Feasibility of outpatient daycase local anaesthestic Rezum™ without sedation.

BACKGROUND: Rezum™ is a relatively new bladder outflow obstruction (BOO) procedure that uses thermal energy through water vapour to cause necrosis of prostatic tissue. The standard delivery of this treatment is in an operating theatre under a general or spinal anaesthetic, or under local anaesthetic with sedation that requires patient monitoring. METHODS: We propose an outpatient daycase method of delivering Rezum™ under local anaesthetic without sedation, using a prostatic local anaesthetic block and cold local anaesthetic gel instillation into the urethra. RESULTS: Preliminary results of our first thirteen patients demonstrate the feasibility of this new technique, with a mean pain score of 2.1 out of 10 on a visual analogue scale, a successful trial without catheter in all 13 patients (one patient voided successfully on second trial), a reduction in mean International Prostate Symptom Score (IPSS) from 20.6 to 5.4, and improvement in maximum flow from 8.8 ml/s to 14.4 ml/s. The complications were minor (Clavien-Dindo less than III) and included a UTI, minor bleeding not requiring admission, and retrograde ejaculation. CONCLUSIONS: We demonstrate that an outpatient local anaesthetic daycase service without sedation is feasible. This can be delivered in a clinic setting, reduce waiting times for BOO surgery, and increase availability of operating theatre for other general anaesthetic urological procedures.

Highly anisotropic electric conductivity in PAN-based carbon nanofibers.

In addition to the chemical and physical properties of nanostructures their successful utilization for applications is strongly triggered by economic aspects. Electrospinning of nanowires from solution followed by subsequent annealing steps is a comparably cheap technique to fabricate conductive carbon nanofibers (CNF) made from polyacrylonitrile (PAN) molecules in large quantities. In this work, we investigated the microscopic properties of the CNFs with diameters of 100-300 nm by means of Raman and x-ray photoelectron spectroscopy and correlated these results with transport measurements done with a 4-tip STM. In particular, we investigated the effect of fiber alignment and knot densities, which can be controlled by applying constant creep due to stress during the stabilization process. The comparison of the conductivity obtained from single CNFs revealed further that the fiber crossings within the ensemble structure act as scattering centers and proofs that the transport is along the surfaces of the CNFs.

Screening for maternal depression in a low education population using a two item questionnaire.

OBJECTIVE: To assess a two-question screening tool, the Patient Health Questionnaire-2 (PHQ-2), for identifying depressive symptomatology in economically disadvantaged mothers of children in pediatric settings and to explore risk factors associated with a positive depression screen. METHODS: A convenience sample of mothers was enrolled at an inner city well-child clinic with children age 3 days to 5 years. The PHQ-2 and Edinburgh Postnatal Depression Scale (EPDS) (as reference scale) were completed. RESULTS: Ninety-four mothers participated. Agreement of the PHQ-2 and EPDS was moderate. The sensitivity of the PHQ-2 for identifying a positive screen on the EPDS was 43.5%; the specificity was 97.2%. The sensitivity of the PHQ-2 was higher for mothers with education beyond high school compared to those with less education. Perceived lack of support with child care and having two or more children were associated with a positive screen. The rate of positive screen was similar for mothers with infants and with older children. CONCLUSION: Given the low sensitivity of the PHQ-2 in lower educated mothers, additional research in populations with varying sociodemographic characteristics is indicated. Similar rates of symptoms for mothers within and beyond the postpartum period and mothers previously screened support the need for periodic screening.

Renewable hydrogen from nonvolatile fuels by reactive flash volatilization.

Droplets of nonvolatile fuels such as soy oil and glucose-water solutions can be flash evaporated by catalytic partial oxidation to produce hydrogen in high yields with a total time in the reactor of less than 50 milliseconds. Pyrolysis, coupled with catalytic oxidation of the fuels and their fragments upon impact with a hot rhodium-cerium catalyst surface, avoids the formation of deactivating carbon layers on the catalyst. The catalytic reactions of these products generate approximately 1 megawatt of heat per square meter, which maintains the catalyst surface above 800 degrees C at high drop impact rates. At these temperatures, heavy fuels can be catalytically transformed directly into hydrogen, carbon monoxide, and other small molecules in very short contact times without the formation of carbon.

