A randomised controlled trial of energetic activity for depression in young people (READY): a multi-site feasibility trial protocol

BACKGROUND

Prevalence of depression is increasing in young people, and there is a need to develop and evaluate behavioural interventions which may provide benefits equal to or greater than talking therapies or pharmacological alternatives. Exercise could be beneficial for young people living with depression, but robust, large-scale trials of effectiveness and the impact of exercise intensity are lacking. This study aims to test whether a randomised controlled trial (RCT) of an intervention targeting young people living with depression is feasible by determining whether it is possible to recruit and retain young people, develop and deliver the intervention as planned, and evaluate training and delivery.

METHODS

The design is a three-arm cluster randomised controlled feasibility trial with embedded process evaluation. Participants will be help-seeking young people, aged 13-17 years experiencing mild to moderate low mood or depression, referred from three counties in England. The intervention will be delivered by registered exercise professionals, supported by mental health support workers, twice a week for 12 weeks. The three arms will be high-intensity exercise, low-intensity exercise, and a social activity control. All arms will receive a 'healthy living' behaviour change session prior to each exercise session and the two exercise groups are energy matched. The outcomes are referral, recruitment, and retention rates; attendance at exercise sessions; adherence to and ability to reach intensity during exercise sessions; proportions of missing data; adverse events, all measured at baseline, 3, and 6 months; resource use; and reach and representativeness.

DISCUSSION

UK National Health Service (NHS) policy is to provide young people with advice about using exercise to help depression but there is no evidence-based exercise intervention to either complement or as an alternative to medication or talking therapies. UK National Institute for Health and Care Excellence (NICE) guidelines suggest that exercise can be an effective treatment, but the evidence base is relatively weak. This feasibility trial will provide evidence about whether it is feasible to recruit and retain young people to a full RCT to assess the effectiveness and cost-effectiveness of an exercise intervention for depression.

TRIAL REGISTRATION

ISRCTN, ISRCTN66452702 . Registered 9 April 2020.

Planning and the English Regions: Conflict and Convergence Amongst the Institutions of Regional Governance

The Regional Development Agencies (RDAs) are just one of many institutional innovations currently being put in place by the new Labour government in the United Kingdom. They are part of a panoply of measures some of which are explicitly aimed at strengthening regional government. However, in this paper we argue that the new innovations are being put in place with insufficient attention paid to the need to reform central and local relations, so that the scope for regional autonomy is limited. The consequence is that relations between regional institutions are much weaker than their links to central government. We compare RDAs and regional planning fora in this regard and show that little thought has gone into harmonising their activities at the regional level as the emphasis has been placed on ensuring that central government retains overall control over policy. We conclude that, if regional autonomy is to be seriously introduced, the central state will have to substantially rethink the scope of national policy, especially in the planning arena.

The role of cytological follow-up after radical vaginal trachelectomy for early-stage cervical cancer

OBJECTIVES

To identify whether recurrences were picked up by cytology alone after radical vaginal trachelectomy and to determine the false-positive rate of abnormal cytology.

METHODS

Retrospective collection of patients from the cancer registry since radical vaginal trachelectomy was first performed in Bristol in 1999. All cytology results were collated and re-reviewed by a senior consultant cellular pathologist at the cytopathology centre in Southmead Hospital, Bristol. Cytology results and pathology and survival data are discussed, and any downgrading or upgrading of reports is reviewed.

RESULTS

Eighteen women were identified and 80 isthmic cytology samples were reviewed. Only one recurrence has occurred. Lower uterine segment sampling was apparent in 25 samples and other endometrial cells in 21 samples: thus 58% showed endometrial cell sampling. Odd metaplastic cells from the newly formed transformation zone were found in 25 samples (31%). Fifteen (19%) showed significant inflammation, two with actinomyces. After cytology review, seven of 80 reports were changed: two between negative and inadequate, two borderline changes in endocervical cells and one mild dyskaryosis were downgraded to negative, and two cases reported as ?glandular neoplasia were changed to squamous cell carcinoma and negative, respectively.

CONCLUSIONS

Cytology reporting may be challenging after trachelectomy. Cytology in our series did not add to the diagnosis of recurrence in the one case in which it occurred. We propose a pragmatic follow-up regime, and discuss the importance of the centralization of cytology reporting in these patients.

Hormone Replacement Therapy after Endometrial Cancer

Endometrial cancer is the fourth most common female cancer in the UK and the most common gynaecological cancer. Quality of life and symptom control needs to be considered in women who enter a surgically induced menopause. Hormone replacement in this population has been controversial to date. The current evidence regarding the safety of estrogen only and combined hormone replacement therapy is discussed in this review. The use of topical vaginal therapies, alternate therapies and the current data regarding testosterone use for symptom control is also outlined.

Risk of epithelial ovarian cancer in asymptomatic women with ultrasound-detected ovarian masses: a prospective cohort study within the UK collaborative trial of ovarian cancer screening (UKCTOCS)

OBJECTIVE

To estimate the risk of primary epithelial ovarian cancer (EOC) and slow growing borderline or Type I and aggressive Type II EOC in postmenopausal women with adnexal abnormalities on ultrasound.

METHODS

This was a prospective cohort study in the ultrasound group of the UK Collaborative Trial of Ovarian Cancer Screening of postmenopausal women with ultrasound-detected abnormal adnexal (unilocular, multilocular, unilocular solid and multilocular solid, solid) morphology on their first scan. Women were followed up through the national cancer registries and by postal questionnaires. Absolute risks of EOC and borderline, Type I and Type II EOC within 3 years of initial scan were calculated.

