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Background: Photodynamic therapy (PDT) involves the activation of a photosensitizer by visible light to produce activated oxygen species within target cells, resulting in their destruction. Evidence-based guidelines support the efficacy of PDT using topical 5-aminolaevulinic acid (ALA-PDT) in actinic keratoses, Bowen disease and basal cell carcinoma (BCC). Efficacy for nodular BCC appears inferior to that for superficial BCC unless prior debulking or repeat treatments are performed. Objectives The aim of this study was to assess the safety and efficacy of adding a novel iron-chelating agent, CP94 (1,2-diethyl-3-hydroxypyridin-4-one hydrochloride), to topical ALA, to temporarily increase the accumulation of the photosensitizer in the tumour., Methods: A mixed topical formulation of ALA + increasing concentrations of CP94 was used to carry out PDT on previously biopsied nodular BCC with no prior lesion preparation using standard light delivery. The area was assessed clinically and surgically excised 6 weeks later for histological examination., Results: Enhanced PDT using 40% CP94 resulted in significantly greater clearance rates in nodular BCC than with ALA-PDT alone, in our protocol of single-treatment PDT with no lesion preparation., Conclusions: The results of this study demonstrate the safe and effective use of an enhanced ALA-PDT protocol for nodular BCC using CP94, with no adverse reactions to this modification. This is the first time this formulation has been used in patients. This formulation is now the focus of further study.

Purpose: We conducted an in-depth exploration of family physicians' and nurses' beliefs and concerns about changes to the family health care service as a result of the new pay-for-performance scheme in the United Kingdom (Quality and Outcomes Framework [QOF])., Methods: Using a semistructured interview format, we interviewed 21 family doctors and 20 nurses in 22 nationally representative practices across England between February and August 2007., Results: Participants believed the financial incentives had been sufficient to change behavior and to achieve targets. The findings suggest that it is not necessary to align targets to professional priorities and values to obtain behavior change, although doing so enhances enthusiasm and understanding. Participants agreed that the aims of the pay-for-performance scheme had been met in terms of improvements in disease-specific processes of patient care and physician income, as well as improved data capture. It also led to unintended effects, such as the emergence of a dual QOF-patient agenda within consultations, potential deskilling of doctors as a result of the enhanced role for nurses in managing long-term conditions, a decline in personal/relational continuity of care between doctors and patients, resentment by team members not benefiting financially from payments, and concerns about an ongoing culture of performance monitoring in the United Kingdom., Conclusions: The QOF scheme may have achieved its declared objectives of improving disease-specific processes of patient care through the achievement of clinical and organizational targets and increased physician income, but our findings suggest that it has changed the dynamic between doctors and nurses and the nature of the practitioner-patient consultation.

A 55-year-old man presented to his primary care provider after a two-week history of worsening cough. He was admitted to the hospital and treated for community acquired pneumonia due to progression of symptoms and an abnormal chest radiograph. Chest computerized tomography demonstrated a large consolidation in the right upper lobe with areas of cavitation consistent with necrosis. Blood and sputum cultures were obtained, and the patient was subsequently diagnosed with pulmonary Salmonella typhimurium infection. The organism was isolated from a sputum specimen only. The patient had a history of chronic alcoholism, bronchitis, and esophageal dysmotility but no evidence of severe immunosuppression or malignancy. The patient responded well to antibiotic therapy with both symptomatic and radiologic improvement. As pulmonary Salmonella infection is exceedingly rare in the immunocompetent patient, a review of the literature is presented.

In 2004, the Institute of Medicine (IOM) issued a report presenting reference intake information about water, sodium, potassium, and other electrolytes for Americans and Canadians. The report established, for the first time, adequate intakes (AI) for total water (from drinking water, beverages, and food) for healthy people. An AI is the recommended average daily intake level based on observed or experimentally-determined approximations or estimates of nutrient intake by a group or groups of apparently health people that are assumed to be adequate. The AI for water is based on US survey data. The recommendations about water intake are for healthy populations--they do not apply to at-risk groups.

Background: Employers pay more than just salary for their employees. Previous studies have largely focused on direct medical and prescription drug costs of gastro-oesophageal reflux disease (GERD), and few have reported on total absenteeism costs., Aims: To examine the annual cost of illness of GERD in an employed US population by benefit category and by place of service for direct medical costs., Methods: Retrospective data analysis from 2001 to 2004. International Classification of Diseases (ICD)-9 codes (530.1, 530.10, 530.11, 530.12, 530.19, 530.81, 787.1x, 787.2x or 251.5x) were used to identify employees with and without GERD (the control group). Measures included medical and prescription drug claims, plus indirect costs for sick leave, short- and long-term disability, and workers' compensation. For a subset of the population, the direct medical claims were analysed by place of service., Results: Data were available for 267,269 eligible employees of which 11,653 had gastro-oesophageal reflux disease. GERD was associated with a mean incremental cost of US $3,355 per employee of which direct medical costs accounted for 65%, prescription drug costs 17%, and indirect costs 19%. The place of service 'out-patient hospital or clinic' accounted for the largest part (47%) of the difference in medical costs., Conclusions: GERD is associated with substantial direct and indirect costs, which highlight the importance of managing the disease effectively.

Objective: To explore the impact of financial incentives for quality of care on practice organisation, clinical autonomy, and internal motivation of doctors and nurses working in primary care., Design: Ethnographic case study., Setting: Two English general practices., Participants: 12 general practitioners, nine nurses, four healthcare assistants, and four administrative staff., Main Outcome Measure: Observation of practices over a five month period after the introduction of financial incentives for quality of care introduced in the 2004 general practitioner contract., Results: After the introduction of the quality and outcomes framework there was an increase in the use of templates to collect data on quality of care. New regimens of surveillance were adopted, with clinicians seen as "chasers" or the "chased," depending on their individual responsibility for delivering quality targets. Attitudes towards the contract were largely positive, although discontent was higher in the practice with a more intensive surveillance regimen. Nurses expressed more concern than doctors about changes to their clinical practice but also appreciated being given responsibility for delivering on targets in particular disease areas. Most doctors did not question the quality targets that existed at the time or the implications of the targets for their own clinical autonomy., Conclusions: Implementation of financial incentives for quality of care did not seem to have damaged the internal motivation of the general practitioners studied, although more concern was expressed by nurses.

