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Background: Less than 200 cases have been reported in the world literature since desmoplastic small round cell tumor (DSRCT) was first described in 1989. To date, chemotherapy, radiation therapy, and surgery have resulted in a poor survival of 30% to 55%. We used hyperthermic intraperitoneal chemotherapy (HIPEC) at the time of complete tumor resection as an adjunct to treatment of pediatric and adolescent patients with DSRCT., Purpose: The aim of this study was to assess survival as a function of disease burden and response to HIPEC in patients with DSRCT., Methods: Twenty-four patients with DSRCT from 1995 to 2008 were evaluated. Eight patients undergoing cytoreductive surgery and HIPEC were compared with 16 historical controls that had chemotherapy +/- radiation therapy or surgery alone., Results: Median age was 12 years in 8 patients who underwent HIPEC. Significant morbidity after HIPEC included renal insufficiency and gastroparesis. There were no operative mortalities. The estimated median overall 3-year survival for patients not undergoing surgery or HIPEC was 26% compared with 71% in patients who underwent HIPEC. Extraabdominal metastasis correlated with poor survival (P = .021)., Conclusion: Hyperthermic intraperitoneal chemotherapy is safe in children with DSRCT. It may prolong disease-free survival in selected cases of DSRCT. It may have a limited role as an adjunct to local control in patients with DSRCT., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Kinetic analysis is used to extract metabolic information from dynamic positron emission tomography (PET) uptake data. The theory of indicator dilutions, developed in the seminal work of Meier and Zierler (1954), provides a probabilistic framework for representation of PET tracer uptake data in terms of a convolution between an arterial input function and a tissue residue. The residue is a scaled survival function associated with tracer residence in the tissue. Nonparametric inference for the residue, a deconvolution problem, provides a novel approach to kinetic analysis-critically one that is not reliant on specific compartmental modeling assumptions. A practical computational technique based on regularized cubic B-spline approximation of the residence time distribution is proposed. Nonparametric residue analysis allows formal statistical evaluation of specific parametric models to be considered. This analysis needs to properly account for the increased flexibility of the nonparametric estimator. The methodology is illustrated using data from a series of cerebral studies with PET and fluorodeoxyglucose (FDG) in normal subjects. Comparisons are made between key functionals of the residue, tracer flux, flow, etc., resulting from a parametric (the standard two-compartment of Phelps et al. 1979) and a nonparametric analysis. Strong statistical evidence against the compartment model is found. Primarily these differences relate to the representation of the early temporal structure of the tracer residence-largely a function of the vascular supply network. There are convincing physiological arguments against the representations implied by the compartmental approach but this is the first time that a rigorous statistical confirmation using PET data has been reported. The compartmental analysis produces suspect values for flow but, notably, the impact on the metabolic flux, though statistically significant, is limited to deviations on the order of 3%-4%. The general advantage of the nonparametric residue analysis is the ability to provide a valid kinetic quantitation in the context of studies where there may be heterogeneity or other uncertainty about the accuracy of a compartmental model approximation of the tissue residue.

Objective: To evaluate community pharmacists' readiness to provide brief interventions on alcohol and to use study findings to develop training to enable them to screen for hazardous or harmful drinking and intervene appropriately., Setting: Community pharmacies in Scotland., Method: Eight community pharmacies in Greater Glasgow, Scotland were purposively selected on the basis of pharmacy (independent, multiple), population deprivation index, location (rural, urban, suburban), and local level of hospital admissions for alcohol misuse. Baseline pharmacist telephone interviews covered: current practice; attitudes towards a proactive role; and perceived training needs. A two-day course was designed focusing on: consequences of problem alcohol use; attitudes; sensible drinking; familiarity with client screening using the Fast Alcohol Screening Tool; brief interventions and motivational interviewing., Main Outcome Measures: Knowledge of problem alcohol use and brief interventions; attitudes; competence. Results Participants felt it was feasible for trained pharmacists to provide brief interventions. Core training needs centred on communication and alcohol related knowledge. The training course was positively evaluated and led to increases in knowledge, attitudinal scores and self related competence., Conclusion: A training programme for pharmacists to deliver brief interventions to problem drinkers was successfully delivered resulting in enhanced knowledge, attitudinal scores and self related competence.