RESULTS

Of 48 053 women who underwent ultrasound examination and had complete scan data, 4367 (9.1% (95% CI, 8.8-9.3%)) had abnormal adnexal morphology. Median follow-up was 7.09 (25(th) -75(th) centiles, 6.03-7.92) years. Forty-seven (32 borderline or Type I, 15 Type II) were diagnosed with EOC. The overall absolute risk of EOC associated with abnormal adnexal morphology was 1.08% (95% CI, 0.79-1.43%); for borderline and Type I it was 0.73% (95% CI, 0.5-1.03%); and for Type II it was 0.34% (95% CI, 0.33-0.79%). In the subgroup (n = 741) with solid elements (unilocular solid, multilocular solid and solid) overall absolute risk was 4.45% (95% CI, 3.08-6.20%), for borderline and Type I it was 3.1% (95% CI, 1.9-4.6%) and for Type II it was 1.3% (95% CI, 0.6-2.4%). 11 982 women had both ovaries visualized and normal annual scans throughout the 3-year follow-up period. In this group, no borderline or Type I and eight Type II cancers were diagnosed.

CONCLUSION

Asymptomatic postmenopausal women with ultrasound-detected adnexal abnormalities with solid elements have a 1 in 22 risk for EOC. Despite the higher prevalence of Type II EOC, the risk of borderline or Type I cancer in women with ultrasound abnormalities seems to be higher than does the risk of Type II cancer. This has important immediate implications for patients with incidental adnexal findings as well as for any future ultrasound-based screening.

Clinical decision-making in a multidisciplinary gynaecological cancer team: a qualitative study

OBJECTIVE

To explore the factors that influence treatment decision-making in a gynaecological cancer team (MDT).

DESIGN

Qualitative study using interviews and observations.

SETTING

Gynaecological cancer MDT meetings and participants' offices.

SAMPLE

A gynaecological cancer MDT and members of that team.

METHODS

Observations of ten MDT meetings and semistructured interviews with 16 team members. Data analysis using the constant comparison technique of grounded theory and ethnography.

MAIN OUTCOME MEASURES

Factors affecting treatment decisions in the MDT meetings.

RESULTS

Disease-centred information was central to decision-making, whereas patient-centred factors such as patient choice and co-morbidity were more peripheral. This was partly due to variation in team members' type and level of participation: senior clinicians occupied the most dominant roles in discussions and decision-making, whereas nurses contributed less but were more likely to focus on patient-related factors. Three main decision-making pathways emerged: a short discussion followed by a clear decision, a prolonged discussion ending in a definite treatment plan, and a lengthy discussion with no clearly stated decision at the end. The type of pathway followed depended on a case's complexity and the extent of agreement among team members.

CONCLUSIONS

The process of treatment decision-making was not consistent for all women but was affected by factors such as the complexity of the case, which team members participated, and the extent of team members' agreement. Improvements are needed to ensure patient-centred information is included for all women and that clear decisions are reached and recorded in all cases.

John Flynn meets James Mackenzie: developing the discipline of rural and remote medicine in Australia

This commentary is a reflection on the lives of two men, whose qualities seem to reflect those needed in the establishment of the academic discipline of rural and remote medicine in Australia. The two men displayed three characteristics which those involved in change require: they were there; they equipped themselves to make a difference; they were not afraid of where change might take them. If rural and remote Australasia is to receive appropriate health care, the main medical workforce has to be made up of contextually trained rural generalists. This rural doctor will be a general practitioner with the additional competencies of paediatrician, internist, obstetrician, anaesthetist, surgeon, emergency physician and so forth, depending on the needs of both rural hospital and community. Without training for this role, our ageing rural workforce will never be renewed. Our medical schools, postgraduate councils and colleges are currently failing to provide appropriate numbers of such Australian trained graduates to fulfil the needs of rural communities. That task needs to be carried out by an academic discipline of rural and remote medicine, working through all these bodies. The current tripartite structure of medical education (4-6 years medical school, 2-3 post-graduate years, 4 years vocational training) with metropolitan domination and frequent transfer of responsibility, is directly contributing to the crisis in rural medicine, where 'rural and remote' is seen as an occasional tourist destination, rather than the centre of the process. The Rural Clinical Schools model needs to be expanded to provide a platform for appropriate education and a training pathway not only for medical students, but also for prevocational, vocational and established rural generalists. Only in this way will we be able to convert the 'Tsunami of medical graduates' expected in 2010 to an adequate supply of rural and remote generalists into the future.

The impact of improving outcomes guidance on surgical management of vulval squamous cell cancer in southwest England (1997-2002)

OBJECTIVE

The objective of this study was to assess the impact of reorganisation of gynaecological services in southwest England following adoption of regionally agreed evidence-based guidelines and publication of the National Improving Outcomes Guidance in 1999.

DESIGN

Prospective audit with cross-checking against histological reports.

SETTING

All 19 acute hospitals in the four Cancer Networks of southwest England.

SAMPLE

All subjects with squamous or verrucous vulval cancer diagnosed between 1997 and 2002.

METHOD

A one-page minimum data set proforma agreed by the South West Gynaecology Tumour Panel was completed by surgeons after treatment of each patient, and was sent to South West Cancer Intelligence Service for entry, collation and analysis. Data are presented for the years 1997 to 2002 inclusive, and comparisons were made between each of the three 2-year cohorts.

MAIN OUTCOME MEASURES

These are standards derived from the guidance.

RESULTS

There were 436 squamous or verrucous vulval cancers registered. Recording of staging was missing in 20% of subjects. The percentage of subjects operated upon by lead gynaecological cancer surgeons increased from 78% in cohort 1 to 93% in cohort 3 (P < 0.001). There is a trend towards more conservative operations, which have lower co-morbidity. High activity surgeons achieved better rates of tumour-free skin margins, but even these were adequate only in 49% of operations. Lymphadenectomy rates did not follow guidance.

CONCLUSION

Centralisation of care of this rare cancer should continue, but specialists need to increase their efforts to ensure adequate skin margins and lymphadenectomy rates while balancing morbidity and the likelihood of recurrence in both fit and frail patients.

