How do academic heads of departments of general practice organize patient care? A European survey.

BACKGROUND. Compared with other clinical disciplines, academic general practice is in a difficult situation with respect to patient care. There are at least three different possible models of working arrangements for heads of departments of general practice: to work in a surgery in a medical school; to work in a surgery in the community, separate from a part-time university post; or to work part-time in a surgery in the community, separate from a university post. AIM. A study was undertaken to explore these models and to gain an understanding of academic teachers' organization of patient care in Europe. METHOD. A total of 77 heads of departments in universities in 12 European countries were sent a questionnaire enquiring about important characteristics of their department, the number of patients they treated per week and how they allocated their time. RESULTS. Sixty nine heads of department (90%) responded. Of respondents, 55% worked part-time in a surgery, separate from a university post, nearly one third worked mainly in a surgery, separate from a part-time university post, and 16% worked in a surgery in a medical school. Those working in a surgery with only a part-time university post spent most time in patient care compared with those working in other models (mean of 57%). Respondents working in a surgery in a medical school spent most time on administration (34%); they spent 22% of their time on patient care and 20% on education. Respondents working in a surgery in a medical school spent 25% of their time on research, those working in a surgery separate from a part-time university post spent 12% of their time on research, and those working mainly in a university with a part-time practice post spent 24% of their time on research. Those working mainly in a university post spent only 17% of their time in patient care. CONCLUSION. Working in a surgery in a medical school represented a well-balanced model of time allocation between patient care, research and education and seemed to be a good approach for the integration of general practice into medical schools. Working part-time in a surgery with a university post is an appropriate model for academic integration, but patient care seemed to be neglected. Those doctors working mainly in the community with a part-time university post were able to provide continuity of care and to come into close contact with the everyday problems of general practitioners. However, they might have to struggle for academic recognition.     

On the probability that a novel variant is a disease-causing mutation

When a novel variant is found in a patient and not in a group of controls, it becomes a candidate for the disease-causing mutation in that patient. At present, no sampling theory exists for assessing the probability that the novel SNP might actually be a neutral variant. We have developed a population genetics-based method for calculating a P-value for a mutation-detection effort. Our method can be applied to a heterozygous patient, a homozygous patient, with or without inbreeding, or to a patient who is a compound heterozygote. Additionally, the method can be used to calculate the probability of finding a neutral variant at frequencies that differ between a group of patients and a group of controls, given some length of sequence examined. This method accounts for the multiple testing that is inherent in identification of variants through sequencing, to be used in subsequent case-control analyses. We show, for example, that for complete resequencing of 10 kb, the probability of finding a neutral variant in a patient and not in 50 controls is about 15%. Thus, discovery of a variant in a patient and not in a group of controls is, on its own, very weak evidence of involvement with disease.     

Protective and immunochemical activities of monoclonal antibodies reactive with the Bacillus anthracis polypeptide capsule

Bacillus anthracis is surrounded by a polypeptide capsule composed of poly-gamma-d-glutamic acid (gammaDPGA). In a previous study, we reported that a monoclonal antibody (MAb F26G3) reactive with the capsular polypeptide is protective in a murine model of pulmonary anthrax. The present study examined a library of six MAbs generated from mice immunized with gammaDPGA. Evaluation of MAb binding to the capsule by a capsular "quellung" type reaction showed a striking diversity in capsular effects. Most MAbs produced a rim type reaction that was characterized by a sharp increase followed directly by a decrease in refractive index at the capsular edge. Some MAbs produced a second capsular reaction well beneath the capsular edge, suggesting complexity in capsular architecture. Binding of MAbs to soluble gammaDPGA was assessed by a fluorescence perturbation assay in which a change in the MAb intrinsic fluorescence produced by ligand binding was used as a reporter for antigen-antibody interaction. The MAbs differed considerably in the complexity of the binding curves. MAbs producing rim type capsule reactions typically produced the more complex binding isotherms. Finally, the protective activity of the MAbs was compared in a murine model of pulmonary anthrax. One MAb was markedly less protective than the remaining five MAbs. Characteristics of the more protective MAbs included a relatively high affinity, an immunoglobulin G3 isotype, and a complex binding isotherm in the fluorescence perturbation assay. Given the relatively monotonous structure of gammaDPGA, the results demonstrate a striking diversity in the antigen binding behavior of gammaDPGA antibodies.     