RNA interference (RNAi) is now widely used for gene silencing in mammalian cells. The mechanism uses the RNA-induced silencing complex, in which Dicer, Ago2, and the human immunodeficiency virus type 1 (HIV-1) TAR RNA binding protein (TRBP) are the main components. TRBP is a protein that increases HIV-1 expression and replication by inhibition of the interferon-induced protein kinase PKR and by increasing translation of viral mRNA. After HIV infection, TRBP could restrict the viral RNA through its activity in RNAi or could contribute more to the enhancement of viral replication. To determine which function will be predominant in the virological context, we analyzed whether the inhibition of its expression could enhance or decrease HIV replication. We have generated small interfering RNAs (siRNAs) against TRBP and found that they decrease HIV-1 long terminal repeat (LTR) basal expression 2-fold, and the LTR Tat transactivated level up to 10-fold. In the context of HIV replication, siRNAs against TRBP decrease the expression of viral genes and inhibit viral production up to fivefold. The moderate increase in PKR expression and activation indicates that it contributes partially to viral gene inhibition. The moderate decrease in micro-RNA (miRNA) biogenesis by TRBP siRNAs suggests that in the context of HIV replication, TRBP functions other than RNAi are predominant. In addition, siRNAs against Dicer decrease viral production twofold and impede miRNA biogenesis. These results suggest that, in the context of HIV replication, TRBP contributes mainly to the enhancement of virus production and that Dicer does not mediate HIV restriction by RNAi.

Objectives: To identify which aspects of quality are important to individual patients with common chronic mild-to-moderate mental health problems presenting to general practice and the best method of involving patients with chronic mental health problems in the research process, and to contrast the relevance of a generic questionnaire developed previously with these individual patient narratives., Methods: Qualitative interviews with 16 patients in Chester and Manchester were subjected to thematic analysis., Results: Six key themes were identified in relation to the individual patient experience set against a generic patient experience: (1) the healthcare system provides a generic 'one size fits all' service, which is incompatible with an individual patient's experience and sense of being as an individual and that privileges medical over social care; (2) patients with mild-to-moderate mental health problems often have feelings of powerlessness and of being 'lost' in a system that is more responsive to severe and acute episodes of illness than to chronic morbidity; (3) patients often have unmet needs in relation to the distress of living with mild-to-moderate mental health problems; (4) there are substantial quality deficits in primary care for people with mild-to-moderate chronic mental health problems; (5) general practitioners are rated highly, and the attributes of a good general practitioner can be identified; patients also value continuity of care; (6) engaging people with common chronic mental health problems in the research/policy process requires generic assessment of quality using questionnaires supplemented with more in-depth methods, such as interviews and focus groups. Interviewees highlighted substantial quality deficits in service provision for people with chronic mental health problems. Involving patients with chronic mild-to-moderate mental health problems in the research/policy process requires multiple user involvement strategies, including questionnaires but supplemented with interviews and discussion groups., Conclusion: Patients with common chronic mental health problems have a clear view about what constitutes quality general practice/practitioner care but highlighted quality deficits for people with chronic mental health conditions.

The HIV-1 spacer peptide p1 is located in the C-terminus of the Gag polyprotein and separates the nucleocapsid (NC) and p6(Gag). Research centered on p1 has been limited and as yet no function has been ascribed to this spacer peptide. We have previously found that the conserved p1 proline residues (position 7 and 13) are critical for replication in the HIV-1 strain HXB2-BH10. In this study we have focused on the proline rich p1-p6(Gag) C-terminus of HIV-1. We individually examined the role of p1 proline's in multiple strains of HIV-1 and investigated the role of three proline residues in p6(Gag) (P24, P25 and P30). Assessment of the HXB2-BH10 based mutants revealed that Gag-Pol incorporation relative to Gag decreased in the p1 mutant virions, with the double proline mutant the most impaired. Mutating both p1 proline residues was found to abolish infectivity in multiple strains of HIV-1. Independent mutation of the p1 proline at position 7 resulted in a strain-dependent suppression of viral infectivity. This defect correlates with the presence of a tyrosine residue at position 9 of p1 and occurs in the early phase of the HIV-1 replication cycle. The p1 proline residues were found to be functionally distinct from P24, P25 and P30 in p6(Gag). This work affords novel insights into our understanding of the role of p1 in HIV-1 replication.

This investigation considered a novel method of enhancing penetration of the topical photosensitizing agent methyl aminolevulinate (MAL) into nodular basal cell carcinomas (BCCs) using an oxygen pressure injection device. Oxygen pressure injection (OPI) is a method to drive compounds into skin using pressured oxygen. The study was an observer-blinded pilot of a single application of MAL to nBCCs, with or without the use of OPI. The BCCs were then excised at different time intervals (0-180 min) and the depth of penetration of the MAL examined using microscopic fluorescence photometry to detect the production of the naturally fluorescent active photosensitiser protoporphyrin IX (PpIX). A highly selective and homogeneous distribution of MAL-induced porphyrin fluorescence was seen in all nBCC tumors studied, and showed a high lesion-to-normal-tissue ratio with very little fluorescence in the surrounding normal tissue. Although it was difficult to compare quantitatively, as individual tumors in each of the different study groups varied, a definite trend of increase in relative tumor concentration of MAL-induced PpIX was observed over time, and this was enhanced when OPI was employed.

Background: There is no agreed definition of 'difficult asthma' or what investigations should be available to investigate these patients. Patients with difficult asthma remain symptomatic on high levels of treatment and are high users of medical resources., Aim: To develop a set of quality indicators for the definition and investigation of difficult asthma., Method: Modified RAND Appropriateness Method was used. An expert panel composed of nine hospital asthma specialists who run 'difficult' asthma clinics and were identified from a short list of key workers in the field. Indicators were rated as necessary to define and investigate difficult asthma., Results: Difficult asthma was defined as 'symptoms persisting beyond therapy consistent with step 4 of the British Thoracic Society (BTS) guidelines' (high dose inhaled corticosteroids and long acting beta(2)-agonists). Eighty-three indicators were identified (40 relating to definition and 43 relating to investigations). Of these 32 (39%) were rated as necessary: 7 out of 40 (18%) for defining difficult asthma and 23 out of 43 (53%) for investigations. Indicators of high medical resource usage were characteristic of the 'difficult' nature of the management of patient with difficult asthma. A framework for the investigation of these patients was created., Conclusion: The listed performance indicators identify a range of requirements that are necessary to define difficult asthma. Targeting of real needs in this group of patients will lead to better patient care and reduction of 'waste' in provision of healthcare.

