Case finding for chronic obstructive pulmonary disease in people attending long-term condition clinics in primary care.

Despite increased interest and awareness of chronic obstructive pulmonary disease (COPD), nearly half of the people with COPD remain undiagnosed. Inviting people at risk for screening is unlikely to be effective as many will not attend. Co-morbidities are common in people with COPD but COPD is also a comorbidity of other long-term conditions and people with these conditions are under regular review in primary care clinics. This study aimed to develop a pilot programme to case find people with COPD among patients attending other long-term clinics in primary care. Twenty-three general practices were recruited to participate in South West England. All current or ex-smokers aged ≥35 attending a long-term condition clinic who were not known to have COPD were asked to complete a questionnaire designed to help identify people with COPD and to perform microspirometry. Practices were asked to collect data on up to 100 patients. One thousand three hundred and thirty-three patients were assessed. Four hundred and ten people (31%) were current smokers. Six hundred and thirteen (46%) had high questionnaire scores and 287 (22%) of these also had a forced expiratory volume in 1 second (FEV1) below the lower limit of normal (LLN). The mean FEV1 in these patients was 59.0% of predicted (range 22-79.0%). Two hundred and twenty-four had an FEV1 between 50% and 80% of predicted, 50 had an FEV1 between 30% and 50% of predicted. One hundred and sixteen (40%) of the people with an FEV1 below the LLN were still smoking and 55 accepted referral to cessation services. A total of 56% of the other smokers assessed but not thought to have COPD also accepted referral. Assessing symptoms and performing microspirometry in people attending long-term condition clinics in primary care is feasible and has a high yield of identifying people likely to have previously undiagnosed COPD.

Rapid assessment breast clinics--evolution through audit.

This observational, cohort study aimed to examine the potential utility of Rapid Assessment Breast Clinics (RABC) beyond cancer detection at presentation. One thousand four hundred and twenty nine women were studied over an 18 month period. 154 (10.7%) had breast cancer - 87.7% of whom were seen expediently with 92.9% being diagnosed at one attendance. One hundred and forty three (10%) of those with a benign diagnosis were found by routine questioning to have significant familial risk separate to their reason for referral. Despite careful triage, considerable contamination of appointment allotment occurred with many who were correctly triaged as non-urgent being seen 'urgently'. One hundred and seventy six attendees (12.3%) had neither the symptom that triggered referral, nor breast lump, nipple discharge nor family history of breast cancer, while 283 (19.8%) had no objective clinical or radiological abnormality. Although RABC reliably categorise malignant versus non-malignant diagnoses despite cluttering by low risk women, a significant proportion of non-cancer patients still require address of future risk rather than reassurance of their present status alone.

Epithelial component of host-tumor interactions in the orthotopic site preference of a mouse mammary tumor.

Mouse mammary tumors grow preferentially upon transplantation into intact mammary glands compared to cleared mammary fat-pads. Both sites provide stroma of the orthotopic site, but the latter lacks epithelial elements. If epithelium from enzymatically dissociated normal mammary glands is added to the tumor cells prior to injection into cleared fat-pads, tumor growth is comparable to that seen in intact mammary fat-pads. The growth-enhancing effects of normal mammary cells are not duplicated by normal kidney or liver cells. These results demonstrate that epithelial-epithelial interactions, as well as stromal-epithelial interactions, are associated with the enhanced growth of mammary tumor cells transplanted into orthotopic sites. The results also suggest that enhancement of tumor growth does not require intact tissue architecture.

Metabolic cooperation between mouse mammary tumor subpopulations in three-dimensional collagen gel cultures.

