Cigarette graphic warning labels increase both risk perceptions and smoking myth endorsement

OBJECTIVE

Cigarette graphic warning labels elicit negative emotion, which increases risk perceptions through multiple processes. We examined whether this emotion simultaneously affects motivated cognitions like smoking myth endorsement (e.g. 'exercise can undo the negative effects of smoking') and perceptions of cigarette danger versus other products.

DESIGN

736 adult and 469 teen smokers/vulnerable smokers viewed one of three warning label types (text-only, low emotion graphic or high emotion graphic) four times over two weeks.

MAIN OUTCOME MEASURES

Emotional reactions to the warnings were reported during the first and fourth exposures. Participants reported how often they considered the warnings, smoking myth endorsement, risk perceptions and perceptions of cigarette danger relative to smokeless tobacco and electronic cigarettes.

RESULTS

In structural equation models, emotional reactions influenced risk perceptions and smoking myth endorsement through two processes. Emotion acted as information about risk, directly increasing smoking risk perceptions and decreasing smoking myth endorsement. Emotion also acted as a spotlight, motivating consideration of the warning information. Warning consideration increased risk perceptions, but also increased smoking myth endorsement. Emotional reactions to warnings decreased perceptions of cigarette danger relative to other products.

CONCLUSIONS

Emotional reactions to cigarette warnings increase smoking risk perceptions, but also smoking myth endorsement and misperceptions that cigarettes are less dangerous than potentially harm-reducing tobacco products.

Calciphylaxis--a topical overview

'Calciphylaxis', a calcification syndrome associated with ischaemic cutaneous necrosis, is acquired naturally in humans in disease states. It is a life and limb-threatening complication, usually observed in patients with renal disease and secondary hyperparathyroidism, but known to occur in the absence of renal or parathyroid disease. The reported mortality rate, which ranges from 60-80%, relates to wound infection, sepsis and organ failure. It is a small-vessel vasculopathy, which is estimated to occur in about 4% of haemodialysis patients. Clinically, violaceous, reticulate areas of cutaneous necrosis and eschar may be evident, particularly in the extremities. In addition to the clinical picture, a raised calcium phosphorous product, an elevated parathyroid hormone level, radiographic evidence of vessel and soft-tissue calcification and the finding of mural calcification affecting small arteries and arterioles on histopathology help to confirm the diagnosis of this entity which generally has a poor prognosis. A high index of suspicion and an active multidisciplinary management approach, with rigorous attention to wound care and prevention of sepsis, are vital in the management of these patients. In this overview, we discuss the pathophysiology, clinical features and associations, risk factors, diagnosis and management issues relating to calciphylaxis.

Gestational stress induces post-partum depression-like behaviour and alters maternal care in rats

Gestational stress (GS) produces profound behavioural impairments in the offspring and may permanently programme hypothalamic-pituitary-adrenal (HPA) axis function. We investigated whether or not GS produced changes in the maternal behaviour of rat dams, and measured depression-like behaviour in the dam, which might contribute to effects in the progeny. We used the Porsolt test, which measures immobility in a forced-swim task, and models depression in rodents, while monitoring maternal care (arched-back nursing, licking/grooming, nesting/grouping pups). Pregnant rats underwent daily restraint stress (1 h/day, days 10-20 of gestation), or were left undisturbed (control). On post-parturition days 3 and 4, dams were placed into a swim tank, and time spent immobile was measured. GS significantly elevated immobility scores by approximately 25% above control values on the second test day. Maternal behaviours, in particular arched-back nursing and nesting/grouping pups, were reduced in GS dams over post-natal days 1-10. Adult offspring showed increased immobility in the Porsolt test, and also hypersecreted ACTH and CORT in response to an acute stress challenge. These data show that GS can alter maternal behaviour in mothers, and this might contribute to alterations in the offspring. GS may be an important factor in maternal post-natal depression, which may in turn detrimentally effect the offspring because depressed mothers do not sufficiently care for their offspring.

Effect of process parameters upon the dopamine and lipid peroxidation activity of selected MIG welding fumes as a marker of potential neurotoxicity

There is growing concern over the neurotoxic effects of chronic occupational exposure to metal fume produced by welding. Elevated iron and manganese levels in the brain have been linked to an increase in lipid peroxidation, dopamine depletion and predisposition to the development of a Parkinson's type condition in advanced cases. Chemical and toxicological analysis of selected welding fumes, generated by model processes, were used in order to evaluate their potential to release solutes that promote oxidation of dopamine and peroxidation of brain lipids in cell free assays. This study compared the effect of shield gas, electrode type and voltage/currect upon the dopamine and brain lipid peroxidation potential of selected welding fume, obtained from metal inert gas (MIG) welding systems. Overall, fume extracts were found to enhance dopamine oxidation and inhibit lipid peroxidation. Significant differences were also found in the oxidising potential of fume generated under differing process conditions; it may therefore be possible to determine the potential neurotoxicity of fumes using this system.

