Staff recognition and its importance for surgical service delivery: a qualitative study in Freetown, Sierra Leone

We examined the views of providers and users of the surgical system in Freetown, Sierra Leone on processes of care, job and service satisfaction and barriers to achieving quality and accessible care, focusing particularly on the main public tertiary hospital in Freetown and two secondary and six primary sites from which patients are referred to it. We conducted interviews with health care providers (N = 66), service users (n = 24) and people with a surgical condition who had chosen not to use the public surgical system (N = 13), plus two focus groups with health providers in primary care (N = 10 and N = 10). The overall purpose of the study was to understand perceptions on processes of and barriers to care from a variety of perspectives, to recommend interventions to improve access and quality of care as part of a larger study. Our research suggests that providers perceive their relationships with patients to be positive, while the majority of patients see the opposite: that many health workers are unapproachable and uncaring, particularly towards poorer patients who are unable or unwilling to pay staff extra in the form of informal payments for their care. Many health care providers note the importance of lack of recognition shown to them by their superiors and the health system in general. We suggest that this lack of recognition underlies poor morale, leading to poor care. Any intervention to improve the system should therefore consider staff-patient relations as a key element in its design and implementation, and ideally be led and supported by frontline healthcare workers.

The Safer Anaesthesia from Education (SAFE)® paediatric anaesthesia course: educational impact in five countries in East and Central Africa

There is an urgent need to improve access to safe surgical and anaesthetic care for children living in many low- and middle-income countries. Providing quality training for healthcare workers is a key component of achieving this. The 3-day Safer Anaesthesia from Education (SAFE)^® paediatric anaesthesia course was developed to address the specific skills and knowledge required in this field. We undertook a project to expand this course across five East and Central African countries (Ethiopia, Kenya, Malawi, Uganda and Zambia) and train local faculty. This study reports the outcomes from course evaluation data, exploring the impact on knowledge, skills and behaviour change in participants. Eleven courses were conducted in a 15-month period, with 381 participants attending. Fifty-nine new faculty members were trained. Knowledge scores (0-50 scale) increased significantly from mean (SD) 37.5 (4.7) pre-course to 43.2 (3.5) post-course (p < 0.0001). Skills scores (0-10 scale) increased significantly from 5.7 (2.0) pre-course to 8.0 (1.5) post-course (p < 0.0001). One hundred and twenty-six participants in Malawi, Uganda and Zambia were visited in their workplace 3-6 months later. Knowledge and skills were maintained at follow-up, with scores of 41.5 (5.0) and 8.3 (1.4), respectively (p < 0.0001 compared with pre-course scores). Content analysis from interviews with these participants highlighted positive behaviour changes in the areas of preparation, peri-operative care, resuscitation, management of the sick child, communication and teaching. This study indicates that the SAFE paediatric anaesthesia course is an effective way to deliver training, and could be used to help strengthen emergency and essential surgical care for children as a component of universal health coverage.

A clinically applicable molecular-based classification for endometrial cancers

BACKGROUND

Classification of endometrial carcinomas (ECs) by morphologic features is inconsistent, and yields limited prognostic and predictive information. A new system for classification based on the molecular categories identified in The Cancer Genome Atlas is proposed.

METHODS

Genomic data from the Cancer Genome Atlas (TCGA) support classification of endometrial carcinomas into four prognostically significant subgroups; we used the TCGA data set to develop surrogate assays that could replicate the TCGA classification, but without the need for the labor-intensive and cost-prohibitive genomic methodology. Combinations of the most relevant assays were carried forward and tested on a new independent cohort of 152 endometrial carcinoma cases, and molecular vs clinical risk group stratification was compared.

RESULTS

Replication of TCGA survival curves was achieved with statistical significance using multiple different molecular classification models (16 total tested). Internal validation supported carrying forward a classifier based on the following components: mismatch repair protein immunohistochemistry, POLE mutational analysis and p53 immunohistochemistry as a surrogate for 'copy-number' status. The proposed molecular classifier was associated with clinical outcomes, as was stage, grade, lymph-vascular space invasion, nodal involvement and adjuvant treatment. In multivariable analysis both molecular classification and clinical risk groups were associated with outcomes, but differed greatly in composition of cases within each category, with half of POLE and mismatch repair loss subgroups residing within the clinically defined 'high-risk' group. Combining the molecular classifier with clinicopathologic features or risk groups provided the highest C-index for discrimination of outcome survival curves.

