGN

Cross-sectional surveys.

METHODS

Ratings of 484 residents, living in 16 homes across England, were used to examine four methods of collecting inter-rater reliability data. Ratings of 382 residents living in 13 homes were used to evaluate criterion validity and to establish norms. Six further homes were used to explore qualitatively the validity of the suggested norms. Ratings of 98 residents living in four further homes were used to examine concurrent validity. The predictive validity of the CBS 'challenge' score was evaluated, using time-sampled direct observation of challenging behaviour in 237 residents, living in 11 homes.

RESULTS

The scale records staff reports of the incidence, frequency and 'management difficulty' of resident behaviour and it can also identify 'challenging residents' through a computed score. It has good internal consistency, good test-retest reliability and adequate validity. Inter-rater reliability is good when staff receive training or when staff groups of at least three, of mixed qualifications, complete the scale. Norms are suggested for prospective studies of the prevalence of challenging behaviour.

CONCLUSIONS

The CBS is quick to complete and may have potential for the evaluation of psychosocial interventions in care settings. It is, as far as we know, the first staff observational rating scale that is based on the reports of care staff, who constitute the backbone of residential care provision. Suggestions for improvements in criterion and content validity are outlined.

Pre-operative serum vascular endothelial growth factor can select patients for adjuvant treatment after curative resection in colorectal cancer

We aim to determine the clinical usefulness of pre-operative serum vascular endothelial growth factor (VEGF) as a predictor of outcome in patients undergoing curative resection for colorectal cancer. Serum VEGF was assayed by quantitative ELISA in 81 patients prior to curative resection for node-negative (n = 53) and node-positive (n = 28) disease. Median follow-up for patients without cancer death was 27 months (range 21-37). Pre-operative serum VEGF was significantly higher in patients who went on to develop metastases than those who did not (median, 713 pg ml-1 vs. 314 pg ml-1, P < 0.0001). Using multivariate Cox regression analysis, pre-operative serum VEGF was the most important prognostic factor independent of nodal status and adjuvant chemotherapy, and was superior to nodal status in predicting outcome (P < 0.00001). At 575 pg ml-1, pre-operative serum VEGF was 64% sensitive and 89% specific in predicting the development of metastases in curative resections, with a positive predictive value of 73% and a negative predictive value of 85%. Pre-operative serum VEGF is a powerful predictor of outcome following curative surgery for colorectal cancer. These data support the measurement of pre-operative serum VEGF as a method for selecting patients who require adjuvant therapy.

Plugging the intramedullary canal of the femur in total knee arthroplasty: reduction in postoperative blood loss

A prospective, randomized trial comparing postoperative drainage was carried out in 120 consecutive knees undergoing total knee arthroplasties divided into 2 groups. In one (55 knees), the entry point for the femoral intramedullary rod was left open. In the other (65 knees), the entry point was closed by an autologous bone plug. The mean drainage after 24 hours and the total drainage were lower when the femoral canal was plugged (800 vs 960 mL and 925 vs 1,165 mL). The bone plug always united, and no loose bodies were seen 6 months after operation. We conclude that the femoral intramedullary guide hole should be plugged with autologous bone because this technique results in a small but significant reduction in early blood loss without countervailing disadvantages.

Do the rich really die young? Alcohol-related mortality and social class in Great Britain, 1988-94

AIMS

To determine whether social class is a major influence on alcohol-related mortality in the general, economically active population of Great Britain.

DESIGN AND PARTICIPANTS

Poisson regression of rates of mortality known to be directly caused by alcohol consumption by age, sex and social class in England, Wales and Scotland.

MEASUREMENTS

The measure of alcohol-related mortality is total deaths from ICD-9 categories 291; 303; 357.5; 425.5; 535.3; 305; 790.3; and 571.0-571.3 over the 7-year period 1988-94. (It excludes deaths for which alcohol-attributable fractions would need to be calculated.) The measure of social class is the British Registrar General's six-fold occupational classification, used to code census and death certification data.