The observation unit: a new interface between inpatient and outpatient care

PURPOSE

Observation units for patients who present to emergency departments with chest pain have become common. We describe our 3-year experience with a multipurpose observation unit in which chest pain accounts for only a minority of patients' presenting clinical syndromes.

SUBJECTS AND METHODS

We analyzed the effects of a 12-bed observation unit on inpatient admissions for common clinical syndromes, as well as its overall effects on inpatient medical admissions during its first 3 years of operation (1996 to 1998) compared with the 3 years preceding its creation (1993 to 1995).

RESULTS

Among 7,507 patients admitted to the observation unit in 1996 to 1998, 6,334 (85%) were discharged home within 23 hours. Total inpatient medical admissions fell by a similar number (n = 5,366) during the 3 years of operation of the observation unit when compared with the 3 preceding years (39,569 admissions in 1996 to1998 versus 44,935 in 1993 to 1995). Analysis of local area trends suggested that the use of the observation unit contributed to reduced hospital admissions, rather than vice versa.

CONCLUSION

Observation units can serve patients with diverse clinical syndromes and may reduce inpatient admissions. This novel "point of care" deserves further evaluation.

Primary peripheral T cell lymphoma of the endometrium

A case of a primary peripheral T cell lymphoma arising in the endometrium is presented. Primary lymphomas of the female genital tract are rare, with endometrial lymphomas and those of T cell type being rarer still. Extensive investigations revealed no other sites of disease and the patient was treated by hysterectomy and chemotherapy. She remains well 33 months later. We believe that this case is exceptionally unusual.

Teaching residents evidence-based medicine skills: a controlled trial of effectiveness and assessment of durability

OBJECTIVES

To measure the effectiveness of an educational intervention designed to teach residents four essential evidence-based medicine (EBM) skills: question formulation, literature searching, understanding quantitative outcomes, and critical appraisal.

DESIGN

Firm-based, controlled trial.

SETTING

Urban public hospital.

PARTICIPANTS

Fifty-five first-year internal medicine residents: 18 in the experimental group and 37 in the control group.

INTERVENTION

An EBM course, taught 2 hours per week for 7 consecutive weeks by senior faculty and chief residents focusing on the four essential EBM skills.

MEASUREMENTS AND MAIN RESULTS

The main outcome measure was performance on an EBM skills test that was administered four times over 11 months: at baseline and at three time points postcourse. Postcourse test 1 assessed the effectiveness of the intervention in the experimental group (primary outcome]; postcourse test 2 assessed the control group after it crossed over to receive the intervention; and postcourse test 3 assessed durability. Baseline EBM skills were similar in the two groups. After receiving the EBM course, the experimental group achieved significantly higher postcourse test scores (adjusted mean difference, 21%; 95% confidence interval, 13% to 28%; P < .001). Postcourse improvements were noted in three of the four EBM skill domains (formulating questions, searching, and quantitative understanding [P < .005 for all], but not in critical appraisal skills [P = .4]). After crossing over to receive the educational intervention, the control group achieved similar improvements. Both groups sustained these improvements over 6 to 9 months of follow-up.

CONCLUSIONS

A brief structured educational intervention produced substantial and durable improvements in residents' cognitive and technical EBM skills.

Narrowband TL-01 phototherapy for patch-stage mycosis fungoides

BACKGROUND

Although patch-stage mycosis fungoides (MF) has a generally good prognosis, and long-term survival rates with current therapies (UV-B, photochemotherapy, topical nitrogen mustards, electron-beam therapy) are similar, there is concern regarding their potential adverse effects. Narrowband or TL-01 UV-B phototherapy (311 nm), in use for more than 10 years, is more effective than broadband UV-B for the treatment of psoriasis, with an efficacy approaching that of psoralen UV-A. This open study assesses TL-01 as an alternative therapy for patch-stage MF.

OBSERVATIONS

Eight white patients (4 men, 4 women; age range, 66-83 years) with histologically proven patch-stage MF received TL-01 phototherapy 3 times weekly using a standard protocol. Complete clearance of MF was achieved in 6 cases in a mean of 9 weeks or 26 treatments (range, 20-37 weeks) and 4 patients have had prolonged remissions. Mean duration of clinical improvement has been 20 months (range, 11-40 months). Partial response to TL-01 or poor histologic improvement was associated with rapid relapse.

CONCLUSIONS

TL-01 is an effective, convenient therapy that may have less risk of long-term adverse effects than current alternatives. Although larger prospective studies are necessary, for some patients intermittent courses of TL-01 may offer effective long-term therapy.

Study design and outcomes in out-of-hospital emergency medicine research: a ten-year analysis

OBJECTIVE

Lack of rigorous study design and failure to follow diverse patient outcomes have been identified as critical gaps in the medical research literature. This study sought to determine whether similar gaps exist in the literature for out-of-hospital interventions.