Objective: To measure changes in quality of care for three major chronic diseases (coronary heart disease, asthma, and type 2 diabetes) between 1998 and 2003., Design: Longitudinal cohort study., Setting: 42 general practices in six geographical areas of England (Avon, Bury/Rochdale, Enfield, Oldham, Somerset, South Essex)., Participants: Medical record data for 2300 patients with diabetes, asthma, or coronary heart disease in 1998, and 1495 patients in 2003., Main Outcome Measure: Quality of care assessed against predefined evidence based review criteria., Results: Between 1998 and 2003, quality of care improved markedly in terms of maximum possible scores on the review criteria, from 60.5% to 78.1% for coronary heart disease (change = 17.6, 95% confidence interval 13.9 to 21.4; P < 0.001), 60.1% to 70.3% for asthma (10.2, 4.6 to 15.8; P = 0.001), and 70.4% to 77.7% for diabetes (7.3, 3.5 to 11.1; P = 0.001). Important changes occurred to several indicators potentially related to improved health outcomes. These included improved control of serum cholesterol (to < or = 5 mmol/l) from 17.6% to 61.4% in coronary heart disease and from 21.5% to 52% in diabetes and control of blood pressure to < or = 150/90 in coronary heart disease from 47.3% to 72.2% and to < or = 145/85 in diabetes from 21.8% to 35.8%. A small, non-significant improvement in glycaemic control occurred among diabetic patients (37.9% to 39.7% with HbA1c < 7.4%). Significant improvements also occurred in the recording of exercise capacity and diet and weight advice for patients with coronary heart disease; of smoking advice, peak flow, and symptoms for patients with asthma; and of creatinine, weight, and HbA(1c) for patients with diabetes. Over the five years, more improvement in coronary heart disease care occurred in large practices and practices in affluent areas., Conclusions: Substantial improvements were seen in quality of care for the three conditions studied between 1998 and 2003, a time of systematic quality improvement initiatives in the NHS. The changes were most marked for coronary heart disease. English general practices could be expected to achieve high clinical quality scores in the initial year of a new contact, which provides financial incentives for high quality care from 2004.

Background: While mental health is a core part of primary care, there are few validated quality measures and little relevant internationally published research. Consensus panel methods are a useful means of developing quality measures where evidence is sparse and/or opinions are diverse. However, little is known about the dynamics of consensus techniques and the factors that influence the judgements and ratings of panels and individual panelists., Objectives: (1) To describe differences in panel ratings on the quality of primary mental health care services by patient, carer, professional and managerial panels within a Delphi procedure; and (2) to explore why different panels and panelists rate quality indicators of primary mental health care differently., Design: Two round postal Delphi technique and exploratory semi-structured interviews., Participants: 115 panelists across 11 panels. Eleven panelists were subsequently interviewed., Results: 87 of 334 indicators (26%) were rated face valid by all 11 panels. There was little disagreement within panel ratings but significant differences between panels. The GP panel rated the least number of indicators valid (n = 138, 41%) and carers the most (n = 304, 91%). The way in which panelists interpreted and conceptualised the indicators and their definition of quality of mental health care affected the way in which participants made their ratings., Conclusions: Stakeholders in primary mental health care have diverse views of quality of care and these differences translate into how they rate quality indicators. Exploratory interviews suggest that ratings are influenced by past experience, expectations, definitions of quality of care, and perceived power relationships between stakeholders.

Background: Photodynamic therapy (PDT) has unique properties which make it suitable for the local treatment of superficial epithelial disorders; it has been suggested as a useful treatment for carcinoma in situ of the vulva., Objectives: To evaluate the effect of the systemic photosensitizing agent meta-tetrahydroxyphenylchlorin (mTHPC or temoporfin; Foscan, Biolitec, Edinburgh, U.K.) in vulval intraepithelial neoplasia type III (VIN III)., Methods: PDT using mTHPC was performed in six patients with VIN III. A dose of 0.1 mg kg(-1) body weight mTHPC was injected intravenously and the area of VIN irradiated 96 h later with 652-nm light from a diode laser. Patients were reviewed 1 week, 6 months and 2 years following treatment., Results: Patients experienced only minimal pain from the initial treatment but two patients subsequently developed severe pain at the treated site for up to 2 weeks following PDT. All patients developed oedema and slough formation at the treated site and one patient developed cellulitis. At 6 months two patients had developed small recurrences of VIN at the original site and one patient had an area of VIN at a new site. These were treated either with further PDT or with a small excision. At 2 years there was no recurrence of VIN at the original site in all patients reviewed., Conclusions: This small case series demonstrates that mTHPC-PDT is a useful initial treatment for VIN III. It is relatively selective, shows good cosmesis and conserves form and function. This is a major advantage over surgery. Repeat treatments are also possible, which is important in a condition such as VIN, which tends to be multifocal. Systemic mTHPC-PDT appears to have an advantage over topical 5-aminolaevulinic acid-PDT as the photosensitizer is distributed widely in areas of disease and consequently identifies foci which may not be apparent clinically but become evident when illuminated.

Background: A series of government initiatives in the UK have included strategies to improve the quality of services received by patients, including fundholding, the development of National Service Frameworks, clinical governance, and Personal Medical Services (PMS). PMS represents a new contractual arrangement between government and general practitioners (GPs) which provides new investment in return for more detailed specification of processes and outcomes of care., Objectives: To evaluate the effects of PMS on the quality of primary mental health care between 1998 and 2001., Design: Multiple longitudinal case studies. Semi-structured interviews with key staff within practices (GPs, nurses, practice managers) and outside (health authority and primary care group/trust managers)., Sample: Six first wave PMS sites which had specifically planned to improve their mental health care., Results: Improvements in mental health care were found in some PMS practices and not in others. Five mechanisms associated with successful quality improvement in mental health were identified: clear goals, effective teamwork within the practice, routine use of protocols and audits, additional resources, and effective collaboration with community and secondary care. Sites where these factors were not present struggled to meet their objectives., Conclusion: The five mechanisms which resulted in improved mental health care were facilitated by the new contractual arrangements in PMS. The new contracts were not a necessary part of these changes, but they enabled sites with an identified interest and motivation to make the changes. The contractual changes were not in themselves sufficient to improve care.