FINDINGS

Alcohol-related mortality rates are higher for men in the manual occupations than in the non-manual occupations, but the relative magnitude depends on age. Men aged 25-39 in the unskilled manual class are 10-20 times more likely to die from alcohol-related causes than those in the professional class, whereas men aged between 55 and 64 in the unskilled manual class are only about 2.5-4 times more likely to die. For women in paid employment there is no consistent class gradient; younger women in the manual classes are more likely to die from alcohol-related causes, but for older women it is those in the professional class who suffer elevated mortality.

CONCLUSIONS

Social class is a risk factor for alcohol-related mortality in Britain, although it is mediated by age and sex. Alcohol appears to be similar to other psychoactive substances, therefore, in that problem use is linked to social structural factors such as poverty, disadvantage and social class. This suggests that social interventions aimed at reducing poverty and inequality have the potential to reduce current levels of alcohol-related harm among the poorest groups in the community.

A comparison of T2 and gadolinium enhanced MRI with CT myelography in cervical radiculopathy

Two MRI strategies which have been reported to be effective in assessing cervical exit foramina, were prospectively compared with CT myelography in 20 patients with cervical radiculopathy. The first strategy utilized 3D T2* images, the second gadolinium enhanced 2D T1 images. Gadolinium (dimeglumine gadopentetate, Schering Ltd) enhanced images did not confer any benefit in the investigation of this condition, probably due to enhancement of herniated disc material and osteophytes adjacent to the neurocentral joint. Three-dimensional (3D) T2* white cerebrospinal fluid images had an accuracy approaching 90% for the diagnosis of foraminal encroachment, compared with a gold standard. MRI including a 3D T2* sequence is thus an acceptable primary investigation for cervical radiculopathy, but when the findings are incompatible with clinical symptomatology, CT myelography is still indicated.

Tissue specific and vitamin D responsive gene expression in bone

Studies of gene expression in bone have adopted a number of molecular approaches that seek to determine those cis and trans-acting factors responsible for the development and physiological regulation of this unique tissue. The majority of studies have been performed in vitro, focussing on the expression of genes such as osteocalcin, bone sialoprotein and type I collagen which demonstrate restricted or altered expression patterns in osteoblasts. These studies have demonstrated a large number of cis and trans acting factors that modulate the tissue specific and vitamin D responsive expression of these genes. These include the response elements and regions mediating basal and vitamin D dependent transcription of these genes as well as some of the transcription factors that bind to these regions and the nucleosomal organisation of these genes within a nuclear framework. In vivo studies, including the introduction of transgenes into transgenic mice, extend these in vitro observations within a physiological context. However, in part due to limitations in each approach, these in vitro and in vivo studies are yet to accurately define all the necessary cis and trans-acting factors required for tissue specific and vitamin D responsive gene expression. Advances have been made in identifying many cis-acting regions within the flanking regions of these genes that are responsible for their restricted expression patterns, but a vector incorporating all the necessary cis-acting regions capable of directing gene expression independent of integration site has not yet been described. Similarly, trans-acting factors that determine the developmental destiny of osteoblast progenitors and the restricted expression of these genes remain elusive and, despite advances in the understanding of protein-DNA interactions at vitamin D response elements contained within these genes, further intermediary factors that interact with the transcriptional machinery to modulate vitamin D responsiveness need to be identified.

The inter-rate reliability of a generic measure of severity of illness

BACKGROUND

There has been increasing interest in the development of measures to quantify baseline severity of illness and thus provide a more meaningful interpretation of health outcomes.

OBJECTIVE

We aimed to assess the inter-rater reliability of a generic measure of illness severity, the Duke University Severity of Illness (DUSOI) checklist.

METHODS

Selected general practices and hospital outpatient departments across Tyneside and Humberside in the UK were used as the setting. Thirty-three clinicians were posted copies of the same set of 14 patient records and asked to rate the severity of illness of each patient using the DUSOI. The subjects were 27 GPs, three consultant chest physicians and three diabetologists. The main outcome measures were: (i) intraclass correlation coefficients used to express clinician agreement upon severity scores; and (ii) a 'gold standard', constructed in order to assess clinician agreement upon the health problems identified in the patient record to be considered as constituents of overall severity.