METHODS

A computerized MEDLINE search was conducted for the ten-year period 1985 through 1994 using the MeSH terms "emergency medical services," "prehospital," and "transportation of patients." Using a standard abstraction form, two investigators independently analyzed articles meeting these inclusion criteria: original research evaluating an out-of-hospital intervention and measuring a patient outcome. Study design was categorized in order of scientific rigor, moving from case series to randomized trial. Measures of outcomes were classified into the six Ds: death, disease, discomfort, disability, dissatisfaction, and debt (cost).

RESULTS

Interobserver agreement was high (kappa = 0.80). For the ten-year period, 3,686 titles, 1,454 abstracts, and 373 articles were examined serially; all 285 studies meeting inclusion criteria were analyzed. Case series (44%) was the most frequently used design, while only 15% were randomized trials. The majority of the studies were retrospective (53%). A single outcome was assessed in 45% of the articles; 41% measured two outcomes, 13% three outcomes, and 1% four outcomes. Death and disease were the most common outcomes evaluated. Disability, debt, discomfort, and dissatisfaction were infrequently measured.

CONCLUSION

Studies of out-of-hospital emergency medical interventions are limited in the scientific rigor of study design and the diversity of patient outcomes measured. To adequately assess the effectiveness of out-of-hospital care, efforts should be directed toward strengthening study designs and examining the full range of patient outcomes.

How does colorectal cancer present? Symptoms, duration, and clues to location

OBJECTIVE

Most colorectal cancers still present with symptoms because screening, although effective, is not yet widely practiced. A careful history and physical examination are still the usual methods for suspecting colorectal cancer and ordering appropriate investigation. Therefore, we studied the symptoms, duration, and clues to location of colorectal cancer.

METHODS

We reviewed both hospital and office records for 204 consecutive patients with colorectal cancer, first diagnosed after symptoms, at one regional referral center from 1983-87. We abstracted data on demographic characteristics, presence and duration of 15 symptoms, and characteristics of the tumors.

RESULTS

The 194 patients included in the study were similar to those with colorectal cancer described elsewhere in terms of age, gender, and tumor location (58% distal to the splenic flexure), and stage (56% stage A or B). The most common symptoms were rectal bleeding (58%), abdominal pain (52%), and change in bowel habits (51%); the majority had anemia (57%) and occult bleeding (77%). The median duration of symptoms (from onset to diagnosis) was 14 wk (interquartile range 5-43). We found no association between overall duration of symptoms and the stage of the tumor. Patient age, gender, and proximal cancer location were also not associated with a longer duration of symptoms before diagnosis. We developed a rule for predicting a distal location of cancer using multiple logistic regression. Independent predictors were (odds ratio [95% CI]): Hb (1.34 for each g/dl [1.16-1.54]); rectal bleeding (3.45 [1.71-6.95]); constipation (3.16 [1.38-7.24]); and proximal symptoms (at least one of anorexia, nausea, vomiting, abdominal pain, or fatigue) (0.48 [0.20-1.02]). The rule had sensitivity of 93% and a specificity of 47%, with an area under the ROC curve of 0.79.

CONCLUSIONS

Until prevention of colorectal cancer is more common, we must continue to rely on clinical findings for detecting this cancer. Our results will remind physicians to keep colorectal cancer on the differential diagnosis of "chronic" gastrointestinal symptoms, and our decision rule may prompt earlier investigation with colonoscopy.

New thoughts on cardiopulmonary resuscitation

The results of cardiopulmonary resuscitation (CPR) have been distressingly poor when one considers the amount of research in this field since 1960. Accordingly, some improvements to present protocols have been suggested. Some of the suggestions can be applied by practicing veterinarians to increase the success rate for external chest massage. In addition, veterinarians are encouraged to switch to internal cardiac massage early in the resuscitation period.

Malignant mesothelioma of the tunica vaginalis: a case with an unusually indolent course following radical orchidectomy and radiotherapy

Malignant mesothelioma (malignant adenomatoid tumour) of the tunica vaginalis testis is a very rare neoplasm with highly aggressive biological behaviour. Treatment is difficult, and widespread local invasion and/or metastatic disease at presentation are associated with a poor prognosis. In this case report we describe for the first time a patient who, despite presenting with locally advanced disease, remains well 10 years after diagnosis and treatment with radical orchidectomy and high dose radiotherapy.

