What is the current role for parenteral lipid emulsions containing omega-3 fatty acids in infants with short bowel syndrome?

Parenteral nutrition associated liver disease is the most common complication of pediatric short bowel syndrome (SBS). There is emerging evidence that the disease may be reversed with the use of parenteral lipid emulsions derived from fish-oils, which contain significant concentrations of omega-3 fatty acids (w3FA). This paper will review the rationale for the use of parenteral lipid emulsions containing w3FA in SBS and the evidence for their efficacy. Given the promising results and apparent safety of these emulsions, we shall also consider what the current role for PN lipid emulsions containing w3FA in children with SBS should be.

Adenosine A2A receptors in ventral striatum, hypothalamus and nociceptive circuitry implications for drug addiction, sleep and pain.

Adenosine A2A receptors localized in the dorsal striatum are considered as a new target for the development of antiparkinsonian drugs. Co-administration of A2A receptor antagonists has shown a significant improvement of the effects of l-DOPA. The present review emphasizes the possible application of A2A receptor antagonists in pathological conditions other than parkinsonism, including drug addiction, sleep disorders and pain. In addition to the dorsal striatum, the ventral striatum (nucleus accumbens) contains a high density of A2A receptors, which presynaptically and postsynaptically regulate glutamatergic transmission in the cortical glutamatergic projections to the nucleus accumbens. It is currently believed that molecular adaptations of the cortico-accumbens glutamatergic synapses are involved in compulsive drug seeking and relapse. Here we review recent experimental evidence suggesting that A2A antagonists could become new therapeutic agents for drug addiction. Morphological and functional studies have identified lower levels of A2A receptors in brain areas other than the striatum, such as the ventrolateral preoptic area of the hypothalamus, where adenosine plays an important role in sleep regulation. Although initially believed to be mostly dependent on A1 receptors, here we review recent studies that demonstrate that the somnogenic effects of adenosine are largely mediated by hypothalamic A2A receptors. A2A)receptor antagonists could therefore be considered as a possible treatment for narcolepsy and other sleep-related disorders. Finally, nociception is another adenosine-regulated neural function previously thought to mostly involve A1 receptors. Although there is some conflicting literature on the effects of agonists and antagonists, which may partly be due to the lack of selectivity of available drugs, the studies in A2A receptor knockout mice suggest that A2A receptor antagonists might have some therapeutic potential in pain states, in particular where high intensity stimuli are prevalent.

Interrelations between three proxies of health care need at the small area level: an urban/rural comparison.

STUDY OBJECTIVE: To examine the relations between geographical variations in mortality, morbidity, and deprivation at the small area level in the south west of England and to assess whether these relations vary between urban and rural areas. DESIGN: A geographically based cross sectional study using 1991 census data on premature limiting long term illness (LLTI) and socioeconomic characteristics, and 1991-1996 data on all cause premature mortality. The interrelations between the three widely used proxies of health care need are examined using correlation coefficients and scatterplots. The distribution of standardised LLTI residuals from a regression analysis on mortality are mapped and compared with the distribution of urban and rural areas. Multilevel Poisson modelling investigates whether customised deprivation profiles improve upon a generic deprivation index in explaining the spatial variation in morbidity and mortality after controlling for age and sex. These relations are examined separately for urban, fringe, and rural areas. SETTING: Nine counties in the south west of England. PARTICIPANTS: Those aged between 0-64 who reported having a LLTI in the 1991 census, and those who died during 1991-1996 aged 0-74. MAIN RESULTS: Relations between both health outcomes and generic deprivation indices are stronger in urban than rural areas. The replacement of generic with customised indices is an improvement in all area types, especially for LLTI in rural areas. The relation between mortality and morbidity is stronger in urban than rural areas, with levels of LLTI appearing to be greater in rural areas than would be predicted from mortality rates. Despite the weak direct relations between mortality and morbidity, there are strong relations between the customised deprivation indices computed to predict these outcomes in all area types. CONCLUSIONS: The improvement of the customised deprivation indices over the generic indices, and the similarity between the mortality and morbidity customised indices within area types highlights the importance of modelling urban and rural areas separately. Stronger relations between mortality and morbidity have been revealed at the local authority level in previous research providing empirical evidence that the inadequacy of mortality as a proxy for morbidity becomes more marked at lower levels of aggregation, especially in rural areas. Higher levels of LLTI than expected in rural areas may reflect different perceptions or differing patterns of illness. The stronger relations between the three proxies in urban than rural areas suggests that the choice of indicator will have less impact in urban than rural areas and strengthens the argument to develop better measures of health care need in rural areas.