A series of subpopulation lines derived from a single mouse mammary tumor were tested for their ability to interact with each other in metabolic cooperation assays in three-dimensional collagen gel cultures. Inhibition of growth in the presence of selective drug (6-thioguanine or 2-fluoroadenine) of two 6-thioguanine-resistant cell lines, 66cl4 and 44FTO, as well as a 2-fluoroadenine-resistant line, 168FAR, occurred in the presence of other sensitive cells, demonstrating the transfer of drug sensitivity to drug-resistant cells. Transfer of drug resistance was shown by using selective medium containing hypoxanthine, aminopterin, and thymidine plus ouabain in which mutual metabolic cooperation between line 66cl4 (also ouabain resistant) and "wild-type" lines is required for growth. Effective communication leading to the transfer of drug resistance and ultimate survival of both cell types occurred in mixtures containing as little as 10% of either cell type. The requirement for mutual metabolic cooperation in hypoxanthine, aminopterin, and thymidine plus ouabain medium prevented line 66 from overgrowing line 66cl4 to the extent that it did in control medium. The ranked abilities of lines 66, 410.4, and 168 to promote growth when mixed with line 66cl4 in collagen cultures in hypoxanthine, aminopterin, and thymidine plus ouabain medium were correlated with the ranked cell densities required for these same cell lines to inhibit growth of line 66cl4 by metabolic cooperation in the presence of 6-thioguanine in monolayer cultures. These ranked abilities may be related to the effectiveness with which each of these cell lines is able to form communicating junctions with line 66cl4.

Diabetes and the Mediterranean diet: a beneficial effect of oleic acid on insulin sensitivity, adipocyte glucose transport and endothelium-dependent vasoreactivity.

Abnormalities in endothelial function may be associated with increased cardiovascular risk in diabetic patients. We examined the effect of an oleic-acid-rich diet on insulin resistance and endothelium-dependent vasoreactivity in type 2 diabetes. Eleven type 2 diabetic patients were changed from their usual linoleic-acid-rich diet and treated for 2 months with an oleic-acid-rich diet. Insulin-mediated glucose transport was measured in isolated adipocytes. Fatty acid composition of the adipocyte membranes was determined by gas-liquid chromatography and flow-mediated endothelium-dependent and -independent vasodilatation were measured in the superficial femoral artery at the end of each dietary period. There was a significant increase in oleic acid and a decrease in linoleic acid on the oleic-acid-rich diet (p<0.0001). Diabetic control was not different between the diets, but there was a small but significant decrease in fasting glucose/insulin on the oleic-acid-rich diet. Insulin-stimulated (1 ng/ml) glucose transport was significantly greater on the oleic- acid-rich diet (0.56+/-0.17 vs. 0.29+/-0.14 nmol/10(5) cells/3 min, p<0.0001). Endothelium-dependent flow-mediated vasodilatation (FMD) was significantly greater on the oleic-acid-rich diet (3.90+/-0.97% vs. 6.12+/-1.36% p<0.0001). There was a significant correlation between adipocyte membrane oleic/linoleic acid and insulin-mediated glucose transport (p<0.001) but no relationship between insulin-stimulated glucose transport and change in endothelium-dependent FMD. There was a significant positive correlation between adipocyte membrane oleic/linoleic acid and endothelium-dependent FMD (r=0.61, p<0.001). Change from polyunsaturated to monounsaturated diet in type 2 diabetes reduced insulin resistance and restored endothelium-dependent vasodilatation, suggesting an explanation for the anti-atherogenic benefits of a Mediterranean-type diet.

Evaluation of the processing functions of a digital subtraction angiography image processor.

A large number of imaging systems for digital subtraction angiography (DSA) are now commercially available. Numerous evaluations of the performance of these systems have been reported in the literature. However systematic evaluations of the processing functions of DSA image processors have not been widely reported. Such an evaluation for one commercial system is presented in this paper. Functions evaluated include linear transformation, logarithmic transformation, integration, subtraction and temporal filtration. The observations indicate that image processing results are frequently achieved by indirect routes which compromise the fidelity of the image data.

A mathematical formulation for the cell-cycle model in somitogenesis: analysis, parameter constraints and numerical solutions.

In this work we present an analysis, supported by numerical simulations, of the formulation of the cell-cycle model for somitogenesis proposed in Collier et al. (J. Theor Biol. 207 (2000), 305-316). The analysis indicates that by introducing appropriate parameter constraints on model parameters the cell-cycle mechanism can indeed give rise to the periodic pattern of somites observed in normal embryos. The analysis also provides a greater understanding of the signalling process controlling somite formation and allows us to understand which parameters influence somite length.