Cell reactions to dielectrophoretic manipulation

The phenomenon of dielectrophoretic particle manipulation holds promise for many biotechnology applications, including cell sorting. In our system cell manipulation normally involves transient exposure (15 minutes) to radio-frequency AC electric fields generated using planar microelectrodes. The present study was designed to investigate the range of acute effects of dielectrophoretic manipulation on the normal physiology of isolated cells. Cells were suspended in isoosmotic Mannitol and exposed to a 5 MHz, 21 V (peak to peak) electric field with 100 micrometer gap electrodes. Cells were assigned to three experimental groups; non-exposed controls, exposed cells processed immediately after cessation of the field, and exposed cells processed after a time delay. SEM observations of spread cells cultured on the devices showed no apparent acute effects of field exposure on cell morphology. Cell-doubling rates in exposed cells subsequent to field-exposure or transient incubation in mannitol were no different from control cells. An MTT 'mitochondrial stress' assay indicated no alteration in the rate of oxidative respiration in exposed cells 0.5 hour after exposure to the field. Western blot analysis indicated upregulation of fos protein in cells 0.5 hour after field-exposure, which was confirmed using densitometry. Reverse transcription of cellular mRNA followed by PCR amplification, polyacrylamide gel electrophoresis and autoradiography of cDNA banding revealed differential gene expression between controls and exposed cells processed immediately after cessation of the field. Differential gene expression persisted in exposed cells at least 0.5 hours after removal from the field. Observations indicated that temperature fluctuation in the mannitol solution was minimal, suggesting that upregulated mRNA may not have been related to thermally-induced heat shock protein. The present study has indicated that exposure to AC fields during dielectrophoretic cell manipulation is associated with upregulation of the intermediate-early gene cfos and also transcription of other as yet unidentified genes. These transcriptional events were not manifest as gross changes in cell morphology or cell-cycle dynamics.

Part II. Evidence-based medicine: a passing fancy or the future of primary care?

Reliable experimental evidence provides a firm scientific foundation for only a minority of the clinical decisions primary care practitioners must make each day. Thus clinicians' experience and judgment must complement and supplement their knowledge of published research studies. This presents a dynamic and difficult challenge to the practitioner--one that is magnified when combined with the never ending influx of medical information, with patients' and physicians' uneasiness with clinical uncertainty, and with new external pressures to standardize care. With these factors in mind, this article will review evidence-based medicine, a process and philosophy for the practice and teaching of clinical medicine that has sparked much controversy in recent years. Clinical scenarios commonly encountered in adult primary care--acute low back pain, hypertension, and screening for vascular disease--illustrate some strengths and limitations of evidence-based medicine.

Multiple widespread eruptive Spitz naevi

A 19-year-old man presented with a widespread eruption of several hundred Sptiz naevi. He is still developing new lesions, 4 years after the problem began. No treatment to date has been satisfactory. The literature on prognosis and treatment of this condition is reviewed.

Are medical students ready to provide HIV-prevention counseling?

PURPOSE

To determine whether medical students were prepared to assess risk and counsel patients about prevention of HIV infection, and whether HIV-related experience produced better knowledge and counseling skills.

METHOD

In 1995, students at four North Carolina medical schools interviewed a standardized patient portraying a young woman concerned about HIV infection. The standardized patient recorded whether students asked risk-behavior questions and provided risk-reduction advice. A 21-item questionnaire assessed the students' knowledge of HIV testing and prevention. Students indicated whether they had had experience in educational settings related to HIV or STDs.

RESULTS

415 students completed both the patient interview and the questionnaire. Many failed to ask the patient about several HIV-risk behaviors. Although nearly all (98%) inquired about condom use, fewer than two thirds asked about the patient's history of STDs, number of sexual partners, or specific sexual practices. Most students advised the patient to use condoms. The average score on the knowledge test was 79%; 70% of students confused anonymous with confidential testing, more than half overestimated the risk of HIV transmission from a needle stick, and nearly one in ten did not know how to use a condom. Educational exposures did not produce significantly better risk assessment, counseling information, or knowledge scores.

CONCLUSION

A majority of experienced medical students did not assess several important risk factors of a patient concerned about HIV infection, and many would have provided incorrect information related to HIV testing and prevention of infection. Patient contact in traditional clinical settings did not influence prevention knowledge or behavior. More innovative methods are needed to train students in HIV-infection prevention and counseling.

Umbilical artery Doppler velocimetry waveform abnormality in fetal gastroschisis

Two cases of notching in the umbilical artery Doppler waveform in a pregnancy with gastroschisis are reported. The etiology of the abnormal Doppler pattern in relation to the displacement of the fetal stomach in this congenital abnormality is discussed.

Superior mesenteric artery Doppler velocimetry and ultrasonographic assessment of fetal bowel in gastroschisis: a prospective longitudinal study

OBJECTIVE

Our purpose was to determine whether Doppler velocimetry of the superior mesenteric artery and its mesenteric branches and ultrasonographic assessment of bowel can predict postnatal outcome in fetuses with gastroschisis.