RESULTS

It was found that the degree of inter-rater reliability of severity scoring was satisfactory, with an intraclass correlation coefficient of 0.43. In terms of identification of problems to be rated, there was considerable agreement between raters and a specially compiled 'gold standard' of health problems.

CONCLUSION

The DUSOI has potential use in routine clinical practice, but strategies should be developed in order to maximize the reliability of rating illness severity on such a generic measure.

Ethnic differences in substance use and alcohol-use-related mortality among first generation migrants to England and Wales

Epidemiological studies among migrant ethnic groups are potentially important as a way to provide insight into the relative importance of genetic, cultural, and socioeconomic factors in the etiology of substance use disorders. This paper summarizes prior United Kingdom studies of the prevalence of substance-use-associated problems in different ethnic groups before analyzing trends in recent mortality data by country of birth. On this evidence, rates of alcohol-related mortality may be marginally higher for those born in the Caribbean than for the native British, but are substantially raised for those born in Ireland and the Indian subcontinent. There is some indication that rates for the Caribbean and possibly the Irish groups have risen more rapidly than for the national population over a 12-year period. These differences in mortality rates seem to have arisen for complex reasons.

Accuracy and reliability of assessment of severity of illness before and after an educational intervention

Severity-of-illness measurement is considered to be an important factor in the risk adjustment of medical outcomes. However, for those measures that involve a high level of clinical judgment, strategies have to be developed to maximize the consistency of rating severity that can be implemented, especially when rating is based upon medical record review. A group of 25 clinicians were sent the same set of 14 patient records, and requested to use the Duke University Severity of Illness (DUSOI) checklist to rate the severity of patients' illness. Written instructions for the use of this instrument were provided. A short educational intervention was than made by the research team, and the clinicians were sent the same set of records to be rated again. Any improvement in the accuracy and reliability of severity assessment over the two ratings was then studied. The educational intervention resulted in identification of fewer irrelevant health problems. However, it had little impact upon the reliability of severity scoring itself, as measured by the intraclass correlation coefficient. Measuring severity of illness is a conceptually complex procedure. However, given its role in outcome interpretation, it may be worth pursuing strategies aimed at maximizing consistency of clinician rating. There are a number of options, including improved written instructions and more intensive training, that could be implemented.

Identification and characterisation of a novel human RNA-binding protein

The processing of heterogeneous nuclear RNA (hnRNA) into a mature message occurs within a number of different nuclear ribonucleoprotein (RNP) complexes which bind to the hnRNA and provide the machinery for these modifying events. Although some components of the nuclear RNP complexes have been isolated, many remain to be elucidated. We report here the isolation of a novel human nucleic-acid-binding protein isolated by screening a lambda gt11 expression library with an oligodeoxyribonucleotide probe. The complete cDNA clone (E5.1) is homologous to a recently published murine sequence. The human gene encodes a ubiquitously expressed mRNA sequence with a putative open reading frame of 305 amino acids and contains a number of domains found in well characterised RNA-binding proteins. The E5.1-derived RNA recognition motif (RRM) is phylogenetically most related to the hnRNP C protein, a component of heterogeneous nuclear RNP particles which participates in mRNA splicing in vitro. E5.1 may, therefore, represent a novel gene, encoding a protein involved in processing of precursor RNAs into mature mRNA.

