Molecular classification of autofluorescence excision margins in oral potentially malignant disorders.

OBJECTIVE: To define molecular differences between autofluorescence and white light defined excision margins in oral potentially malignant disorders (OPMD) using transcriptome expression profiles. MATERIALS AND METHODS: Excisional biopsy specimens were taken from 11 patients at three different sites for each lesion: centre, white light margin and autofluorescence margin. The lesions were diagnosed histopathologically as oral epithelial dysplasia, oral lichenoid dysplasia, oral lichen planus or other. Transcriptome analysis was performed by RNA sequencing, hierarchical clustering, differential expression and biological pathway analysis. RESULTS: For hierarchical clustering, the samples broadly clustered according to histology rather than the margins with lichenoid samples clustering together. Differential expression analysis showed that independent of histology, there was greater molecular dysregulation between the lesion centre and autofluorescence margin compared to the lesion centre and white light margin. Furthermore, the autofluorescence and white light margins were molecularly distinct, indicating the white light margins harboured abnormality. CONCLUSION: Our results indicate that the molecular profile of OPMD changes with divergence away from the centre of the lesion, and that autofluorescence determined margins are superior to the white light margin in achieving a clear molecular margin when excising an OPMD.

The impact of physician compliance on screening mammography for older women.

Screening mammography is underutilized, even for women older than 50 years for whom there is a general consensus that regular annual screening is appropriate and necessary. To evaluate reasons for this underutilization, we studied a random sample of 517 women in Los Angeles, Calif who were older than 50 years. All women were found to be underscreened, especially women older than 65 years. For example, approximately 35% of women 50 to 64 years old and 47% of women aged 65 years and older never had had even one mammogram. Analyses revealed that the most important factor that predicted whether a women ever had had a mammogram was whether her physician had talked to her about mammography. Women were between four and 12 times more likely, depending on their age group, to have had a mammogram at some time if their physicians discussed it with them. The discussions did not need to be lengthy or complex. These results indicate that physicians need to know that discussing screening mammography with their patients has a major impact on breast cancer screening behaviors.

The importance of physician communication on breast cancer screening of older women.

BACKGROUND: Breast cancer screening rates, especially for mammography, continue to lag for older women, particularly for women older than 65 years. METHODS: We investigated the associations of key variables with reported rates of mammography and clinical breast examination in a sample of 972 women older than 50 years; 724 of them were older than 65 years. They were surveyed in late 1990 through 30-minute bilingual telephone interviews. RESULTS: Although it was hypothesized that race, age, health status, and physician-patient communication variables would influence utilization rates, only the communication variables (and two access variables) significantly predicted a recent mammogram or clinical breast examination. In particular, the style of the communication--the patient's report of the physician's enthusiasm for mammography when it was discussed with women at the office visit--influenced the women's screening behavior significantly. Women who perceived that their physicians had some enthusiasm for mammography were more than four and a half times more likely than women whose physicians had no or little enthusiasm for mammography to have had one within the previous year. Other findings were that about half of the Los Angeles, Calif, women in this study reported a recent mammogram, an increase from the one third who reported one in the previous survey of 1988; a decline in screening was not reported until after age 75 years. About a quarter of the study women, on the other hand, had never been screened despite the long-standing recommendation for regular screening of women older than 50 years and the risk of breast cancer increasing with age. Surprisingly, women at higher risk of breast cancer were not being screened any more systematically than women at lower risk. CONCLUSION: We conclude that improved physician-patient communication skills could be a highly effective and easy-to-learn strategy to increase overall screening rates.

Search for persistent infection with poliovirus or other enteroviruses in amyotrophic lateral sclerosis-motor neurone disease.

A longstanding hypothesis proposes that amyotrophic lateral sclerosis-motor neurone disease (ALS-MND) is a late consequence of subclinical poliovirus (PV) infection. In this study, RNA extracts of CNS tissue from 28 patients with ALS-MND and 7 controls were assayed by nested polymerase chain reaction (PCR) using primers to the 5'-untranslated region (UTR) of the enterovirus (EV) genome which is highly conserved between EVs including PV, echovirus and coxsackie viruses. The integrity of RNA extracted from either archival paraffin-embedded or frozen CNS tissue was assessed by detection of constitutive Ableson tyrosine kinase (ABL) mRNA by PCR. Of 63 tissue samples assayed, 81% (51/63) were ABL-positive corresponding to 78% (22/28) of the ALS-MND cases and all controls. None of the 27 ALS-MND cases (i.e. 21 ABL+ and 6 ABL-) in which paraffin-embedded tissue was used nor any of the age and sex matched controls were positive for specific PV/EV RNA. Moreover, CNS tissue from 14 different locations obtained from one patient < 2 hrs after death and immediately frozen, showed no evidence of PV/EV at any site by PCR. Disease duration, degree of tissue autolysis and duration of tissue storage were all excluded as factors which may predispose to negative results. The sensitivity of the PV PCR was determined to be 40-400 copies (12.5 - 125 ag) of synthetic EV RNA transcripts in 1 microgram of cellular RNA and the assay was shown to detect all types of PV and and other EVs tested. Thus it seems unlikely that a persistent PV or related EV infection is implicated in ALS-MND unless there has been alteration in the 5'-UTR of the virus genome.