Objective: To examine the associations of nutrition knowledge, food label use, and food intake patterns among Latinas with and without diagnosed diabetes., Design: This was a case-control study., Subjects/setting: A convenience sample of 201 (100 cases with diagnosed type 2 diabetes, 101 controls without diagnosed diabetes) nonpregnant, nonbreastfeeding Latinas without severe health conditions, aged 35 to 60 years were interviewed by bicultural interviewers. Diverse community-based recruitment methods were used., Statistical Analyses Performed: Independent samples t test, Mann-Whitney U, and chi(2) tests, and multivariate logistic regression were performed., Results: Food labels self-efficacy and stage of change, and average nutrition knowledge scores were similar between cases and controls (P>0.05). Within the diabetes group, nutrition knowledge was greater among those who had seen a registered dietitian or a diabetes educator (P=0.020). Cases reported consuming artificially sweetened desserts and beverages more frequently than controls (P<0.001). Pooled sample cross-sectional analyses showed that nutrition knowledge was positively related to food label use, which in turn was related to a more healthful food intake pattern (P<0.05). After adjusting for likely confounders, socioeconomic status (SES) was positively related to nutrition knowledge (P=0.001) and intakes of fruits, vegetables, and meats (P

The production of volatile analyte species by UV photolysis in the presence of low-molecular-weight organic acids as an alternative to chemical vapor generation has been of recent interest. The mechanism of this process is not well understood. Proposed mechanisms often involve photolytic cleavage of the organic acid as the initial step. Evidence suggests that this may not be the dominant route for UV photolysis vapor generation. In this work computational methods were applied to determine a possible alternative mechanism in the absence of free-radical production. The proposed mechanism specifically focused on selenium vapor generation. An energetically favored mechanism was found for UV photolysis of inorganic selenium in the presence of formic and acetic acids which is consistent with previously reported experimental results.

Land application has become a widely applied method for treating wastewater. However, it is not always clear which soil-plant systems should be used, or why. The objectives of our study were to determine if four contrasting soils, from which the pasture is regularly cut and removed, varied in their ability to assimilate nutrients from secondary-treated domestic effluent under high hydraulic loadings, in comparison with unirrigated, fertilized pasture. Grassed intact soil cores (500 mm in diameter by 700 mm in depth) were irrigated (50 mm wk(-1)) with secondary-treated domestic effluent for two years. Soils included a well-drained Allophanic Soil (Typic Hapludand), a poorly drained Gley Soil (Typic Endoaquept), a well-drained Pumice Soil formed from rhyolitic tephra (Typic Udivitrand), and a well-drained Recent Soil formed in a sand dune (Typic Udipsamment). Effluent-irrigated soils received between 746 and 815 kg N ha(-1) and 283 and 331 kg P ha(-1) over two years of irrigation, and unirrigated treatments received 200 kg N ha(-1) and 100 kg P ha(-1) of dissolved inorganic fertilizer over the same period. Applying effluent significantly increased plant uptake of N and P from all soil types. For the effluent-irrigated soils plant N uptake ranged from 186 to 437 kg N ha(-1) yr(-1), while plant P uptake ranged from 40 to 88 kg P ha(-1) yr(-1) for the effluent-irrigated soils. Applying effluent significantly increased N leaching losses from Gley and Recent Soils, and after two years ranged from 17 to 184 kg N ha(-1) depending on soil type. Effluent irrigation only increased P leaching from the Gley Soil. All P leaching losses were less than 49 kg P ha(-1) after two years. The N and P leached from effluent treatments were mainly in organic form (69-87% organic N and 35-65% unreactive P). Greater N and P leaching losses from the irrigated Gley Soil were attributed to preferential flow that reduced contact between the effluent and the soil matrix. Increased N leaching from the Recent Soil was the result of increased leaching of native soil organic N due to the higher hydraulic loading from the effluent irrigation.

Nanocrystal budesonide (nanobudesonide) is a suspension for nebulization in patients with steroid-responsive pulmonary diseases such as asthma. The pharmacokinetics and safety of the product were compared to those of Pulmicort Respules. Sixteen healthy volunteers were administered nanobudesonide 0.5 and 1.0 mg, Pulmicort Respules 0.5 mg, and placebo in a four-way, randomized crossover design. All nebulized formulations were well tolerated, with no evidence of bronchospasm. Nebulization times were significantly shorter for nanobudesonide compared to Pulmicort Respules. Because of a low oral bioavailability, plasma concentration of budesonide is a good marker of lung-delivered dose. The pharmacokinetics of nanobudesonide 0.5 and 1.0 mg were approximately dose proportional with respect to Cmax, AUC(0-t), and AUC(0-infinity). Nanobudesonide 0.5 mg and Pulmicort Respules 0.5 mg exhibited similar AUCs, suggesting a similar extent of pulmonary absorption. A higher Cmax was noted with nanobudesonide 0.5 mg, and the tmax was significantly different, suggesting a more rapid rate of drug delivery of nanobudesonide 0.5 mg than Pulmicort Respules. In conclusion, nebulized nanobudesonide 0.5 mg was safe in healthy volunteers, with a similar extent of absorption as Pulmicort Respules.