G/C element contributes to the cell line-specific expression of the proximal osteocalcin promoter

Sequential activation of cell type-specific genes occurs during osteoblast development. The promoter of one such gene, osteocalcin, has been widely studied, but the DNA sequences that govern osteoblast-specific expression have not been defined. The proximal osteocalcin promoter linked to pTKCAT directs strong promoter activity in osteoblast-like ROS17/2.8 cells and comparatively weak promoter activity in nonosteoblastic NIH3T3 cells. To identify sequences important in conferring cell-specific expression of the osteocalcin gene, a deletion series of the human proximal promoter was constructed and the activities assessed in ROS17/2.8 and NIH3T3 cells. These studies identified a 30 bp sequence within the proximal promoter (osteocalcin repressor element-1 [ORE-1]) which is responsible for repressing the transcriptional activity in NIH3T3 cells. In electrophoretic mobility shift assays from both NIH3T3 and ROS17/2.8 cells, a protein complex bound to the ORE-1 that was related to a complex which binds the G/C-rich repressor element in the collagen type I (alpha 1) promoter. In addition, there was a second complex from NIH3T3 cells but not ROS17/2.8 cells that bound the ORE-1 fragment. The presence of this additional factor in NIH3T3 cells parallels the observation that constructs carrying the ORE-1 sequence have repressed promoter activity relative to the analogous constructs lacking the ORE-1 when transfected into NIH3T3 and suggests that the NIH3T3-specific factor is a repressor. These data indicate that the G/C element in the ORE-1 contributes to the repression of osteocalcin gene transcription in a nonosteoblast cell line. The high homology between the ORE-1 sequence and a related sequence in the collagen type I (alpha 2) proximal promoter suggests that homologous regions in other osteoblast-expressed genes may function similarly.

The osteocalcin and collagen type I (alpha 1) promoters share common basal regulatory units

Sequential activation of osteoblast-specific genes occurs during cell development. Regulation of these genes is through the cooperation between basal, hormone-responsive, and growth factor-responsive transcriptional control elements. The active hormone, 1,25-dihydroxyvitamin D3 plays an important role in the regulation of osteocalcin and other osteoblast-expressed genes. As well as containing a vitamin D response element, the upstream region of the osteocalcin promoter also has potent basal activity in the osteoblast-like ROS17/2.8 cell line. The present study identifies a short DNA sequence that contributes to basal promoter activity. This osteocalcin cis-acting response element (OSCARE-1) has two basal regulatory elements: a G/C-rich element and an adjacent reverse CCAAT element. Homologous sequences have been characterized as negative and positive basal regulatory elements, respectively, in the promoter of the collagen type I (alpha 1) gene. In electrophoretic mobility-shift assays, this collagen regulatory unit and OSCARE-1 produce similar banding patterns and bind common ROS17/2.8 nuclear proteins. Mutations of the G/C element in the collagen promoter showed that it functions as an inhibitory element in NIH-3T3 cells. Introduction of the same mutations into the G/C element of the OSCARE-1 unit exposed a similar repressive activity in NIH-3T3 cells, which correlated with an altered electrophoretic mobility-shift assay banding pattern. We have shown a similarity between a basal regulatory unit in the distal osteocalcin promoter and a unit in the proximal collagen type I (alpha 1) promoter. The fact that similar units are present in other osteoblast-specific promoters suggests that OSCARE-1-like units may be a common regulator of osteoblast-expressed genes.

Deficiency of malic enzyme: a possible marker for malignancy in lymphoid cells

Soluble malic enzyme (MEs) has been examined in long-term human lymphoid cell lines cultured from 101 individuals. In 65 out of 66 lines derived from people without lymphoreticular malignancy the enzyme was very active. Lines established from 35 individuals with various forms of lymphoreticular malignancy were also examined, including in some cases more than 1 line derived from the same patient. In all cases where the cell line was thought to be derived from normal cells MEs was active, but in 27 out of 29 lines thought to be derived from malignant cells (from 25 patients) MEs was not detected. In the case of two patients with chronic lymphatic leukaemia 'normal' lines active for malic enzyme, and 'leukaemic' lines lacking malic enzyme, had been cultured from the same individual. Preliminary investigations of the lack of malic enzyme in somatic cell hybrids derived from lymphoma and leukaemia cell lines are compatible with an alteration at the level of the structural locus MEs on chromosome 6. However, the restoration of MEs activity in one line by fusion with mouse teratocarcinoma cells suggests that the alteration may be of a regulatory nature.