Physician-reported determinants of screening mammography in older women: the impact of physician and practice characteristics.

OBJECTIVE: Despite having markedly higher breast cancer risk, compliance of older women with screening mammography has been poor. This study was undertaken to determine which physician and patient practice characteristics were associated with high self-reported mammography referral rates for older women. METHODS: Primary care physicians (n = 129) from three socioeconomically diverse communities in Los Angeles were surveyed. Agreement with annual screening and self-reported referral rates were assessed for two groups of women, those 65 to 74 years of age and those 75 years and older. Screening outcomes were compared with physician and patient practice characteristics using bivariate and multivariate techniques. RESULTS: Although 73% of physicians agreed with annual screening of women aged 65 to 74 years, only 24% of physicians reported actually screening most women seen in this age group. Similarly, 57% of physicians agreed that women age 75 years and older should be screened annually, but only 21% reported recommending mammograms for most women seen in this age group. In multivariate analysis, white physicians (adjusted OR = 9.1), younger physicians (adjusted OR = 3.85), and those who used the American Cancer Society's low cost mammography projects (adjusted OR = 5.01) were more likely to report screening the majority of women seen. DISCUSSION: This study suggests that although physicians' intentions to screen older women may be relatively high, a gap exists between intentions and what is reported to be accomplished in practice. Race/ethnicity and physician specialty were the two strongest predictors of high self-reported referral rates, suggesting that targeted interventions may be useful.

Repair of nasocanthal malignant neoplasms. Combined laissez-faire and chemosurgery techniques.

A simplified method for management of nasocanthal malignant neoplasms combines the laissez-fiare technique first reported by this author with the Mohs technique of microscopic control of cancer cell eradication. Basically, with a little surgical help, the wound is allowed to granulate in spontaneously.

A modified Fasanella-Servat procedure for ptosis.

This procedure was first suggested for "minimal ptosis of 3-4 mm." However, since the amount of ptosis varies widely with the etiological factors, the true indication in any given case is not the amount of ptosis but the amount of levator action. Hence, unless there is at least 10 mm of levator action, this operation is contraindicated. Since the levator (except that part of the aponeurosis that is adherent to the tarsus) is not involved, the procedure has been simplified accordingly.

Cumulative sum failure analysis of a policy change from on-pump to off-pump coronary artery bypass grafting.

BACKGROUND: Use of the sequential probability cumulative sum (CUSUM) technique may be more sensitive than standard statistical analyses in detecting a cluster of surgical failures. We applied CUSUM methods to evaluate the learning curve after a policy change by a single surgeon from routine on-pump (cardiopulmonary bypass [CPB]) to off-pump coronary artery bypass grafting (OPCAB). METHODS: Fifty-five consecutive first-time coronary artery bypass patients (CPB group) were compared with the next 55 patients undergoing an attempt at routine OPCAB using the same coronary stabilizer. The goal in OPCAB patients was to obtain complete revascularization, albeit with a low threshold for conversion to CPB to maximize patient safety during the learning curve. Preoperative patient risk was calculated using previously validated models of the Cardiac Care Network of Ontario. The occurrence of operative mortality and nine predefined major complications (myocardial infarction, bleeding, stroke, renal failure, balloon pump use, mediastinitis, respiratory failure, life-threatening arrhythmia, and sepsis) was compared between the CPB and OPCAB groups using Wilcoxon, Fisher exact, and two-tailed t tests, as well as CUSUM methodology. An intention to treat analysis was performed. RESULTS: The CPB and OPCAB groups had similar predicted mortality and length of stays (2.2% +/- 2.5%, 8.1 +/- 2.5 days versus 2.4% +/- 3.5%, 8.1 +/- 2.4 days, respectively). The mean number of grafts per patient was 3.1 +/- 0.7 in the CPB group versus 3.0 +/- 0.7 in the OPCAB group (p = 0.45). Two of 55 (3.6%) CPB patients died, as opposed to 1 of 55 (1.8%) OPCAB patients (p = 0.99). Eight of 55 CPB patients (14.5%) incurred major complications, as opposed to 4 of 55 (7.3%) OPCAB patients (p = 0.36). Median hospital length of stay was 6.0 days in the CPB group versus 5.0 days in the OPCAB group (p = 0.28). On CUSUM analysis, the failure curve in CPB patients approached the upper 80% alert line after eight cases, whereas the curve in OPCAB patients reached below the lower 80% (reassurance) boundary 28 cases after the policy change, indicating superior results in the OPCAB group despite the learning curve. CONCLUSIONS: A policy change from coronary artery bypass on CPB to routinely attempting OPCAB can be accomplished safely despite the learning curve. CUSUM analysis was more sensitive than standard statistical methods in detecting a cluster of surgical failures and successes.