A tomographic evaluation of the non-visualised oral cholecystogram.

Tomographic examination was carried out on 27 patients in whom there was no opacification of the gallbladder after routine cholecystography using a double dose of contrast medium. Decisive findings were present in 24 of these cases. The findings included the presence of radiolucent and opaque calculi within the gallbladder, or within the common bile duct, and dilatation of the common bile duct. In the three cases in which no information was gained by tomography, cystic duct obstruction was found at operation.

Cross-cultural validation of the Inventory of School Motivation (ISM): Motivation Orientations of Navajo and Anglo students.

The Motivation Orientation scales of the Inventory of School Motivation (ISM) were validated across Navajo (n = 760) and Anglo (n = 1012) students in the U.S. Confirmatory factor analysis (CFA) supported the 8-factor structure of motivation orientations for the total sample and the Navajo and Anglo subsamples, although Navajo students did not distinguish well between the Effort and Task constructs. However, of 39 survey items, only 30 items were invariant across groups in factor loadings on respective a priori constructs. The findings show that even though the ISM Motivation Orientation scales are applicable to students of different cultural backgrounds, meaningful cross-cultural comparisons should use the 30 items that mean the same to both cultural groups; whereas studies that do not involve cross-cultural comparisons may use the complete version of the scales.

The Patient Self-Determination Act. Advance directives available to Minnesota patients.

The Patient Self-Determination Act requires most health care institutions to inform patients of their right to refuse medical care and their right to provide advance direction regarding their wishes should they become incompetent. Although the PSDA does not apply to physicians, it will probably increase the demand for communication with patients on such matters. Patients will undoubtedly ask how to formulate advance directives. While physicians should make it clear that they are not providing legal advice to patients on such issues, they may wish to indicate that a guardianship and a living will are options available under Minnesota law. Additionally, as indicated above, a number of arguments exist that durable powers of attorney for health care are valid in Minnesota, as well. Physicians should familiarize themselves with living will forms and may wish to make them available to patients upon request. (Living will forms can be obtained by contacting the Minnesota Medical Association at 612/378-1875.) Patients with questions regarding durable powers of attorney should be advised to seek legal counsel.

Getting the best price from health plans. Legal pitfalls of physician cooperation.

Antitrust laws place significant limits on collective action among independent practicing physicians. The lawful options most likely to appeal to physicians include the complete merger of physician practices or the significant involvement of a physician or group in a partially integrated legitimate joint venture, such as a provider-sponsored PPO. Neither activity should be undertaken without the assistance of legal counsel. Change in the overall thrust of antitrust law is unlikely, and physicians must protect themselves from liability through careful business planning and the use of competent legal counsel.

Technetium 99Tcm pyrophosphate scanning in the assessment of the painful hip prosthesis.

Technetium 99Tcm pyrophosphate bone scans were done on 35 patients who complained of persistent hip following total hip replacement. The scans of six patients were normal and the symptoms of these patients either resolved (three) or greatly improved (three) without further treatment. Twenty-nine patients had abnormal scans. Seventeen of these were due to infection or loosening of the prosthesis. Paget's disease of bone, protrusion of the prosthesis and heterotopic ossification also caused scan abnormalities. These causes could not be distinguished from one another on the scan. A radiograph of the hip is essential for interpreting the scan correctly. Scanning of the painful hip prosthesis helps to detect patients in whom serious complications are present or are likely to develop.

Computer-assisted tomography in the assessment of cervical spine trauma.

Four patients with cervical spine trauma were examined by computerised tomography in addition to standard radiography and additional useful information was thereby gained. The axial projection is particularly useful in studying the cervical spinal canal and neural arch. The examination may be performed rapidly without moving the patient, an important consideration after severe trauma.

Thermographic assessment of synovial haemangioma.

Three patients with synovial haemangioma of the knee were examined by thermography. This technique disclosed extensive subcutaneous distribution of haemangiomata which had been unsuspected clinically. Localised and diffuse lesions can be differentiated by this method. This information is important in planning surgery and in assessment of prognosis.