Laparoscopic-assisted versus open ileocolic resection for adolescent Crohn disease.

BACKGROUND: Laparoscopic-assisted ileocolic resection for Crohn disease has been reported as an acceptable alternative to the open procedure in adults. We evaluated our experience with this procedure in the adolescent population. METHODS: All adolescents undergoing ileocolic resection for Crohn disease during a 3-year period were retrospectively reviewed. Intraoperative and early postoperative results were analyzed, comparing those undergoing the laparoscopic-assisted approach with those having open resection. RESULTS: Eleven patients (mean age, 15.6 years) underwent open and 12 patients (mean age, 16.5 years) underwent laparoscopic-assisted resection. None had undergone previous resection. The two groups did not differ with respect to time from diagnosis to surgery, indications for surgery, preoperative medical therapy, operative time, or length of intestine resected. One patient in the laparoscopic-assisted group was converted to an open procedure. There were no intraoperative complications in either group. Although no statistically significant differences were noted for number of days on narcotic, total dosage of narcotic, and time to regular diet, patients undergoing laparoscopic-assisted resection were discharged 2.2 days earlier (5.4 vs. 7.6; P < 0.05). There was one wound infection and one intraabdominal abscess in the open resection group, and a single patient in the laparoscopic-assisted group with postoperative fever and a wound infection. CONCLUSIONS: Laparoscopic-assisted ileocolic resection is a safe alternative to open surgery in adolescent patients with Crohn disease.

Conditional epidermal expression of TGFbeta 1 blocks neonatal lethality but causes a reversible hyperplasia and alopecia.

To study the role of transforming growth factor type beta1 (TGFbeta1) in epidermal growth control and disease, we have generated a conditional expression system by using the bovine keratin 5 promoter to drive expression of the tetracycline-regulated transactivators tTA and rTA, and a constitutively active mutant of TGFbeta1 linked to the tetO target sequence for the transactivator. This model allows for induction or suppression of exogenous TGFbeta1 with oral doxycycline. Maximal expression of TGFbeta1 during gestation caused embryonic lethality, whereas partial suppression allowed full-term development with neonatal lethality characterized by runting, epidermal hypoproliferation, and blocked hair follicle growth. With complete suppression, phenotypically normal double transgenic (DT) mice were born. Acute induction of TGFbeta1 in the epidermis of adult mice inhibited basal and follicular keratinocyte proliferation and reentry of telogen hair follicles into anagen. However, chronic expression of TGFbeta1 in adult DTs caused severe alopecia characterized by epidermal and follicular hyperproliferation, apoptosis, as well as dermal fibrosis and inflammation. Readministration of doxycycline to tTA DT mice caused hair regrowth within 14 days. The mRNA and protein for Smad7, an inhibitor of TGFbeta signaling, were up-regulated in the epidermis and hair follicles of alopecic skin and rapidly induced in rTA mice in parallel with the TGFbeta1 transgene, suggesting that the hyperproliferative phenotype may result in part from development of a sustained negative feedback loop. Thus, this conditional expression system provides an important model for understanding the role of TGFbeta1 during development, in normal skin biology, and in disease.

Dopamine D2 receptor inhibition of adenylyl cyclase is abolished by acute ethanol but restored after chronic ethanol exposure (tolerance).

Dopamine D2 (D2) receptors seem to mediate reinforcing responses to addicting drugs. A stably transfected NG108-15 cell line expressing the long form of the rat brain D2 receptor (D2L) was used to determine how ethanol modifies D2 receptor coupling to adenylyl cyclase. Activation of D2L receptors by the D2 receptor-specific agonist R-(-)-2,10,11-trihydroxy-N-propylnorapomorphine hydrobromide (NPA) inhibits both basal and receptor-stimulated cAMP production in these cells. Ethanol added acutely prevents D2L receptor inhibition of cAMP production. After chronic exposure to ethanol, however, D2L receptor coupling to adenylyl cyclase becomes tolerant to rechallenge with ethanol, i.e., ethanol no longer inhibits D2L receptor coupling and NPA inhibition of cAMP production is restored. Acute ethanol does not change NPA binding to D2 receptor in cell membranes but abolishes guanosine-5'-O-(3-thio)triphosphate induction of a lower-affinity state; chronic ethanol is without effect. The protein kinase A (PKA) inhibitor adenosine 3',5' cyclic monophosphorothioate, Rp-isomer, prevents acute ethanol inhibition of D2L receptor coupling. In contrast, the PKA activator adenosine 3',5' cyclic monophosphorothioate, Sp-isomer, reverses chronic ethanol-induced tolerance of D2L receptor coupling, restoring coupling to an ethanol-sensitive state. These results suggest that D2L receptor coupling to adenylyl cyclase via G(i) develops tolerance to ethanol inhibition, which appears to be influenced by PKA activity.