Complement anaphylatoxins in idiopathic mixed cryoglobulinemia

Basophil activation, observed in patients with idiopathic mixed cryoglobulinemia, has been related to the complement anaphylatoxins C4a, C3a and C5a. In the present study the plasma levels of the complement anaphylatoxins have been evaluated in 21 patients affected with idiopathic mixed cryoglobulinemia. The plasma concentration of C3a desArg was significantly higher in the patients than in the healthy controls; conversely the plasma values of C4a desArg were significantly lower. C5a desArg was not detectable in plasma from any subject. The high plasma level of C3a desArg in our patients may suggest a role for C3a anaphylatoxin in 'in vivo' basophil activation. No correlation was found between the plasma concentrations of C3a desArg or C4a desArg, the amount of cryoprecipitate and the clinical activity of the disease.     

Site-specific single amino acid changes to Lys or Arg in the central region of the movement protein of a hybrid bromovirus are required for adaptation to a nonhost

A hybrid Cowpea chlorotic mottle virus (CCMV) [CCMV(B3a)] in which the CCMV 3a movement protein gene is replaced by the 3a (B3a) gene of Brome mosaic virus cannot infect cowpea systemically. Previously, analysis of RNA3 cDNA clones constructed from cowpea-adapted mutants derived from CCMV(B3a) revealed that a single codon change in the B3a gene allowed CCMV(B3a) to infect cowpea systemically. In this study, to extend the analysis of the CCMV(B3a) adaptation mechanism, we directly sequenced B3a gene RT-PCR products prepared from 28 cowpea plants in which cowpea-adapted mutants appeared, and found seven patterns of a codon change localized at five specific positions in the central region (Ser(118), Glu(132), Glu(138), Gln(178), and Ser(180)). All of the patterns involved an amino acid change to Lys or Arg. Mutational analysis of the B3a gene demonstrated that a single codon change resulting in either Lys or Arg at any of the five positions was sufficient for the adaptation of CCMV(B3a) to cowpea. In contrast, CCMV(B3a) variants with a codon change resulting in Lys or Arg at three other positions (137, 155, and 161) in the B3a gene not only showed lack of systemic infection of cowpea but also showed weakened initial cell-to-cell movement in the inoculated leaves and diminished B3a accumulation in protoplasts. These results suggest that adaptive changes in the B3a gene are site-specifically selected in cowpea plants.     

Local secretory response by the mouse uterine epithelium to the presence of a blastocyst or a blastocyst-like bead

Summary The ultrastructure of the uterine secretion appearing locally at the site of a blastocyst or a blastocyst-like bead was compared to the ultrastructure of the secretion present in a sterile horn of similarly treated mice. The secretion consisted of a homogeneous substance with small vesicles. The secretion was sparse and only slightly electron dense in a sterile horn, while it was more abundant and denser in a horn with a luminal object. Around a blastocyst, the secretion appeared more dense than it did around a bead, while the small vesicles of the secretion were more frequently occurring around a bead than around a blastocyst. It is concluded that a luminal object like a blastocyst is capable of eliciting a local secretory activity in the uterine epithelium, and it is suggested that this secretion is rich in hydrolytic enzymes.     

Towards a pathogenetic definition of multiple sclerosis in terms of integrative transformation of generic pathologic processes

The multiple sclerosis disease process is presented in the light of a generic pathobiologic phenomenon on equal terms with such other phenomena as ischemia, neoplasia, infection and congenital malformation, with the added improviso that it would also constitute a true form of integrative resolution of these other generic phenomena towards a real transformation of events in terms of both cellular forms of injury and also in terms of pathogenesis and evolution. Perhaps, in the final analysis, a putative infectious agent is implicated in multiple sclerosis whose peculiar attributes are reflected in a distinctive immunologic response beyond even the conventional concepts of either hypersensitivity or of immunologic surveillance. In a sense, perhaps, a particular patient immunologic constitution in an environment conducive to exposure to a putative agent results in a form of integration of this agent leading to persistent demyelinative relapse of the affected oligodendrocyte on an essential background of a distinct plaque centered on a specific vessel of supply. The recognition of the oligodendrocyte as a specialized astrocyte might in itself strictly characterize such a generic demyelinative process of multiple sclerosis in terms of its essential remitting/relapsing course.     