Human immunodeficiency virus type 1 (HIV-1) contains two copies of genomic RNA that are noncovalently linked via a palindrome sequence within the dimer initiation site (DIS) stem-loop. In contrast to the current paradigm that the DIS stem or stem-loop is critical for HIV-1 infectivity, which arose from studies using T-cell lines, we demonstrate here that HIV-1 mutants with deletions in the DIS stem-loop are replication competent in peripheral blood mononuclear cells (PBMCs). The DIS mutants contained either the wild-type (5'GCGCGC3') or an arbitrary (5'ACGCGT3') palindrome sequence in place of the 39-nucleotide DIS stem-loop (NL(CGCGCG) and NL(ACGCGT)). These DIS mutants were replication defective in SupT1 cells, concurring with the current model in which DIS mutants are replication defective in T-cell lines. All of the HIV-1 DIS mutants were replication competent in PBMCs over a 40-day infection period and had retained their respective DIS mutations at 40 days postinfection. Although the stability of the virion RNA dimer was not affected by our DIS mutations, the RNA dimers exhibited a diffuse migration profile when compared to the wild type. No defect in protein processing of the Gag and GagProPol precursor proteins was found in the DIS mutants. Our data provide direct evidence that the DIS stem-loop is dispensable for viral replication in PBMCs and that the requirement of the DIS stem-loop in HIV-1 replication is cell type dependent.

Quality indicators have been developed throughout Europe primarily for use in hospitals, but also increasingly for primary care. Both development and application are important but there has been less research on the application of indicators. Three issues are important when developing or applying indicators: (1). which stakeholder perspective(s) are the indicators intended to reflect; (2). what aspects of health care are being measured; and (3). what evidence is available? The information required to develop quality indicators can be derived using systematic or non-systematic methods. Non-systematic methods such as case studies play an important role but they do not tap in to available evidence. Systematic methods can be based directly on scientific evidence by combining available evidence with expert opinion, or they can be based on clinical guidelines. While it may never be possible to produce an error free measure of quality, measures should adhere, as far as possible, to some fundamental a priori characteristics (acceptability, feasibility, reliability, sensitivity to change, and validity). Adherence to these characteristics will help maximise the effectiveness of quality indicators in quality improvement strategies. It is also necessary to consider what the results of applying indicators tell us about quality of care.

Objective: HIV-1 particles are enriched with cholesterol; however, the significance of this cholesterol enrichment is unknown. This study examines the structural and functional roles of cholesterol in HIV-1 replication., Methods: Using methyl-beta-cyclodextrin (CD) to remove cholesterol from the HIV-1 envelope, buoyant density and infectivity of the cholesterol-deficient HIV-1 particles were compared with the untreated control. The specificity and requirement of cholesterol as an HIV-1-associated lipid were investigated by replenishing cholesterol-deficient HIV-1 with cholesterol, cholestenone (a cholesterol structural analogue) or sphingomyelin (a structurally unrelated yet virion-associated lipid)., Results: CD-mediated removal of virion cholesterol increased the buoyant density of virion particles and reduced HIV-1 infectivity. Trans-supplementation of exogenous cholesterol rescued the defects associated with CD-induced cholesterol depletion in HIV-1. However, the restoration of viral infectivity could not be achieved by trans-supplementation of either cholestenone or sphingomyelin., Conclusion: This study provides the first direct evidence that HIV-1-associated cholesterol is important for the maintenance of virion structure and infectivity. While the buoyant density of cholesterol-defective HIV-1 can be restored by a cholesterol structural analogue, cholestenone, the requirement for cholesterol is essential for HIV-1 infectivity., (Copyright 2002 Lippincott Williams & Wilkins)

This power considers the process of implementing clinical governance in primary care and its impact on quality improvement. It discuss how clinical governance is being implemented both at the level of Primary Care Organisations and general practices, and the challenges to implementing clinical governance. It also suggests a model for promoting the factors that will help clinical governance improve quality of care. The experience of implementing clinical governance is broadly positive to date. However, the government needs to match its commitment to a ten-year programme of change with realistic timetables to secure the cultural and organisational changes needed to improve quality of care.

Objectives: To field test the reliability, validity, and acceptability of review criteria for angina, asthma, and type 2 diabetes which had been developed by expert panels using a systematic process to combine evidence with expert opinion., Design: Statistical analysis of data derived from a clinical audit, and postal questionnaire and semi-structured interviews with general practitioners and practice nurses in a representative sample of general practices in England., Setting: 60 general practices in England., Main Outcome Measures: Clinical audit results for angina, asthma, and type 2 diabetes. General practitioner and practice nurse validity ratings from the postal questionnaire., Results: 54%, 59%, and 70% of relevant criteria rated valid by the expert panels for angina, asthma, and type 2 diabetes, respectively, were found to be usable, valid, reliable, and acceptable for assessing quality of care. General practitioners and practice nurses agreed with panellists that these criteria were valid but not that they should always be recorded in the medical record., Conclusion: Quality measures derived using expert panels need field testing before they can be considered valid, reliable, and acceptable for use in quality assessment. These findings provide additional evidence that the RAND panel method develops valid and reliable review criteria for assessing clinical quality of care.

Objectives: To investigate the concept of clinical governance being advocated by primary care groups/trusts (PCG/Ts), approaches being used to implement clinical governance, and potential barriers to its successful implementation in primary care., Design: Qualitative case studies using semi-structured interviews and documentation review., Setting: Twelve purposively sampled PCG/Ts in England., Participants: Fifty senior staff including chief executives, clinical governance leads, mental health leads, and lay board members., Main Outcome Measures: Participants' perceptions of the role of clinical governance in PCG/Ts., Results: PCG/Ts recognise that the successful implementation of clinical governance in general practice will require cultural as well as organisational changes, and the support of practices. They are focusing their energies on supporting practices and getting them involved in quality improvement activities. These activities include, but move beyond, conventional approaches to quality assessment (audit, incentives) to incorporate approaches which emphasise corporate and shared learning. PCG/Ts are also engaged in setting up systems for monitoring quality and for dealing with poor performance. Barriers include structural barriers (weak contractual levers to influence general practices), resource barriers (perceived lack of staff or money), and cultural barriers (suspicion by practice staff or problems overcoming the perceived blame culture associated with quality assessment)., Conclusion: PCG/Ts are focusing on setting up systems for implementing clinical governance which seek to emphasise developmental and supportive approaches which will engage health professionals. Progress is intentionally incremental but formidable challenges lie ahead, not least reconciling the dual role of supporting practices while monitoring (and dealing with poor) performance.