Analysis of factors associated with maternal mortality in Kenyan hospitals.

This paper examines the association of the sociodemographic characteristics of women and the unobserved hospital factors with maternal mortality in Kenya using multilevel logistic regression. The data analysed comprise hospital records for 58,151 obstetric admissions in sixteen public hospitals, consisting of 182 maternal deaths. The results show that the probability of maternal mortality depends on both observed factors that are associated with a particular woman and unobserved factors peculiar to the admitting hospital. The individual characteristics observed to have a significant association with maternal mortality include maternal age, antenatal clinic attendance and educational attainment. The hospital variation is observed to be stronger for women with least favourable sociodemographic characteristics. For example, the risk of maternal death at high-risk hospitals for women aged 35 years and above, who had low levels of education, and did not attend antenatal care is about 280 deaths per 1000 admissions. The risk for similar women at low-risk hospitals is about 4 deaths per 1000. To complement results from the analysis of individual patient records, the paper includes findings from hospital staff reports regarding the maternal mortality situation at the hospitals.

Factors associated with unfavourable birth outcomes in Kenya.

Studies addressing factors associated with adverse birth outcomes have almost exclusively been based on hospital statistics. This is a serious limitation in developing countries where the majority of births do not occur within health facilities. This paper examines factors associated with premature deliveries, small baby's size at birth and Caesarean section deliveries in Kenya based on the 1993 Kenya Demographic and Health Survey data. Due to the hierarchical nature of the data, the analysis uses multilevel logistic regression models to take into account the family and community effects. The results show that the odds of unfavourable birth outcomes are significantly higher for first births than for higher order births. Furthermore, antenatal care (measured by frequency of antenatal care visits and tetanus toxoid injection) is observed to have a negative association with the incidence of premature births. For the baby's size at birth, maternal nutritional status is observed to be a predominant factor. Short maternal stature is confirmed as a significant risk factor for Caesarean section deliveries. The observed higher odds of Caesarean section deliveries among women from households of high socioeconomic status are attributed to the expected association between socioeconomic status and the use of appropriate maternal health care services. The odds of unfavourable birth outcomes vary significantly between women. In addition, the odds of Caesarean section deliveries vary between districts, after taking into account the individual-level characteristics of the woman.

Cloning of a novel isoform of the mouse NBMPR-sensitive equilibrative nucleoside transporter (ENT1) lacking a putative phosphorylation site.

We have isolated a mouse cDNA clone corresponding to a novel isoform of the NBMPR-sensitive equilibrative nucleoside transporter (ENT1). The cDNA contains a 6 bp deletion in the open reading frame that changes the amino acid composition in a consensus casein kinase II (CKII) phosphorylation site at Ser-254. The clone containing Ser-254 is termed mENT1.1 and the clone lacking the serine termed mENT1.2. The deduced amino acid sequence of mENT1.1 corresponds to the previously cloned human and rat ENT1 proteins at Ser-254. Tissue distribution studies show that mRNA for both ENT1 isoforms are ubiquitously co-expressed in mouse. Analysis of genomic DNA corresponding to mouse ENT1 indicates the isoforms can be produced by alternative splicing at the end of exon 7. CEM/C19 cells stably expressing mENT1.1 and mENT1.2 show similar dose response curves for NBMPR and dipyridamole inhibition of [(3)H]adenosine uptake as well as exhibiting comparable selectivity for both purine and pyrimidine nucleosides but not the corresponding nucleobases.

A multilevel analysis of the effects of rurality and social deprivation on premature limiting long term illness.

