Comparison of patients' needs and doctors' perceptions of information requirements related to a diagnosis of oesophageal or gastric cancer.

The aim of this study was to assess the information needs of patients diagnosed with oesophageal and gastric cancer and to compare these with their perceived information needs in the opinion of junior doctors. One hundred patients and 100 doctors responded to a questionnaire regarding the information needs of cancer patients. Seventy-nine per cent of patients wanted as much information as possible about their diagnosis, but only 35% of doctors were willing to give all the available information (P < 0.0001). Seventy-seven per cent of patients wanted to receive their diagnosis from a consultant whereas only 5% of doctors believed that patients should receive their diagnoses from a consultant (P < 0.0001). Eighty-four per cent of doctors were willing to communicate a serious illness with a good prognosis, yet only 43% would communicate a diagnosis with a poor prognosis (P < 0.0001). All 100 doctors had received formal training in breaking bad news, but 20 considered this inadequate. Socio-economic deprivation was associated with poor access to supplementary Internet derived information (P < 0.001). The majority of patients with a diagnosis of oesophagogastric cancer want a great deal of information regarding their illness, which contrasts with doctors' perceptions. Adequate training in information disclosure may help address this issue.

Bluetongue virus in the Mediterranean Basin 1998-2001.

Bluetongue (BT) exists around the world in a broad band covering much of the Americas, Africa, southern Asia, northern Australia and, occasionally, the southern fringe of Europe. It is considered to be one of the most important diseases of domestic livestock. Recently the virus causing this disease has extended its range northwards into areas of Europe never before affected and has persisted in many of these locations causing the greatest epizootic of the disease on record. The reasons for this dramatic change in BT epidemiology are complex but are linked to recent extensions in the distribution of its major vector, Culicoidesimicola, to the involvement of novel Culicoides vector(s) and to an apparent ability of the virus to overwinter in the absence of adult vectors. In addition, the effects of these changes have been exacerbated by problems in control, particularly in relation to vaccination. This paper explores these areas and highlights prospects for the future.

Effect of temperature on the transmission of orbiviruses by the biting midge, Culicoides sonorensis.

The influence of temperature on the likelihood of Culicoides sonorensis Wirth & Jones (Diptera: Ceratopogonidae) transmitting African horse sickness virus (AHSV) serotypes 4 and 6, bluetongue virus (BTV) serotypes 10 and 16 and epizootic haemorrhagic disease of deer virus (EHDV) serotype 1 was investigated. Extrinsic incubation periods (EIP), vector competence and vector survival were determined at 15, 20, 25 and 30 degrees C. The effect of humidity on vector survival was also investigated by maintaining adult C. sonorensis at 40, 75 and 85% r.h. at each temperature. Higher temperatures were associated with a shorter EIP for all virus serotypes except AHSV6, to which C. sonorensis was orally refractory, increased vector competence for AHSV4 and EHDV1, but not for BTV10 or BTV16, and a reduction in vector survival. Humidity interacted with temperature in influencing vector survival, such that at low temperatures, lower humidity (40 and 75% r.h.) was detrimental for survival (up to 18% reduction in longevity), whereas at high temperatures, high humidity (85% r.h.) was detrimental (up to 36% reduction in longevity). In general, the transmission potential of C. sonorensis for AHSV4, EHDV1, BTV10 and BTV16 was greater at higher temperatures, because although vector survival was reduced, this was more than compensated for by the accompanying decrease in duration of the EIP.

Using climate data to map the potential distribution of Culicoides imicola (Diptera: Ceratopogonidae) in Europe.

Culicoides imicola, a vector of bluetongue virus and African horse sickness virus, is principally Afro-Asian in distribution, but has recently been found in parts of Europe. A logistic regression model based on climate data (temperature, saturation deficit, rainfall and altitude) and the published distribution of C. imicola in Iberia was developed and then applied to other countries in Europe, to identify locations where C. imicola could become established. The model identified three temperature variables as significant determinants of the distribution of C. imicola in Iberia (minimum of the monthly minimum temperatures, maximum of the monthly maximum temperatures and number of months per year with a mean temperature > or = 12.5 degrees C). The model indicated that under current conditions, the distribution of C. imicola in Spain, Greece and Italy could be extended and the vector could potentially invade parts of Albania, Yugoslavia, Bosnia and Croatia. To simulate the effect of global warming, temperature values in the model were increased by 2 degrees C. Under these conditions, the potential spread of C. imicola in Europe would be even more extensive.

Prediction of areas around the Mediterranean at risk of bluetongue by modelling the distribution of its vector using satellite imaging.

Bluetongue is an infectious disease of ruminants caused by a virus transmitted by biting midges, one species of which, Culicoides imicola, is the major vector in the Old World. Following an epizootic of African horse sickness,a related disease, in Iberia and Morocco between 1987 and 1991, C imicola was trapped for two years at 44 sites in the affected region and models were developed for predicting the abundance of C imicola at these sites. Discriminant analysis was applied to identify the best model of three levels of abundance from 40 Fourier-processed remotely sensed variables and a digital elevation model. The best model correctly predicted the abundance level at 41 of the 44 sites. The single most important variable was the phase of the annual cycle of the normalised difference vegetation index. The model was used to predict the abundances of C imicola elsewhere around the Mediterranean and predicted high levels of abundance in many areas recently affected by bluetongue, including the Balearics, Sardinia, Sicily, eastern Greece, western Turkey, Tunisia and northern Algeria. The model suggests that eastern Spain, the island of Ibiza, the provinces of Lazio and Puglia in Italy, the Peloponnese and parts of northern Algeria and Libya may be at risk of bluetongue in 2001.