Delivery of local anaesthetic via a sternal catheter to reduce the pain caused by sternal fractures: first case series using the new technique

Sternal fractures cause considerable pain, and a proportion of patients require admission for analgesia. Local anaesthetic techniques have been used to reduce the pain from chest wall injuries and may reduce complications from these injuries. The use of a local anaesthetic delivered via a sternal catheter over a fractured sternum has been described in a patient whose pain was inadequately controlled with opiates. This technique was recently offered to patients in the emergency department at the Royal Devon and Exeter Hospital, Exeter, UK, and the experiences of patients and doctors are reported. Findings from this first case series suggest that the technique seems to be effective, well tolerated and acceptable to patients.

Laparoscopically assisted radical vaginal hysterectomy (Coelio-Schauta): a comparison with open Wertheim/Meigs hysterectomy

The objective of this study was to compare the safety, efficacy, and short-term benefits of the Coelio-Schauta procedure with open Wertheim/Meigs radical abdominal hysterectomy. We retrospectively analyzed records of our first 35 consecutive patients undergoing laparoscopically assisted radical vaginal hysterectomy (LARVH) for early cervical cancer and 32 consecutive patients of open radical hysterectomy (ORH) performed between 1999 and 2005 in our institution. We analyzed patient age, bodyweight, previous abdominal surgery, operating time, blood loss, perioperative complications, postoperative bladder dysfunction, other postoperative complications, and histologic type. The FIGO stage, excision margins, node count and node status, follow-up, and recurrence rates were also taken into account. We excluded stage IA and stage II disease patients to reduce the impact of tumor size on the outcome of the surgery. This left 27 patients with stage IIB disease who had LARVH and 28 patients with stage IB disease who had ORH. These patients formed the study group. The cohorts were similar in age, bodyweight, previous abdominal surgery, histologic subtype, FIGO stage, resection margins, node count and node status, length of follow-up, and recurrence. There were statistically significant differences between LARVH and ORH for duration of surgery (mean 160 vs 132 min), intraoperative blood loss (479 vs 715 mL), hospital stay (mean 5 vs 9.3 days), postoperative complications (6 vs 20 patients), and duration of bladder catheterization (mean 4.4 vs 8.8 days). Four LARVH patients and no ORH patients had urinary tract injury that was repaired. None had long-term sequelae. Our data confirm that LARVH is a suitable alternative to ORH hysterectomy for small-volume stage IB1 cervical cancer with similar clinical efficacy and a superior postoperative recovery and postoperative morbidity profile. Urinary tract trauma is a clear risk in the early stages of the learning curve.

Stage III and IV ovarian cancer in the South West of England: five-year outcome analysis for cases treated in 1998

This study evaluates the 5-year outcome data for the management of advanced ovarian cancer in the South West of England. Anonymized data for 361 stage III and IV ovarian cancers registered between January 1, 1998, and December 31, 1998, were obtained from the central gynecological tumor database. The following data were identified: age at diagnosis, FIGO stage, American Society of Anesthesiologists (ASA) grade, tumor differentiation, treating network and surgeon, amount of residual disease after debulking surgery, current life status, and date of death if applicable. Survival analysis was performed using Kaplan-Meier crude survival for univariate analysis, and multivariate analysis was performed by Cox regression. In our data the 5-year survival for patients with stage III was 16% and with stage IV was 10%. Survival analysis demonstrated that patients in whom the disease was debulked to less than 1 cm were more likely to be alive 5 years after diagnosis than those with a 2-cm residuum (P < 0.0001). There was no significant survival difference for those patients operated on by subspecialist surgeons despite these surgeons being twice as likely to achieve optimal debulking. Therefore, there must be other variables influencing survival apart from cytoreductive surgery. While there is near-complete data collection about ovarian cancer surgery, our database on chemotherapy is incomplete. This is clearly crucial for a complete view of cancer care in our region.

Stage III and IV ovarian cancer in the South West of England: five-year outcome analysis for cases treated in 1998

This study evaluates the 5-year outcome data for the management of advanced ovarian cancer in the South West of England. Anonymized data for 361 stage III and IV ovarian cancers registered between January 1, 1998, and December 31, 1998, were obtained from the central gynecological tumor database. The following data were identified: age at diagnosis, FIGO stage, American Society of Anesthesiologists (ASA) grade, tumor differentiation, treating network and surgeon, amount of residual disease after debulking surgery, current life status, and date of death if applicable. Survival analysis was performed using Kaplan–Meier crude survival for univariate analysis, and multivariate analysis was performed by Cox regression. In our data the 5-year survival for patients with stage III was 16% and with stage IV was 10%. Survival analysis demonstrated that patients in whom the disease was debulked to less than 1 cm were more likely to be alive 5 years after diagnosis than those with a 2-cm residuum (P < 0.0001). There was no significant survival difference for those patients operated on by subspecialist surgeons despite these surgeons being twice as likely to achieve optimal debulking. Therefore, there must be other variables influencing survival apart from cytoreductive surgery. While there is near-complete data collection about ovarian cancer surgery, our database on chemotherapy is incomplete. This is clearly crucial for a complete view of cancer care in our region.

Disease association of two distinct interleukin-18 promoter polymorphisms in Caucasian rheumatoid arthritis patients

Interleukin (IL)-18 is an important mediator of innate and adaptive immunity. We searched for an association of IL-18 promoter single-nucleotide polymorphisms (SNP) with rheumatoid arthritis (RA) in Caucasians. The entire study population was composed of two independent cohorts from Germany (n=200) and Scotland (n=410). Presence of IL-18 SNP at positions -607 and -137 was determined by allele-specific PCR in 327 RA patients and 283 healthy donors (HD). Diplotype distributions of both loci were in Hardy-Weinberg equilibrium (HWE) in the German and Scottish HD cohorts. In contrast, locus -607 was in HW disequilibrium in German, and locus -137 in Scottish RA patients. Diplotypic exact chi(2) tests suggested that -607CC was overrepresented in German, and -137CC in Scottish RA patients, but conservative chi(2) trend analyses could not prove any significant disease association of these single loci. SNP -607 and -137 were in strong linkage disequilibrium. The -607C(*)-137C haplotype was more prevalent in German RA (3.2 vs 1.2%) and in Scottish RA patients (4.1 vs 0.9%) than in the respective HD cohorts. These observations suggest that SNP of both positions contribute to the genetic background of RA pathogenesis.