STUDY OBJECTIVE: To examine the geographical variation in self perceived morbidity in the south west of England, and assess the associations with rurality and social deprivation. DESIGN: A geographically based cross sectional study using 1991 census data on premature Limiting Long Term Illness (LLTI). The urban-rural and intra-rural variation in standardised premature LLTI ratios is described, and correlation and regression analyses explore how well this is explained by generic deprivation indices. Multilevel Poisson modelling investigates whether Customized Deprivation Profiles (CDPs) and area characteristics improve upon the generic indices. SETTING: Nine counties in the south west of England PARTICIPANTS: The population of the south west enumerated in the 1991 census. MAIN RESULTS: Intra-rural variation is apparent, with higher rates of premature LLTI in remoter areas. Together with high rates in urban areas and lower rates in the semi-rural areas this indicates the existence of a U shaped relation with rurality. The generic deprivation indices have strong positive relations with premature LLTI in urban areas, but these are a lot weaker in semi-rural and rural locations. CDPs improve upon the generic indices, especially in the rural settings. A substantial reduction in unexplained variation in rural areas is seen after controlling for the level of local isolation, with higher isolation, at the wider geographical scale, being related to higher levels of LLTI. CONCLUSIONS: This study highlights the need to treat rural areas as heterogeneous, although this has not been the tendency in health research. Generic deprivation indices are unlikely to be a true reflection of levels of deprivation in rural environments. The importance of CDPs that are specific to the area type and health outcome is emphasised. The significance of physical isolation suggests that accessibility to public and health services may be an important issue, and requires further research.

Ethanol acts synergistically with a D2 dopamine agonist to cause translocation of protein kinase C.

Ethanol and other drugs of abuse increase synaptic dopamine levels; however, little is known about how ethanol alters dopaminergic signaling. We have reported that ethanol induces translocation of delta and epsilon protein kinase C (PKC) in neural cells in culture. Using NG108-15 and Chinese hamster ovary cell lines that express the dopamine D2 receptor (D2R), we show here that the D2R agonist R(-)-2,10,11-trihydroxy-N-propyl-noraporphine hydrobromide (NPA) also causes translocation of delta and epsilon PKC to the same sites as ethanol-induced translocation. D2R agonist and ethanol-induced translocation of delta and epsilon PKC share a common pathway that is blocked by pertussis toxin and requires phospholipase C (PLC) activity. These data suggest that both D2R agonists and ethanol activate PLC via a trimeric G protein leading to production of diacylglycerol with subsequent activation and translocation of delta and epsilon PKC. Moreover, ethanol and NPA, when present together at low concentrations that alone are ineffective, act synergistically to cause translocation of delta and epsilon PKC. Our data suggest that ethanol causes translocation of delta and epsilon PKC but cells expressing the D2R, such as neurons in the nucleus accumbens, may be particularly sensitive to low concentrations of ethanol.

Conditional gene expression in the epidermis of transgenic mice using the tetracycline-regulated transactivators tTA and rTA linked to the keratin 5 promoter.

To produce conditional expression of genes in the mouse epidermis we have generated transgenic mouse lines in which the tetracycline-regulated transcriptional transactivators, tTA and rTA, are linked to the bovine keratin 5 promoter. The transactivator lines were crossed with the tetOlacZ indicator line to test for transactivation in vivo. In the absence of doxycycline, the K5/tTA line induced beta-galactosidase enzyme activity in the epidermis at a level 500-fold higher than controls, and oral and topical doxycycline caused a dose- and time-dependent suppression of beta-galactosidase mRNA levels and enzyme activity. In the K5/rTA lines, doxycycline induced beta-galactosidase activity between 3- and 50-fold higher depending on the founder line, and this occurred within 24-48 h after dosing. Histochemical analysis of all lines localized beta-galactosidase expression to the basal layer of the epidermis and the outer root sheath of the hair follicle, as well as other keratin 5 positive tissues. In several K5/rTA lines, skin-specific transactivation was restricted to the hair follicle. Treatment of these double transgenic mice with 12-O-tetradecanoyl-phorbol-13-acetate caused rapid migration of beta-galactosidase marked cells from the hair follicle through the interfollicular epidermis, demonstrating the usefulness of this specific double transgenic for fate mapping cells in the epidermis. These results show that the tetracycline regulatory system produces effective conditional gene expression in the mouse epidermis, and suggest that it should be amenable to suppression and activation of foreign genes during development and specific pathologic conditions relevant to the epidermis.