Climate change: effects on culicoides--transmitted viruses and implications for the UK.

Changes in the distribution and abundance of insects are likely to be amongst the most important and immediate effects of climate change. We review here the risk that climate change poses to the UK's livestock industry via effects on Culicoides biting midges, the vectors of several arboviruses, including those that cause bluetongue (BT) and African horse sickness (AHS). The major old-world vector of BT and AHS viruses, C. imicola, occurs in southern Europe and will spread further north as global temperatures increase. It is unlikely, however, that in the foreseeable future it will reach and become established in the UK. As the distribution of C. imicola moves north, however, it may bring BT and AHS viruses into the range of other Culicoides species that are known to be competent vectors and which occur much further north. Once infected via this 'baton effect', these species may be able to spread the viruses over much of Europe, including the UK. Climate change may increase their vector competence further and will also increase the likelihood of viruses surviving from one year to the next. An additional risk is that the predicted increase in the frequency of short periods of hot temperatures may lead to the creation of novel vector species, by removing the barriers that in colder conditions make them refractory to viral infection.

Symptomatic hereditary type-II protein C deficiency caused by a missense mutation in exon IX of the protein C gene (Gly381 to Ser).

We report the characterization of the genetic defect in a family with hereditary type-II protein C (PC) deficiency. The propositus is a 28-year-old woman with a history of thrombosis. Her PC activity level (58%) and PC antigen level (115%) are compatible with the diagnosis of type-II PC deficiency. Her asymptomatic sister is also PC deficient. Analysis of the PC gene of the propositus revealed a point mutation (G to A) at nucleotide 8856, which results in the replacement of Gly381 by Ser in the heavy chain of PC. The amino acid change occurs close to the active-site serine at a residue which is highly conserved among the serine proteases. The mutation is also present in the PC gene of the propositus' sister. Her brother, who is asymptomatic, has a normal genotype with respect to the mutation at nucleotide 8856.

The risk of thromboembolism in asymptomatic patients with protein C and protein S deficiency: a prospective cohort study.

BACKGROUND: Prospective studies on the incidence of thrombosis in asymptomatic individuals with hereditary protein C- or protein S deficiency have not been performed so far. OBJECTIVE: We have carried out a prospective cohort study in 44 asymptomatic protein C- and protein S deficient subjects and in 49 asymptomatic non-deficient relatives (age at study entry > 14 years) of symptomatic deficient patients. METHODS: 20 asymptomatic protein C deficient (median age 20 years) and 24 asymptomatic protein S deficient patients (median age 21.5 years) were prospectively followed and compared with 20 asymptomatic non-deficient relatives (median age 25 years) of protein C- and 29 (median age 27 years) of protein S deficient patients. The total observation period was 118.8 patient years for protein C deficient and 92.8 for protein S deficient patients. Patients were not on anticoagulants except for short duration in case of high risk situations. RESULTS: Eight thromboembolic events (1 pulmonary embolism, 1 deep vein thrombosis + pulmonary embolism, 3 deep vein thrombosis, 1 caval vein thrombosis and 2 superficial vein thrombosis) occurred in 6 deficient patients. The incidence of thromboembolism was 2.5% per patient year for protein C deficient and 3.5% per patient year for protein S deficient patients. 4 events occurred spontaneously, in 2 patients thromboembolic events were triggered by high risk situations (caesarean section, minor trauma). In the controls no thromboembolic events occurred. The probability for thromboembolism was significantly higher in protein C and protein S deficient patients compared to the control group (Wilcoxon test, p = 0.002, log rank test, p = 0.001). One major and 5 minor uneventful surgeries were carried out in the deficient patients using heparin prophylaxis. 1/8 pregnancies was complicated by superficial vein thrombosis during the second trimester despite prophylactic heparin administration. The same pregnancy was complicated by pulmonary embolism 5 weeks after delivery after discontinuation of heparin. CONCLUSIONS: Asymptomatic deficient relatives of symptomatic patients with protein C or protein S deficiency are at an increased risk of thrombosis compared to nondeficient individuals. Prophylactic treatment seems to be highly effective in high risk situations.

[Chronic lymphatic leukemia]. / Chronisch lymphatische Leukämie.

Chronic lymphocytic leukemia of the B-cell type (B-CLL) is the most common type of leukemia. The diagnosis is based on the demonstration of sustained lymphocytosis, bone marrow lymphocytosis and the presence of CD 19/CD5 positive cells. The most important prognostic factor is the stage of the disease (according to RAI or BINET) and the lymphocyte doubling time. Most early stage patients do not benefit from chemotherapy and, indeed, some of these patients never require treatment. Stage A patients with active disease and stage B patients are treated conventionally with chlorambucil/prednisone, but the optimum dosage and duration of chlorambcil treatment has not yet been established. In stage C patients anthracycline containing regimens appear to be more effective. The nucleoside analogues fludarabine and 2-chlorodeoxyadenosine (cladribine) have been shown to be active in patients refractory to alkylating agents. Their role in primary treatment is currently being evaluated in ongoing studies. For a small proportion of patients with advanced disease aged less than 55 years allogeneic or autologous bone marrow transplantation offers the chance of long term remission and possibly even cure, which never can be achieved with conventional chemotherapy.