CONCLUSIONS

Molecular classification of ECs can be achieved using clinically applicable methods on formalin-fixed paraffin-embedded samples, and provides independent prognostic information beyond established risk factors. This pragmatic molecular classification tool has potential to be used routinely in guiding treatment for individuals with endometrial carcinoma and in stratifying cases in future clinical trials.

Psychological outcomes in critically ill patients receiving renal replacement therapy: a matched-pairs analysis

We conducted a single-centre observational study over five years to assess the impact of renal replacement therapy on the psychological health of survivors of critical illness. We hypothesised that the added burden of renal replacement would increase the prevalence and severity of anxiety, depression and stress reactions in these patients, compared with matched pairs (matched for age, sex and APACHE II score) who did not receive renal replacement. Participants completed postal questionnaires. A total of 342 patients with acute kidney injury received renal replacement. One hundred and seventy-nine (52.3%) survived to hospital discharge, and 161 (47.1%) were alive at 90 days. Seventy-seven (47.8% of survivors) completed questionnaires. We found 77 matches for the Hospital Anxiety and Depression Scale analysis and 72 for the Impact of Events Scale analysis. Clinically relevant symptoms of psychiatric morbidity were common, with anxiety and depression affecting 49 (63.6%) patients and stress reactions affecting 24 (33.3%) patients. Mean scores (95% CI) were 11.4 (9.6-13.2) and 20.1 (15.7-24.6), respectively. On multivariate analysis, we found no significant differences between renal replacement patients and controls, in either the frequency or severity of these symptoms.

First reflections: third-year dentistry students' introduction to reflective practice

INTRODUCTION

To develop both professionally and personally, health professionals need to build essential skills in reflective practice. Educators generally agree that these skills should be developed as part of curricula for health professional students. The aims were to introduce reflective practice to third-year dentistry students and to evaluate the students' self-perceived reflective skills before and after their reflective activities.

MATERIALS AND METHODS

Using a written questionnaire, third-year dentistry students' perceptions of reflective practice were gathered before and after their first clinic placement. Students also completed two reflective writing pieces about their clinical placements.

RESULTS

The students' reflective writing pieces were allocated into one of the three categories: non-reflector, reflector and critical reflector. Content analysis of students' perceptions of reflective practice revealed nine themes. Eight main themes emerged from students' suggestions for improving their reflective abilities.

DISCUSSION AND CONCLUSION

Issues around the assessment of reflective writing are discussed, and students' suggestions for improving their reflective abilities are presented.

Germline mutations in CDH1 are infrequent in women with early-onset or familial lobular breast cancers

BACKGROUND

Germline mutations in CDH1 are associated with hereditary diffuse gastric cancer; lobular breast cancer also occurs excessively in families with such condition.

METHOD

To determine if CDH1 is a susceptibility gene for lobular breast cancer in women without a family history of diffuse gastric cancer, germline DNA was analysed for the presence of CDH1 mutations in 318 women with lobular breast cancer who were diagnosed before the age of 45 years or had a family history of breast cancer and were not known, or known not, to be carriers of germline mutations in BRCA1 or BRCA2. Cases were ascertained through breast cancer registries and high-risk cancer genetic clinics (Breast Cancer Family Registry, the kConFab and a consortium of breast cancer genetics clinics in the United States and Spain). Additionally, Multiplex Ligation-dependent Probe Amplification was performed for 134 cases to detect large deletions.

RESULTS

No truncating mutations and no large deletions were detected. Six non-synonymous variants were found in seven families. Four (4/318 or 1.3%) are considered to be potentially pathogenic through in vitro and in silico analysis.

CONCLUSION

Potentially pathogenic germline CDH1 mutations in women with early-onset or familial lobular breast cancer are at most infrequent.