Objectives: The aim of this study was to compare two different approaches to the measurement of quality in general practice: data derived from routine NHS data sets and results from an index derived from patient-collected data., Methods: A secondary analysis of existing data sets and a cross-sectional survey were carried out in Lothian, Coventry, Oxfordshire and west London. The subjects comprised randomly selected and consenting practices, and a sample of patients within these practices. A National Health Service Practice Performance Index (NHSPPI) was constructed from 16 routinely available NHS performance indicators. The Consultation Quality Index (CQI) combines the Patient Enablement Instrument (PEI) with a measure of how well the patient knew the doctor, and with observed consultation length., Results: Scores for 12 of the 16 indicators varied significantly across the four regions. Mean practice NHSPPI score overall was 21.6 (SD 4.3), which varied significantly across regions. NHSPPI was predicted by practice list size, weighted deprivation index and proportion of other language patients in the practice, although their effects could not be separated. Overall there was no correlation between NHSPPI and CQI, although the prescribing component of the index was positively correlated to mean consultation length and negatively correlated with how well patients knew their doctors., Conclusions: Good quality care as assessed by patients on completion of their consultation is independent of good quality care as assessed by best available measures of practice performance. We suggest that the CQI and the NHSPPI are at least as ready for use as other measures of performance in general practice.

Objectives: To assess variation in the quality of care in general practice and identify factors associated with high quality care., Design: Observational study., Setting: Stratified random sample of 60 general practices in six areas of England., Outcome Measures: Quality of management of chronic disease (angina, asthma in adults, and type 2 diabetes) and preventive care (rates of uptake for immunisation and cervical smear), access to care, continuity of care, and interpersonal care (general practice assessment survey). Multiple logistic regression with multilevel modelling was used to relate each of the outcome variables to practice size, routine booking interval for consultations, socioeconomic deprivation, and team climate., Results: Quality of clinical care varied substantially, and access to care, continuity of care, and interpersonal care varied moderately. Scores for asthma, diabetes, and angina were 67%, 21%, and 17% higher in practices with 10 minute booking intervals for consultations compared with practices with five minute booking intervals. Diabetes care was better in larger practices and in practices where staff reported better team climate. Access to care was better in small practices. Preventive care was worse in practices located in socioeconomically deprived areas. Scores for satisfaction, continuity of care, and access to care were higher in practices where staff reported better team climate., Conclusions: Longer consultation times are essential for providing high quality clinical care. Good teamworking is a key part of providing high quality care across a range of areas and may need specific support if quality of care is to be improved. Additional support is needed to provide preventive care to deprived populations. No single type of practice has a monopoly on high quality care: different types of practice may have different strengths.

Background: Lipid rafts are currently an intensely investigated topic of cell biology. In addition to a demonstrated role in signal transduction of the host cell, lipid rafts serve as entry and exit sites for microbial pathogens and toxins, such as FimH-expressing enterobacteria, influenza virus, measles virus and cholera toxin. Furthermore, caveolae, a specialised form of lipid raft, are required for the conversion of the non-pathogenic prion protein to the pathogenic scrapie isoform., Objectives: A number of reports have shown, directly or indirectly, that lipid rafts are important at various stages of the human immunodeficiency virus type-1 (HIV-1) replication cycle. The purpose of this paper is to provide a brief overview of the role of membrane-associated lipid rafts in cell biology, and to evaluate how HIV-1 has hijacked this cellular component to support HIV-1 replication. Special sections are devoted to discussing the role of lipid rafts in (1) the entry of HIV-1, (2) signal transduction regulation in HIV-1-infected cells, (3) the trafficking of HIV-1 proteins via lipid rafts during HIV-1 assembly; and a further section discusses the role of cholesterol in mature HIV-1., Summary: Like a number of other pathogens, HIV-1 has evolved to rely on the host cell lipid rafts to support its propagation during multiple stages of the HIV-1 replication cycle. This review has highlighted the importance of lipid rafts in HIV-1 replication.

Objectives: To identify prescribing indicators based on prescribing analysis and cost (PACT) data that have face validity for measuring quality or cost minimisation., Design: Modified two round Delphi questionnaire requiring quantitative and qualitative answers., Setting: Health authorities in England., Participants: All health authority medical and pharmaceutical advisers in the first round and lead prescribing advisers for each health authority in the second round., Main Outcome Measures: Face validity (median rating of 7-9 on a nine point scale without disagreement) and reliability (rating 8 or 9) of indicators for assessing quality and cost minimisation., Results: Completed second round questionnaires were received from 79 respondents out of 99. The median rating was 7 for cost minimisation and 6 for quality, and in all except four cases individual respondents rated indicators significantly higher for cost than for quality. Of the 41 indicators tested, only seven were rated valid and reliable for cost minimisation and five for quality., Conclusion: The 12 indicators rated as valid by leading prescribing advisers had a narrow focus and would allow only a limited examination of prescribing at a general practice, primary care group, or health authority level.

Sarcoidosis has long been associated with mycobacterial infection, especially with Mycobacterium tuberculosis, although a causal association has not been proven. Atypical mycobacteria have also been implicated in causing sarcoidosis, but there is as yet no conclusive evidence. We report the activation of cutaneous sarcoidosis following infection with M. marinum, raising further questions about the role of these bacteria in causing this chronic granulomatous disorder.

Background: Moves towards a 'primary care-led' National Health Service (NHS) and towards evidence-based care have focused attention upon the need for evaluative research relating to the structure, delivery, and outcome of primary health care in the United Kingdom (UK). This paper describes work carried out to inform the Department of Health Committee on Research and Development (R&D) in Primary Care (Mant Committee)., Aim: To describe the extent and nature of current research capacity in primary care in the UK and to identify future needs and priorities., Method: Funding data were requested from NHS National Programmes, NHS Executive Regional Offices, the Department of Health (DoH), Scottish Office, Medical Research Council, and some charities. A postal survey was sent to relevant academic departments, and appropriate academic journals were reviewed from 1992 to 1996. In addition, interviews were conducted with academic and professional leaders in primary care., Results: Overall, total annual primary care R&D spend by the NHS and the DoH was found to be 7% of the total spend, although annual primary care R&D spend differs according to funding source. Journals relating to primary care do not, with some notable exceptions (e.g. British Journal of General Practice, Family Practice), have high academic status, and research into primary care by academic departments is, with perhaps the exception of general practice, on a small scale. The research base of most primary care professions is minimal, and significant barriers were identified that will need addressing if research capacity is to be expanded., Conclusion: There are strong arguments for the development of primary care research in a 'primary care-led' NHS in the UK. However, dashes for growth or attempts to expand capacity from the present infrastructure must be avoided in favour of endeavours to foster a sustainable, long-term research infrastructure capable of responding meaningfully to identified needs.