Rapid and sensitive genotyping of hepatitis C virus by single-strand conformation polymorphism.

There is an increasing demand for genotyping hepatitis C virus (HCV) isolates due to the rapidly expanding list of distinct HCV genotypes and the mounting evidence of genotype-specific clinical consequences. We describe an SSCP-based assay for determining genotypes in HCV infections. HCV RNA extracted from serum was amplified by a sensitive nested-PCR assay producing a 287 bp fragment of the conserved 5' non-coding region (NCR) and analysed by non-denaturing polyacrylamide gel electrophoresis. Following empirical optimisation of the SSCP assay we identified distinct conformation polymorphisms (characteristic band patterns) corresponding to types 1a, 1b, 2a, 2b, 2c, 3 and 4 found in the Western Australian population. Seventy-three HCV RNA-positive samples were used to evaluate the SSCP genotyping assay for accuracy and efficiency by comparison with the previously established genotyping methods of manual direct sequencing and dideoxy fingerprinting. SSCP genotyping was in concord with control methods while performing more rapidly and at a fraction of the cost. Moreover, SSCP detected two co-infected samples that were not shown by the control methods. The PCR-SSCP assay provides an accurate and rapid method for genotyping of HCV RNA-positive samples at the 5' NCR by type-specific sequence polymorphisms which is applicable to large-scale screening.

Rapid genotyping of hepatitis C virus isolates by dideoxy fingerprinting.

A number of distinct hepatitis C virus (HCV) types and subtypes have been identified by DNA sequencing of multiple genome regions. It has been postulated that these might also reflect phenotypic differences in the nature of HCV infection. Recent evidence suggests a relationship between HCV genotype and alpha-interferon response in patients with chronic hepatitis C. A simplified method of genotyping in comparison to direct DNA sequencing was investigated with the intention of providing a rapid, less labour-intensive method for routine genotyping. HCV RNA was extracted from serum by a modified guanidinium/acid-phenol extraction and peripheral blood lymphocytes using RNAzol B (Cinna-Biotecx). The RNA was reverse transcribed and a 287 bp segment of the 5' non-coding region (5' NCR) amplified using a nested-PCR reaction. PCR products were purified using Qiaquick spin columns. Products were directly sequenced by cycle sequencing. Dideoxy termination analysis was carried out by cyclic extension of a 33P-labelled primer by Tth polymerase with termination by dideoxy thiamine (ddT) or cytosine (ddC). Reaction products were analysed by electrophoresis on denaturing 7 M urea/6% acrylamide gels followed by autoradiography. Computer aided sequence analysis indicated that conserved 5' NCR sequence variation alone was sufficient to identify HCV types 1a, 1b, 2a, 2b, 3 and 4. Dideoxy fingerprinting improved greatly the efficiency of genotyping with an approximate four-fold increase in throughput. In addition, the results were very easily analysed although it was essential to run appropriate controls for each genotype. Reactions incorporating ddT distinguished types 1, 2a, 2b, 3 (provisionally 1a & 1b); a ddC reaction confirmed 1a and 1b typing.(ABSTRACT TRUNCATED AT 250 WORDS)

Confirmatory analysis of opinions regarding the pros and cons of mammography.

This investigation extends prior research to apply decision-making constructs from the transtheoretical model (TTM) of behavior change to mammography screening. Study subjects were 8,914 women ages 50-80, recruited from 40 primarily rural communities in Washington State. Structural equation modeling showed that favorable and unfavorable opinions about mammography (i.e., pros and cons) fit the observed data. Analysis of variance supported the associations between readiness to obtain screening (i.e., stage of adoption) and opinions about mammography (i.e., decisional balance) previously found in research using smaller samples from another geographic region. This report extends these earlier studies by using structural equation modeling, opinion scales based both on principal component analyses and on a priori definitions, a developmental sample and a confirmatory sample, and by sampling from a different geographic region. It is recommended that future research examine whether opinions regarding the cons of mammography are more individually specific than the pros.