Temporally regulated overexpression of parathyroid hormone-related protein in the mammary gland reveals distinct fetal and pubertal phenotypes.

We have previously demonstrated that overexpression of parathyroid hormone-related protein (PTHrP) in the mammary glands of transgenic mice results in defects in ductal elongation and branching during puberty and in lobuloalveolar development during pregnancy. In addition, we have shown that PTHrP is necessary for the formation of the initial ductal tree during embryonic mammary development. In order to examine the effect of varying the timing of PTHrP overexpression on mammary development, we created tetracycline-regulated, K14-tTA/Tet(O)-PTHrP double transgenic mice. In this report, we document that this 'tet-off' system directs transgene expression to the mammary gland and that it is fully repressed in the presence of tetracycline. Using these mice, we demonstrate that transient overexpression of PTHrP before birth causes defects in ductal branching during puberty and that overexpression of PTHrP during puberty decreases the rate of ductal elongation. Furthermore, we demonstrate that if PTHrP overexpression is initiated after ductal morphogenesis is completed, lobuloalveolar development is unaffected. Finally, we demonstrate that the impairment in ductal elongation caused by PTHrP is associated with an increase in the basal rate of epithelial cell apoptosis in terminal end buds and a failure to increase end bud cell proliferation and decrease apoptosis in response to estrogen and progesterone.

Promoting education, mentorship, and support for pediatric research.

Pediatricians have an important role to play in the advancement of child health research and should be encouraged and supported to pursue research activities. Education and training in child health research should be part of every level of pediatric training. Continuing education and access to research advisors should be available to practitioners and academic faculty. Recommendations to promote additional research education and support at all levels of pediatric training, from premedical to continuing medical education, as well as suggestions for means to increase support and mentorship for research activities, are outlined in this statement.

A common ancestral origin of the frequent and widespread 2299delG USH2A mutation.

Usher syndrome type IIa is an autosomal recessive disorder characterized by mild-to-severe hearing loss and progressive visual loss due to retinitis pigmentosa. The mutation that most commonly causes Usher syndrome type IIa is a 1-bp deletion, described as "2299delG," in the USH2A gene. The mutation has been identified in several patients from northern and southern Europe and from North America, and it has been found in single patients from South America, South Africa, and China. Various studies have reported a range of frequencies (.16-.44) among patients with Usher syndrome, depending on the geographic origin of the patients. The 2299delG mutation may be the one that most frequently causes retinitis pigmentosa in humans. Given the high frequencies and the wide geographic distribution of the mutation, it was of interest to determine whether the mutation resulted from an ancestral mutational event or represented a mutational hotspot in the USH2A gene. Haplotype analysis was performed on DNA samples from 116 unrelated patients with Usher syndrome type IIa; the patients were from 14 countries and represented 148 2299delG alleles. On the basis of six single-nucleotide polymorphisms within the USH2A gene, 12 core haplotypes were observed in a panel of normal chromosomes. However, in our analysis, only one core haplotype was found to be associated with the 2299delG mutation. The data indicate that the widespread geographic distribution of the 2299delG mutation is the result of an ancestral mutation that has spread throughout Europe and into the New World as a result of migration.

Parathyroid hormone-related protein maintains mammary epithelial fate and triggers nipple skin differentiation during embryonic breast development.