Hemophagocytic lymphohistiocytosis (HLH) is a rare disease resulting from abnormal proliferation of histiocytes in tissues and organs. Although the disease generally presents with systemic symptoms such as pancytopenia, coagulopathy, and organomegaly, HLH may also present with central nervous system (CNS) manifestations. CNS events can range from irritability to encephalopathy and coma. Retinal and intracranial hemorrhages are among the neuropathologic findings in these children. Patients who present with CNS findings may have symptoms that mimic those of inflicted injury. These children are at risk, therefore, for misdiagnosis as victims of child abuse. Such an error causes not only unnecessary additional trauma to the family but also, more important, a delay in initiating effective therapy. We present 3 cases of children with HLH who initially came to medical attention with neurologic findings, all suspected to be victims of child abuse. Subsequent laboratory evaluations, however, were consistent with the diagnosis of HLH. No additional evidence of child abuse was obtained, and the charges eventually were dropped. Two of the 3 children died from their disease shortly after presentation; the third is surviving with no evidence of HLH several months after allogeneic bone marrow transplantation. Although the diagnosis of child abuse certainly is all too common, clinicians need to be diligent and informed to avoid assigning this label erroneously. Several laboratory findings of HLH may alert physicians to the possibility of this diagnosis. The timely diagnosis of and institution of therapy for HLH may reduce ultimate morbidity and mortality.

Objective: To determine whether an inactivated bovine respiratory syncytial virus (BRSV) vaccine would protect calves from infection with virulent BRSV., Design: Randomized controlled trial., Animals: 27 nine-week-old calves seronegative for BRSV exposure., Procedure: Group-1 calves (n = 9) were not vaccinated. Group-2 calves (n = 9) were vaccinated on days 0 and 21 with an inactivated BRSV vaccine containing a minimum immunizing dose of antigen. Group-3 calves (n = 9) were vaccinated on days 0 and 21 with an inactivated BRSV vaccine containing an amount of antigen similar to that in a commercial vaccine. All calves were challenged with virulent BRSV on day 42. Clinical signs and immune responses were monitored for 8 days after challenge. Calves were euthanatized on day 50, and lungs were examined for lesions., Results: Vaccination elicited increases in BRSV-specific IgG and virus neutralizing antibody titers and in production of interferon-gamma. Virus neutralizing antibody titers were consistently less than IgG titers. Challenge with BRSV resulted in severe respiratory tract disease and extensive pulmonary lesions in control calves, whereas vaccinated calves had less severe signs of clinical disease and less extensive pulmonary lesions. The percentage of vaccinated calves that shed virus in nasal secretions was significantly lower than the percentage of control calves that did, and peak viral titer was lower for vaccinated than for control calves., Conclusions and Clinical Relevance: Results suggest that the inactivated BRSV vaccine provided clinical protection from experimental infection with virulent virus and decreased the severity of pulmonary lesions. Efficacy was similar to that reported for modified-live BRSV vaccines.

Data collected in the Arrestee Drug Abuse Monitoring (ADAM) program on alcohol and other drug use among arrestees provide a valuable opportunity to examine the relationship between alcohol use and violence. The data are used to explore the combined use of alcohol and other drugs among offenders and the relationships between substance use and the offenders' demographic characteristics and offenses. These findings are used to identify changes in the offenders' alcohol and other drug use over time.

Four important changes have been introduced in the revised guidelines for the management of women with abnormal cervical smears, 1998. 1. For the purposes of management, atypical squamous cells of undetermined significance (ASCUS) and atypical glandular cells of undetermined significance (AGUS) have been included with low grade squamous intraepithelial lesions (LSIL/CIN1/HPV) except where the smear raises the possibility of a high grade squamous intraepthelial lesion (HSIL) or favours glandular dysplasia. 2. Women with low grade cytological and histological intraepithelial abnormalities will, after initial follow-up, revert to three yearly screening. 3. Requirements for those practising colposcopy have been defined. 4. A formal review of all cases of invasive cervical cancer is advocated.