THE ASSOCIATION OF LOBULAR BREAST CANCER WITH GERMLINE MUTATIONS OF CDH1

Background: CDH1 encodes the cell-cell adhesion molecule, E-cadherin, for which loss of expression facilitates the infiltrative and metastatic potential of cancers. Germline mutations in CDH1 are associated with hereditary diffuse gastric cancer (HDGC), and in this setting female carriers have been estimated to have a 39-50% risk of lobular breast cancer (LBC) by age 80 years. Aim: To determine the frequency of CDH1 germline mutations inindividuals with early-onset LBC or those with LBC and a family history of multiple breast cancers but no gastric cancers. Methods: Germline DNA analysis of CDH1 in women with LBC, for whom germline BRCA1 and BRCA2 mutations have been excluded, who have been (1) diagnosed before the age of 45 years or (2) diagnosed at any age and have a family history of breast cancer. Results: Analysis of 194 LBC cases has thus far revealed two novel missense mutations predicted to affect protein function. Functional assays to assess their pathogenicity along with germline analyses of the remaining 200 cases are currently underway. Several unreported silent changes have also been identified and will be measured in a case- control sample to assess whether they are associated with LBC risk. Conclusion: Germline CDH1 mutations may cause a small proportion of familial and early onset LBC.

Germline E-cadherin mutations in familial lobular breast cancer

BACKGROUND

The cell surface glycoprotein E-cadherin (CDH1) is a key regulator of adhesive properties in epithelial cells. Germline mutations in CDH1 are well established as the defects underlying hereditary diffuse gastric cancer (HDGC) syndrome, and an increased risk of lobular breast cancer (LBC) has been described in HDGC kindreds. However, germline CDH1 mutations have not been described in patients with LBC in non-HDGC families. This study aimed to investigate the frequency of germline CDH1 mutations in patients with LBC with early onset disease or family histories of breast cancer without DGC.

METHODS

Germline DNA was analysed in 23 women with invasive lobular or mixed ductal and lobular breast cancers who had at least one close relative with breast cancer or had themselves been diagnosed before the age of 45 years, had tested negative for a germline BRCA1 or BRCA2 mutation, and reported no personal or family history of diffuse gastric cancer. The full coding sequence of CDH1 including splice junctions was amplified using PCR and screened for mutations using DHPLC and sequencing.

RESULTS

A novel germline CDH1 truncating mutation in the extracellular portion of the protein (517insA) was identified in one woman who had LBC at the age of 42 years and a first degree relative with invasive LBC.

CONCLUSIONS

Germline CDH1 mutations can be associated with invasive LBC in the absence of diffuse gastric cancer. The finding, if confirmed, may have implications for management of individuals at risk for this breast cancer subtype. Clarification of the cancer risks in the syndrome is essential.

Hereditary diffuse gastric cancer: Natural history, pathology, screening limitations, and prophylactic total gastrectomy in CDH1 mutation carriers

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Background: Hereditary diffuse gastric cancer (HDGC) is a potentially fatal disease that occurs due to mutations in the E- cadherin (CDH1) gene, as discovered in 1998. Its penetrance ranges between 70–80%. Its morbidity and mortality can be altered favorably through genetic counseling, germline mutation testing, and highly-targeted management that includes prophylactic total gastrectomy. Lobular breast cancer has been identified as an integral lesion in HDGC. Methods: This international collaborative group on HDGC is comprised of 56 mutation-positive families, which is the world’s largest resource of such families. Cancer diagnoses were verified with pathology slides/tissue block review when possible, or reports. Genetic counseling covering the pros and cons of mutation testing, screening and its limitations, and the option of prophylactic total gastrectomy was provided. Results: Findings on 56 HDGC mutation-positive families show carrier testing to have been performed on 267 individuals, of which 123 were CDH1 mutation positive. Prophylactic gastrectomies were performed on 14 families involving 50 individuals. Occult cancer was diagnosed in 31 (31/39=79.5%; results are pending on the remaining 11), based upon pathology and verbal reports. Five individuals underwent prophylactic gastrectomy prior to genetic counseling, 3 of whom later tested negative for mutations. In one of these remarkable HDGC families, 11 first cousins who tested positive for the CDH1 mutation underwent prophylactic total gastrectomy. On a post-surgery questionnaire, they each stated that the decision for the prophylactic procedure was the “right one” for them. In each case, a parent had died of HDGC sequelae, adding to the cousins’ acceptance of DNA testing and surgery. They considered their post-operative nutritional programs to have been acceptable. Conclusion: HDGC and its life-threatening sequelae were significantly ameliorated in CDH1 mutation carriers through total prophylactic gastrectomy in patients at enormous lifetime risk for HDGC. Decision for mutation testing and surgery may be more acceptable through intensive education in concert with a compassionate management team.

No significant financial relationships to disclose.