High plasma levels of apo(a) fragments in Caucasians and African-Americans with end-stage renal disease: implications for plasma Lp(a) assay

Apolipoprotein(a) [apo(a)] is a plasma glycoprotein that is highly polymorphic in size due to differences in the number of a tandemly arrayed cysteine-rich repeat called kringle (K)4 at its N-terminus. Most plasma apo(a) is covalently attached to apolipoprotein B-100 and circulates as part of lipoprotein(a) [Lp(a)]. A fraction of apo(a) circulates free of lipoproteins. Almost all of the free apo(a) consists of fragments containing variable numbers of K4 repeats derived from the N-terminal region. Previously we provided evidence suggesting that the apo(a) fragments present in human plasma are the source of the apo(a) fragments in human urine. If this were the case, it would be expected that plasma levels of fragments would be higher in subjects with end-stage renal disease (ESRD). In this paper we quantified the levels of apo(a) fragments and plasma Lp(a) in 26 Caucasian and 26 African-American subjects with ESRD and 52 healthy subjects matched for race, sex and the size of the apo(a) isoforms. The plasma levels of apo(a) fragments and Lp(a) were both higher in the ESRD subjects. In addition, the ratio of apo (a) fragments to total immunodetectable apo(a) was increased in ESRD. To determine how much the increase in the apo(a) fragments contributed to the increase in plasma Lp(a) in ESRD, the plasma Lp(a) levels were measured employing two different anti-apo(a) enzyme-linked immunoabsorption assays (ELISA). One assay detected both free and bound apo(a), whereas the other assay detected only bound apo(a). Although the plasma levels of apo(a) in the ESRD subjects tended to be higher using the assay that detected both fragments and full-length apo(a), the increase was modest. Thus, although a greater proportion of the apo(a) in ESRD plasma circulates as fragments, most of the elevation in plasma levels of Lp(a) associated with renal insufficiency is due to an increase in intact Lp(a).     

The cholesteryl ester transfer protein (CETP) locus as a candidate gene in abdominal aortic aneurysm

Abdominal aortic aneurysm (AAA) is a relatively common disease of the elderly presenting as progressive dilatation of the abdominal aorta. The condition shows a pronounced tendency to cluster in families, indicating a genetic component in the disease aetiology. We have screened the cholesteryl ester transfer protein (CETP) gene, which has been proposed as a candidate gene in AAA, by means of SSCP, DNA sequencing and restriction analysis in a cohort of patients with AAA and a matching control group drawn from the Irish population. The analysis has demonstrated sequence variation at four sites in the CETP gene: an A-T transversion in exon 9 (producing a Lys309-Stop codon substitution), a G-A transition in exon 14 (producing a conservative Va1421-Ile substitution), a C-T transition in intron 12 and a G-A transition in intron 15. None of the last three sites corresponded with sites of functional significance in the protein, suggesting that this reflects neutral polymorphism at the CETP locus. Furthermore, the frequencies of these four polymorphisms in the AAA patient and control groups were not significantly different. These data therefore suggest that CETP may be excluded as a candidate gene in abdominal aortic aneurysm.     

Activity of the thoracic muscles during thermal hyperpnea

Electrical activity of the thoracic muscles and the oxygen consumption of the animal were studied in unanesthetized cats with pre-implanted electrodes. Heating the cats in a climatic chamber led to a marked increase in the minute volume of respiration, accompanied by a reduction in the oxygen consumption of the animal and a decrease in the combined electrical activity in the serratus, external oblique abdominal, and internal and external intercostal muscles. Activity in the diaphragm and the interchondral muscles was unchanged during hyperpnea. The results point to a decrease in the heat production in the thoracic muscles during thermal hyperpnea as a result of a decrease in the electrical activity of most of the respiratory muscles.     