Objective: To determine the frequency of thymic involvement in Langerhans' cell histiocytosis and describe its imaging appearance before and after treatment., Materials and Methods: A retrospective review of the radiology and clinical records of all patients diagnosed with Langerhans' cell histiocytosis at DeVos Children's Hospital between 1992 and 1998., Results: Of the 14 patients diagnosed with Langerhans' cell histiocytosis, 7 demonstrated multisystem involvement. The thymus was involved in 5 of 7 patients. The thymus was enlarged in 5; thymic contours were nodular/lobulated in 2; cystic changes were noted in 4; and dystrophic vascular-appearing calcifications were seen in 1. In all cases, findings regressed or resolved following chemotherapy., Conclusion: The thymus is commonly involved in Langerhans' cell histiocytosis, especially in multisystem disease. Radiologically, the thymus is enlarged and may be smooth or lobulated/nodular in contour, possibly containing cysts and calcifications.

We report the development of an electrotransformation method applicable to all strains of Saccharopolyspora erythraea examined to date. Vegetatively grown mycelia were rendered electrocompetent by subjecting mycelial suspensions to ultrasound pulses. The protocol provides an alternative route for the introduction of DNA into filamentous microorganisms otherwise recalcitrant to transformation techniques.

The Cmv1 resistance gene controls splenic replication of murine cytomegalovirus (MCMV) and confers natural killer (NK) cell-mediated resistance to otherwise lethal infection. The Cmv1 phenotypes of 13 inbred mouse strains have been assessed, and it was found that the Cmv1r resistance phenotype was restricted to the C57BL/6J and Ma/MyJ strains. We have further analyzed the linkage of Cmv1 to the NK gene complex (NKC) mapping to distal mouse chromosome 6 in 99 (BALB/c x C57BL/6J)F1 x BALB/c backcross mice using cloned gene probes and microsatellite markers from this region. No recombinants were observed between Cmv1 and the NKC-associated Ly49 and musNKR-P1 multigene families, nor the Kap locus, nor with 7 microsatellite markers, indicating that Cmv1 is closely linked (< 1 cM) to all of these markers. Analysis of the genotype of the MCMV-susceptible BXD8 RI strain around the NKC region revealed that it had C57BL/6J alleles at microsatellite markers immediately proximal and distal to Cmv1. This suggests that the Cmv1s phenotype of this strain is due to a germ-line mutation. Thus, the close linkage of Cmv1 to the Ly49 and musNKR-P1 multigene families suggests that it may represent an NK cell recognition structure encoded in the NKC region.

Two hundred consecutive coronary arteries in 157 patients undergoing angioplasty were randomized to fast or slow balloon deflation. Angioplasty was successful in 188 cases (101 with slow and 87 with fast deflation). There was no significant difference between the 2 groups with regard to the total number of dissections, although there was a greater number in the slow deflation group, and no difference in the number of minor dissections (National Heart, Lung, and Blood Institute types A and B). There was a significantly greater number of more severe dissections (types C to F) in the slow deflation group (20 vs 5; p = 0.013). It is proposed that the greater number of severe dissections is due to either increased turbulence or movement of the partially deflated balloon during slow deflation. Thus, slow balloon deflation during coronary angioplasty is associated with a higher complication rate than is conventional rapid deflation.

There is controversy concerning the relative safety and efficacy of the 2 currently available percutaneous transluminal coronary angioplasty dilatation systems--fixed-wire (FW) and over-the-wire (OW). A randomized, prospective trial comparing the 2 systems was performed to examine this controversy. Of 1,513 patients undergoing percutaneous transluminal coronary angioplasty at 3 centers between June 1990 and October 1991, 602 (40%) fulfilled the eligibility criteria for the study. There were 643 lesions, of which 327 were randomized to FW and 316 to OW systems. There was no difference in the success rate between FW (92%) and OW (94%) systems. Inability to cross with a wire was infrequent with either system (FW: 1.8%; and OW: 1.6%). Inability to cross with a balloon when the wire crossed the lesion did not occur. An FW system was successful in 6 cases (1.9%) in which the OW system had been unsuccessful, whereas an OW system succeeded in 14 (4.3%) after the FW system had been unsuccessful (p = NS). Time to cross stenoses was 200 +/- 21 and 233 +/- 22 seconds, procedural time was 21 +/- 1.3 and 21 +/- 1.0 minutes, fluoroscopy time was 6.7 +/- 0.4 and 7.1 +/- 0.4 minutes, contrast used was 89.0 +/- 4.2 and 84.0 +/- 3.5 ml, and number of cine runs was 5.9 +/- 3.0 and 6.3 +/- 3.4 in the FW and OW systems, respectively. Complications were infrequent with either system (FW: 10.4%; and OW: 9.5%). Acute closure occurred in 1.8 and 2.2% of cases in the FW and OW systems, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