Prior reports have demonstrated that both parathyroid hormone-related protein (PTHrP) and the type I PTH/PTHrP receptor are necessary for the proper development of the embryonic mammary gland in mice. Using a combination of loss-of-function and gain-of-function models, we now report that PTHrP regulates a series of cell fate decisions that are central to the survival and morphogenesis of the mammary epithelium and the formation of the nipple. PTHrP is made in the epithelial cells of the mammary bud and, during embryonic mammary development, it interacts with the surrounding mesenchymal cells to induce the formation of the dense mammary mesenchyme. In response, these mammary-specific mesenchymal cells support the maintenance of mammary epithelial cell fate, trigger epithelial morphogenesis and induce the overlying epidermis to form the nipple. In the absence of PTHrP signaling, the mammary epithelial cells revert to an epidermal fate, no mammary ducts are formed and the nipple does not form. In the presence of diffuse epidermal PTHrP signaling, the ventral dermis is transformed into mammary mesenchyme and the entire ventral epidermis becomes nipple skin. These alterations in cell fate require that PTHrP be expressed during development and they require the presence of the PTH/PTHrP receptor. Finally, PTHrP signaling regulates the epidermal and mesenchymal expression of LEF1 and (&bgr;)-catenin, suggesting that these changes in cell fate involve an interaction between the PTHrP and Wnt signaling pathways.

The impact of a clinic-based literacy intervention on language development in inner-city preschool children.

OBJECTIVE: To determine the effect of a clinic-based literacy intervention on the language development of preschool children. METHODS: A convenience sample of families presenting to 2 urban pediatric clinics for well-child care met the following criteria: the family was Latino or black and English- or Spanish-speaking; the child was 2 to 5.9 years old, with no neurodevelopmental disability, at a gestational age of 34 weeks or more, and not attending kindergarten. Participants at the first clinic (intervention group) were exposed to a literacy support program, based on Reach Out and Read (ROR), during the previous 3 years. At the second clinic (comparison group), a similar program started 3 months before the study. Parent-child reading activities were measured using the READ Subscale of the StimQ. Language development was measured using the One-Word Expressive and Receptive Picture Vocabulary Tests, and was performed in the child's primary language. RESULTS: A total of 122 study participants (49 interventions and 73 comparisons) met inclusion criteria and completed all measures. Intervention and comparison families were similar for most sociodemographic variables. Intervention families reported reading together with their children approximately 1 more day per week. Intensity of exposure to ROR (measured by total number of contacts with the program) was associated with increased parent-child reading activities, as measured by the StimQ-Read Subscale (r = 0.20). Intervention children had higher receptive language (mean: 94.5 vs 84.8) and expressive language (mean: 84.3 vs 81.6). After adjusting for potential confounders in a multiple regression analysis, intervention status was associated with an 8.6-point increase (95% confidence interval [CI]: 3.3, 14.0) in receptive language (semipartial correlation [SR]coefficient = 0.27), and a 4.3-point increase (95% CI: 0.04, 8.6) in expressive language (SR = 0.17). In a similar multiple regression, each contact with ROR was associated with an adjusted mean 0.4-point increase (95% CI: 0.1, 0.6) in receptive score, and an adjusted mean 0.21-point increase (95% CI: 0. 02, 0.4) in expressive score. CONCLUSIONS: ROR is an important intervention, promoting parental literacy support and enhancing language development in impoverished preschool children. Integration of literacy promoting interventions such as these into routine pediatric health care for underserved populations can be recommended.

Identification of novel USH2A mutations: implications for the structure of USH2A protein.

Usher syndrome type II is an autosomal recessive disorder, characterised by stable hearing impairment from childhood and progressive retinitis pigmentosa from the late teens. Mutations in the USH2A gene, located on 1q41, were recently shown to be responsible for Usher syndrome type IIa. We have investigated the molecular pathology of Usher type II by screening the USH2A gene for mutations in 31 unrelated patients from Denmark and Norway. Besides the frequent 2299delG mutation, which accounted for 44% of the disease alleles, a heterogeneous spectrum of mutations was identified. Sixteen new, putative disease-causing mutations were detected, of which 12 were private and four were shared by unrelated patients. The disease-causing mutations were scattered throughout the gene and included six nonsense and seven missense mutations, two deletions and one small insertion. In addition, six non-pathogenic polymorphisms were identified. All missense mutations resulted in major amino acid side-chain alterations. Four missense mutations affected the N-terminal part of USH2A, whereas three missense mutations affected the laminin-type epidermal growth factor-like (LE) domain. The structural consequences of the mutations affecting the LE domain are discussed in relation to the three-dimensional structure of a LE-module of the mouse laminin gamma1 chain.