Gastrin stimulates receptor-mediated proliferation of human esophageal adenocarcinoma cells

The prevalence of esophageal adenocarcinoma in the setting of Barrett's metaplasia continues to increase in Western nations at a rate greater than any other cancer. The trophic properties of gastrin have been documented in gastric, pancreatic and colon cancer cell lines, suggesting a potential role for this regulatory peptide in the growth of these malignancies. The aims of these studies were to identify and characterize the presence of functional cholecystokinin type-2 (gastrin) receptors on the membranes of human esophageal adenocarcinoma cells. Reverse transcriptase-polymerase chain reaction (RT-PCR) demonstrated the presence of cholecystokinin type-2 receptor transcripts in human esophageal adenocarcinoma cell lines. Competitive binding assays revealed specific binding of gastrin in SEG-1 cells (IC50 of 2.4 x 10(-8) M). This finding was confirmed by laser scanning confocal microscopy through internalization of rhodamine green labeled gastrin heptapeptide in SEG-1 cells. Gastrin caused a dose-dependent increase in proliferation of SEG-1 cells when compared to controls. This effect was abolished by co-incubation with L365,260, a CCK-2-specific receptor antagonist. Gastrin-induced phosphorylation of the p44 and p42 mitogen-activated protein kinases was demonstrated by Western blot analysis. In conclusion, the studied human esophageal adenocarcinoma cell lines possess cholecystokinin type-2 (gastrin) receptors. Receptors bind gastrin, resulting in increased proliferation in SEG-1 cells.

Morphological study of dentin irradiated by solid-state ultraviolet lasers: a comparison of wavelength and repetition rate

OBJECTIVE

In this study, we examined the surface morphology of dentin after being ablated by the third, fourth, and fifth harmonics of the Nd:YAG laser. The influences of the repetition rate with respect to the wavelength were also investigated.

BACKGROUND DATA

Typically, excimer lasers have been used as the primary sources of ultraviolet (UV) laser wavelengths to investigate laser ablation of dentin. In the past decade, developments in nonlinear optical technology have given rise to higher conversion efficiencies of the fourth and fifth harmonics of the Nd:YAG laser. To this end, sufficient energy densities of the fourth and fifth harmonics of the Nd:YAG laser have been generated to ablate dentin.

MATERIALS AND METHODS

Thin dentin samples (typically 1 mm) were irradiated by the third, fourth, and fifth harmonics of the Nd:YAG laser. Ablation occurred at repetition rates of 1, 5, 10, and 20 Hz, using similar energy densities for each laser wavelength. An environmental scanning electron microscope was used to assess the resultant surface morphology.

RESULTS

Dentine surfaces after 355-nm ablation exhibited plugging at each repetition rate. Similar surfaces were exhibited after 266-nm ablation. "Plugging" over dentine tubules was less obvious after 213-nm laser ablation. The results may highlight the impact of different absorption characteristics of each wavelength.

CONCLUSION

Solid-state UV laser ablation of dentin exhibits similar properties to excimer laser ablation. At similar energy densities, the deeper UV laser wavelengths exhibit less "plugging" of dentin tubules, suggesting a lower thermal impact.

Investigation of infection with Campylobacter jejuni in a man with hypogammaglobulinaemia using PCR-single-stranded conformational polymorphism (PCR-SSCP) typing

This study investigated several episodes of infection of Campylobacter jejuni in an immunocompromised male with hypogammaglobulinaemia, presenting with diarrhoea and bacteraemia over a 16-month period, by employing three phenotyping and four genotyping schemes, including the single-stranded conformational polymorphism (SSCP) technique to establish if infection was reinfection or persistent infection. Four isolates from blood culture and two faecal isolates of Campylobacter jejuni were obtained from the patient by direct selective plating on Skirrow Selective agar. Isolates were characterised at the sub-species level by Penner serology, Preston biotyping, Preston phage-typing, as well as E3CJC2 restriction fragment length polymorphism (RFLP), 16S ribotyping, flagellin (flaA) RFLP and single-stranded conformational polymorphism (SSCP) analyses. Phenotyping and genotyping sub-species analyses demonstrated that the patient was infected with at least two different strains of Campylobacter jejuni, i. e. one strain that persisted throughout the 16-month period and another strain that was transient suggesting reinfection from a different source. SSCP analysis was the most discriminatory of all the typing schemes examined and demonstrated an altered genotype of the persistent strain, whereby there were subtle modifications to the hypervariable regions of the flaA gene. Overall, as SSCP examines the hypervariable region of the flaA gene and as this technique can detect point mutations, differences between SSCP banding patterns may represent markers and thus examine mutations that occur under immune selection, thereby permitting the C. jejuni to evade the host immune response. In conclusion, this study describes the novel use of SSCP genotyping of C. jejuni and demonstrated that this method is a highly discriminatory technique which may be beneficial in outbreak characterisation, but which is not suitable to examine the clonal patterns of C. jejuni over a long period of time.