Retinoblastoma protein function and p16INK4a expression in actinic keratosis, squamous cell carcinoma in situ and invasive squamous cell carcinoma of the skin and links between p16INK4a expression and infiltrative behavior.

p16INK4a is involved in many important regulatory events in the cell and the expression and function is closely associated with the retinoblastoma protein (Rb). Earlier, we have in colorectal cancer and in basal cell carcinoma showed that p16INK4a is upregulated at the invasive front causing cell cycle arrest in infiltrative tumor cells via a functional Rb. This role for p16INK4a as a regulator of proliferation when tumor cells infiltrate might besides a general cyclin-dependent kinase (cdk) inhibitory effect explain why p16INK4a is deregulated in many tumor forms. The expression pattern of p16INK4a in relation to Rb-function in squamous cancer and precancerous forms of the skin has not been fully detailed. We therefore characterized the expression of p16INK4a, Rb-phosphorylation and proliferation in actinic keratosis, squamous cell carcinoma in situ and invasive squamous cell carcinoma with special reference to infiltrative behavior. The expression of p16INK4a varied between the lesions, with weak and cytoplasmic p16INK4a expression and functional Rb in actinic keratosis. Strong nuclear and cytoplasmic p16INK4a expression was observed in all carcinomas in situ in parallel with lack of Rb-phosphorylation but high proliferation indicating a nonfunctional Rb. Invasive squamous carcinoma showed a mixed p16INK4a expression pattern where some tumors had strong cytoplasmic p16INK4a expression, large fraction of Rb-phosphorylated cells and high proliferation. Interestingly, despite this disability of p16INK4a to inhibit proliferation there was an upregulation of cytoplasmic p16INK4a in infiltrative cells compared to tumor cells towards the tumor center. A similar scenario but strong and combined nuclear and cytoplasmic p16INK4a expression in infiltrative cells, was observed in other invasive squamous cancers. This suggests that the p16INK4a upregulation in infiltrative cells is governed independently of the subcellular localization or of the potential to affect proliferation via Rb, and suggests a potentially proliferation independent function for p16INK4a in infiltrative behavior.     

Diagnosis and management of cases of suspected dermatomycosis in The Netherlands: influence of general practice based potassium hydroxide testing.

BACKGROUND. Microscopy of a potassium hydroxide preparation of skin scrapings or nail clippings, although widely advocated as a test for dermatomycosis, is used in only a small proportion of cases. AIM. This study set out to investigate the effect of potassium hydroxide testing on the subjectively assessed probability that a dermatomycosis was present. METHOD. The study was undertaken in 1992 in Limburg, a province in the south of the Netherlands. Ten general practitioners and eight trainees completed a questionnaire and performed a potassium hydroxide preparation for each patient presenting with a skin condition that they thought might be caused by dermatomycosis. Skin or nail material was also sent to a microbiology laboratory where another potassium hydroxide preparation as well as a culture were performed, these two tests serving as a gold standard against which to judge the potassium hydroxide preparation by the general practitioners. Data from a total of 164 cases were analysed. RESULTS. The results of the potassium hydroxide test carried out in the practice had a considerable influence on the subjectively assessed probability that a dermatomycosis was present, especially if the outcome was positive. The indication for antifungal treatment was altered as a result of the test in a quarter of all cases, mostly from negative to positive. Use of the practice potassium hydroxide test could increase the proportion of correct therapeutic decisions from 54% to 69%, with 20% of cases being undertreated. Of cases that gave a positive test result in the practice 83% also had a positive laboratory test result, while of cases that gave a negative practice result 43% were positive in the laboratory. CONCLUSION. The potassium hydroxide test improves the diagnostic process in cases of possible dermatomycosis and may result in a change in management. The test can provide a confirmation of the diagnosis of dermatomycosis but is not useful in the exclusion of this diagnosis.     

Frequency discrimination training engaging a restricted skin surface results in an emergence of a cutaneous response zone in cortical area 3a.