Low-level lead exposure and cognitive development in early childhood.

The authors studied toddlers with low-level lead exposure to determine whether adverse developmental effects were evident. The study sample consisted of a cohort of 68 children aged 12 to 36 months who had blood lead levels lower than 25 microg/dL on a routine screening in a large urban public hospital clinic. Children with blood lead levels between 10 and 24.9 microg/dL had a mean Mental Developmental Index (Bayley Scales of Infant Development, Second Edition) score that was 6.3 points lower than that of children with blood lead levels between 0 and 9.9 microg/dL (95% confidence interval: 0.6, 11.9). After adjusting for confounders, the difference was 6.2 points (95% confidence interval: 1.7, 10.8). Pediatricians and public health entities should continue in their efforts to reduce the lead burden through environmental control and ongoing surveillance.

PTHrP regulates epidermal differentiation in adult mice.

Emerging evidence suggests that parathyroid hormone-related peptide (PTHrP) serves as a regulator of the development and/or differentiation of a number of organs, including endochondral bone, the tooth, and the mammary gland. Although disruption of the PTHrP gene by homologous recombination results in a lethal chondrodystrophy, PTHrP-knockout mice that have been rescued by the transgenic replacement of the peptide in cartilage display abnormalities in ectodermally derived structures including the skin. At 6-8 wk of age, these rescued PTHrP-knockout mice displayed a markedly thinned epidermis and striking hyperkeratosis, hypoplastic sebaceous glands, and a fibrotic dermis. In contrast, transgenic mice that overexpress PTHrP by virtue of the human keratin-14 promoter displayed a thickened ventral epidermis with marked acanthosis and papillomatosis, hyperplastic sebaceous glands, and a cellular dermis. The absence of PTHrP appeared to result in the reduction of the basal keratinocyte compartment and premature acquisition of suprabasal and granular differentiation markers, whereas overexpression of the peptide generated reciprocal findings. No difference in the epidermal proliferation rate was found in PTHrP-null skin and although an increase was observed in keratin 14-PTHrP transgenic animals, their epidermis did not express the hyperplasia marker K6. Finally, the replacement of PTHrP in the basal keratinocytes of rescued PTHrP-knockout mice under the direction of the keratin 14 promoter reversed the abnormalities seen in PTHrP-null skin. These findings suggest that PTHrP regulates the rate of keratinocyte differentiation in the skin of adult mice.

Parathyroid hormone-related protein is required for tooth eruption.

Parathyroid hormone (PTH)-related protein (PTHrP)-knockout mice die at birth with a chondrodystrophic phenotype characterized by premature chondrocyte differentiation and accelerated bone formation, whereas overexpression of PTHrP in the chondrocytes of transgenic mice produces a delay in chondrocyte maturation and endochondral ossification. Replacement of PTHrP expression in the chondrocytes of PTHrP-knockout mice using a procollagen II-driven transgene results in the correction of the lethal skeletal abnormalities and generates animals that are effectively PTHrP-null in all sites other than cartilage. These rescued PTHrP-knockout mice survive to at least 6 months of age but are small in stature and display a number of developmental defects, including cranial chondrodystrophy and a failure of tooth eruption. Teeth appear to develop normally but become trapped by the surrounding bone and undergo progressive impaction. Localization of PTHrP mRNA during normal tooth development by in situ hybridization reveals increasing levels of expression in the enamel epithelium before the formation of the eruption pathway. The type I PTH/PTHrP receptor is expressed in both the adjacent dental mesenchyme and in the alveolar bone. The replacement of PTHrP expression in the enamel epithelium with a keratin 14-driven transgene corrects the defect in bone resorption and restores the normal program of tooth eruption. PTHrP therefore represents an essential signal in the formation of the eruption pathway.