Uncoupling of betaIIPKC from its targeting protein RACK1 in response to ethanol in cultured cells and mouse brain.

Protein kinase C (PKC) is involved in many neuroadaptive responses to ethanol in the nervous system. PKC activation results in translocation of the enzyme from one intracellular site to another. Compartmentalization of PKC isozymes is regulated by targeting proteins such as receptors for activated C kinase (RACKs). It is possible, therefore, that ethanol-induced changes in the function and compartmentalization of PKC isozymes could be due to changes in PKC targeting proteins. Here we study the response of the targeting protein RACK1 and its corresponding kinase betaIIPKC to ethanol, and propose a novel mechanism to explain how ethanol modulates signaling cascades. In cultured cells, ethanol induces movement of RACK1 to the nucleus without affecting the compartmentalization of betaIIPKC. Ethanol also inhibits betaIIPKC translocation in response to activation. These results suggest that ethanol inhibition of betaIIPKC translocation is due to miscompartmentalization of the targeting protein RACK1. Similar events occurred in mouse brain. In vivo exposure to ethanol caused RACK1 to localize to nuclei in specific brain regions, but did not affect the compartmentalization of betaIIPKC. Thus, some of the cellular and neuroadaptive responses to ethanol may be related to ethanol-induced movement of RACK1 to the nucleus, thereby preventing the translocation and corresponding function of betaIIPKC.

Genomic organization and expression of the mouse equilibrative, nitrobenzylthioinosine-sensitive nucleoside transporter 1 (ENT1) gene.

We have cloned and characterized the genomic structure of the mouse gene for the NBMPR-sensitive equilibrative nucleoside transporter (mENT1), which is located on chromosome 17C. About 12-kb of genomic DNA was sequenced including the promoter region, 12 exons, 11 introns, and the 3'-untranslated region. All exon-intron junction sequences conform to the GT/AG rule. Primer extension analysis demonstrated a transcription initiation site located 252 bp upstream of the translation start site. Analysis of the 2.5-kb 5'-flanking sequence shows putative binding sites for several transcription factors, including GATA-1, IRF-2, Pit-1, myogenin, CREB, Sp-1, Ap-2, MAZ, and GR. We demonstrated that mouse ENT1 mRNA was highly expressed in heart, spleen, lung, liver, and testis. Lower levels of expression were detected in brain and kidney. Functional analysis of the 5'-flanking region showed that the nucleotide sequence from -652 to -111 contains cis-regulatory elements that promote gene expression. We found two Sp-1 binding sites (-296/-303, -307/-313) and two MAZ binding sites (-353/-359, -522/-528) in this region. Luciferase assay results suggest that MAZ and Sp-1 transcription factors are important positive regulators of transcription for the ENT1 gene in NG108-15 cells.

The determinants of delivery care in Kenya.

This paper examines the determinants of place of delivery and childbirth attendant in Kenya based on the 1993 Kenya Demographic and Health Survey data. The analysis utilizes multilevel logistic and multilevel multinomial regression models for the place of delivery and the type of childbirth attendant, respectively. The results show that delivery care in Kenya is determined by a wide range of factors: socioeconomic and cultural factors associated with the individual woman or her household, her demographic status or reproductive behavior relating to a specific birth, as well as availability and accessibility of health services within her community. In addition, a significant variation in delivery care behavior is observed between women and between communities, implying that there are unobserved factors within families and communities that have a significant effect on delivery care. The woman or family effect on delivery care is particularly strong, but varies by distance to the nearest delivery care facility.

Contraceptive use dynamics of Asian women in Britain.

In-depth interviews were conducted with married Asian women from Indian, Pakistani and Bangladeshi backgrounds, to investigate patterns of contraceptive use and influences on contraceptive decision making. The results show two distinctively different contraceptive 'lifecycles'. Non-professional women typically have little knowledge about contraception until after their marriage or first birth. Their patterns of contraceptive behaviour show low levels of contraceptive use until after their first birth, when condom use is most prevalent. Non-professional women are influenced by their extended family, religion and cultural expectations on their fertility and family planning decisions. Professional women show an entirely different pattern of contraceptive behaviour. They are more likely to have knowledge about contraception before marriage, use some method of contraception throughout their childbearing years (typically the pill) and cite personal, practical or economic considerations in their fertility decisions rather than religious, cultural or extended family influences.

