Waiting times: monitoring the total postreferral wait.

OBJECTIVES--To determine whether the period spent on the true inpatient waiting list is a valid indication of the total time that patients have to wait for an operation; and to assess the feasibility of monitoring the total "postreferral waiting time" by using existing computerised information systems. SETTING--Three randomly selected Scottish hospitals. SUBJECTS--Waiting list patients admitted to hospital for operations during June to August 1993 in six major specialties, separate attention being focused on cataract operations and hip and knee replacements. MAIN OUTCOME MEASURE--The total time that patients have to wait for an operation after the initial general practitioner referral--the postreferral waiting time--compared with that spent at the final stage of the process on the true inpatient waiting list. RESULTS--In the specialties investigated roughly half (58 days; 53%) of the average postreferral wait of 110 days was spent on the true inpatient waiting list, one third (35 days; 32%) being spent on the outpatient waiting list and one sixth (17 days; 15%) waiting between waiting lists. Only a quarter of cataract patients (73/292) were treated within three months of general practitioner referral compared with over three quarters (228/292) within three months of being placed on the inpatient waiting list. Nevertheless, within a year over 99% of patients (290) had been treated whichever date was taken as the starting point. CONCLUSIONS--Monitoring postreferral waiting times would provide a much more accurate picture for purchasers and patients of waiting times for treatment than is obtained by focusing exclusively on the true inpatient waiting list and facilitate fairer comparisons between NHS trusts in national league tables. Stringent national and local monitoring is essential to ensure (a) that future reductions in the time waiting on true inpatient waiting lists are not gained at the expense of longer periods waiting to be placed on the lists, and (b) that no increases occur in the number of patients placed instead on deferred waiting lists or exempted from the normal maximum waiting time guarantees.     

Higher professional training in general practice: provision of master's degree courses in the United Kingdom in 1993.

Review of a 1993 survey of the 29 United Kingdom departments of general practice (or equivalent) identified seven master''s degree courses available for general practitioners. Up to another 11 are planned within the next five years. Around 50 general practitioners undertake all such courses at any one time. Possible reasons for this low uptake include cost, lack of flexibility of courses, and the prospect of writing a thesis. Appropriate master''s courses are essential to the future development of general practice, and this paper postulates the characteristics of an "ideal" course.     

Familial unbalanced translocation t(8;15)(p23.3;q11) with uniparental disomy in Angelman syndrome

A 29-year-old male with Angelman syndrome and an unbalanced reciprocal translocation, 45,XY,-8,-15,+der(8),t(8;15)(p23.3;q11)pat, was evaluated with DNA studies. These showed the underlying mechanism to be paternal uniparental disomy. This is the second case reported of Angelman syndrome that has resulted from a familial unbalanced reciprocal translocation.     

T cell recognition of melanoma antigens in association with HLA-A1 on allogeneic melanoma cells

Previous studies have shown that recognition of melanoma by cytotoxic T lymphocytes may be restricted by HLA-A1, A2 and other HLA antigens. The present study examined the cytotoxic specificity and major histocompatibility complex restriction of cloned cytotoxic T lymphocytes (CTL) isolated from a patient with the HLA phenotype A3,31 who had been immunized with a vaccine prepared from HLA-A1,3 melanoma cells. Cytotoxic assays against HLA-typed allogeneic melanoma cells indicated that cloned CTL from the patient were able to kill allogeneic melanoma cells expressing HLA-A1 but not other HLA-A1-positive cells. Studies on a representative clone indicated that proliferation and cytokine (tumour necrosis factor ) production in response to melanoma cells was also associated with HLA-A1 on melanoma cells. Response to the melanoma cells was associated with interleukin-4 (IL-4) rather than IL-2 production. The antigen recognized in the context of HLA-A1 on allogeneic melanoma cells was detected in cytotoxic assays on cells from 9 of 12 HLA-A1⁺ melanoma cell lines and did not appear to be the product of the MAGE-1 or-3 genes. These findings suggest that T cells can recognize melanoma antigens in the context of alloantigens and that allogeneic vaccines containing immunodominant alloantigens may generate CTL that are ineffective against autologous melanoma. The study does not, however, exclude the possibility that CTL with specificity to the latter may be activated by allogeneic vaccines, and further studies are needed to answer this question.     