Pediatric ambulance utilization in a large American city: a systems analysis approach.

BACKGROUND: Research on utilization of ambulances by pediatric patients lacks an objective, reproducible tool for the evaluation of patterns of ambulance use by both the providers and the users of this resource. OBJECTIVES: 1) To develop an objective, diagnosis-based measure of appropriateness of ambulance utilization. 2) To use the measure to evaluate whether Municipal Ambulance Service dispatchers assign ambulances appropriately, and whether parents/caretakers request ambulances appropriately. STUDY DESIGN: 1) Development of the pediatric ambulance need evaluation (PANE) tool: The consensus of an expert panel was used to assign patients arriving by ambulance to three levels of prehospital transport need based upon their ultimate hospital discharge diagnoses, and were as follows: required advanced life support ambulance (ALS); required basic life support ambulance (BLS); required a less acute mode of transport (LAT). 2) Assessment of appropriateness of ambulance assignments by EMS call-receiving operators (CRO) and of ambulance requests by parents/caretakers: Comparison of actual type of ambulance assigned and of need for ambulance, using the PANE tool and hospital admission rates as gold standards. DATA COLLECTION: Level of prehospital transport provided (ALS vs BLS), ultimate ED diagnosis, and ED disposition (admission vs discharge) was collected for each patient from information abstracted from the prehospital and ED records. SETTING: Bellevue Hospital Center and Harlem Hospital Center, two level I trauma centers in New York City, both with Pediatric Emergency Departments staffed 24 hours a day by attending physicians and residents. PATIENT SELECTION: Consecutive sample of 2633 patients, birth to 18 years of age, who arrived to either hospital by ambulance as primary transports from the field over a one-year period. RESULTS: 1) Development of PANE tool: At Bellevue Hospital, 7% of ED visits arrived by ambulance; at Harlem Hospital, 5% arrived by ambulance. Using these ambulance arrivals, 215 diagnoses were identified for inclusion in the PANE tool. An expert panel categorized each diagnosis as requiring ALS, BLS, or LAT, with a high level of interobserver agreement (weighted kappa = 0.793). As a measure of external validity of the PANE, admission rates were highest in the ALS group, next highest in the BLS group, and lowest in the LAT group (chi2 for trend, P < 0.05). 2) Assessment of ambulance assignments and requests: According to the PANE tool, the sensitivity of dispatcher assignment of ALS ambulances was 72 %. Therefore, 28 % of patients who required an ALS ambulance received BLS care. 50% of patients assigned to an ALS ambulance did not require that level of care, and 1/3 of these were categorized by the PANE as not requiring an ambulance at all. CONCLUSIONS: The PANE tool compared favorably to admission rates as a measure of the severity of illness of patients arriving by ambulance. Applying the PANE tool, we conclude that the majority of requests for ambulances are appropriate, and that the majority of the time dispatchers were able to dispatch the appropriate level of care. However, there is room for significant improvement in utilization of ambulances, and tools like the PANE will be useful in achieving this goal.

Low-level lead exposure and behavior in early childhood.