PIP: In-depth interviews on the patterns of contraceptive use and influences on contraceptive decision making were conducted among married Asian women from an Indian, Pakistani and Bangladeshi background. The data collected showed that there are significant variations in Asian women's reproductive strategies. Variations are evident in knowledge about family planning methods, timing of a first birth and timing of first use of contraception, birth spacing, and fertility. There are two distinctively different patterns of contraceptive use among Asian women: those of professional and nonprofessional women. Nonprofessional women usually have little knowledge about contraception until after their marriage or first birth. This is evident in their patterns of contraceptive behavior, which show low levels of contraceptive use until after their first birth. In contrast, professional women are more likely to have significant knowledge about contraceptive options before marriage and are able to make informed choices on their contraceptive needs. Unlike nonprofessional women, their fertility and family planning decision are not influenced by family, religion, or cultural expectations, but rather cites personal, practical, and economic considerations on their fertility decisions.

Chronic dipyridamole therapy produces sustained protection against cardiac ischemia-reperfusion injury.

Sustained protection against ischemia-reperfusion injury is not available for patients at risk for myocardial infarction who may require emergent reperfusion therapy. Whereas ischemic preconditioning and adenosinergic agents reduce myocardial injury, they are only effective when given immediately before ischemia or reperfusion. We recently found chronic ethanol exposure, an adenosine uptake inhibitor, produced sustained cardioprotection against ischemia-reperfusion injury. We now ask whether chronic dipyridamole therapy, a clinically usable nucleoside transport inhibitor, induces similar cardioprotection. Perfused hearts from guinea pigs, given dipyridamole (4 mg. kg(-1). day(-1)) in their water for 2-6 wk (n = 10 for each group), underwent ischemia-reperfusion. Injury was assessed by recovery of left ventricular developed (LVDP) and end-diastolic (LVEDP) pressures and creatine kinase release. During reperfusion, hearts from dipyridamole-treated animals (6 wk) had 74% higher LVDP, 28% lower LVEDP, and 61% lower creatine kinase release versus controls. Adenosine A(1)-receptor antagonism (8-cyclopentyl-1, 3-dipropylxanthine; 200 nM) abolished the protection of dipyridamole but A(2) antagonism (3,7-dimethyl-1-propargylxanthine; 10 mM) did not. Dipyridamole therapy produces sustained protection against ischemia-reperfusion injury in guinea pigs. This cardioprotection requires adenosine A(1) receptor signaling at the time of ischemia.

What determines geographical variation in rates of acceptance onto renal replacement therapy in England?

OBJECTIVE: To determine the independent effects of need and supply factors on the known geographical variation in acceptance rates onto renal replacement therapy (RRT) in England. METHODS: Data were obtained from all renal units in England on the characteristics of all cases aged 16 years and over, resident in England, who were accepted onto RRT in 1991 and 1992. Of these, 5715 (94.5%) had a valid postcode that could be matched to a census ward. Multilevel modelling using Poisson regression was used. The number of acceptances in each census ward within age bands 16-34, 35-64 and 65+ was the dependent variable. Independent effects modelled were: (1) individual factors (age, sex); (2) census ward need factors--ethnicity (expressed as the percentage of the ward population that was Asian or African-Caribbean), socio-economic deprivation--and supply factors--'access' to the nearest renal unit using crowfly and road travel time and distance, and services available to each ward expressed as number of haemodialysis stations per 100,000 catchment population of the nearest renal unit; (3) district health authority level effects. RESULTS: Age was a major determinant of acceptance, with a 7-fold higher rate in males aged over 64 years compared with younger men. Acceptance rates were lower in females, with a negative age-sex interaction in females aged over 64 years. The percentage of both Asian and African-Caribbean populations per ward was a highly significant positive determinant. Deprivation was also a significant determinant, best represented by a customised index. There was an inverse relation of acceptance with distance, especially road travel time. Other supply side variables had a significant effect though there was no independent district effect. There was some variation in the strength of these relationships by type of area (Greater London, urban and non-urban). CONCLUSIONS: Need and supply factors influence service use as expressed as acceptance onto RRT. Pressure to expand RRT services needs to be aimed at areas with large minority ethnic populations and those living far from existing units.