Epidural infusion or combined femoral and sciatic nerve blocks as perioperative analgesia for knee arthroplasty †

BACKGROUND

Peripheral neural blockade appears to provide effective analgesia with potentially less morbidity than central neuraxial techniques. We compared the relative benefits of combined femoral (3-in-1) and sciatic nerve block with epidural blockade for postoperative knee arthroplasty analgesia.

METHODS

Sixty patients, ASA I-III, undergoing unilateral knee replacement were prospectively randomized to receive either a lumbar epidural infusion or combined single-shot femoral (3-in-1) and sciatic blocks (combined blocks). All patients received standard general anaesthesia. Visual analogue pain scores and rescue opioid requirements were recorded at four time points postoperatively. Patient satisfaction, morbidity, block insertion time, perioperative blood loss and rehabilitation indices were also assessed.

RESULTS

In both groups, pain on movement was well controlled at discharge from recovery and 6 h postoperatively but increased at 24 and 48 h. Median (95% CI) analogue scale scores were 0 (0-0), 15 (0-30), 55 (38-75) and 54 (30-67) mm for epidural block and 0.5 (0-22), 21.5 (10-28), 40 (20-50) and 34.5 (21-55) mm for combined block. VAS pain scores with the combined blocks were significantly lower at 24 h (P=0.004). Total morphine usage was low in both groups: median epidural group 17 mg (8-32) versus combined blocks 13 mg (7.8-27.5). Patient satisfaction was high in both groups with median (95% CI) scores of 100 (85-100), 83 (70-100) and 82 (57-90) mm for epidural and 90 (73-100), 100 (77-100) and 97 (80-100) mm for combined blocks (not significant). Perioperative blood loss and rehabilitation indices were also similar.

CONCLUSIONS

Combined femoral (3-in-1) and sciatic blocks offer a practical alternative to epidural analgesia for unilateral knee replacements.

Pain on medical wards in a district general hospital

BACKGROUND

Little attention has been paid to pain on medical wards, with publications limited to the management of surgical patients. We wanted to establish the prevalence and severity of pain in the general medical setting, and how this compared with other clinical specialties.

METHODS

All consenting adult in-patients were assessed daily for 5 days. Patients recorded the occurrence and severity of pain, and whether their pain was bearable. The pain team reviewed patients with unbearable pain.

RESULTS

1594 questionnaires were completed, representing 54% of the target population. 887 patients reported pain, 17% with pain scores over 6, and 10% with unbearable pain. The distribution of pain was similar for all ward types with 52% of patients on medical wards reporting pain. Of these, 20% reported severe pain and 12% unbearable pain. When patients with pain scores over 6 were analysed by consultant specialty, elderly care, general medicine, and general surgery scored highest. In each specialty 20-25% of patients with pain reported a pain score over 6. In patients reviewed by the pain team, reasons for poor analgesia included inadequate information, pain assessment, analgesic prescribing, and administration and patient reporting.

CONCLUSION

Patients in all hospital specialities experience pain. Until the issue of pain management in medical patients is fully addressed the situation will not improve.

The management of women with apparent early ovarian cancer in the south-west region of England

This study investigated the management of women with apparent early ovarian cancer in the South West region of England. This was retrospective review of prospectively collected data supplement by case note review. All women registered with stage 1 ovarian cancer in the 2 years from January 1997 to December 1998 were identified from the database of the Regional Cancer Organisation (RCO). Data on staging and subsequent management were obtained from the RCO database. Additional information was collected from the patients' casenotes. We considered the accuracy of staging, consideration of fertility-sparing surgery, evidence of multidisciplinary approach to management, appropriateness of oncological referral and adjuvant therapy. Of 222 cases of stage 1 ovarian cancer identified from the RCO database, 168 casenotes were available for inspection. Eighty-seven cases were confirmed as FIGO stage 1 but the substage was amended in 21 cases. There were insufficient data available in 75 cases to confirm the stage assigned. Six cases were re-staged to FIGO stage 3a. Fertility-sparing surgery was considered in four of 10 nulliparous patients of reproductive age. Thirty-nine patients with disease more advanced than FIGO stage 1b were not referred for onco1 logical opinion. Even after Calmine-Hine guidelines are implemented, women with early ovarian cancer may still be treated in general hospitals. There is an urgent need to provide clear local guidelines for the management of these patients.

The surgical management of women with ovarian cancer in the south west of England

The surgical management of epithelial ovarian cancer in the South West of England was studied in the two years 1997-1998 in order to determine the factors that influence the outcome of surgery and to provide a baseline from which to assess the effect of centralisation of cancer services. All hospitals in the South West region of England participating in the Regional Cancer Organisation's longitudinal study of outcomes in gynaecological malignancies are included. Six hundred and eighty-two patients with epithelial ovarian cancer were registered with the RCO in the two-year study period. Five hundred and ninety-five women were offered primary cytoreductive surgery of which 438 were said to be optimally cytoreduced. Applying multivariate models to analyse the outcome of surgery, older patients (OR = 0.82 per 5-year increase in age, P = 0.0003), patients treated in hospitals managing fewer than ten cases of ovarian cancer per year (OR = 1.92, P = 0.02) and patients with FIGO stage 3 (OR = 0.02, P < 0.0001) or 4 (OR = 0.002, P < 0.0001) disease were less likely to be optimally cytoreduced. Gynaecological oncologists were 2.06 times more likely to attain optimal cytoreduction when compared to general gynaecologists and this was statistically significant (P = 0.01). The results from this study support the argument that limiting surgery for ovarian malignancy to specialised surgeons improves the extent of cytoreductive surgery.