OBJECTIVE: To assess whether small elevations in blood lead level were associated with measurable behavioral changes in a group of poor children between 1 and 3 years old. METHODS: The study population consisted of children presenting for routine well-child care to the pediatric clinic at Bellevue Hospital Center, a large urban public hospital. The following inclusion criteria were used for entry into the study: age 12 to 36 months; capillary lead screening result <1.21 micromol/L (25 microg/dL); no known prior history either of blood lead level >1.21 micromol/L (25 microg/dL) or lead exposure requiring chelation therapy; Latino or African-American; English or Spanish spoken in the home; biological mother as primary caretaker; child not presently attending day care; full-term, singleton gestation; birth weight at least 2500 g; no known neurologic or developmental disorder; and no severe chronic disease, including human immunodeficiency virus infection. Study enrollment was simultaneously stratified by capillary lead level and age. All children between 12 and 36 months attending the pediatric clinic during the study period received screening capillary blood measures of lead level following the recommendations of the Centers for Disease Control and Prevention and the American Academy of Pediatrics as part of routine primary care. During periods of enrollment, consecutive lead measurements performed in the pediatric clinic were reviewed by one of the researchers. For those children meeting entry criteria based on lead level and age, further eligibility based on the remainder of the inclusion criteria was determined through parental interview and review of the medical record. Lead exposure was assessed with a single capillary blood specimen, using atomic absorption spectrophotometry. Subjects were considered to be lead-exposed if their lead level was between 0.48 and 1.20 micromol/L (10 and 24.9 microg/dL) and nonexposed if their lead level was between 0 and 0.48 micromol/L (0 and 9.9 microg/dL). Behavior was assessed using the Behavior Rating Scale (BRS) of the Bayley Scales of Infant Development, second edition. The BRS in this age group consists of three components: an Emotional Regulation Factor that measures hyperactive/distractible/easy-frustration behaviors; an Orientation-Engagement Factor that measures fear/withdrawal/disinterest behaviors; and a Motor Quality Factor that assesses the appropriateness of movement and tone. The BRS is scored as a percentile; lower scores reflect more problematic behaviors. Researchers performing the BRS were blinded to capillary lead results. Information was collected concerning factors that might confound the relationship between lead and behavior. Demographic factors were collected, including: child's age, gender, and country of origin; mother's age, marital status, parity, country of origin, and primary language spoken; parental education, and occupation and receipt of public assistance. Socioeconomic status was determined using the Hollingshead Two-Factor Index of Social Position. Maternal verbal IQ was assessed using the Peabody Picture Vocabulary Test-Revised. Maternal depression was assessed using the Center for Epidemiologic Studies-Depression Scale. Cognitive stimulation provided in the home was assessed using a new office-based instrument, the StimQ, which measures the quantity and quality of play materials and parent-toddler activities in the child's home. To assess the child for iron deficiency, we performed a hematocrit and mean corpuscular volume at the time of the capillary lead evaluation. A presumptive diagnosis of iron deficiency was made if the child was either anemic (defined as a hematocrit <32) or had a mean corpuscular volume <72. RESULTS: The study sample consisted of 72 children. Children in the lead-exposed group (n = 41) had a mean BRS behavior score that was 15.8 points lower than that of children in the nonexposed group (n = 31), which was significant by the Stu

Increased prevalence of abnormal Papanicolaou smears in urban adolescents.

OBJECTIVE: To determine the secular trend in the prevalence of cervical dysplasia as evidenced by abnormal Papanicolaou smear results in sexually active adolescents. DESIGN: Descriptive case series. SETTING: Outpatient department of an urban public hospital. PARTICIPANTS: All sexually active adolescents with Papanicolaou smear results recorded during 2 periods: January 1, 1982, through December 31, 1983 (n = 577), and January 1, 1992, through December 31, 1993 (n = 871). MEASUREMENTS: Age, ethnicity, patient care location in which the Papanicolaou smear preparation was performed, and Papanicolaou smear results were obtained for each patient. For patients with more than 1 Papanicolaou smear result during the specified period, only the first result was included in this study. Papanicolaou smear results were classified according to the Bethesda system as within normal limits, benign cellular change, atypical squamous cells of undetermined significance, lowgrade squamous intraepithelial lesion, or high-grade squamous intraepithelial lesion. Any Papanicolaou smear classified as atypical squamous cells of undetermined significance or low- or high-grade squamous intraepithelial lesion was defined as abnormal. RESULTS: The prevalence of abnormal Papanicolaou smear results was 2.8% in 1982 through 1983 vs 11.7% in 1992 through 1993; prevalence odds ratio was 4.7 (95% confidence interval, 2.7-8.3). The higher rate of abnormal Papanicolaou smear results in 1992 through 1993 persisted after controlling for age, patient care location, and ethnicity in a logistic regression model (adjusted prevalence odds ratio, 5.0; 95% confidence interval, 2.8-8.9). The prevalence of benign cellular change was 8.7% in 1982 through 1983 vs 20.1% in 1992 through 1993; prevalence odds ratio was 2.7 (95% confidence interval, 1.9-3.8). CONCLUSIONS: The prevalence of abnormal Papanicolaou smear results has significantly increased in the last decade in sexually active adolescents seen at a city hospital clinic. The results of this study emphasize the importance of routine Papanicolaou smear screening for all sexually active female adolescents.