Objective: To develop review criteria to assess the quality of care for three major chronic diseases: adult asthma, stable angina, and non-insulin dependent diabetes mellitus., Subjects and Methods: Modified panel process based upon the RAND/UCLA (University College of Los Angeles) appropriateness method. Three multiprofessional panels made up of general practitioners, hospital specialists, and practice nurses., Results: The RAND/UCLA appropriateness method of augmenting evidence with expert opinion was used to develop criteria for the care of the three conditions. Of those aspects of care which were rated as necessary by the panels, only 26% (16% asthma, 10% non-insulin dependent diabetes, 40% angina) were subsequently rated by the panels as being based on strong scientific evidence., Conclusion: The results show the importance of a systematic approach to combining evidence with expert opinion to develop review criteria for assessing the quality of three chronic diseases in general practice. The evidence base for the criteria was often incomplete, and explicit methods need to be used to combine evidence with expert opinion where evidence is not available.

Background: The aim of the study was to assess the face validity of quality indicators being proposed for use in general practice by health authorities., Method: A national survey of health authorities was carried out to identify quality indicators being proposed for use in general practice. A two-stage Delphi process was used to establish general practitioners' (GPs') and health authority managers' views on the face validity of identified indicators. A total of 240 separate indicators identified by health authorities and the NHS Executive as potential markers of the quality of general practice care were assessed. Indicators related to access, organizational performance, preventive care, care for a small number of chronic diseases, prescribing and gatekeeping. The subjects were a purposive sample of 47 health authority managers and 57 general practice course organizers., Results: Thirty-six indicators received median validity scores of 8 or 9 out of a maximum possible score of 9. Of this set, 83 per cent was rated identically by both groups of respondents. Prescribing and gatekeeping indicators generally received low validity scores., Conclusion: Acceptable face valid indicators were identified for all domains except gatekeeping. However, the indicators rated by the sample do not cover all aspects of care. No indicators were proposed for use by health authorities relating to effective communication, care of acute illness, health outcomes or patient evaluation. Although it is possible to develop indicators of general practice care which have face validity in the view of both GPs and managers, these will be very partial measures of quality. In the indicators used in this study, no explicit distinction was made between indicators designed to assess minimum standards with which all practices should comply, and indicators which could be used to reward higher levels of performance. Failure to separate these will result in antagonism from practitioners to quality improvement initiatives in the NHS, and a failure to engage the profession in improving quality of care.

The objective of this multicentre study was to undertake a systematic comparison of face-to-face consultations and teleconsultations performed using low-cost videoconferencing equipment. One hundred and twenty-six patients were enrolled by their general practitioners across three sites. Each patient underwent a teleconsultation with a distant dermatologist followed by a traditional face-to-face consultation with a dermatologist. The main outcome measures were diagnostic concordance rates, management plans and patient and doctor satisfaction. One hundred and fifty-five diagnoses were identified by the face-to-face consultations from the sample of 126 patients. Identical diagnoses were recorded from both types of consultation in 59% of cases. Teledermatology consultations missed a secondary diagnosis in 6% of cases and were unable to make a useful diagnosis in 11% of cases. Wrong diagnoses were made by the teledermatologist in 4% of cases. Dermatologists were able to make a definitive diagnosis by face-to-face consultations in significantly more cases than by teleconsultations (P = 0.001). Where both types of consultation resulted in a single diagnosis there was a high level of agreement (kappa = 0.96, lower 95% confidence limit 0.91-1.00). Overall follow-up rates from both types of consultation were almost identical. Fifty per cent of patients seen could have been managed using a single videoconferenced teleconsultation without any requirement for further specialist intervention. Patients reported high levels of satisfaction with the teleconsultations. General practitioners reported that 75% of the teleconsultations were of educational benefit. This study illustrates the potential of telemedicine to diagnose and manage dermatology cases referred from primary care. Once the problem of image quality has been addressed, further studies will be required to investigate the cost-effectiveness of a teledermatology service and the potential consequences for the provision of dermatological services in the U.K.

Objective: To investigate the serum levels of insulin-like growth factor-I (IGF-I) in patients with fibromyalgia (FM) compared to healthy controls and patients with other rheumatic diseases, and to explore possible etiologic mechanisms of low IGF-I levels in patients with FM., Methods: Five hundred patients with FM and 152 controls (74 healthy blood donors, 26 myofascial pain patients and 52 patients with other rheumatic diseases) were studied. All had measurements of acid extracted serum IGF-I. A subset of 90 patients with FM were evaluated for clinical features that might explain low IGF-I levels. Twenty-five patients with FM underwent growth hormone (GH) provocation testing with l-dopa and clonidine., Results: The mean serum IGF-I level in patients with FM was 138 +/- 56 ng/ml and in controls 215 +/- 86 ng/ml (p = 0.00000000001). Low levels of IGF-I were not due to depression, tricyclic medications, nonsteroidal antiinflammatory drugs, poor aerobic conditioning, obesity, or pain level. Patients with focal myofascial pain syndromes had normal IGF-I levels (236 +/- 68), as did most patients with other rheumatic disorders, unless they had concomitant FM. Patients with FM with initially normal levels often had a rapid decline of IGF-I over 1 to 2 years. Most patients with FM with low IGF-I levels failed to secrete GH after stimulation with clonidine and l-dopa., Conclusion: Many, but not all, patients with FM have low levels of IGF-I that cannot be explained by clinical associations. These results suggest that low IGF-I levels in patients with FM are a secondary phenomenon due to hypothalamic-pituitary-GH axis dysfunction.

