"The doctor will see you now": Direct support professionals' perspectives on supporting adults with intellectual and developmental disabilities accessing health care during COVID-19.

BACKGROUND: It is critical to consider how rapid changes in health care delivery and the rise in use of virtual modalities have impacted adults with intellectual and developmental disabilities and caregivers. OBJECTIVE: The purpose of this paper is to describe direct support professionals' experiences assisting adults with intellectual and developmental disabilities in accessing virtual and in-person health care during COVID-19. METHODS: A content analysis was conducted on responses obtained from an online questionnaire distributed to 942 direct support professionals in Canada. Descriptive statistics were used to report the type of visits that occurred and open text responses describing these visits were coded. RESULTS: Twenty four percent of direct support professionals reported supporting someone at an in-person medical appointment, 22% reported attending at least one video-based virtual appointment and 58% reported supporting at least one phone based virtual appointment in the first 5 months of the pandemic. They identified several barriers and facilitators with each type of visit which suggests there is no "single way" to provide health care to this group, but that optimal care depends on maximizing the fit between the person's abilities, the skill set of direct support professionals and health care providers, and the presenting health care issue. CONCLUSIONS: Study findings provide insight into the experience of health care for this population during COVID-19 and can be used to support direct support professionals and adults with intellectual and developmental disabilities to adapt to safe, supportive and comprehensive virtual and in-person health care during the pandemic and beyond.

Help-seeking experiences of men diagnosed with colorectal cancer: a qualitative study.

Advanced-stage diagnosis of colorectal cancer (CRC) leads to poor prognosis and reduced survival rates. The current study seeks to explore the reasons for diagnostic delays in a sample of Australian men with CRC. Semi-structured interviews were conducted in a purposive sample of 20 male CRC patients. Data collection ceased when no new data emerged. Interviews were audiotaped, transcribed and thematically analysed using Andersen's Model of Total Patient Delay as the theoretical framework. Most participants (18/20) had experienced lower bowel symptoms prior to diagnosis. Patient-related delays were more common than delays attributable to the health-care system. Data regarding patient delays fit within the first four stages of Andersen's model. The barriers to seeking timely medical advice were mainly attributed to misinterpretation of symptoms, fear of cancer diagnosis, reticence to discuss the symptoms or consulting a general practitioner. Treatment delays were a minor cause for delayed diagnosis. Delay in referral and scheduling for colonoscopy were among the system-delay factors. In many instances, delays resulted from men's failure to attribute their symptoms to cancer and, subsequently, delay in diagnosis.

A trial of a self-assessment tool of problems following treatment of colorectal cancer: a prospective study in Australia primary care.

Patients treated for colorectal cancer (CRC) experience considerable physical, social and psychological morbidity. In this study, 66 participants with stages I-III CRC were enrolled in this study. Participants completed the self-assessment tool for patients (SATp) over a 5-month period and visited a general practitioner with a copy of their SATp to assist in the management of any problems associated with CRC treatment. General practitioners' notes were reviewed for management actions. Of the 66 participants, 57 visited a general practitioner over the 5-month study period. A total of 547 problems were identified (median 7; IQR: 3-12.25). Participants with physical problems were more likely to consult their general practitioner (OR: 1.84, CI: 1.05-3.21, P = 0.03) compared to those with psychological problems. The number of problems experienced by participants did not have any influence on the decision to visit a general practitioner. Psychological problems (P < 0.01) significantly reduced over the 5-month study period. Regular use of the SATp facilitates the identification of long-term CRC treatment-related problems. Some of these problems could then be addressed in primary care.

Patients' perspectives on the role of their general practitioner after receiving an advanced cancer diagnosis.

The aim of this study was to explore patients' perspectives on the role of their general practitioner (GP) after an advanced cancer diagnosis. A qualitative research approach was used. Semi-structured interviews were conducted and data were analysed using a constant comparative methodology. Participants were eligible if they were diagnosed with advanced cancer and referred for palliative radiotherapy. Data saturation was achieved after 21 interviews. Key themes included (1) obtaining diagnosis and referral for advanced cancer treatment; (2) preference for specialist oncology care; (3) a preference for GP to act as an advocate; and (4) obtaining ongoing routine care from their GP. GP involvement in the patients' management was dependent on: time since diagnosis, GP's involvement in diagnosis and referral, doctor/patient relationship, additional chronic conditions requiring management, frequency of seeing oncologist and specialist recommendation to involve GP. Patients want GPs to have varying levels of involvement following an advanced cancer diagnosis. Not all communication between GPs and patients was positive suggesting communication skills training may be a priority. Patients wished to maintain continunity of care for their non-cancer related issues and healthcare of their family members. Future research needs to focus on working with GPs to increase their role in the management of advanced cancer.