Search for persistent enterovirus infection of muscle in inflammatory myopathies.

To investigate the hypothesis that the inflammatory muscle diseases (IMD) polymyositis (PM) and dermatomyositis (DM) may be due to a chronic, persistent enterovirus (EV) infection we sought to determine the prevalence of these viruses in muscle tissue using both nested polymerase chain reaction (PCR) and dot-blot hybridization assays. Thirty-six frozen muscle biopsies from 32 adult cases of IMD and 42 biopsies from 36 control subjects with other neuromuscular disorders were studied. Primers for PCR were chosen to conserved regions of the 5'-untranslated region of the EV genome. Constitutive Ableson tyrosine kinase (ABL) mRNA was detected by PCR to confirm the integrity of muscle RNA extracts. The sensitivity of the EV PCR was determined to be 40-400 copies (12.5-125 ag) of synthetic EV RNA transcript against a background of 1 microgram of cellular RNA. The specificity was assessed using a range of enteroviral and unrelated viral isolates extracted from cell cultures. Of the 78 samples tested, ABL mRNA was successfully detected in all but four samples. The time the biopsies spent in ultracold storage (1-73 months) did not appear to influence the integrity of extracted RNA. When assayed for EV RNA by nested PCR, none of 29 IMD cases (i.e., 28 PM and 1 DM) nor sequential biopsies from 3 PM patients were found to be positive. All 42 control biopsies were also negative for EV RNA.(ABSTRACT TRUNCATED AT 250 WORDS)

Testing mammography equipment: evolution over a 4-year period.

The results of quality control (QC) tests on 70 mammography units in Southern California from 1986 to 1990 are reported. Thirteen facilities, selected because they housed all of the mammography units in three communities involved in a National Institutes of Health research project, had their units tested twice at an interval of 1 year. Fourteen self-selected units were also tested twice at intervals ranging from 1-3 years. Forty-three self-selected units in 31 additional facilities had testing only once. All 70 units underwent measurement of focal spot size or resolution, tube output, half-value layer (HVL), automatic exposure control (AEC) accuracy, relative kVp accuracy, mean glandular dose, and imaging of several test objects. The test results for the units tested once showed no significant differences compared to those tested twice. For the latter, once the units were tested and determined to be acceptable, retesting showed differences only in overall film optical density, dose, and AEC performance.

Mammography screening: successes and problems in implementing widespread use in the United States.

Deterrents to the use of screening mammography include perceived risks of radiation, perceived "unnecessary" biopsies and overdiagnosis, and high cost. In addition, physicians and patients have attitudinal barriers that do not reflect objective realities. Professional and public education efforts are needed to enable women and their physicians to develop a more sophisticated understanding of the usefulness of screening mammography and the role played by the radiologist. As part of their efforts to increase the implementation of screening mammography, the American College of Radiology has developed a Mammography Accreditation Program for radiological facilities and has produced a free Mammography Resource Kit for radiologists, while the American Cancer Society has undertaken the support of local and national campaigns to establish screening programs at reduced cost. Both organizations continue to strive in partnership to increase the acceptance of screening throughout the United States.

Costs and cost-effectiveness of a church-based intervention to promote mammography screening.

OBJECTIVES: To evaluate the costs of implementing a church-based, telephone-counseling program for increasing mammography use, and to identify the components of costs and the likely cost-effectiveness in hypothetical communities with varying characteristics. DATA SOURCES/STUDY SETTING: An ethnically and socioeconomically diverse sample of 1,443 women recruited from 45 churches participating in the Los Angeles Mammography Promotion (LAMP) program were followed from 1995 to 1997. STUDY DESIGN: Churches were stratified into blocks and randomized into three intervention arms-telephone counseling, mail counseling, and control. We surveyed participants before and after the intervention to collect data on mammography use and demographic characteristics. DATA COLLECTION/EXTRACTION METHODS: We used call records, activity reports, and interviews to collect data on the time and materials needed to organize and carry out the intervention. We constructed a standard model of costs and cost-effectiveness based on these data and the Year One results of the LAMP program. PRINCIPAL FINDINGS: The cost in materials and overhead to the church site was $10.89 per participant and $188 per additional screening. However, when the estimated cost for church volunteers' time was included, the cost of the intervention increased substantially. CONCLUSIONS: A church-based program to promote the use of mammography would be feasible for many churches with the use of volunteer labor and resources.

Breast cancer screening adherence: does church attendance matter?