Phenylalanine 393 exerts thermodynamic control over the heme of flavocytochrome P450 BM3

Site-directed mutants of the phylogenetically conserved phenylalanine residue F393 were constructed in flavocytochrome P450 BM3 from Bacillus megaterium. The high degree of conservation of this residue in the P450 superfamily and its proximity to the heme (and its ligand Cys400) infers an essential role in P450 activity. Extensive kinetic and thermodynamic characterization of mutant enzymes F393A, F393H, and F393Y highlighted significant differences from wild-type P450 BM3. All enzymes expressed to high levels and contained their full complement of heme. While the reduction and subsequent treatment of the mutant P450s with carbon monoxide led to the formation of the characteristic P450 spectra in all cases, the absolute position of the Soret absorption varied across the series WT/F393Y (449 nm), F393H (445 nm), and F393A (444 nm). Steady-state turnover rates with both laurate and arachidonate showed the trend WT > F393Y >> F393H > F393A. Conversely, the trend in the pre-steady-state flavin-to-heme electron transfer was the reverse of the steady-state scenario, with rates varying F393A > F393H >> F393Y approximately wild-type. These data are consistent with the more positive substrate-free [-312 mV (F393A), -332 mV (F393H)] and substrate-bound [-151 mV (F393A), -176 mV (F393H)] reduction potentials of F393A and F393H heme domains, favoring the stabilization of the ferrous-form in the mutant P450s relative to wild-type. Elevation of the heme iron reduction potential in the F393A and F393H mutants facilitates faster electron transfer to the heme. This results in a decrease in the driving force for oxygen reduction by the ferrous heme iron, so explaining lower overall turnover of the mutant P450s. We postulate that the nature of the residue at position 393 is important in controlling the delicate equilibrium observed in P450s, whereby a tradeoff is established between the rate of heme reduction and the rate at which the ferrous heme can bind and, subsequently, reduce molecular oxygen.

A prospective regional audit of surgical management of endometrial cancer in the South and West of England

The results of a prospective audit of surgical management of endometrial cancer in the South and West of England is presented. A minimum data set was defined and information collected prospectively. There was limited tertiary referral to a gynaecological oncologist. The role of centralisation of endometrial cancer care has been questioned, as surgery has traditionally been simple in patients perceived to be at increased risk of more radical surgery. However, this audit demonstrates that standards of even this simple care within the region are often inadequate, with only one-third of patients having basic staging procedures performed fully. This has important implications for patients management, future interpretation of outcome data and clinical governance in endometrial cancer care.

A critical evaluation of current protocols for the follow-up of women treated for gynecological malignancies: a pilot study

This retrospective review was undertaken to determine the efficacy of routine follow-up in the detection and management of recurrent cancer. The case notes of all women attending a regional cancer center who were diagnosed with cancer in 1997 were reviewed. Of 81 new cancers followed up for a median of 42 months (range 36-48), 14 have recurred after curative treatment and there were six cases of persistent disease. The median number of clinic visits per patient was 3.5 (range 1-16). Eight recurrences (57.1%) were diagnosed at scheduled outpatient appointments, three (2 l.4%) presented to the general practitioner (GP), and three were seen as emergencies in hospital. Seventeen patients with persistent/recurrent disease have died and three are alive with disease. The median time from initial presentation to disease recurrence was 12 months (range 5-25) and the median time from recurrence to death was 5 months (range 1-20). The longest interval between onset of symptoms and diagnosis of recurrence (4 months) occurred in those presenting at scheduled outpatient clinics. This study demonstrates that the current follow-up protocol is associated with delays in diagnosing recurrence, because symptomatic patients postpone seeking help until their scheduled visit. We have therefore commenced a prospective study evaluating other models of follow-up.

Spatial localization after different types of retinal detachment surgery

PURPOSE

To compare the effect on spatial localization of two different forms of surgery for primary rhegmatogenous retinal detachment.

METHODS

Two groups of 30 patients (one group undergoing conventional external scleral-buckling procedures, the other undergoing vitrectomy procedures) were recruited. They pointed at targets appearing on a computer touchscreen without being able to see their hands, while viewing targets with the non-surgically treated eye. The sizes of the horizontal pointing errors were recorded on three separate occasions: before surgery, on the first postoperative day, and approximately 10 days later.

RESULTS

On the first postoperative day a significant change in localization of 2.9 +/- 0.9 degrees [SD]) was observed in the scleral-buckling group, compared with 1.3 +/- 0.6 degrees in the vitrectomy group. These changes resolved by the second postoperative assessment.

CONCLUSIONS

These results, particularly in patients in the scleral-buckling group in whom greater manipulation of the extraocular muscles inevitably occurs, are consistent with an alteration in the extraretinal eye position information that is used in spatial localization. This is likely to be a consequence of modified efference copy and/or extraocular muscle proprioception.

Rational re-design of the substrate binding site of flavocytochrome P450 BM3

Bacillus megaterium P450 BM3 is a fatty acid hydroxylase with selectivity for long chain substrates (C(12)-C(20)). Binding or activity with substrates of chain length <C(12) has not been reported. Rational mutagenesis was used to re-design the enzyme to encourage binding of short chain fatty acids (C(4)-C(10)). We show that wild-type P450 BM3 has activity and weak affinity for substrates as short as butyrate (C(4)). However, turnover/binding of short chain substrates is dramatically increased by introducing a novel substrate carboxylate binding site close to the heme. Mutant L181K shows catalytic efficiency (k(cat)/K(M)) increased >13-fold with butyrate, while the L75T/L181K double mutant has k(cat)/K(M) increased >15-fold with hexanoate and binding (K(d)) improved >28-fold for butyrate. Removing the arginine 47/lysine 51 carboxylate binding motif at the mouth of the active site disfavours binding of all fatty acids, indicating its importance in the initial recognition of substrates.