An investigation of factors that influence general practitioners' referral of computed tomography scans in patients with headache.

AIM: In assessing patients with headaches, general practitioners (GPs) play an important role in determining which patients require computed tomography (CT) scans. The purpose of this study was to identify factors that influence GPs' decisions to refer CT scans for patients with headaches. MATERIALS AND METHODS: A self-administered survey was presented to GPs in Western Australia. One hundred and twenty-eight vignettes describing patients who may have required CT referral for headache were constructed encompassing six clinical variables. Nine vignettes, selected at random, were presented to each respondent. Respondents were asked if they would refer the patient for diagnostic imaging tests, if so, which imaging modalities would they request, how urgently and the perceived benefits of the requested imaging modality. Multinomial logistic regression was used for the multivariate analysis. RESULTS: We received 105 completed questionnaires (21%). GPs were more likely to refer patients with headaches for diagnostic imaging and CT scans in the following clinical scenarios: patients with a history of colorectal cancer and epilepsy; and patients feeling unwell for the past 6 weeks and headache being exacerbated with valsalva manoeuvrers. Private health insurance and other respondent demographics such as GPs experience and site of care increased imaging referral. CONCLUSION: GP's referral decisions of diagnostic imaging and CT examinations for patients with headaches are dependent on clinical scenarios and the likelihood of a significant pathology. Further research is required to identify the significant clinical findings with regard to the CT referrals and ensure that CT scans are not requested in patients who are unlikely to benefit.

The management of Type 2 diabetes: a survey of Australian general practitioners.

OBJECTIVE: To explore how clinical and demographic variables impact on the management of diabetes mellitus in general practice. DESIGN: A structured vignette survey was conducted in Australia. This included nine vignettes chosen at random from 128 developed around seven clinical variables. Respondents were asked to recommend a change in treatment and make specific recommendations. A random sample of general practitioners (GPs) were recruited. Two diabetologists involved in the development of national guidelines also participated. RESULTS: 125 (13.8%) GPs participated. Statistical analyses were used to generate outcome measures. GPs recommended a change in treatment for most (81.1%) cases; were less likely to prescribe a statin (68.5% GPs vs. 76.3% diabetologists), less likely to treat hypertension (66.7% vs.89%) and less likely to refer for lifestyle modification (82.3% vs. 96.5%). Significant disagreement occurred around prescribing or changing oral hypoglycaemics. No GP characteristics showed significant impact. The proportion of GPs who agreed with diabetiologists on dose and choice of drugs was 35.7% for statins, 49.6% for antihypertensives and 39.6% for oral hypoglycaemics. CONCLUSIONS: There were significant differences between diabetologists and GPs on the management of diabetes. The survey suggests significant under-dosing by GPs. These findings warrant further investigation.

Management of cases that might benefit from radiotherapy: a standardised patient study in primary care.

The aim of this study was to assess general practitioner (GP) consultations with standardised patients presenting with cancer-related problems that might benefit from radiotherapy. Standardised patient scenarios were constructed with indications for radiotherapy or with side effects of radiotherapy. Six GPs consulted six standardised patients. All consultations were video recorded. Two GPs independently rated the consultation performance using the Leicester Assessment Package (LAP). Each consultation was also assessed by two radiation oncologists to assess specific decisions taken or advice offered to 'patients' in each case. The mean duration of consultations was 13 min and 55 s. Three GPs differed significantly (P < 0.025) in competencies measured by the LAP, but not as assessed by radiation oncologists. There was no significant difference in LAP scores when reviewed by scenario. However, there was significant differences in the management of the case with prostate cancer (P= 0.005) and data suggest that GPs management of different problems presented varied widely. These data are consistent with the published literature which suggests that in practice not all patients are appropriately advised or referred. There is a need for innovations to support GPs to manage patients who would benefit from radiotherapy.

Repeat attenders at National Health Service walk-in centres - a descriptive study using routine data.