Efficient extracellular production of hybrid E. coli heat-labile enterotoxin B subunits in a marine vibrio

Abstract Escherichia coli heat-labile enterotoxin B subunit (EtxB) has been proposed as a potential protein carrier for the delivery of heterologous peptides to target cells, particularly for the oral delivery of epitopes to the mucosal immune system. In this study, two extensions to the C-terminus of EtxB were genetically engineered that correspond to a well-characterized neutralising epitope of glycoprotein D from herpes simplex virus (EtxB-gD) and to the C-terminal nine amino acids from the 38 kDa subunit of HSV-encoded ribonucleotide reductase (EtxB-R2). Here we describe the extracellular secretion of the two hybrid EtxBs from a marine Vibrio harbouring a broad-host range inducible expression vector containing the hybrid genes. Large amounts of intact fusion proteins (15–20 mg per liter of culture) were secreted into the medium upon induction. These hybrid proteins maintained the receptor-binding activity of the native toxin as well as being cross-reactive with anti-EtxB and anti-heterologous peptide monoclonal antibodies.     

Mating-induced loss of sex pheromone and sexual receptivity in insects with emphasis on Helicoverpa zea and Lymantria dispar

Mating in most species of insects leads to a transient or permanent loss in sexual receptivity of the females. Among moths, this loss of receptivity is often accompanied with a loss of the sex pheromone in the absence of calling, which also could be temporary or permanent. Most of the earlier work on changes in reproductive behavior after mating was done with Diptera in which sperm and/or male accessory gland secretions were shown to be responsible for termination of receptivity. In the corn earworm moth, Helicoverpa zea, mated females become depleted of pheromone and become nonreceptive to further mating attempts, but only for the remainder of the night of mating. A pheromonostatic peptide isolated from the accessory glands of males may be responsible for the depletion of pheromone, while the termination of receptivity is independently controlled. In the gypsy moth, Lymantria dispar, the changes in behavior following mating are permanent. In this species, the switch from virgin to mated behavior involves three steps: a physical stimulation associated with mating, transfer of viable sperm to the spermatheca, and commencement of oviposition. Signals generated by these factors operate through neural pathways and, unlike in H. zea, accessory gland factors seem not to be involved. © 1994 Wiley-Liss, Inc.

1 This article is a US Government work and, as such, is in the public domain in the United States of America.

     

1.56 Å structure of mature truncated human fibroblast collagenase

The X-ray crystal structure of a 19 kDa active fragment of human fibroblast collagenase has been determined by the multiple isomorphous replacement method and refined at 1.56 Å resolution to an R-factor of 17.4%. The current structure includes a bound hydroxamate inhibitor, 88 waters and three metal atoms (two zincs and a calcium). The overall topology of the enzyme, comprised of a five stranded β-sheet and three α-helices, is similar to the thermolysin-like metalloproteinases. There are some important differences between the collagenase and thermolysin families of enzymes. The active site zinc ligands are all histidines (His-218, His-222, and His-228). The presence of a second zinc ion in a structural role is a unique feature of the matrix metalloproteinases. The binding properties of the active site cleft are more dependent on the main chain conformation of the enzyme (and substrate) compared with thermolysin. A mechanism of action for peptide cleavage similar to that of thermolysin is proposed for fibroblast collagenase. © 1994 Wiley-Liss, Inc.     