Blood propofol concentration and psychomotor effects on driving skills

We studied psychomotor performance in 10 healthy volunteers during recovery after a target-controlled infusion of propofol. Choice reaction time, dual task tracking with secondary reaction time and a within-list recognition task were assessed at target blood propofol concentrations of 0.8, 0.4 and 0.2 microgram ml-1. Performance was impaired most at the highest blood propofol concentration (choice reaction time increased by a mean of 247 ms and secondary reaction time by a mean of 178 ms). Choice reaction time and dual task tracking with secondary reaction time were the most sensitive and reliable methods of assessment (significant difference from baseline (P < 0.05) at a propofol concentration of 0.2 microgram ml-1 with choice and secondary reaction time testing). Within-list recognition assessment of memory was not sufficiently sensitive at very low propofol concentrations. The impairment in choice and secondary reaction time with a blood propofol concentration of 0.2 microgram ml-1 was less than that observed with a blood alcohol concentration of 50 mg 100 ml-1 and no greater than that observed with a blood alcohol concentration of 20 mg 100 ml-1 in a previous study involving healthy volunteers.

Remifentanil-based anesthesia versus a propofol technique for otologic surgical procedures

Otologic procedures require a still surgical field and are associated with a 50% incidence of emetic symptoms. Propofol reduces nausea and vomiting but not intraoperative movement. This study compares a remifentanil/propofol anesthetic to a propofol/fentanyl combination to determine which provides the best perioperative conditions for otologic microsurgery. Eighty healthy patients were randomly assigned to receive one of the anesthetic combinations. Demographic data, hemodynamic variables, movement, and bispectral index monitoring values in addition to anesthetic emergence, nausea, vomiting, pain, and other recovery variables were compared between groups with appropriate statistical methods. Both groups were similar. Times to eye opening (7.7 +/- 0.7 vs 12.4 +/- 1.2 minutes) and extubation (9.8 +/- 0.9 vs 12.4 +/- 1.0 minutes) were shorter with remifentanil. This group also had lower hemodynamic variables and movement (23% vs 65%) under anesthesia. Postoperative pain was mild in both groups, but remifentanil patients had more than the propofol group. All other postoperative parameters were similar. Remifentanil-based anesthesia produces better hemodynamic stability, less movement, and faster emergence after otologic surgery, with propofol's antiemetic effect, for the same cost.

MARINE SEISMIC SURVEYS— A STUDY OF ENVIRONMENTAL IMPLICATIONS

An experimental program was run by the Centre for Marine Science and Technology of Curtin University between March 1996 and October 1999 to study the environmental implications of offshore seismic survey noise. This work was initiated and sponsored by the Australian Petroleum Production and Exploration Association. The program:characterised air gun signal measurements; modelled air gun array sources and horizontal air gun signal propagation;developed an 'exposure model' to predict the scale of potential biological effects for a given seismic survey over its duration;made observations of humpback whales traversing a 3D seismic survey;carried out experiments of approaching humpback whales with a single operating air gun;carried out trials with an air gun approaching a cage containing sea turtles, fishes or squid; andmodelled the response of fish hearing systems to airgun signals.The generalised response of migrating humpback whales to a 3D seismic vessel was to take some avoidance manoeuvre at >4 km then to allow the seismic vessel to pass no closer than 3 km. Humpback pods containing cows which were involved in resting behaviour in key habitat types, as opposed to migrating animals, were more sensitive and showed an avoidance response estimated at 7−12 km from a large seismic source. Male humpbacks were attracted to a single operating air gun due to what was believed the similarity of an air gun signal and a whale breaching event (leaping clear of the water and slamming back in). Based on the response of captive animals to an approaching single air gun and scaling these results, indicated sea turtles displayed a general 'alarm' response at an estimated 2 km range from an operating seismic vessel and behaviour indicative of avoidance estimated at 1 km. Similar trials with captive fishes showed a generic fish 'alarm' response of swimming faster, swimming to the bottom, tightening school structure, or all three, at an estimated 2−5 km from a seismic source. Modelling the fish ear predicted that at ranges

Tumor necrosis factor alpha regulates collagenolytic activity in preovulatory ovine follicles: relationship to cytokine secretion by the oocyte-cumulus cell complex

The pleiotropic cytokine tumor necrosis factor (TNF)-alpha has been implicated in the mechanism of ovulation. Experiments were designed to test the hypothesis that TNF-alpha secreted from the oocyte-cumulus cell complex stimulates follicular collagenase production and thereby contributes to ovarian wall degradation and ovulatory rupture. Proestrous ewes were treated with GnRH to synchronize the onset of the gonadotropin surge; ovulation occurs approximately 24 h later. There was an increase in TNF-alpha (immunoassay) in antral fluid of preovulatory follicles at 18 h after GnRH, which was related to tissue collagenolytic bioactivity (radiolabeled type I substrate digestion by enzymatic extract) and collagen (hydroxyproline) depletion. Intrafollicular injection of TNF-alpha antibodies at 12 h after GnRH negated the rise in follicular collagenolytic bioactivity (and is known to block ovulation in the sheep). Moreover, collagenase production was enhanced when follicular tissues (0 h GnRH) were incubated (6 h) with recombinant TNF-alpha; this effect was abolished by the transcriptional inhibitor actinomycin D. Secretion of TNF-alpha by oocyte-cumulus cell complexes isolated from preovulatory follicles simulated the in vivo circumstance. Immunostaining indicated that TNF-alpha was confined mainly to the oocyte before GnRH administration, accumulated in cumulus cells during the mid-to-late preovulatory period, and was expended with the imminent approach of ovulation. To our knowledge, this is the first report specifying that up-regulation of collagenase expression is a target mode of TNF-alpha action in preovulatory follicles. The oocyte-cumulus cell complex is an apparent source of soluble TNF-alpha.