STUDY DESIGN

The normal reference range for the superior mesenteric artery pulsatility index was determined by studying 161 normal fetuses. Over a 24-month period superior mesenteric artery pulsatility index, superior mesenteric artery mesenteric branches systolic/diastolic ratio, bowel diameter, and bowel wall thickness were prospectively and longitudinally obtained from 17 fetuses with gastroschisis. Poor neonatal outcome was defined by bowel resection or staged repair of the defect or a hospital stay > 50 days.

RESULTS

Doppler velocimetry of the superior mesenteric artery and its mesenteric branches proved minimally useful in prognosticating neonatal outcome. No difference was found in the superior mesenteric artery pulsatility index between the good and poor neonatal outcome groups (p = 0.99). Longitudinal data analysis on all fetuses with gastroschisis showed an increase in bowel diameter with advancing gestation (p < 0.0001). A greater rate of increase in bowel diameter with advancing gestation was noted in the poor-neonatal-outcome group compared with the good-neonatal-outcome group (p < 0.01). Mean bowel diameter obtained before delivery was significantly greater in the poor-neonatal-outcome group (p = 0.03). Bowel diameter obtained at 28 to 32 weeks was the best predictor of poor neonatal outcome. A cutoff value of bowel diameter > 10 mm at 28 to 32 weeks had a sensitivity of 83%, a specificity of 88%, a positive predictive value of 83%, and a negative predictive value of 88% for poor neonatal outcome.

CONCLUSIONS

Doppler velocimetry of the superior mesenteric artery and its branches is not predictive of poor neonatal outcome in fetuses with gastroschisis. A bowel diameter > 10 mm between 28 and 32 weeks appears to be the best predictor of poor neonatal outcome. This newly defined variable warrants further investigation given its significant predictive power.

Effect of hypothermia on microglial reaction in ischemic brain

Intra-ischemic hypothermia is known to protect neurons against ischemic injury. Microglial cells have been shown to become activated following ischemia and are speculated to play significant roles in the evolution of ischemic neuronal injury. In this study, we examined the effect of intra-ischemic hypothermia on the microglial reaction in the hippocampus following transient forebrain ischemia produced in gerbils by 10 min bilateral carotid occlusion at 30 degrees C or at 37 degrees C, followed by normothermic reperfusion for 1-7 days. Microglial cells were visualized by histochemical staining with isolectin-B4 from Griffonia simplicifolia. Brains subjected to normothermic ischemia showed activation of microglia at 1 day post-ischemia; this increased with further recirculation, becoming intense by 3 days and diminished by 7 days. Ischemia under hypothermic conditions was not associated with activation of microglia, and these brains showed no significant neuronal damage, whereas the brains subjected to normothermic ischemia showed extensive neuronal necrosis in the CA1 region after 1 and 7 days reperfusion. The presence of activated microglial cells in the CA1 region prior to and in parallel with evolution of ischemic neuronal damage, the lack of such activation in brains subjected to the neuroprotective action of intra-ischemic hypothermia, together with the known potential capability of microglial cells to release cytotoxic substances appear to indicate that these cells could contribute significantly to ischemic neuronal necrosis.

GFAP-immunoreactivity following hypothermic forebrain ischemia

This study investigated the effect of intra-ischemic hypothermia on astroglial reactions in the hippocampus following cerebral ischemia. Mongolian gerbils were subjected to forebrain ischemia by bilateral carotid occlusion of 10 min at a) 30 degrees C and b) 37 degrees C followed by normothermic reperfusion ranging from 1 to 3 days (d). The astrocytes were visualized by immunostaining against glial fibrillary acidic protein (GFAP), and neuronal injury was evaluated by using hematoxylin-eosin staining. In normothermic brains, reactive astrocytosis was noted in 1 and 2 d postischemic animals, becoming prominent in the 3 d postischemic group. Intense GFAP-positive cells with thickened processes were noted in all regions of the hippocampus, especially the CA1 region. These cells were seen to have migrated toward the stratum pyramidale which was normally devoid of such staining. Hypothermia significantly inhibited the GFAP-upregulation seen 3 d after normothermic ischemia. There was no significant neuronal damage in the 3 d hypothermic ischemic group. Since glial cell activation, as evidenced by GFAP-upregulation, precedes as well as accompanies neuronal damage, and since hypothermia, known to be neuroprotective, inhibits glial cell activation in the 3 d postischemic brain, it appears that glial cells play critical roles in neuronal survival or death following ischemia.