Combined UV and IR laser ablation of dentine

OBJECTIVE

The aim of this study was to increase the rate of removal of dentine tissue by a 213-nm laser through the introduction of an Er:YAG assisting laser.

BACKGROUND DATA

The rate of dentine removal is increased by using a CO2 laser to assist a XeCl excimer laser.

METHODS

Extracted human teeth were sliced parallel to the crown and exposed to 213-nm laser and Er:YAG laser beams that were spatially and temporally aligned. The 213-nm laser radiation was generated using a Q-switched Nd:YAG (5 nsec, 10 Hz) and three nonlinear crystals. The Er:YAG laser was free running with a pulse duration of 100 microsec and a pulse repetition rate of 10 Hz. A fluence range of 5-18.6 J/cm2 (213 nm) and 0.6-1.3 J/cm2 (Er:YAG) was used. Axial ablation rates were measured for different pulse energies and pulse overlaps.

RESULTS

The ablation rate of dentine increased in most cases by a factor of two. The highest ablation rate achieved was 18.3 microm/pulse +/- 2.51, which is more than twice the highest ablation rate previously published using a 213-nm laser. Changes in the pulse superpositions that were investigated did not present a significant change in the ablation rate.

CONCLUSIONS

The Er:YAG laser can be used to increase the removal rate of dentine by a short-pulse ultraviolet (UV) laser.

Isolation and characterization of substance P-containing dense core vesicles from rabbit optic nerve and termini

In neurons, neuropeptides and other synaptic components are transported down the axon to the synapse in vesicles using molecular motors of the kinesin family. In the synapse, these neuropeptides are found in dense core vesicles (DCVs), and, following calcium-mediated exocytosis, they interact with receptors on the target cell. We have developed a rapid, large-scale technique for purifying peptide-containing DCVs from specific nuclei in the central nervous system. By using differential velocity gradient and equilibrium gradient centrifugation, neuropeptide-containing DCVs can be separated by size and density from optic nerve (ON) and its termini, the lateral geniculate nuclei and the superior colliculi. Isolated DCVs contain neuropeptides (substance P and brain-derived neurotrophic factor), synaptic vesicle (SV) membrane proteins (SV2, synaptotagmins, synaptophysin, Rab3 and synaptobrevin), SV-associated proteins (alpha-synuclein), secretory markers for DCVs previously isolated (secretogranin II), and beta-amyloid precursor protein. By using electron microscopic techniques, DCV were also visualized and shown to be immunoreactive for neuropeptides, neurotrophins, and SV membrane proteins. Because of the interesting group of physiological and potentially pathophysiological proteins associated with these vesicles; this isolation procedure, applicable to other CNS nuclei, should represent an important research tool.

The distribution of neurokinin-1 and neurokinin-2 receptors in human central airways

The precise locations of neurokinin (NK)-1 and NK-2 receptors in human airways, and their role in airway inflammatory diseases, have not been carefully examined. To determine the distribution of NK-1 and NK-2 receptors in human central airways, and to determine whether their distribution was different in smokers, we examined surgical specimens from patients undergoing lung resection for limited lung lesions. We mapped NK-1 and NK-2 receptors in four groups of subjects: four asymptomatic nonsmokers, seven asymptomatic smokers, seven symptomatic smokers with normal lung function, and eight symptomatic smokers with chronic airflow limitation. Tissues were immunostained with anti-NK-1- and anti-NK-2-receptor antibodies. Expression of NK-1 and NK-2 receptors was quantified through light microscopy and image analysis. Both NK-1 and NK-2 receptors were found in bronchial glands, bronchial vessels, and bronchial smooth muscle. Although no receptors were observed in the epithelium, receptors were occasionally found in nerves (NK-1) and in inflammatory cells (NK-2) such as T lymphocytes, macrophages, and mast cells. The distribution of both NK-1 and NK-2 receptors was similar in all the tissues examined in the four groups of subjects. These data show that NK-1 and NK-2 receptors are present in human central airways and that their expression is not modified by cigarette smoking.

