Stereotactic Body Radiotherapy for Posterior Element Only Spinal Metastases: Outcomes and Validation of Recommended Clinical Target Volume Delineation Practice

PURPOSE/OBJECTIVE(S)

Spine stereotactic body radiotherapy (SBRT) results in improved local control and pain response compared to conventional external beam radiotherapy. Consensus stipulates MRI-based delineation of the clinical target volume (CTV) is critical and is based on spine segment sector involvement. The applicability of these contouring guidelines to metastases confined to the posterior elements is unknown. The purpose of this study was to determine the patterns of failure, as well as the safety of treating posterior element metastases when the vertebral body was intentionally excluded from the CTV.

MATERIALS/METHODS

A retrospective review of a prospectively maintained database of 605 patients and 1412 spine segments treated with spine SBRT was performed. Only treated segments involving the posterior elements alone were included for the analyses. The primary outcome was local failure, as per SPINO recommendations, and secondary outcomes included patterns of failure, toxicities. Clinical and tumor factors were reported with descriptive statistics. The cumulative risk of local failure was estimated using the Fine-Gray method, accounting for death before local failure as a competing risk.

RESULTS

A total of 24/605 patients and 31/1412 segments within the database were treated to the posterior elements only. Local failure occurred in 11/31 segments. The cumulative rate of local recurrence was 9.7% at 12 months and 30.8% at 24 months. Amongst local failures, the most common histologies were renal cell carcinoma (36.4%) and non-small cell lung cancer (36.4%). At baseline, 4/11 (36.4%) segments with local failure (36.4%) had epidural disease and 8/11 (72.7%) had paraspinal disease. Most local failures were treated in the de novo setting (8/11, 72.7%). 6/11 (54.5%) failed exclusively within treated CTV sectors and 5/11 (45.5%) with both treated and adjacent untreated sectors. Of these five, four had disease progression within the untreated vertebral body. No failures occurred exclusively within the untreated vertebral body. One patient (4.2%) experienced a grade 4 skin toxicity and one patient (4.2%) developed an iatrogenic Grade 1 vertebral compression fracture.

CONCLUSION

Posterior element alone metastases are rare. Our analyses support SBRT consensus contouring guidelines such that the vertebral body can be excluded from CTV in spinal metastases confined to the posterior elements.

Reaching Ambulatory Older Adults with Educational Tools: Comparative Efficacy and Cost of Varied Outreach Modalities in Primary Care

BACKGROUND

Providing patients with access to health information that can be obtained outside of an office visit is an important part of education, yet little is known about the effectiveness of outreach modalities to connect older adults to online educational tools. The objective was to identify the effectiveness and cost of outreach modalities providing online information about advance care planning (ACP) for older adults.

METHODS

Six different outreach modalities were utilized to connect patients to online educational tools (ACP video decision aids). Participants were 13,582 patients aged 65 and older of 185 primary care providers with appointments over a 30-month period within a large health system in the greater New York City area. Main outcome measures were number of online video views and costs per outreach for each modality.

KEY RESULTS

There were 1150 video views for 21,407 remote outreach events. Text messages, sent to the largest volume of patients (8869), had the highest outcome rate (9.6%) and were the most economical ($0.09). Characterization of phone calls demonstrated 21.7% engagement in the topic of ACP but resulted in minimal video views (<1%) and incurred the highest cost per outreach ($2.88). In-office handouts had negligible results (<1%).

CONCLUSIONS

Text was the most cost-effective modality to connect older adults to an online educational tool in this pragmatic trial, though overall efficacy of all modalities was low.