Expression of c-fos and fos-B proteins following transient forebrain ischemia: effect of hypothermia

Immediate early genes are induced by transient global ischemia. Using immunohistochemistry we studied the effect of intraischemic hypothermia (30 degrees C) on the expression of c-fos and fos-B proteins following 10 min forebrain ischemia in the gerbil. Postischemia (PI) periods of 1 hour (h), 6 h, 1 day (d) and 2 d and nonischemic controls were examined in normothermic and hypothermic brains. In normothermic ischemic brains, marked expression of c-fos occurred in the dentate gyrus after 1 h PI which extended to CA2-4 regions by 6 h. Hypothermia hastened the time course of c-fos expression as it was expressed simultaneously in the dentate gyrus as well as CA2-4 regions after only 1 h, and by 6 h the expression remained only in the CA2-4 regions and not the dentate gyrus in hypothermic ischemic brains. There was no difference in its expression between normothermic and hypothermic brains in the 1 d and 2 d PI animals. Somewhat similar changes were noted in fos-B expression. In normothermic ischemic brains fos-B was induced in the dentate gyrus by 1 h PI, and by 6 h it extended to involve CA1-4 cells. The hypothermic ischemic brains showed faster induction of fos-B so that the dentate gyrus as well as CA1-4 regions were immunopositive at 1 h PI. There was no difference in its expression between normothermic and hypothermic brains in the subsequent PI periods of 6 h, 1 d and 2 d. The shift towards faster sequential induction of these genes by hypothermia in ischemic brains may be indicative of preservation of or faster recovery of mechanisms involved in intracellular signalling.

Differences in end-of-life decision making among black and white ambulatory cancer patients

OBJECTIVE

African-American (black) and white individuals have been shown to differ in their desire for life-sustaining treatments and their use of living wills for end-of-life care, but the reasons for these differences are unclear. This study was designed to test the hypothesis that these ethnic differences exist because black patients trust the health care system less, fear inadequate medical treatment more, and feel less confident that living wills can give them more control over their terminal care.

DESIGN

Cross-sectional, in-person survey conducted from November 1993 to June 1994.

SETTING

Two medical oncology clinics with 40% to 50% black patient representation.

PARTICIPANTS

Ambulatory cancer patients, 92 black and 114 white, who were awaiting their physician visits and agreed to participate (76% of those eligible). Patients were excluded if they were under age 40 or if they had nonmelanoma skin cancer only.

MEASUREMENTS AND MAIN RESULTS

Black ambulatory cancer patients wanted more life-sustaining treatments (odds ratio [OR] 2.8; 95% confidence interval [CI] 1.4-5.3), and were less likely to want to complete a living will at some time in the future (OR 0.36; 95% CI 0.17-0.75) than were white patients after controlling for socioeconomic variables. However, these differences were not related to lack of trust or fear of inadequate medical treatment in this study population. Both groups of patients trusted the health care system and felt that physicians treated patients equally well. Neither group feared inadequate or excessive medical care, and the majority of both groups agreed that living wills would help them keep control over their terminal care.

CONCLUSIONS

Black and white cancer patients make different end-of-life choices, even after adjusting for likely explanatory variables. The other factors that influence decision making remain unclear and need to be further explored if physicians are to understand and help their patients make choices for end-of-life care.

Teaching dietary counseling skills to residents: patient and physician outcomes. The CADRE Study Group

Our objective was to determine whether an educational intervention and prompting intervention for physicians improved dietary counseling of patients with high blood cholesterol and resulted in beneficial changes in patients' diets and cholesterol levels. We instituted a factorial design, multicenter, randomized, placebo-controlled trial to test two interventions. We tested the trial at continuity care clinics of internal medicine residents at seven community and university medical centers in the northern and eastern United States. Our participants were 130 internal medicine residents and 254 adult outpatients with blood cholesterol levels of 240-300 mg/dL. Interventions included an educational program for resident physicians designed to improve their skills and confidence in dietary counseling (two one-hour sessions with specially prepared printed materials for use in counseling) and a prompting intervention, which was a fingerstick blood cholesterol determination prior to the patient's clinic visit. Resident physicians' knowledge, attitudes, and self-reported behaviors were assessed prior to the intervention and 10 months later using chart audits and questionnaires. Residents' behaviors were also assessed by exit interviews with patients. Patients' knowledge, attitudes, behaviors, and fingerstick blood cholesterol levels were measured at baseline and 10 months later. The educational program increased the percentage of physicians who were confident in providing effective dietary counseling (baseline of 26% to 67%-78%; P < .01). The prompting intervention approximately doubled the frequency of physician counseling (P = .0005) and increased the likelihood that patients would try to change their diets. When both interventions were combined, most outcomes were better, although not statistically significant. Cholesterol levels, however, decreased only marginally and were no different among groups at 10-month follow-up. Despite success in changing physicians' attitudes and behaviors and increasing patients' willingness to change their diets, there was no significant change in patients' cholesterol levels. Medical Subject Headings (MeSH): randomized controlled trial; cholesterol; patient education; behavior therapy; education, medical; diet.