Randomized trial of cyclophosphamide, methotrexate, and fluorouracil chemotherapy added to tamoxifen as adjuvant therapy in postmenopausal women with node-positive estrogen and/or progesterone receptor-positive breast cancer: a report of the National Cancer Institute of Canada Clinical Trials Group. Breast Cancer Site Group

PURPOSE AND METHODS

By the mid 1980s, tamoxifen alone was considered standard adjuvant therapy for postmenopausal women with node-positive, estrogen receptor (ER)- or progesterone receptor (PgR)-positive breast cancer. From 1984 through 1990, 705 eligible postmenopausal women with node-positive, ER- or PgR-positive breast cancer were randomized to a National Cancer Institute of Canada Clinical Trials Group (NCIC CTG) study that compared tamoxifen 30 mg by mouth daily for 2 years (TAM) versus TAM plus chemotherapy with all-intravenous cyclophosphamide 600 mg/m2, methotrexate 40 mg/m2, and fluorouracil 600 mg/m2 given every 21 days for eight cycles (CMF).

RESULTS

There were no significant differences in overall survival, recurrence-free survival, locoregional recurrence-free survival, or distant recurrence-free survival between the two treatment arms. However, there was significantly greater severe toxicity, which included leukopenia (P < .0001), nausea and vomiting (P < .0001), and thromboembolic events (P < .0001), as well as significantly more mild or greater toxicity, which included thrombocytopenia (P = .04), anemia (P = .02), infection (P = .0004), mucositis (P = .0001), diarrhea (P = .0001), and neurologic toxicity (P = .006), in women who received TAM plus CMF.

CONCLUSION

The addition of CMF to TAM adds no benefit and considerable toxicity in this group of women.

Antineutrophil cytoplasmic antibodies in myelodysplasia

Antibodies to neutrophil cytoplasmic antigens (ANCA) are good serological markers for patients with mainly vasculitic conditions. Two main types of ANCAs have been detected, the first termed cytoplasmic antineutrophil cytoplasmic antibody (cANCA) are mainly associated with patients with Wegener's granulomatosis, the other termed perinuclear antineutrophil cytoplasmic antibody (pANCA) are mainly associated with patients with renal vasculitis, rheumatic and collagen disorders. These antibodies are against various constituents of neutrophil granules. In patients with myelodysplasia, defects in normal granulocyte development are seen. We report a series of twelve patients with myelodysplasia of whom at least four showed a low titre and one a high titre of pANCA. Two of these patients also had demonstrable activity against myeloperoxidase (MPO). None of these patients had any evidence of systemic or cutaneous vasculitis or of any autoimmune disorder. There was no pANCA positivity in an age matched control group.

Autoantibodies following parvovirus B19 infection

This study was undertaken to assess the incidence and significance of autoantibody production following B19 infection, 53 patients with acute B19 infection (positive for serum anti-B19 IgM) were studied; symptoms were rash and arthralgia (n = 26), rash (n = 7), arthralgia (n = 16), aplastic crisis (n = 3), and intrauterine death (n = 1). These patients were followed for 26-85 months (mean 57 months) and re-assessed for persistent symptoms, serum anti-B19 antibodies, and serum autoantibodies. At follow-up, 14 test and two control patients had one or more serum autoantibodies (anti-nuclear antibody, anti-smooth muscle antibody, gastric parietal cell antibody, anti-reticulin antibody, anti-mitochondrial antibody, rheumatoid factor) at a titre of > or = 40 (P = 0.004). Seven test patients and no control patients had serum autoantibody at a titre > or = 160. Of these seven test patients, only one had persistent symptoms. At follow-up assessment, this woman was 48-year-old, had persistent arthralgia for 4 years following acute B19 infection, rheumatoid factor at a titre of 160 (1920 IU/ml), and had been independently diagnosed as having rheumatoid arthritis. In conclusion, results of the present study showed that low titre autoantibody production was common following symptomatic B19 infection, however, while interesting from a virological standpoint, this finding may be of little significance for future development of autoimmune disease.