Hormonal control of urokinase plasminogen activator secretion by sheep ovarian surface epithelial cells

Secretion of urokinase plasminogen activator (uPA) by ovarian surface epithelium (OSE) adjacent to the preovulatory ovine follicle has been implicated in apical tissue degradation and follicular rupture. In vitro experiments were designed to test the hypothesis that uPA release by OSE is under direct hormonal control. Epithelial cells were isolated from the ovarian surface of sheep using a polytetrafluorethylene scraper designed to dislodge adherent cells from culture flasks. Amidolytic cleavage of a uPA-specific chromogen (carbobenzoxy-L-gamma-glutamyl [alpha-ot-but]-glycyl-arginine-p-nitroanilide monoacetate) was used as a measure of enzymatic bioactivity in OSE-conditioned incubation media. Secretion of uPA by OSE suspensions from proestrous ewes was stimulated by exposure (2 h) to a preovulatory surge-like concentration of LH. OSE cells obtained during the luteal phase or anestrus were not responsive to LH. Baseline rates of uPA secretion and expression of estradiol receptors (in situ immunofluorescence detection) were not affected by reproductive status. Induction of uPA secretion by anestrous OSE was attained after priming (6 h) with estradiol-17beta; responsiveness was attributed to gonadotropin receptor (ligand binding) up-regulation. Monolayers of OSE established on polyethylene membranes secreted uPA predominately in a basal (i.e., toward the substratum) direction. We suggest that OSE in juxtaposition with the (hyperemic) wall of the preovulatory follicle is perfused by surge levels of LH, invoking uPA release into underlying ovarian tissues.

Mitogenic and antioxidant mechanisms of estradiol action in preovulatory ovine follicles: relevance to luteal function

The objectives of this investigation were to determine the intrafollicular mechanisms and physiological consequences of estradiol actions in preovulatory ovine follicles. Acute suppression of estradiol production in proestrous ewes by an aromatase inhibitor (Arimidex) was associated with follicular lipid peroxidation, testosterone accumulation, and a granulosa cell deficiency (decreased proliferation/increased apoptosis). Estradiol-17beta stimulated granulosa proliferating cell nuclear antigen (PCNA) and protected cells from oxidative (H(2)O(2)) stress-induced apoptosis in vitro; the PCNA, but not the antiapoptotic response, was negated by the transcriptional inhibitor actinomycin D. Thus, it appears that genomic/mitotic and cytoprotective (oxygen-scavenging) modes of estradiol action operate in preovulatory follicles. Luteal (large steroidogenic cell) function was diminished following ovulation induction of estradiol-deficient follicles. It is suggested that inadequate exposure of the preovulatory follicle to estradiol caused the granulosa lutein insufficiency.

Plasmin cleaves tumor necrosis factor alpha exodomain from sheep follicular endothelium: implication in the ovulatory process

Ovulation in the sheep is predicated on plasmin up-regulation at the ovarian surface-follicular interface, release of tumor necrosis factor (TNF) alpha from contiguous endothelium, and apoptotic cell death. The objectives of this investigation were to determine whether plasmin elicits TNFalpha secretion from thecal endothelium of ovine follicles, to characterize the site(s) of enzymatic attack, and to assess the physiological consequence of soluble TNFalpha action. Endothelial cells of thecal tissues isolated from antral follicles of eCG-primed anestrous ewes shed (histochemical depletion) TNFalpha into incubation medium (ovarian cell DNA fragmentation bioassay, Western blot detection) upon exposure to plasmin. Immunopurification and N-terminal sequence analysis indicated that TNFalpha was excised from its transmembrane precursor at the Arg79-Ser80 and Lys88-Pro89 linkages. Microinjection of TNFalpha into the apical wall of explanted follicles induced cellular apoptosis and stigma development. We suggest that plasmin-mediated cleavage of TNFalpha exodomain from its membrane anchor along thecal endothelium is a determinant of tissue dissolution within the formative ovulatory rupture site of ewes.

Assessment of intubating conditions in adults after induction with propofol and varying doses of remifentanil

We have assessed intubating conditions in three groups of 60 ASA I or II patients after induction of anaesthesia with propofol 2 mg kg-1 and remifentanil 0.5, 1.0 or 2.0 micrograms kg-1. Tracheal intubation was graded according to ease of laryn-goscopy, position of the vocal cords, coughing, jaw relaxation and movement of the limbs. Intubation was successful in 80%, 90% and 100% of patients after remifentanil 0.5, 1.0 or 2.0 micrograms kg-1, respectively. Overall intubating conditions were regarded as acceptable in 20%, 50% and 80% of patients, respectively. All three groups had a decrease in arterial pressure after induction but there was no difference between groups. The decrease in arterial pressure was not regarded as clinically significant. Intubating conditions were best after induction with remifentanil 2 micrograms kg and propofol 2 mg kg-1.

The management of cervical carcinoma within the south west region of England. Expert Tumour Panel

OBJECTIVE

1. To audit the management of cervical carcinoma in the South West Region with the aim of identifying and addressing deficiencies. 2. To determine whether recent NHS restructuring has affected the provision of cancer care.

DESIGN

Retrospective review of hospital case notes.

SETTING

All hospitals in the South West Region of England.

POPULATION

Three hundred and twenty-four women with a diagnosis of cervical carcinoma: 191 were diagnosed in 1989 and 133 in 1993.

MAIN OUTCOME MEASURES

Documentation of patient assessment and management.

RESULTS

There was a mean delay of 17 days (range 0-66) from cervical smear to cytology report and 34 days (range 1-380) from general practitioner referral to attendance at a hospital clinic. Overall, 175 women (54%) had evidence of cytological assessment prior to treatment and 137 (42%) had a colposcopic assessment; 49% had cytological assessment and 37% had colposcopy in 1989, compared with 60% and 50%, respectively, in 1993. Excluding 49 cases of micro-invasive carcinoma, 238 case notes (86%) contained evidence of clinical examination; 195 women (71%) had had an examination under anaesthesia, 115 (42%) a chest radiograph, 123 (45%) an intravenous urogram or renal ultrasound, and 92 (33%) cystoscopy. One hundred and forty-seven women (53%) had FIGO staging recorded in the notes. As first line treatment, 69 had conservative surgery (39 for Stage IA), 138 had radiotherapy, and 107 had radical surgery. Ten had radical surgery for Stage IA but eight had a > 3 mm invasion or lymphatic/vascular spread. Thirty-one had Stage IB treated with radiotherapy of whom 14 were younger than 50 years of age. Following radical surgery 30% had evidence of sampling > or = 10 nodes, and 9% had tumour extending to the resection margins.