Renal duplication anomalies in the fetus: clues for prenatal diagnosis

Duplex kidneys are one of the most common major congenital abnormalities of the urinary tract. The antenatal diagnosis of duplex kidney and its associated ureterocele is infrequent. We report on our experience with the prenatal diagnosis of duplex kidneys in seven fetuses over the past 24 months. In all fetuses, the sagittal length of the duplex kidney was above the 95th centile for gestational age. A 'cyst-like' structure in the upper pole of the duplex kidney and a ureterocele in the urinary bladder were present in all of the seven fetuses. An ipsilateral dilated ureter was seen in six of seven fetuses. Postnatal confirmation of renal duplication anomalies was obtained in all neonates. Increased familiarity of the prenatal sonographer with duplex kidney will allow for its antenatal diagnosis and thus early postnatal treatment.

Prenatal ultrasonographic fetal rib length measurement: correlation with gestational age

The availability of normal data on fetal rib bone length would be of value in a variety of circumstances under which ultrasound examinations are performed. Fetal rib length measurements were obtained in 257 singleton fetuses in a prospective cross-sectional study. The study population consisted of pregnancies between 14 and 40 weeks with no evidence of growth disturbances, or structural or karyotypic abnormalities. Fetal rib length, as a function of gestational age, was expressed by the regression equation: RL = -0.5834 + 0.2030 (GA), where RL is the rib length in centimeters and GA the gestational age in weeks. The correlation was R = 0.94 (p < 0.0001). The normal limits of fetal rib length are defined, and a high correlation between fetal rib length, gestational age, and other standard determinants of fetal growth is demonstrated. Our results indicate that fetal rib length can be a useful adjunct in determining normal fetal growth and in the management of the pregnancy with fetal skeletal dysplasia.

Acute severe low back pain. A population-based study of prevalence and care-seeking

STUDY DESIGN

Telephone interviews were conducted with a random sample of adults in 4437 North Carolina households. The response rate was 79%.

OBJECTIVE

The prevalence of low back pain and the correlates of care-seeking in a defined population were examined.

SUMMARY OF BACKGROUND DATA

Previous research on low back pain has used varying definitions of the illness of low back pain, and has admixed patients with acute and chronic low back pain. Acute low back pain was examined in this study as a distinct phenomenon separate from chronic low back pain.

METHODS

Respondents completed a detailed interview regarding the occurrence of and care sought for back pain in 1991. Acute back pain was defined as functionally limiting pain lasting less than 3 months.

RESULTS

From this sample, 485 individuals had at least one occurrence of acute severe low back pain in 1991, representing 7.6% of the adult population. Symptoms were reported less commonly in individuals older than age 60 years (5% vs. 8.5%) and in nonwhites compared with whites (5% vs. 8.5%). Thirty-nine percent of those with back pain sought medical care; 24% sought care initially from an allopathic physician, 13% from a chiropractor, and 2% from other providers. More prolonged pain, more severe pain, and sciatica were associated with care-seeking. Gender, income, age, rural residence, and health insurance status did not correlate with the decision to seek medical care. Younger age, male gender, and nonjob-related pain did correlate with the decision to seek care from a chiropractor.

CONCLUSIONS

Acute back pain is common. Care is often sought regardless of income and insurance status. Seeing a health care provider for acute back pain may not be discretionary from the perspective of the patient.

Hypothermia preserves expression of beta-actin mRNA in ischemic brain

The expression of a cytoskeletal protein, beta-actin, mRNA was examined in hypothermic ischemic brains. Mongolian gerbils were subjected to forebrain ischemia by bilateral carotid occlusion of 10 min at 30 degrees C followed by normothermic reperfusion for 1 h or 6 h, 1 day or 3 days, 2 weeks or 1 month. The expression of beta-actin mRNA was determined in hypothermic controls and postischemic (PI) animals subjected to intra-ischemic hypothermia using in situ hybridization. On comparing the pattern of expression of beta-actin in hypothermic ischemic brains with that in normothermic ischemic brains, it was noted that there was no significant decline in its expression in the CA1 region of hypothermic ischemic brains as noted in the normothermic ischemic brains (reported by us previously). Only one hypothermic ischemic animal in the 2 week PI period showed marked reduction in its expression in the CA1 region. These results indicate that hypothermia leads to preservation of the expression of a cytoskeletal protein, beta-actin, in a selectively vulnerable region of the brain following ischemia.

The effect of hypothermia on induction of heat shock protein (HSP)-72 in ischemic brain

Intra-ischemic hypothermia has been demonstrated to be protective against ischemic neuronal injury. The present study examined the effect of moderate hypothermia on the expression of heat shock protein (HSP)-72 following transient forebrain ischemia in gerbils by immunohistochemistry. Global forebrain ischemia with concurrent moderate hypothermia (30 degrees C) was induced in gerbils by 10-minute bilateral carotid artery occlusion followed by recirculation periods of 1 hour (h), 6h, 24h, and 48h. Normothermic forebrain ischemic animals with similar recirculation periods were utilized for comparison of the HSP expression. Sham-operated normothermic and hypothermic animals were also included. 72-kDa heat shock protein immunoreactivity was demonstrated in the hippocampus and neocortex of the normothermic ischemic animals following 24h and 48h recirculation similar to that reported previously. However, the immunoreactivity was absent in the brains of the animals subjected to hypothermic ischemia or sham-operation. Only the ependymal cells were immunopositive in all hypothermic brains as was the case with all normothermic brains. The hypothermic ischemic brains showed no significant necrosis in the hippocampus. These findings suggest that the protection of ischemic neuronal necrosis conferred by intra-ischemic hypothermia is not associated with induction of HSP-72 protein and that mechanisms other then HSP-72 protein induction are likely to be responsible for this neuroprotective effect.