Linkage analysis of 26 Canadian breast and breast-ovarian cancer families

We have examined 26 Canadian families with hereditary breast or ovarian cancer for linkage to markers flanking the BRCA1 gene on chromosome 17q12-q21. Of the 15 families that contain cases of ovarian cancer, 94% were estimated to be linked to BRCA1. In contrast, there was no overall evidence of linkage in the group of 10 families with breast cancer without ovarian cancer. A genetic recombinant in a breast-ovarian cancer family indicates a placement of BRCA1 telomeric to D17S776, and helps to define the region of assignment of the cancer susceptibility gene. Other cancers of interest that appeared in the BRCA1-linked families included primary peritoneal cancer, cancer of the fallopian tube, and malignant melanoma.

Accuracy of family cancer history in breast cancer patients

We assessed the validity of information reported by patients with breast cancer on cancer in first- and second-degree relatives. In Toronto, Canada, 165 patients completed mailed questionnaires about cancer in relatives and were then interviewed in person. Their reports were compared with relatives' hospital records, cancer registry or death records for presence of cancer, site and age at diagnosis. Questionnaire and interview reports agreed with records for 82-96% of reports on first-degree and 48-80% on second-degree relatives. Proband reports of cancer sites in first-degree relatives were generally accurate (breast 99%, ovary 100%, prostate 85%, colon 93%). Reports of cancer sites in second-degree relatives were accurate for prostate cancer but only for 85% of breast and 72% of colon cancers. Age at diagnosis of breast cancer was correct in 92% of cases in first-degree and 54% in second-degree relatives. The interview contributed additional information about the presence of cancer in second-degree relatives, and the site and age at diagnosis in first- and second-degree relatives. In a similar population the questionnaire alone should yield adequate data for identifying families that warrant further investigation.

Abdominal migraine: a cause of abdominal pain in adults?

Eighty-five patients with non-organic abdominal pain, were interviewed with the help of a questionnaire. Those who responded to a high fibre diet were excluded from the study. Twenty-seven patients had multiple pains and 58 described a single pain, which was intermittent in 39. A detailed analysis of the symptoms and family history of the latter group suggested that in 19 patients the symptoms might have been caused by abdominal migraine. Six of these 19 had typical migraine-associated symptoms during the attack, characteristic abdominal pain and a family or personal history of classical migraine. Abdominal migraine should be considered in patients with non-organic abdominal pain where symptoms are not typical of irritable bowel syndrome and when organic disease has been excluded.

Extended critical care orientation program a recruitment/retention incentive

The Prince of Wales, Prince Henry, and Prince of Wales Children's Hospital offered an Extended Critical Care Orientation Program for the first time in 1990. This program included pre-course worksheets, a five day lecture series and an Individual Clinical Learning Contract. This paper will consider the impact that the program has had on the critical care units involved. Ongoing evaluation questionnaires indicated that the program was successful. The program met with continued support and enthusiasm from nurse administrators, nursing unit managers, clinical educators, ward staff and course participants. Early figures have indicated that at twelve months post program, the overall retention rate was 71%, compared to 41.1% in the twelve months prior to program commencement.

Genetic markers and inflammatory bowel disease: immunoglobulin allotypes (GM, KM) and protease inhibitor

We have studied immunoglobulin allotypes (GM and KM) in 101 patients with Crohn's disease, 51 patients with ulcerative colitis, and 99 healthy local blood donor controls. In addition, protease inhibitor (PI) types were examined in a random subset of patients and in all controls. No significant differences were found between Crohn's disease patients and controls, or between ulcerative colitis patients and controls, in the frequencies of GM phenotypes, GM haplotypes, KM phenotypes, or PI phenotypes.

Compliance in a randomized clinical trial of dietary fat reduction in patients with breast dysplasia

Dietary compliance was studied in 57 women participating for 1 y in a randomized clinical trial of dietary fat reduction. Nutrient analysis of food records, collected at 0, 6, and 12 mo, was compared with changes observed in lipid profiles and with chemical analysis of duplicate diets. Both food records and duplicate meals showed a significant decrease in fat intake (from 36 to 23% of total calories, p less than 0.0001) and a significant increase in carbohydrate (from 43 to 56% of total calories, p less than 0.0001) in the intervention group. The calculated nutrient intake from food records tended to overestimate the intake of protein, fat, and carbohydrate compared with the chemically analyzed method. The mean level of plasma cholesterol in the intervention group was significantly reduced (7.3%, p less than 0.01) in the first 6 mo after a reduction in dietary fat but the levels observed did not differ significantly between the groups at any time.