CONCLUSIONS

Record keeping was inadequate but appeared to indicate inconsistent cytological, clinical, colposcopic and radiological assessment, leading to inappropriate clinical delays and conservative surgery. Radical surgery often appeared inadequate, but poor node sampling rates may also reflect insufficient histopathological preparation or reporting. There was a reduction in the number of new cases of cervical carcinoma diagnosed in 1993, perhaps reflecting an observed increase in cytological surveillance. No other alterations in clinical practice were observed over the four-year period. We feel it is imperative to standardise assessment throughout the region with a minimum clinical and histopathological dataset.

Intraoperative anesthetic management of patients undergoing glomus tumor resection using a low-dose isoflurane-fentanyl technique

Glomus jugulare and vagale tumors present unique problems to both anesthesiologists and surgeons. The anesthetic plant must be tailored to each patient and provide hemodynamic stability, a consistent intraoperative environment, and rapid awakening after prolonged administration. In this report, we describe our anesthetic method used for paraganglioma resection, which utilizes a combination technique of low-dose isoflurane with a narcotic infusion initiated after bolus administration. Results from the last three patients anesthetized by this "balanced" technique were compared to a similar patient who received isoflurane anesthesia exclusively for a major portion of the surgical procedure. The patients receiving the balanced anesthesia required no hemodynamic support during the procedure and were awakened within 15 to 25 minutes of surgical completion. The patient receiving high-dose isoflurane, however, had a prolonged anesthetic wake-up time and did not follow verbal commands for approximately 12 hours after surgical completion. This patient also required hemodynamic support with a phenylephrine infusion during tumor resection. The balanced technique seems to be superior to a straight inhalational technique. Neurological assessment and intubation times after prolonged surgery were reduced with superb hemodynamic stability throughout. This anesthetic method produces a stable intraoperative environment and provides deep surgical anesthesia during periods when muscle relaxants cannot be utilized.

The case for conservative management of "incomplete excision" of CIN after laser conization

Three hundred thirteen laser cone biopsies were performed for cervical intraepithelial neoplasia (CIN) over a 4-year period. The mean age of the patients was 39.9 years and average cytology follow-up was just under 3 years. Six patients defaulted colposcopic review and were excluded from analysis. Of the 75 cases with CIN extending to the endocervical resection margin, 9 (12%) were found to have residual disease. Only 2 (3.6%) of 56 cases with CIN extending to the ectocervical margin had residual CIN detected. In the 176 cases in which the CIN lesion was excised completely there have been no cases of residual CIN. The overall detection of residual disease was 3.6%. Further surgery in those cases with CIN extending to the resection margin is excessive. These patients should be managed conservatively with regular cytological follow-up.

Recurrent squamous cell carcinoma of the vulva: a study of 73 cases

In a study of 73 patients, diagnosed with recurrent squamous cell carcinoma of the vulva between 1975 and 1990, the effect of clinical variables on the outcome was evaluated. The overall 5-year survival rate was 35.2%. Of the 73 patients, 33 (45.2%) originally had Stage I or II disease and 40 (54.8%) Stage III or IVA; 49 (67.1%) recurred less than 2 years and 24 (32.9%) more than 2 years after initial surgery; and 39 (53.4%) recurred on the vulva only, while 34 (46.6%) recurred beyond the vulva. Of 59 patients who had groin lymph node dissection at initial surgery, 26 (44%) had negative and 33 (56%) had positive nodes. By means of univariate analyses, a significant worsening in outcome was demonstrated with advancing original stage of disease (P < 0.001), positivity of groin lymph nodes (P < 0.01), shortening of recurrence-free interval (P < 0.001), and extension of recurrence beyond the vulva (P < 0.001). In a multivariate analysis (Cox proportional hazards model) recurrence site was the strongest and the only significant predictor of survival. The death risk showed a 3.7-fold increase (95% confidence intervals: 1.6 to 8.7, P = 0.002) for recurrence beyond the vulva over recurrence on the vulva only. For patients who recurred in the vulva only, wide radical local excision provided acceptable survival results, while for all other patients, regardless of type of treatment, the outcome was poor.

Pulmonary sarcoidosis: changes on follow-up CT examination

OBJECTIVE

To determine serial changes in the pattern, distribution, and extent of disease over time, and to determine if any specific findings could be used to predict prognosis in patients with pulmonary sarcoidosis, we reviewed the CT scans of 18 patients with pulmonary sarcoidosis.

MATERIALS AND METHODS

The study included 18 patients with biopsy-proved sarcoidosis and pulmonary abnormalities who had two serial high-resolution CT examinations (1.5-mm collimation, high-spatial-frequency reconstruction algorithm) 4-49 months apart. Initial and follow-up CT scans were evaluated independently and then directly compared with each other by two observers. Scans were assessed for the presence, extent, and severity of ground-glass, nodular, and irregular linear opacities; interlobular septal thickening; cystic air spaces; and architectural distortion. If a finding was predominant, it was noted.

RESULTS

Reversible findings included ground-glass, nodular, and irregular linear opacities and septal thickening. Irreversible findings included cystic air spaces and architectural distortion. Follow-up CT showed overall improvement in 12 of 18 patients, progression in five, and no change in one. A predominant pattern of disease could be determined for each patient. Fourteen patients had predominant nodular opacities; of these, 11 had improved by follow-up. Four had predominant irregular linear opacities; of these, three showed progression of disease on follow-up. The presence of any other specific abnormalities, including ground-glass opacities, was not helpful in predicting improvement or worsening of disease on the follow-up examination.

CONCLUSION

In pulmonary sarcoidosis, ground-glass, nodular, and irregular linear opacities and interlobular septal thickening represent potentially reversible disease, while cystic air spaces and architectural distortion are irreversible findings. Follow-up CT usually shows improvement in patients with predominant nodular opacities, while disease tends to progress in patients with predominant irregular opacities.