A 13-month study of wild mice (Mus domesticus) in wheatlands in southeastern Australia contrasted changes in the seroprevalence of antibody to 13 viruses and the occurrence of helminths with changes in their population dynamics. Mice were seropositive for mouse hepatitis virus (MHV), rotavirus, minute virus of mice (MVM), mouse adenovirus (MAdV), reovirus (reo 3), and murine cytomegalovirus (MCMV). The seroprevalences of all but rotavirus varied significantly with time and increased with host density. Near the end of the study, host density declined rapidly and the seroprevalence of MVM and reo 3 increased significantly. These two viruses had low seroprevalence when host survival was high and high seroprevalence when host survival was low, indicating they may play a role in regulating mouse populations. In the case of MVM, there was evidence of a viral epizootic during the decline in mouse abundance. The prevalence of four helminths (Taenia taeniaeformis, Syphacia obvelata, and Vampirolepis spp.) differed significantly with time but showed no apparent association with host density. These findings highlight the need for further study on the effect of viruses on the population dynamics of mice.

Mentoring has been proposed as one strategy to attract minority students to the radiologic sciences profession. This case study describes a minority mentoring program conducted for pre-radiologic science students at a Midwestern university during the 1991-92 academic year. Ten minority radiologic science students enrolled in the mentoring program. The study showed that mentoring may be a viable option to serve the special needs of minorities for recruitment and retention.

The resistance of mice to lethal infection by murine CMV (MCMV) is under complex host genetic control with contributions from both H-2 and non-H-2 genes. We have previously shown that an autosomal, non-MHC encoded gene, Cmv-1, controls MCMV replication in the spleen. We have investigated the mechanism by which the Cmv-1 resistance gene confers protection against MCMV infection. Using H-2 compatible irradiation bone marrow chimeras, the enhanced resistance to MCMV infection that is associated with the Cmv-1l allele in the C57BL background was shown to be mediated by an irradiation-sensitive bone marrow-derived cell population, or a factor produced by these cells. The lack of correlation between serum IFN titers and the strain distribution pattern of Cmv-1 in CXB recombinant inbred mouse strains suggests that IFN does not mediate resistance conferred by this gene. Similarly, the lack of effect of in vivo depletion of mature CD4+ and CD8+ T cells on virus replication in C57BL/6J mice indicates that T cells are unlikely to be involved. In contrast, in vivo depletion of NK cells by injection of the anti-NK1.1 mAb PK136 abrogated restricted splenic virus replication in C57BL/6J----BALB.B chimeric mice and in the Cmv-1l CXB strains. These data indicate that the effect of the Cmv-1 gene is mediated by NK cells. The significant augmentation in NK cell activity after MCMV infection of the susceptible Cmv-1h strains (BALB/cBy), CXBG/By, CXBH/By, CXBI/By, and CXBK/By) indicates the existence in these mice of NK cells that are functionally and phenotypically distinct from those in Cmv-1l strains. NK cells present in the Cmv-1h strains are unable to restrict efficiently splenic MCMV replication in vivo, possibly due to a lack of specificity for virus-infected target cells. Finally, flow cytometric analysis of NK1-1 expression in CXB and BXD RI mice together with MCMV replication studies in the BXD RI strains indicate that Cmv-1 is closely linked to NK1.1 and other loci that reside on a distal segment of murine chromosome 6 in a region that has recently been defined as the natural killer complex.

The Department of Health and the Cancer Society invited a working group to review the 1985 recommendations on cervical screening. Minor modifications have been made to the earlier recommendations in the light of more information about the effectiveness of different screening policies, and in the expectation that comprehensive cytology registers to ensure recall and follow up of abnormalities will be in place shortly. All women from the age of 20 up to 70 years should be offered cervical screening every three years. Any woman who has never had sexual intercourse or who has had a hysterectomy with complete removal of the cervical epithelium for a benign condition need not be screened. Women should have a second smear within one year if they have never had a smear before or if more than five years have passed since their last smear. But recall through the register should not be more frequently than three yearly for women with a history of normal smears.