Diminished complications in a non DR3 DR4 family with insulin-dependent diabetes

A family is reported in which the mother and both of her children developed insulin-dependent diabetes mellitus between 9 and 19 months of age, reflecting the importance of heredity in the natural history of this disease. That overt complications of diabetes were not present in any of the individuals, and that blood sugars were maintained close to normal on relatively small amounts of exogenous insulin, suggests a protective function in these patients related to residual secretion of insulin by beta cells. Human lymphocyte antigen (HLA) typing in this family showed that, although the diabetic children had identical HLA types, neither the mother nor her children possessed the diabetes-associated antigen HLA-DR3 or HLA-DR4. This raises the possibility that selective loss of diabetes-susceptible fetuses (suggested to be responsible for the low risk of diabetic mothers producing diabetic offspring) may be influenced by the HLA type of the mother.

A critique of the methodology of studies of benign breast disease and breast cancer risk

After almost a century of research the relationship of benign breast disease to breast cancer risk is still controversial. The present investigation assessed this controversy by examining all published cohort studies that examined the risk of breast cancer in subjects with benign breast disease for their compliance with widely accepted standards for the conduct of etiologic research. Most of these studies describe the breast cancer incidence in women who have had breast biopsies. The 16 standards included a description of the population studied, a definition of benign breast disease, an account of follow-up, and a description of the analysis of risk. Of the 36 studies examined, 22 reported finding an increase in breast cancer risk in women with benign breast disease and all met more methodologic standards than the 11 studies reporting no increase in risk (3 studies reported no conclusions). In particular, none of the 11 "negative" studies calculated the number of cancers expected in the population studied, whereas all 22 "positive" studies did so. There is thus considerable statistical support from well-conducted studies for the view that benign breast disease is associated with an increase in breast cancer risk. By contrast, there is no credible support for the contrary view, which is often based on small studies in which no cancers were observed or on studies whose conclusions are not supported by an appropriate analysis of the data they contain.

Progressive passive Heymann nephritis in the rat

Progressive passive Heymann nephritis was produced in rats by simultaneous intravenous injections of heterologous antirat glomerular basement membrane antiserum and heterologous antirat kidney tubular fraction 3 antibody. The animals were killed at 16 weeks by which time approximately one-half of them were severely proteinuric. The glomeruli showed beaded immune deposits around the capillaries by immunofluorescence, and on electron microscopy osmiophilic deposits were noted in the subepithelial zones and within the glomerular basement membrane. The lesion resembled that of severe Heymann nephritis. gamma-Globulin eluted from the kidneys contained an autologous IgG that reacted with the brush border region of the renal proximal tubules of normal rats. This component was present in proteinuric and nonproteinuric animals. It is concluded that the progression results from the development of autoantibodies to the tubular nephritogenic antigen and the proteinuria is related to increasing deposition of immune complexes in the glomeruli.

Strategies for dietary intervention studies in colon cancer

As a result of many studies in descriptive and analytic epidemiology, in animal carcinogenesis, and in the direct examination of body fluids for mutagens/carcinogens, it is possible to develop a list of dietary factors that may be associated with the high rate of colon cancer and related cancers in Western countries. This paper is concerned with the design of intervention studies to clarify which of these factors is important. The size of such intervention trials is influenced primarily by two factors: the incidence of the disease outcome studied in a control population and the magnitude of risk reduction in a treated group. Calculations based on a variety of assumptions suggest that a randomized trial in which cancer mortality is measured as the outcome of the intervention in a healthy population is probably too costly to be justified by current evidence linking the disease to diet. However, precursor lesions can be considered as an alternative outcome. The choice of the precursor lesion depends on the link to the disease in question, the prevalence of the lesion in the population, and the ease of detection. Recent developments in the application of endoscopic methods and in the description of the pathologic process leading to cancer suggest the use of gastrointestinal polyps as "precursor lesions" as the outcome of a trial. We illustrate these points with a protocol for a study in progress, a randomized double-blind study of the effect of ascorbic acid and alpha-Tocopherol on the rate of recurrence of colorectal polyps.