OBJECTIVES: Whilst numerous studies have examined repeat attendance at general practices or emergency departments, little is known about repeat attenders at walk-in centres. The aim of this study was to examine age, gender, socio-economic status, distance from walk-in centre, day and time of attendance in relation to repeat attendance at walk-in centres. STUDY DESIGN: Descriptive study using routine data from four walk-in centres in England, two of which were located in London and were accessible to local and commuter populations. METHODS: Data for 2 years (2003-2004) were examined. Age, gender, day and time of attendance were obtained from administrative records. Distance was calculated from the census output area of residence to walk-in centre attended. The Index of Multiple Deprivation (Income Domain) was used as an indicator of socio-economic deprivation at the small-area level. RESULTS: Thirty-nine percent of 272,701 attendances by 166,486 patients were repeat attendances. Seventy percent of patients attended once, 27.9% attended two to five times, and 2.2% attended on over five occasions over the 2-year study period. Patients attending the two London walk-in centres lived closer than those attending the two walk-in centres outside London (percentage living 6 km or more from walk-in centre: 9% and 12% compared with 18% and 22%). The London walk-in centres had a higher percentage of single attenders (74.1% and 78%) compared with the other two walk-in centres (63.3% and 64.7%). Repeat attenders lived closer to walk-in centres than single attenders. Adjusted odds ratios for patients living within 3 km of the walk-in centre relative to patients living 6 km or more from the walk-in centre ranged from 1.59 [95% confidence interval (CI) 1.42-1.78] to 3.34 (95% CI 3.12-3.57) for patients attending two to five times, and from 2.37 (95% CI 1.36-4.11) to 14.99 (95% CI 11.30-19.88) for patients with over five attendances. There was substantial variation with significant contrasting patterns in odds ratios across walk-in centres in relation to the other variables. Repeat attenders were older than single attenders at three of the four walk-in centres. Repeat attenders tended to be more likely to be male at two walk-in centres, and less likely to be male at the other two walk-in centres. Socio-economic deprivation tended to be associated with repeat attendance at one of the walk-in centres. There were also significant and contrasting patterns in relation to day and, to a lesser extent, time of attendance. CONCLUSIONS: Users living near walk-in centres are more likely to be repeat attenders. Age, gender, socio-economic deprivation, day and time of attendance had significantly higher or lower odds ratios for repeat attendance at different walk-in centres, suggesting that organizational and other factors may determine patterns of repeat attendance.

Increases in asthma hospital admissions associated with the end of the summer vacation for school-age children with asthma in two cities from England and Scotland.

In school-age asthmatics, an increase in hospitalizations has been reported in early autumn. This increase in admissions is conjectured to be associated with the return back to school. In the UK schools in England complete their summer vacations 2 weeks later than in Scotland and so there should be a lag between the two countries in the increase in asthma episode. Daily hospital asthma admission data from Aberdeen (in Scotland) and Doncaster (in England) for the period July 23rd to October 8th for years 1999-2004 were included in the analysis. There are peaks in hospitalization after the return back to school for both Aberdeen and Doncaster with the peak for Doncaster appearing 2 weeks after Aberdeen. This study has demonstrated peaks in admissions in school-age children around the return back to school in two cities where different school return dates were reflected in a 2-week lag effect. These data therefore provide strong evidence that peaks in admissions are associated with the end of the summer holidays.

Measuring the quality of referral letters about patients with upper gastrointestinal symptoms.

BACKGROUND: General practitioners state the reason for referring patients in referral letters. The paucity of information in these letters has been the source of criticism from specialist colleagues. OBJECTIVE: To invite general practitioners to set standards for referral letters to gastroenterologists and to apply these standards to actual referral letters to one specialist gastroenterology unit. METHODS: A scoring schedule was designed based on the responses to a questionnaire survey of a large sample of all general practitioners in one locality. Altogether 350 consecutive letters to a district general hospital about patients referred for an upper gastrointestinal specialist opinion were subsequently scored using the schedule. RESULTS: 102 practitioners responded to the survey. Their responses imply that colleagues assess and record findings on 18 potential features of upper bowel disease. In practice most referral letters address fewer than six features of upper bowel disease. The mean number of positive features of upper gastrointestinal disease reported in each letter was one. CONCLUSIONS: This study reported a failure to meet "peer defined" standards for the content of referral letters set by colleagues in one locality. Referral letters serve many purposes, however, encouraging full documentation of specific clinical findings may serve to increase the pre-referral assessments performed in practice.

In lymph node-negative invasive breast carcinomas, specific chromosomal aberrations are strongly associated with high mitotic activity and predict outcome more accurately than grade, tumour diameter, and oestrogen receptor.