Immunization status as determined by patients' hand-held cards vs medical records.

OBJECTIVE: To determine whether patients' hand-held immunization cards provide accurate assessments of immunization status when compared with their corresponding medical records. SETTING: Urban hospital emergency department immunization program. DESIGN: Comparison of 2 criterion standards. PATIENTS: Children aged 4 months to 6 years who presented consecutively with their immunization cards and received routine care in the hospital's pediatric clinic. SELECTION: Of 673 eligible patients seen in the immunization program from November 1992 to October 1993, 140 were randomly selected for comparison of immunization card and medical record immunization dates; in addition, all 123 eligible patients seen between August and October 1994 were selected. Of the total of 263 children, medical records for 257 (98%) were available for review. The dates of diphtheria-tetanus-pertussis, polio, measles-mumps-rubella, and Haemophilus influenzae type b immunization from immunization cards and medical records were recorded, as were patient age, sex, and ethnicity. Immunization card-medical record immunization date pairs were compared. Each immunization card and medical record was categorized as up to date, due for immunization, or delayed 2 months or more for any immunization at the time of the visit. RESULTS: In 218 (85%) of 257 cases, the immunization card and medical record immunization dates were identical (McNemar test, P = .63). The immunization card and medical record agreed that patients were due for immunization in 91 cases and agreed that patients were not due for immunization in 138 cases (kappa = 0.77; 95% confidence interval, 0.70-0.85). The immunization card and medical record agreed that patients were delayed for 1 or more immunizations in 51 cases and agreed that patients were not delayed in 187 cases (kappa = 0.79; 95% confidence interval, 0.71-0.88). CONCLUSION: The hand-held immunization card is a suitable alternative to the medical record when the need for immunization is assessed or when rates of immunization delay in populations are determined.

Parathyroid hormone-related protein: evidence for isoform- and tissue-specific posttranslational processing.

Parathyroid hormone-related protein (PTHrP) is expressed by malignant tumors and leads to the syndrome of humoral hypercalcemia of malignancy. It is also expressed by a wide variety of nonmalignant tissues, in which it appears to play distinct paracrine and/or autocrine roles. The human PTHrP gene encodes three cDNA-predicted initial translational products of 139, 141, and 173 amino acids. Most human cell lines contain mRNAs encoding all three PTHrP isoforms. The physiological rationale for the existence of these three highly similar transcripts is unknown. In order to determine whether the protein products derived from these three transcripts differ, we transfected Chinese hamster ovary (CHO) cells and rat insulinoma (RIN) cells individually with cDNAs encoding human PTHrP(1-139), PTHrP(1-141), and PTHrP(1-173). Cell extracts and conditioned medium were then chromatographed using reversed-phase HPLC and analyzed using region-specific PTHrP immunoassays. As we had previously observed in SKRC-1 (renal cell carcinoma) and RIN(1-141) cells, multiple amino-terminal PTHrP species as well as a separate midregion PTHrP species were identified in all six cell lines. In addition, both CHO and RIN cell lines transfected with the PTHrP(1-139) construct contained a previously unrecognized carboxy-terminal fragment that reacted with a PTHrP(109-138) antiserum. This carboxy-terminal fragment was physically distinct from the midregion fragment discovered earlier and was also present in conditioned medium, indicating that it is a secretory form, rather than a biosynthetic intermediate or a degradation product.(ABSTRACT TRUNCATED AT 250 WORDS)