Objective: To compare the process of out of hours care provided by general practitioners from patients' own practices and by commercial deputising services., Design: Randomised controlled trial., Setting: Four urban areas in Manchester, Salford, Stockport, and Leicester., Subjects: 2152 patients who requested out of hours care, and 49 practice doctors and 183 deputising doctors (61% local principals) who responded to those requests., Main Outcome Measures: Response to call, time to visit, prescribing, and hospital admissions., Results: 1046 calls were dealt with by practice doctors and 1106 by deputising doctors. Practice doctors were more likely to give telephone advice (20.2% v 0.72% of calls) and to visit more quickly than deputising doctors (median delay 35 minutes v 52 minutes). Practice doctors were less likely than deputising doctors to issue a prescription (56.1% v 63.2% of patients) or to prescribe an antibiotic (43.7% v 61.3% of prescriptions issued) and more likely to prescribe genetic drugs (58.4% v 32.1% of drugs prescribed), cheaper drugs (mean cost per prescription pounds 3.28 v pounds 5.04), and drugs in a predefined out of hours formulary (49.8% v 41.1% of drugs prescribed). There was no significant difference in the number of hospital admissions., Conclusions: By contrast with practice doctors, deputising doctors providing out of hours care less readily give telephone advice, take longer to visit at home, and have patterns of prescribing that may be less discriminating.

Objective: To compare the outcome of out of hours care given by general practitioners from patients' own practices and by commercial deputising services., Design: Randomised controlled trial., Setting: Four urban areas in Manchester, Salford, Stockport, and Leicester., Subjects: 2152 patients who requested out of hours care, and 49 practice doctors and 183 deputising doctors (61% local principals in general practice) who responded to the requests., Main Outcome Measures: Health status outcome, patient satisfaction, and subsequent health service use., Results: Patients seen by deputising doctors were less satisfied with the care they received. The mean overall satisfaction score for practice doctors was 70.7 (95% confidence interval 68.1 to 73.2) and for deputising doctors 61.8 (59.9 to 63.7). The greatest difference in satisfaction was with the delay in visiting. There were no differences in the change in health or overall health status measured 24 to 120 hours after the out of hours call or subsequent use of the health service in the two groups., Conclusions: Patients are more satisfied with the out of hours care provided by practice doctors than that provided by deputising doctors. Organisation of doctors into large groups may produce lower levels of patient satisfaction, especially when associated with increased delays in the time taken to visit. There seem to be no appreciable differences in health outcome between the two types of service.

Computers have gained rapid acceptance in general practice. A recent development has been the use of computers to run practice appointment systems. This study demonstrates the benefits of installing a computerized appointment system, with improved service for patients, and more efficient use of time by both doctors and receptionists.

Objective: To evaluate the impact of a 6 month group therapy program on the treatment of patients with fibromyalgia (FM). Since FM is a common problem in rheumatology practice, a program was designed to treat patients in a group setting using allied health professionals., Methods: The FM group (15 to 25 patients) met once a week for 6 months. The average session lasted 90 min and consisted of formal lectures, group sessions emphasizing behavior modification, stress reduction techniques, strategies to improve fitness and flexibility and support sessions for spouses/significant others. The 2 major outcome measures were the fibromyalgia impact questionnaire (FIQ) and the total tender point score. Secondary outcome measures were the quality of life scale, questionnaires to assess coping strategies and attitudes to illness, an index of aerobic conditioning, flexibility, distance walked in 6 min., Beck depression and Beck anxiety questionnaires. Patients were followed 2 years and compared to a group of patients outside the program., Results: Between 1989 and 1993 170 patients were evaluated and 104 patients completed the program. At the end of the 6 months 73 (70%) of patients had <11 tender points and FIQ improved 25%. Having a pain profile on MMPI or having major depression, did not predict poorer outcome. Thirty-three patients followed for 2 years after the program continue to show improvement. A control group of 29 patients who never entered the program showed no significant improvement., Conclusion: The group treatment of patients with FM in an outpatient setting shows promise; a more formal controlled study is needed to confirm this impression.

Background: Symptoms are an everyday part of most peoples' lives and many people with illness do not consult their doctor. The decision to consult is not based simply on the presence or absence of medical problems. Rather it is based on a complex mix of social and psychological factors., Objectives: This literature review seeks to explore some of the pathways to care and those factors associated with low and high rates of consultation., Methods: The paper examines the impact of socioeconomic and demographic factors on consultation rates and, using a revised version of the Health Belief Model, it highlights the psychological factors which influence decisions to seek medical care. Barriers which can inhibit consultation are discussed, as the decision to seek care will only result in a consultation if there is adequate access to care., Results and Conclusions: Whilst poor health status and social disadvantage increase both "objective" medical need and in turn, consultation rates, a range of other social and psychological factors have been shown to influence consulting behaviour.

Background: The proportion of U.S. adults 35 to 74 years of age who were overweight increased by 9.6 percent for men and 8.0 percent for women between 1978 and 1990. Since the prevalence of smoking declined over the same period, smoking cessation has been suggested as a factor contributing to the increasing prevalence of overweight., Methods: To estimate the influence of smoking cessation on the increase in the prevalence of overweight, we analyzed data on current and past weight and smoking status for a national sample of 5247 adults 35 years of age or older who participated in the third National Health and Nutrition Examination Survey, conducted from 1988 through 1991. The results were adjusted for age, sociodemographic characteristics, level of physical activity, alcohol consumption, and (for women) parity., Results: The weight gain over a 10-year period that was associated with the cessation of smoking (i.e., the gain among smokers who quit that was in excess of the gain among continuing smokers) was 4.4 kg for men and 5.0 kg for women. Smokers who had quit within the past 10 years were significantly more likely than respondents who had never smoked to become overweight (odds ratios, 2.4 for men and 2.0 for women). For men, about a quarter (2.3 of 9.6 percentage points) and for women, about a sixth (1.3 of 8.0 percentage points) of the increase in the prevalence of overweight could be attributed to smoking cessation within the past 10 years., Conclusions: Although its health benefits are undeniable, smoking cessation may nevertheless be associated with a small increase in the prevalence of overweight.

Objective: To examine prevalence of overweight and trends in overweight for children and adolescents in the US population., Design: Nationally representative cross-sectional surveys with an in-person interview and a medical examination, including measurement of height and weight., Participants: Between 3000 and 14,000 youths aged 6 through 17 years examined in each of five separate national surveys during 1963 to 1965, 1966 to 1970, 1971 to 1974, 1976 to 1980, and 1988 to 1991 (Cycles II and III of the National Health Examination Survey, and the first, second, and third National Health and Nutrition Examination Surveys, respectively)., Main Outcome Measures: Prevalence of overweight based on body mass index and 85th or 95th percentile cutoff points from Cycles II and III of the National Health Examination Survey., Results: From 1988 to 1991, the prevalence of overweight was 10.9% based on the 95th percentile and 22% based on the 85th percentile. Overweight prevalence increased during the period examined among all sex and age groups. The increase was greatest since 1976 to 1980, similar to findings previously reported for adults in the United States., Conclusions: Increasing overweight among youths implies a need to focus on primary prevention. Attempts to increase physical activity may provide a means to address this important public health problem.