The objectives of this study were to analyse whether specific chromosomal gains and losses in lymph node-negative breast cancer correlate with other features and to evaluate their prognostic value. Seventy-six lymph node-negative breast carcinomas (median follow-up 46 months; range 9-105 months) were used. Histological grade, tumour type, maximal tumour diameter, oestrogen/progesterone receptor (ER/PR), mitotic activity index (MAI), and mean nuclear area (MNA) were assessed. Whole genome DNA analysis was performed by comparative genomic hybridization (CGH). Chromosomal aberrations were compared with classical and other prognostic features. Kaplan-Meier curves and multivariate survival analysis (Cox model) were used to assess the prognostic value of the CGH and other data. Fifteen (21.4%) out of 70 patients (six cases were lost to follow-up) developed locoregional (n=3) or distant metastases (n=12). The following criteria were prognostic for (any) recurrence (in decreasing significance): 3q gain, simultaneous gain at 1q and 8q, MAI < versus > or =10, MNA < versus > or =63 microm. Loss of 1p occurred significantly more often in the large group of ductal breast carcinomas with a MAI > or =10 (n=38) than in cancers with a MAI<10. Moreover, 8/15 (53%) patients with recurrences had a gain at 3q, as opposed to three (5.5%) of the 55 recurrence-free patients. This association was even stronger in ductal carcinomas (hazard ratio=10.9, p<0.0001). Cox regression revealed that the 3q gain was the strongest prognostic factor; other features did not have additional prognostic value. In conclusion, loss of 1p is associated with a high MAI. A gain of 3q is a stronger predictor of recurrence than grade, MAI, and other features in invasive breast cancers.

Prospective multicenter evaluation of the morphometric D-score for prediction of the outcome of endometrial hyperplasias.

Prospective multicenter evaluation of the WHO classification and the morphometric D-score to predict endometrial hyperplasia cancer progression. In 132 endometrial hyperplasias WHO classification was performed by two experienced gynecologic pathologists. The D-score was assessed blindly by technicians in a routine diagnostic setting. Development of endometrial carcinoma during a 1-10-year follow-up was used as the end point. Eleven of 132 patients (8%), 10 of 61 (16%) atypical hyperplasias, and 1 of 71 (1%) nonatypical hyperplasias developed cancer. Twenty-six curettings had a D-score < or = 0 ("unfavorable" or endometrial intraepithelial neoplasia) of which 10 (38%) developed cancer. None of the 86 cases with a D-score > 1 ("favorable") and one of the 20 (5%) cases with 0 < D-score < or = 1 ("uncertain") developed cancer. Sensitivity of the D-score was 100%, specificity 82%, the positive and negative predictive values were 38% and 100%, respectively. These values are similar to those in three prior retrospective D-score studies but higher than the WHO values (which are 91%, 58%, 16%, and 99%, respectively). The D-score in endometrial hyperplasias is a more sensitive and specific marker for cancer prediction than the WHO classification, can be assessed in a routine clinical setting on standard hematoxylin and eosin sections (15-30 minutes per case), and is highly reproducible and cost-effective (U.S. $50 per case).

Ki-67 immunoquantitation in cervical intraepithelial neoplasia (CIN): a sensitive marker for grading.

The aim of this study was to assess the value of Ki-67 immunoquantitation with a computerized image analysis system for grading support in cervical intraepithelial neoplasia (CIN). Sixty-five 'blind' consensus biopsies (23 CIN 1, 22 CIN 2, and 20 CIN 3) were used as a learning set. Measurements were done in the carefully selected most severely dysplastic part of the epithelium of each CIN case. The resulting discriminating combination of quantitative features was then prospectively applied on 121 new biopsies (test set) and compared with the classical CIN grade assessed routinely by six different pathologists and with the blind review grades assessed by two experienced pathologists. In the learning set of 65 cases, a jack-knifed stepwise discriminant analysis showed that the 90th percentile of the stratification index and the number of positive nuclei per 100 microm basal membrane are the best discriminating set of features to distinguish the three CIN grades at the same time. With these features, two CIN 1 cases were 'misclassified' as CIN 2 and nine CIN 2 cases as CIN 3. Overall agreement, therefore, was only 83%. However, recut of the paraffin blocks in the two 'misclassified' CIN 1 cases revealed CIN 2 in the first and CIN 3 in the other, while the other CIN 1 cases that were correctly classified with Ki-67 quantitation remained CIN 1. Likewise, nine CIN 2 cases were misclassified as CIN 3, but in two of these nine cases histological follow-up clearly indicated CIN 3. Agreement may thus be higher than the 83% in the learning set suggests. In the subsequent prospective evaluation on 121 routine CIN cases (test set), agreement between routine CIN grades (by six independent different pathologists) and quantitative Ki-67 classification was 78%. However, when compared with the blind review CIN grades of two expert pathologists, agreement was 97% and sensitivity, specificity, and positive and negative predictive value were very high. It is concluded that Ki-67 immunoquantitation is a useful diagnostic adjunct to distinguish different CIN grades and may also be a sensitive biological indicator of progression of seemingly low-grade CIN.