Genetically determined resistance to murine cytomegalovirus is observed in adult mice and is mediated in part by genes of the H-2 complex, with the H-2k haplotype conferring resistance. This model was used to examine the effect of primary maternal infection on fetal outcome. The severity of fetal growth retardation and death after primary maternal infection on day 8 of pregnancy was found to be genetically determined. Fetal viability and weight were significantly lower in infected BALB/c mothers (H-2d) than in CBA(H-2k) and BALB.K(H-2k) mothers. However, fetal infection was not detected, suggesting that the resistance mechanisms operate at the level of the mother or placenta. By directly inoculating fetuses in utero, it was shown that genetic factors in the fetus can influence the level of fetal infection and viability. These results point to the possibility that host genetic factors may modulate maternal and fetal cytomegalovirus infections in humans.

The genetic basis of the control of acute splenic MCMV infection was studied after intraperitoneal inoculation of the virus. Classical Mendelian analyses using C57BL/6 (resistant) and BALB/c (susceptible) parental strains disclosed an autosomal dominant non-H-2 gene that regulates splenic virus replication. The probable location of this gene, to which we have assigned the symbol Cmv-1, is on chromosome 6 as defined by the strain distribution pattern of splenic MCMV replication in CXB recombinant inbred mice. Although there is a similar hierarchy of resistance to MCMV and HSV-1 with respect to the C57BL and BALB genetic backgrounds, the strain distribution pattern of HSV-1 replication in recombinant inbred mice suggests that Cmv-1 is not involved in restricting the spread of this virus. This is the first clear identification of a non-H-2 gene regulating the magnitude of MCMV infection. Elucidation of the function of this gene may be a fundamental step towards understanding the control of systemic CMV infection.

Genetically determined resistance to the lethal effects of infection with murine cytomegalovirus (MCMV) has been reported previously in adult and newborn mice. We examined the pathogenesis of MCMV infection in resistant (CBA, H-2k) and susceptible (BALB/c, H-2d) mice infected intraperitoneally on the day of birth. BALB/c mice developed a severe interstitial pneumonitis and myocarditis 10 days post-infection. Their pulmonary and tissues contained high MCMV titres and large numbers of MCMV-antigen positive cells. MCMV also infected the endothelial and myointimal cells of the coronary arteries in newborn BALB/c mice. Only limited infection and pathological changes were seen in CBA mice. Since the severe disease in BALB/c mice resembles the pneumonitis and less frequently reported myocarditis observed after perinatal HCMV infection, the newborn mouse model will be useful for studying the consequences and treatment of such infections, the influence of the host genotype on disease severity and the possible association between perinatal HCMV infection and atherosclerosis.

Because of concern about the rising incidence of cervical cancer in young women, the Department of Health and the Cancer Society invited a working group to make recommendations on cervical screening. There is now compelling evidence that cytological screening is an effective preventive measure. All women who have had sexual intercourse should be offered screening. They should be screened as soon as possible after commencing sexual activity, or when first receiving contraceptive advice, antenatal care, or treatment of a sexually transmitted disease. If the first smear is negative, it should thereafter be repeated at least every three years. A special effort must be made to reach women who have never been screened, including those who are middle-aged, or elderly. The cervical smear test should be part of the assessment of women with gynaecological symptoms regardless of whether there has been a negative smear within the previous three years. The three-yearly schedule also does not apply to women who have had an abnormal smear.

The Cancer Society and the Department of Health invited a working group to make recommendations on screening by mammography. Mammography offers the best opportunity for preventing deaths from breast cancer. Randomised trials suggest that mortality can be reduced by about 30% in women over 50; the value of routine mammography in younger women is still uncertain. Apart from financial costs, the main drawback of mammography is that many women receive unnecessary investigation because of false-positive results. Careful design and monitoring of programmes is essential to ensure that the benefits of screening outweigh the disadvantages. In New Zealand there is a shortage of radiologists, pathologists, and clinicians who are skilled in the specialised techniques required for the screening of asymptomatic women. Decisions about routine screening should be delayed until pilot programmes have been established, with assessment of their effectiveness, economic efficiency, and social acceptability. Recommendations for the design of such programmes are made.