1. The responses of cortical neurons evoked by cutaneous stimulation were investigated in the hand representation of cortical area 3a in adult owl monkeys that had been trained in a tactile frequency discrimination task. Cortical representations of the hands in these experimental hemispheres were compared with those representing the opposite, untrained hand, as well as with those representing a passively stimulated hand in a second class of control monkeys. 2. A large cutaneous representation of the hairy and glabrous skin surfaces of the hand emerged in area 3a in each trained hemisphere. 3. With the emergence of cutaneous responses recorded for neurons at many area 3a locations, the normally recorded deep receptor inputs were no longer evident at most of these locations. 4. There was a greater territory of representation of the small area of skin that was stimulated in the behavioral task in trained monkeys, when compared with the representations of corresponding skin sites in the opposite hemisphere of the same monkeys, or to the representations of equivalent skin sites stimulated in passively stimulated control monkeys. 5. There was great variability in the receptive-field properties of neurons responsive to cutaneous inputs among trained monkeys. In most recording sites within the representations of the behaviorally engaged hands, the cutaneous receptive fields were large, extending over a significant part of the glabrous or hairy surfaces of the hand. However, in one monkey, very small, topographically ordered cutaneous receptive fields were recorded over a wide zone of area 3a. 6. The physiologically defined borders between areas 3a and 3b were in register with the cytoarchitectonically defined borders between these two cortical areas in trained and in control monkeys. 7. This study demonstrates that there is a reorganization of the cutaneous and "deep" representation of hand in cortical area 3a, with the main change being an emergence of a large cutaneous representation and the parallel disappearance of a large part of the normal deep representation in this field. These changes are discussed in light of the possible functional roles of cortical area 3a.     

A new genomic mechanism leading to cri-du-chat syndrome

Using standard banding techniques, a within-arm intrachromosomal insertion can be mistakenly interpreted as a paracentric inversion. The need to correctly distinguish between these two types of chromosome rearrangements is emphasized by their different reproductive risks. For carriers of an intrachromosomal insertion, the empiric risk of having a liveborn child with a recombinant chromosome leading to a genetic imbalance is at least 15%, whereas the risk for a carrier of a paracentric inversion having a liveborn child with a recombinant chromosome leading to a genetic imbalance is thought to be practically negligible. We report a unique observation in which a paracentric inversion in the short arm of chromosome 5, 46,XX,inv(5)(p13.3p15.3), was identified in a women who had a daughter with an apparently terminal deletion in the distal short arm of chromosome 5, 46,XX,del(5)(p14.3), and the clinical diagnosis of cri-du-chat syndrome. We further characterized the rearrangement, and fluorescence in situ hybridization (FISH) and microsatellite analyses confirmed the paracentric inversion in the mother and showed the deletion in the daughter was maternal in origin. Therefore, this represents a case in which a confirmed paracentric inversion likely resulted in a viable terminal deletion. We propose a mechanism involving dicentric chromosome formation with subsequent breakage and telomere healing during meiosis. This illustrates a new genomic mechanism of chromosome rearrangement leading to cri-du-chat syndrome and should provide significant information for the medical management of patients with other terminal deletion syndromes.     

MiR-34a inhibits proliferation and migration of breast cancer through down-regulation of Bcl-2 and SIRT1

MicroRNA-34a(miR-34a), a pivotal member of the p53 network, was found to be down-regulated in multiple types of tumors and further reported as a tumor suppressor microRNA. However, the profile and biological effects of miR-34a in breast cancer are still unclear. In this study, we aimed to determine the effect of miR-34a on the growth of breast cancer and to investigate whether its effect is achieved by targeting Bcl-2 and SIRT1. We examined miR-34a levels in breast cancer cell lines and breast cancer specimens by qRT-PCR. Proliferation assay, apoptosis assay, and morphological monitoring were performed to assess the tumor suppression effect of miR-34a in breast cancer cell lines. Western blotting was used to identify the targets of miR-34a. We also investigated the anti-tumor effects of the treatment combining miR-34a with 5-FU in breast cancer cells. We found that miR-34a expression was down-regulated in 5 breast cancer cell lines compared with the immortalized normal mammary epithelial cell line 184A1, and was also down-regulated by almost 50 % in breast cancer samples compared with their corresponding adjacent non-malignant breast tissues. Ectopic restoration of miR-34a in breast cancer cells suppressed cells proliferation, invasion, and induced apoptosis. Bcl-2 and SIRT1 as the targets of miR-34a were found to be in reverse correlation with ectopic expression of miR-34a. Furthermore, the treatment combining miR-34a with 5-FU significantly showed more efficient anti-tumor effects than single treatment of miR-34a or 5-FU. Since miR-34a functions as tumor suppressor microRNA in breast cancer, modulating miR-34a level in breast cancer was suggested to be a new and useful approach of breast cancer therapy.     