Little is known about the health behaviors of church attendees. This article reviewed telephone interview data of 1,517 women who were church members from 45 churches located in Los Angeles County to determine their breast cancer screening status and to identify the key predictors of screening. Almost all of this sample (96%) reported attending church at least once a month. Key predictors of screening included physician-patient communication, ethnic background, and having medical insurance. Although church-related predictors were not significantly related to screening adherence, the authors compared community-based screening rates from another sample to their sample rates and found that, when controlling for income and education, church members fared better on mammography screening than women who were community residents. This finding suggests that frequent church attendance contributes to better mammography screening status and that the relationship between religious involvement and health behaviors needs further explanation.

Dealing with diversity: recruiting churches and women for a randomized trial of mammography promotion.

There is little documentation about the recruitment process for church-based health education programs. In this study, the authors recruit African American, Latino, and white churches and women members (age 50 to 80) for a randomized church-based trial of mammography promotion in Los Angeles County. Efforts to enhance recruitment began 10 months before churches were invited to participate and included a variety of community-based strategies. Subsequently, 45 churches were recruited over a 5-month period through group pastor breakfast meetings and church-specific follow-up. In close collaboration with the 45 churches, the authors administered church-based surveys over 6 months and identified 1,967 age-eligible women who agreed to be contacted by the program team. It was found that an extended resource intensive period of relationship-building and community-based activities were necessary to conduct church-based programs effectively, particularly among older and ethnically diverse urban populations.

Amine oxidase activities in brown adipose tissue of the rat: identification of semicarbazide-sensitive (clorgyline-resistant) activity at the fat cell membrane.

Amine oxidase activity, previously described in homogenates of brown adipose tissue of the rat, has now been investigated in preparations of isolated fat cells. It was found that the specific activities of both monoamine oxidase A (MAO) and of the semicarbazide-sensitive clorgyline-resistant amine oxidase (SSAO) were higher in isolated fat cells than in the original whole tissue. Brown adipocytes therefore represent a major source of both these enzymes. In plasma membranes prepared from these isolated brown fat cells by borate extraction there was a similar enrichment of activity of SSAO and of the plasma membrane marker enzyme, phosphodiesterase I. However in preparations of cell membranes made by binding the cells to polycation-coated beads, enrichment of phosphodiesterase I activity was much greater than that of SSAO. It is suggested that the disposition of the enzyme within the cell membrane may account for the discrepancy in these results, i.e. the sidedness of the membrane may be important. Histochemical visualization of enzyme activity in whole tissue at the ultrastructural level was undertaken. Positive staining of mitochondria was achieved in the presence of the MAO substrate, tryptamine. Staining around the edges of the brown fat cells was observed with the SSAO substrates, tyramine and benzylamine. Staining was largely absent when substrate was omitted or after pretreatment with the irreversible SSAO inhibitor, hydralazine and the slowly reversible inhibitor, semicarbazide. It is not definitely proven that this staining represents sites of enzyme activity but the results are consistent with evidence from other studies indicating that SSAO in brown adipose tissue of the rat may be found predominantly at the fat cell surface.(ABSTRACT TRUNCATED AT 250 WORDS)

Barriers to cancer prevention in the older person.

Barriers to cancer screening are numerous and include both immutable barriers, such as a patient's low income, as well as more mutable barriers; fortunately, most barriers are potentially mutable ones. These encompass, among others, doctor patient communication patterns, inadequate and inaccurate health information, at attitudinal barriers such as patient anxiety, and community barriers, such as the lack of a provider reminder system to patients that prompts compliance. One of the easiest enablers of patient screening to implement is for clinicians to communicate their enthusiastic belief in screening to their older patients. Numerous studies now have documented the effectiveness of the physician's role in increasing patient compliance with screening guidelines.

The influence of ethnicity, socioeconomic status, and psychological barriers on use of mammography.

This study assessed the relative influence of psychological barriers, SES, and ethnic differences in mammography use for a community sample of 586 White, 227 Black, and 150 Hispanic women. Confirmatory factor analyses with latent variables indicated plausible factor structures for all groups on items related to barriers to mammography. Summed indicators of SES, fear of radiation, embarrassment, pain, anxiety, and cost concerns were correlated significantly with mammography use for the pooled group. Separate analyses by ethnicity indicated a substantial relationship between mammography use and cost concerns by White and Black women, and fear of pain by Black and Hispanic women. Use of mammography was associated more highly with SES among Hispanic women. Pooled logistic regression analyses controlling for SES and ethnicity showed that the psychological barriers, especially concern about cost, remained important independent predictors of mammography use. We explore sociocultural explanations for less mammography use by Hispanic women, especially those less acculturated.