Safety and efficacy of inclisiran in South African patients at high cardiovascular risk: A subanalysis of the ORION phase III clinical trials

Inclisiran significantly reduced low-density lipoprotein cholesterol (LDL-C) in individuals with heterozygous familial hypercholesterolaemia, established atherosclerotic cardiovascular disease (ASCVD) or ASCVD risk equivalents (type 2 diabetes, familial hypercholesterolaemia or a 10-year risk of a cardiovascular event ≥20%) in the ORION phase III clinical trials. Infrequent dosing at days 1, 90, 270 and 450 resulted in a mean LDL-C reduction of ~50%. A total of 298 participants from South Africa (SA) were enrolled. Local data are needed to support the use of inclisiran in the SA population, potentially addressing an unmet need for additional LDL-C-lowering therapies. Objectives. To analyse the ORION phase III trial data to assess the efficacy and safety of inclisiran in SA participants. Methods. ORION-9, 10 and 11 were randomised, double-blind, phase III trials. Participants were receiving maximally tolerated statins with or without other lipid-lowering therapies (excluding protein convertase subtilisin/kexin type 9 (PCSK9) inhibitors). Participants were randomised 1:1 to inclisiran sodium 300 mg/284 mg (free acid) or placebo administered at days 1, 90, 270 and 450. The co-primary endpoints were the LDL-C percentage change from baseline to day 510 and the time-averaged percentage change in LDL-C from baseline after day 90 up to day 540. Key secondary endpoints included the absolute change in LDL-C from baseline to day 510, the time-averaged absolute change from baseline after day 90 up to day 540, and changes in other lipids and lipoproteins. Results. The mean age of the participants was 58.6 years (56% male). The mean LDL-C level at baseline was 3.6 mmol/L. At day 510, inclisiran reduced LDL-C levels by 54.2% compared with placebo (95% confidence interval (CI) -61.3 - -47.2; p&lt;0.0001). The corresponding time-averaged reduction in LDL-C was 52.8% (95% CI -57.9 - -47.8; p&lt;0.0001). Treatment-emergent adverse events at the injection site were more common with inclisiran compared with placebo (10.1% v. 0.7%); however, all were mild or moderate in nature and none were persistent. Conclusion. Inclisiran, given in addition to maximally tolerated standard lipid-lowering therapy, is effective and safe and results in robust reductions in LDL-C in SA patients at high cardiovascular risk.

The impact of flash glucose monitoring on the clinical practice of healthcare professionals working in diabetes care

AIMS

Research has identified that healthcare professionals' attitudes in clinical consultations impact the efficacy of their communication with service users and the blood glucose monitoring behaviours of their clients. Yet no research has sought to understand the impact of flash glucose monitoring on the experience of undertaking clinical consultations. This qualitative study aimed to explore the impact that flash glucose monitoring has on the clinical practice of healthcare professionals.

METHODS

Semi-structured interviews were conducted with seventeen Healthcare Professionals (female: n = 13; male: n = 4) working with flash glucose monitoring, analysed via Thematic Analysis.

RESULTS

Three themes were identified: (1) Delivering Person-centred Care; (2) Shift in Diabetes Management; and (3) Time Burden. These themes highlight that flash glucose monitoring facilitates person-centred care through the provision of comprehensive data which improves communication between healthcare professionals and service users. However, preparing for consultations which integrate flash glucose monitoring requires a significant, potentially burdensome time investment.

CONCLUSIONS

Flash glucose monitoring enhances the strategic ability of healthcare professionals to provide evidence-based patient-centred care. This facilitates growth in service users' self-efficacy and encourages targeted diabetes self-management. However, further training is needed to optimise the ability of clinicians to rapidly interrogate and present monitoring data to users.

High-risk behaviours, and their associations with mental health, adherence to antiretroviral therapy and HIV parameters, in HIV-positive men who have sex with men

Objectives

To investigate the patterns and frequency of multiple risk behaviours (alcohol, drugs, smoking, higher risk sexual activity) among men who have sex with men (MSM) living with HIV.

Methods

Cross sectional study.

Results

147 out of 819 HIV‐positive MSM exhibited a high‐risk phenotype (defined as >3 of smoking, excess alcohol, sexually transmitted infection and recent recreational drug use). This phenotype was associated with younger age, depressive symptoms and <90% adherence in multivariable logistic regression.

Conclusion

In a cohort of MSM, a small, but significant proportion exhibited multiple concurrent risk behaviours.