A uterine leiomyoma in which a leiomyosarcoma with osteoclast-like giant cells and a metastasis of a ductal breast carcinoma are present

Leiomyosarcoma of the uterus is a rare tumor, and the presence of osteoclast-like giant cells in this tumor is even rarer. A leiomyosarcoma arising in a leiomyoma is also quite unique. Breast cancer metastasizing to the uterus is seldom seen as well. A 70-year-old woman presented with metastasized breast cancer to the bones. An evaluation of the computed tomographic scan was made, which showed an enlarged uterus with a tumor. The tumor was a leiomyoma in which a leiomyosarcoma with osteoclast-like giant cells as well as a metastasis of a ductal breast carcinoma was present. To our knowledge, this is the first report of a leiomyosarcoma containing osteoclast-like giant cells, present in a leiomyoma, in a uterus also containing a ductal breast cancer metastasis present in the leiomyoma and myometrium.     

A case of minute intraductal papillary mucinous tumor of the pancreas presenting with recurrent acute pancreatitis

Intraductal papillary mucinous tumor (IPMT) of the pancreas, a lesion consisting of mucin-producing cells with neoplastic potential, is characterized by duct ectasia, mucin hypersecretion, often extensive papillary intraductal growth, varying degrees of cytologic atypia, and relatively indolent growth. The clinical presentation of IPMT of the pancreas is characterized by chronic or recurrent attacks of abdominal discomfort often in association with low level pancreatic enzyme elevations. Less commonly these lesions may be detected as asymptomatic radiographic abnormalities. Interestingly, a case of a minute IPMT (2 mm in height and 7 mm in length, adenoma) in the main pancreatic duct presenting with acute pancreatitis in a 55 year-old man has been reported in the Japanese literature. Recently, we also experienced a case of a minute IPMT in a branch pancreatic duct causing repeated bouts of acute pancreatitis in a 75 year-old man. A filling defect at the neck of the main pancreatic duct seen on an endoscopic retrograde pancreatogram performed after recovery of the second attack of acute pancreatitis led the patient to undergo an exploratory laparotomy. After a near-total pancreatectomy was carried out, a minute (3 x 7 mm) IPMT of borderline malignancy was discovered in a branch duct at the head portion near the pancreatic neck without any lesions in the main pancreatic duct. Surprisingly, despite the resective surgery the patient died of carcinomatosis 8.5 months after the operation. We herein report a case of a minute but aggressive IPMT of the pancreas with a review of the literature.     

Sequence microheterogeneity in apolipoprotein(a) gene repeats and the relationship to plasma Lp(a) levels

Lipoprotein(a) [Lp(a)] is a cholesterol ester-rich atherogeniclipoprotein that is composed of a particle of low density lipoproteinand a large glycoprotein, apolipoprotein(a) [apo(a)]. Apolipoprotein(a)varies in size over a {small tilde}500 kDa range due to inter-allelicdifferences in the number of tandemly repeated kringle 4 (K4)-encoding5. 5 kb sequences in the apo(a) gene. Only one of the 10 differenttypes of K4 repeats in the apo(a) gene, the so-called type 2K4 repeats, vary in number between apo(a) alleles. In this paper,we show that there is microheterogeneity within the sequenceof the type 2 K4 repeat. Dralll restriction digestion and genomicblotting revealed that a subset of the type 2 K4-encoding sequencescontained a Dralll site (K4-D). The proportion of apo(a) allelesthat had at least one K4-D repeat ranged from 25% in Caucasiansto 50% in the Chinese. K4-D repeats were clustered at the end(s)of the type 2 K4 tandem array and the number and patterns ofthe K4-D repeats were in linkage disequilibrium with flankingsequence polymorphisms; these features are remarkably similarto the minisatellite variant repeats (MVRs) found in variablenumber of tandem repeat sequences (VNTRs). In addition, a Dralllpattern that comprised 9% of the sample was invariably associatedwith low plasma levels of Lp(a) in Caucasians.