Spouses' masculinity and femininity were examined in relation to longitudinal change in marital satisfaction and behavior displayed in a problem-solving discussion. Results indicated, first, that wives' satisfaction declined to the extent that their husband endorsed fewer desirable masculine traits (Study 1) and more undesirable masculine traits (Study 2). Second, masculinity and femininity covaried with problem-solving behavior, particularly for behavioral sequences involving husbands' responses to wives' negative behavior. Finally, the relation between husbands' masculinity and change in wives' satisfaction was not mediated by husbands' behavior; instead, sex role and behavioral variables made independent contributions to change in wives' satisfaction. These results are important because they highlight the value of examining intraindividual and interpersonal variables when determining how marriages improve and deteriorate.

Objectives: To study the number, demography, and clinical details of patients who agreed or refused to attend centralised primary care centres for out of hours medical care and to study the satisfaction with the service of those who attended., Design: Data collected by telephonists and doctors. Satisfaction questionnaires given to patients who attended., Setting: Five out of hours primary care centres in the United Kingdom., Subjects: All patients contacting the deputising service to request medical help out of hours who were asked to attend a primary care centre. The study terminated when 1000 patients had agreed to attend (200 from each centre). 1000 patients not agreeing to attend were also sampled., Results: The attendance rate varied from 8.9% to 52.3% in the five centres. The overall standardised attendance rate was 22.4%. The attendance rate was highest in children under 5 (465/2380, 19.5%) and fell with increasing age. Of the 1000 sampled non-attenders, 403 said that they had no transport and 345 said that they were too ill to attend. Those who attended were seen by the doctor more quickly. There was no significant difference between the groups in the number who received a prescription (810 attenders v 820 non-attenders, P = 0.57) or who were admitted to hospital (59 v 52, P = 0.5). Satisfaction with the service among those who attended was very high; 95% (694/731) said that they would be prepared to attend under similar circumstances in the future., Conclusion: Most patients are not able or prepared to attend a central facility for primary care out of hours. Substantial cultural change will be necessary and careful consideration given to planning if such centres are to provide a major part of out of hours care.

Objective: To examine trends in overweight prevalence and body mass index of the US adult population., Design: Nationally representative cross-sectional surveys with an in-person interview and a medical examination, including measurement of height and weight., Setting/participants: Between 6000 and 13,000 adults aged 20 through 74 years examined in each of four separate national surveys during 1960 to 1962 (the first National Health Examination Survey [NHES I]), 1971 to 1974 (the first National Health and Nutrition Examination Survey [NHANES I]), 1976 to 1980 (NHANES II), and 1988 to 1991 (NHANES III phase 1)., Results: In the period 1988 to 1991, 33.4% of US adults 20 years of age or older were estimated to be overweight. Comparisons of the 1988 to 1991 overweight prevalence estimates with data from earlier surveys indicate dramatic increases in all race/sex groups. Overweight prevalence increased 8% between the 1976 to 1980 and 1988 to 1991 surveys. During this period, for adult men and women aged 20 through 74 years, mean body mass index increased from 25.3 to 26.3; mean body weight increased 3.6 kg., Conclusions: These nationally representative data document a substantial increase in overweight among US adults and support the findings of other investigations that show notable increases in overweight during the past decade. These observations suggest that the Healthy People 2000 objective of reducing the prevalence of overweight US adults to no more than 20% may not be met by the year 2000. Understanding the reasons underlying the increase in the prevalence of overweight in the United States and elucidating the potential consequences in terms of morbidity and mortality present a challenge to our understanding of the etiology, treatment, and prevention of overweight.

Purpose: This study investigated the relationships among four methods of detecting depression in patients with fibromyalgia., Methods: Data were obtained from 100 women (mean age 43 years) who had been diagnosed with fibromyalgia. Instruments included a computerized Diagnostic Interview Schedule (C-DIS), Beck Depression Inventory (BDI), an adjusted "disease-free" BDI (BDI-A), and Minnesota Multiphasic Personality Inventory depression subscale (MMPI-D). Chance-corrected concordance, sensitivity, specificity, and accuracy among the four methods were calculated., Results: The C-DIS detected 22% and BDI-A 29% with current major depression. The BDI and MMPI-D yielded higher estimates of 55% of the 44%, respectively. Agreement on the diagnosis among the four methods was significantly greater than chance. When compared with the C-DIS, the BDI was the most sensitive instrument and the BDI-A most specific.

Objective: To determine the immunocytologic characteristics of the various subsets of nonseptic olecranon bursal fluid mononuclear cells., Methods: Twenty consecutive patients with culture negative olecranon bursitis had immunocytochemical and flow cytometric analysis performed using a panel of monoclonal antibodies to determine lymphocyte and monocyte/macrophage population subtypes and proportions., Results: In traumatic bursitis (n = 9), the mean (+/- SD) white blood cell (WBC) count/mm3 was 1,368 +/- 1,559; WBC mononuclear differential count was 29.5 +/- 19% lymphocytes and 55 +/- 26% monocyte/macrophages. In idiopathic bursitis (n = 11), the mean WBC/mm3 was 376 +/- 515; WBC mononuclear differential count was 28.5 +/- 16% lymphocytes and 52 +/- 27% monocytes/macrophages. Flow cytometry revealed 88% CD2+ T lymphocytes in the lymphocyte population, 3% B lymphocytes and CD4/CD8 T cell mean ratio of 2.5 +/- 1.5 for traumatic bursitis and 88% CD2+ T lymphocytes, 4% B lymphocytes and CD4/Cd8 ratio of 1.4 +/- 0.6 for idiopathic bursitis (p < 0.05, t test). Both groups contained increased proportions of lymphocyte subtypes expressing activation markers: CD25+, CD26+ and HLA DR+ compared to normal peripheral blood. In traumatic bursitis, the mean percent of CD14+ cells (monocyte/macrophages) was 62 +/- 24; in idiopathic bursitis, the mean percent was 51 +/- 28. The vast majority expressed high levels of HLA-DR indicating activation., Conclusion: We observed a preponderance of activated T cell subpopulations and monocyte/macrophages suggesting an immunologic role for these cell populations in the development and perpetuation of nonseptic bursitis.