Frequent attenders in general practice: an attempt to reduce attendance.

BACKGROUND: 'Frequent attenders' in general practice are known to include patients with a variety of problems. Most studies of frequent attenders have not assessed the impact of providing GPs with detailed summaries of the clinical records of these patients on consultation rates. Good medical records are associated with good care. If it is not relatively easy or quick for GPs to ascertain which chronic illness or psychosocial problems the patient has from the records, it will be difficult to manage the patient proactively. OBJECTIVE: The aim of this study was to investigate the impact on the consultation rate of providing a detailed and accessible summary of patients' problems including physical, social and psychological data based on information already recorded in the patients' records. METHOD: A prospective controlled study was made of frequent attenders at one UK general practice comprising four full-time GPs. A total of 104 frequent attenders were identified by examining the lists of patients attending the surgery and by including the names of patients identified by GPs from memory. The final study groups were patients who consulted a GP 11 times or more in a year. The sample was divided into two groups. In both groups, the clinical notes were summarized for data relating to physical, social and psychological problems. In the intervention group, summaries were displayed prominently in the notes which were marked with a distinctive label. GPs were asked to read and initial the available summaries in these notes. In the control group, summaries were not included in the notes and the notes were not highlighted in any way. The consultation rate of these 104 patients was recorded for 5 months after the availability of the summaries in the notes. RESULTS: Summarizing the notes in the style described in this study failed to reduce the consultation rate of the identified frequent attenders (Kruskal-Wallis H = 2.75, P = 0.1) Furthermore, in the intervention group, patients for whom there was evidence that the summaries had been consulted by their GP (24; 46%) continued to attend as frequently as those whose summaries were not endorsed as consulted (mean attendance 4.8 consultations compared with 4.2 in 5 months). CONCLUSION: Frequent attenders often have multiple problems, but prominently displayed summaries of their history for use by GPs during consultations do not reduce the frequency of consultations.

Low p53 and high bcl-2 expression in Reed-Sternberg cells predicts poor clinical outcome for Hodgkin's disease: involvement of apoptosis resistance?

A high number of activated cytotoxic T lymphocytes (CTL) in Hodgkin's disease (HD) biopsy specimens is related to an unfavorable clinical outcome, suggesting that resistance of the Hodgkin and Reed-Sternberg (H-RS) cells to CTL-mediated killing is an important pathogenic factor in HD. bcl-2 and defective p53 are known to inhibit apoptosis induced either by CTLs or by therapy. The purpose of this study was to use immunohistochemical techniques to analyze whether differences in expression of these proteins in H-RS cells in primary biopsy specimens from 78 patients with HD were related to clinical outcome and to assess the number of CTLs in those cells. Cases with H-RS cells mostly staining positive for bcl-2 but negative for p53 had a poor prognosis (55% 5-yr survival). In the group of patients whose H-RS cells had low positivity for both p53 and bcl-2, the 5-year survival was 90%. p53 expression in a high percentage of H-RS cells was invariably related to a 100% 5-year survival, irrespective of bcl-2 expression. Biopsy specimens from patients with a fatal clinical outcome, in which few H-RS cells expressed p53 and many H-RS cells expressed bcl-2, contained relatively many activated CTLs. These data demonstrate that the combination of expression of the apoptosis-regulating proteins p53 and bcl-2 in the H-RS cells can be used as a prognostic marker for HD, and they indicate that resistance to apoptosis of H-RS cells is an important pathogenic mechanism. Our data also support the hypothesis that in patients with a poor prognosis, apoptosis-resistant H-RS cells might be selected for by the presence of many activated CTLs.

Multiprimed cDNA synthesis followed by PCR is the most suitable method for Epstein-Barr virus transcript analysis in small lymphoma biopsies.