Postprandial versus preprandial blood glucose monitoring in women with gestational diabetes mellitus requiring insulin therapy

BACKGROUND

The fetuses of women with gestational diabetes mellitus are at risk for macrosomia and its attendant complications. The best method of achieving euglycemia in these women and reducing morbidity in their infants is not known. We compared the efficacy of postprandial and preprandial monitoring in achieving glycemic control in women with gestational diabetes.

METHODS

We studied 66 women with gestational diabetes mellitus who required insulin therapy at 30 weeks of gestation or earlier. The women were randomly assigned to have their diabetes managed according to the results of preprandial monitoring or postprandial monitoring (one hour after meals) of blood glucose concentrations. Both groups were also monitored with fasting blood glucose measurements. The goal of insulin therapy was a preprandial value of 60 to 105 mg per deciliter (3.3 to 5.9 mmol per liter) or a postprandial value of less than 140 mg per deciliter (7.8 mmol per liter). Obstetrical data and information on neonatal outcomes were collected.

RESULTS

The prepregnancy weight, weight gain during pregnancy, gestational age at the diagnosis of diabetes and at delivery, degree of compliance with therapy, and degree of achievement of target blood glucose concentrations were similar in the two groups. The mean (+/- SD) change in the glycosylated hemoglobin value was greater in the group in which postprandial measurements were used (-3.0 +/- 2.2 percent vs. 0.6 +/- 1.6 percent, P < 0.001) and the infants' birth weight was lower (3469 +/- 668 vs. 3848 +/- 434 g, P = 0.01). Similarly, the infants born to the women in the postprandial-monitoring group had a lower rate of neonatal hypoglycemia (3 percent vs. 21 percent, P = 0.05), were less often large for gestational age (12 percent vs. 42 percent, P = 0.01) and were less often delivered by cesarean section because of cephalopelvic disproportion (12 percent vs. 36 percent, P = 0.04) than those in the preprandial-monitoring group.

CONCLUSIONS

Adjustment of insulin therapy in women with gestational diabetes according to the results of postprandial, rather than preprandial, blood glucose values improves glycemic control and decreases the risk of neonatal hypoglycemia, macrosomia, and cesarean delivery.

Antenatal diagnosis and treatment of fetal goitrous hypothyroidism: case report and review of the literature

The recognition and treatment of fetal hypothyroidism are believed to be important to optimize growth and intellectual development in affected fetuses. We present a case of fetal goiter diagnosed by ultrasonography in the second trimester of pregnancy. Cordocentesis performed at 28 weeks confirmed the presence of fetal hypothyroidism. Fetal therapy was performed with weekly intra-amniotic injections of thyroxine from 29 to 36 weeks. A repeat cordocentesis at 35 weeks showed normalization of fetal thyroid function. The fetal goiter decreased rapidly in size following fetal treatment. Amniotic fluid levels of thyroid stimulating hormone (TSH) and free thyroxine were obtained with each amniocentesis. Sulfated iodothyronine concentrations in maternal blood were obtained before and after fetal thyroxine treatment. This report discusses the role of amniotic fluid levels of TSH and free thyroxine and maternal levels of sulfated iodothyronine in the diagnosis and management of fetal hypothyroidism. A review of the English literature is presented.

Umbilical artery flow velocity waveforms in monoamniotic twins with cord entanglement

BACKGROUND

Monoamniotic twins with ultrasonographic evidence of umbilical cord entanglement present a management challenge in the antepartum period.

CASES

We report two pregnancies with monoamniotic twins and ultrasonographic evidence of cord entanglement in which longitudinal Doppler flow velocity waveforms of the umbilical and middle cerebral arteries were obtained. A notch in the umbilical artery velocity waveform was noted in one twin member at 33 weeks' gestation and in both twin members of the other pregnancy at 31 weeks' gestation. Worsening of the umbilical artery velocity waveform notch with advancing gestation was noted in one fetus.

CONCLUSION

The presence of a notch in the umbilical artery velocity waveform may reflect hemodynamic alterations in the fetal-placental circulation secondary to narrowing of the umbilical vessels involved in cord entanglement. This Doppler finding may be useful in the antepartum management of these pregnancies.