Variability in life history traits of the aphid,Acyrthosiphon pisum (Harris), from sexual and asexual populations

Many aphid species have shown remarkable adaptability by invading new habitats and agricultural crops, although they are parthenogenetic and might be expected to show limited genetic variation. To determine if the mode of reproduction limits the level of genetic variation in adaptively important traits, we assess variation in 15 life history traits of the pea aphid, Acyrhosiphon pisum (Harris), for five populations sampled along a north-south transect in central North America, and for three traits for three populations from eastern Australia. The traits are developmental times and rates as affected by temperature, body weights as affected by temperature, fecundity, measures of migratory tendency, and photoperiodic responses. The most southerly population from North America is shown to be obligately parthenogenetic, as are the Australian populations, and the four more northerly North American populations are facultatively parthenogenetic with the number of parthenogenetic generations per year increasing from north to south. The broad-sense heritabilities of life history traits varied from 0.36 to 0.71 for nine quantitive traits based on a comparison of within-and between-lineage variances. Using these traits, 7–13 distinct genotypes (i.e. clones) were identified among each of the 18 lines sampled from the North American populations, but the number did not differ significantly among populations. The level of genetic variation differed from trait to trait. For 4 of 12 quantitative traits, the level of variation in the obligately parthenogenetic population from North America was lowest, but significantly lower than all the sexual populations for only 1 trait. The obligately parthenogenetic population had the highest level of genetic variation for two traits, and had intermediate levels for the others. The most northerly population, which was sexual and had relatively few parthenogenetic generations each year, had the lowest level of variation for 5 of 12 traits and the highest level of variation for 2 traits. There was no decline in variability from north to south correlated with the increase in the annual number of parthenogenetic generations. The Australian populations showed no less variation than the North American populations for two of three traits, although the pea aphid was introduced to Australia only 5 years prior to the study, whereas the aphid has been in North America for at least 100 years. The mode of reproduction has not had a substantial impact on the level of genetic variation in life history traits of the pea aphid, but there are population-specific factors that effect the level of variation in certain traits.     

Comparative physiology and demography of three Neotropical forest shrubs: alternative shade-adaptive character syndromes

A suite of functionally-related characters and demography of three species of Neotropical shadeadapted understory shrubs (Psychotria, Rubiaceae) were studied in the field over five years. Plants were growing in large-scale irrigated and control treatments in gaps and shade in old-growth moist forest at Barro Colorado Island, Panama. Irrigation demonstrated that dry-season drought limited stomatal conductance, light saturated photosynthesis, and leaf longevity in all three species. Drought increased mortality of P. furcata. In contrast, irrigation did not affect measures of photosynthetic capacity determined with an oxygen electrode or from photosynthesis-CO₂ response curves in the field. Drought stress limited field photosynthesis and leaf and plant survivorship without affecting photosynthetic capacity during late dry season. Leaves grown in high light in naturally occurring treefall gaps had higher photosynthetic capacity, dark respiration and mass per unit area than leaves grown in the shaded understory. P. furcata had the lowest acclimation to high light for all of these characters, and plant mortality was greater in gaps than in shaded understory for this species. The higher photosynthetic capacity of gap-grown leaves was also apparent when photosynthetic capacity was calculated on a leaf mass basis. Acclimation to high light involved repackaging (higher mass per unit leaf area) as well as higher photosynthetic capacity per unit leaf mass in these species. The three species showed two distinct syndromes of functionally-related adaptations to low light. P. limonensis and P. marginata had high leaf longevity (3 years), high plant survivorship, low leaf nitrogen content, and high leaf mass per unit area. In contrast, P. furcata had low leaf survivorship (1 year), high plant mortality (77–96% in 39 months), low leaf mass per unit area, high leaf nitrogen content, and the highest leaf area to total plant mass; the lowest levels of shelf shading, dark respiration and light compensation; and the highest stem diameter growth rates. This suite of characters may permit higher whole-plant carbon gain and high leaf and population turnover in P. furcata. Growth in deep shade can be accomplished through alternative character syndromes, and leaf longevity may not be correlated with photosynthetic capacity in shade adapted plants.