In this study, the reverse transcriptase-polymerase chain reaction (RT-PCR) for the reliable detection of multiple Epstein-Barr virus (EBV) transcripts was optimized and subsequently evaluated on lymphoma specimens. Since often only small lymphoma biopsies are available for analysis of EBV transcripts, several RT-protocols to generate cDNA from multiple targets were applied. These were multi-primer, oligo-dT primed and random hexamer primed cDNA synthesis. Multi-primer cDNA synthesis appeared to be the most suitable method for subsequent PCR analysis of EBV targets; simultaneous priming with up to 10 specific antisense primers (for EBNA1 and 2, LMP1 and 2, BARF0, BHRF1, BZLF1, C promoter activity and the RNA control genes U1A and c-abl) followed by PCR showed no loss of sensitivity compared to single-specific antisense priming. Transcripts were specifically detected in up to one EBV-positive JY cell in a background of 50,000 EBV-negative BJAB cells, with the exception of BZLF1 and QK spliced EBNA1 transcripts which could only be detected in 1000 and 10,000 EBV-positive cells, respectively. The analytical sensitivities of all the primers used in PCR, including BZLF1 and QK EBNA1 primers, were 1-10 copies of cloned RT-PCR products. The multi-primed RT-PCR was evaluated on lymphomas (n = 13). In cases with proper RNA quality, EBV expression patterns found were identical to those found in previous studies using single-primed RT-PCR assays. In conclusion, this study shows that multi-primed RT-PCR analysis can be used efficiently for EBV transcript analysis in small lymphoma biopsies, thereby facilitating studies concerning the role of EBV in lymphomagenesis.

Presence of Epstein-Barr virus latency type III at the single cell level in post-transplantation lymphoproliferative disorders and AIDS related lymphomas.

AIMS: To investigate the expression pattern of Epstein-Barr virus (EBV) latent genes at the single cell level in post-transplantation lymphoproliferative disorders and acquired immunodefiency syndrome (AIDS) related lymphomas, in relation to cellular morphology. METHODS: Nine post-transplantation lymphoproliferative disorders and three AIDS related lymphomas were subjected to immunohistochemistry using monoclonal antibodies specific for EBV nuclear antigen 1 (EBNA1) (2H4), EBNA2 (PE2 and the new rat anti-EBNA2 monoclonal antibodies 1E6, R3, and 3E9), and LMP1 (CS1-4 and S12). Double staining was performed combining R3 or 3E9 with S12. RESULTS: R3 and 3E9 anti-EBNA2 monoclonal antibodies were more sensitive than PE2, enabling the detection of more EBNA2 positive lymphoma cells. Both in post-transplantation lymphoproliferative disorders and AIDS related lymphomas, different expression patterns were detected at the single cell level. Smaller neoplastic cells were positive for EBNA2 but negative for LMP1. Larger and more blastic neoplastic cells, sometimes resembling Reed-Sternberg cells, were LMP1 positive but EBNA2 negative (EBV latency type II). Morphologically intermediate neoplastic cells coexpressing EBNA2 and LMP1 (EBV latency type III), were detected using R3 and 3E9, and formed a considerable part of the neoplastic population in four of nine post-transplantation lymphoproliferative disorders and two of three AIDS related lymphomas. All samples contained a subpopulation of small tumour cells positive exclusively for Epstein-Barr early RNA and EBNA1. The relation between cellular morphology and EBV expression patterns in this study was less pronounced in AIDS related lymphomas than in post-transplantation lymphoproliferative disorders, because the AIDS related lymphomas were less polymorphic than the post-transplantation lymphoproliferative disorders. CONCLUSIONS: In post-transplantation lymphoproliferative disorders and AIDS related lymphomas, EBV latency type III can be detected by immunohistochemistry in a subpopulation of tumour cells using sensitive monoclonal antibodies R3 and 3E9. Our data suggest that EBV infected tumour cells in these lymphomas undergo gradual changes in the expression of EBV latent genes, and that these changes are associated with changes in cellular morphology.

Autonomy: the need for limits.

This essay addresses the issue of the autonomy of the National Health Service (NHS) patient in the UK. It is argued, with reference to clinical examples, that some patients abuse their rights to medical care to the detriment of other patients and the service providers. A case is made for limiting the rights of patients in order to improve the service for all who use it. A range of mechanisms are considered with a discussion of the issues raised by each solution in turn.