Patient understanding of genetic information influences reproductive decision making in retinoblastoma

BACKGROUND

Retinoblastoma is the most common malignant tumour of the eye in childhood, with nearly all bilateral tumours and around 17% to 18% of unilateral tumours due to an oncogenic mutation in the RB1 gene in the germline. Genetic testing enables accurate risk assessment and optimal clinical management for the affected individual, siblings, and future offspring.

MATERIAL AND METHODS

We carried out the first UK-wide audit of understanding of genetic testing in individuals with retinoblastoma. A total of 292 individuals aged 16 to 45 years were included.

RESULTS

Patients with bilateral disease were significantly more likely to understand the implications of retinoblastoma for siblings and children. There was a significant association between not knowing the results of genetic testing or not understanding the implications and not having children, particularly in women. Surprisingly, this was also true for individuals treated for unilateral disease with a low risk of retinoblastoma for their offspring.

CONCLUSION

We are concerned that individuals may be making life choices based on insufficient information regarding risks of retinoblastoma and reproductive options. We suggest that improvement in transition care is needed to enable individuals to make informed reproductive decisions and to ensure optimal care for children born at risk of retinoblastoma.

Twice-daily dapagliflozin co-administered with metformin in type 2 diabetes: a 16-week randomized, placebo-controlled clinical trial

AIMS

To evaluate the efficacy and safety of twice-daily dosing of dapagliflozin and metformin, exploring the feasibility of a fixed-dose combination.

METHODS

In this 16-week, phase III, randomized, double-blind placebo-controlled study, adults who were receiving metformin administered twice daily (≥1500 mg/day) and had inadequate glycaemic control were randomized 1:1:1:1 to receive dapagliflozin twice daily (2.5 or 5 mg), placebo or dapagliflozin 10 mg once daily (which was included as a benchmark). The primary endpoint was change from baseline glycated haemoglobin (HbA1c) level. Secondary endpoints included changes in fasting plasma glucose (FPG) level and body weight.

RESULTS

Four hundred adults were randomized to dapagliflozin (2.5 mg twice daily, 5 mg twice daily, 10 mg once daily) or placebo co-administered with metformin twice daily. At 16 weeks, the adjusted mean change in HbA1c from baseline was significantly reduced in the dapagliflozin 2.5 mg twice daily and 5 mg twice daily groups versus placebo (-0.52 vs. -0.30%, p = 0.0106 and -0.65% vs. -0.30%, p < 0.0001). There were also significantly greater improvements for dapagliflozin twice daily groups versus placebo in FPG body weight and achievement of HbA1c level of <7%. Efficacy outcomes for dapagliflozin twice daily were numerically similar to those for dapagliflozin once daily. Dapagliflozin twice daily was well tolerated.

CONCLUSIONS

Dapagliflozin 2.5 or 5 mg twice daily added to metformin was effective in reducing glycaemic levels in patients with type 2 diabetes inadequately controlled with metformin alone. This study supports the development of a fixed-dose combination regimen.

Diagnosing tuberculous pericarditis

BACKGROUND

Definitive diagnosis of tuberculous pericarditis requires isolation of the tubercle bacillus from pericardial fluid, but isolating the organism is often difficult.

AIM

To improve diagnostic efficiency for tuberculous pericarditis, using available tests.

DESIGN

Prospective observational study.

METHODS

Consecutive patients (n = 233) presenting with pericardial effusions underwent a predetermined diagnostic work-up. This included (i) clinical examination; (ii) pericardial fluid tests: biochemistry, microbiology, cytology, differential white blood cell (WBC) count, gamma interferon (IFN-gamma), adenosine deaminase (ADA) levels, polymerase chain reaction testing for Mycobacterium tuberculosis; (iii) HIV; (iv) sputum smear and culture; (v) blood biochemistry; and (vi) differential WBC count. A model was developed using 'classification and regression tree' analysis. The cut-off for the total diagnostic index (DI) was optimized using receiver operating characteristic (ROC) curves.

RESULTS

Fever, night sweats, weight loss, serum globulin (>40 g/l) and peripheral blood leukocyte count (<10 x 10(9)/l) were independently predictive. The derived prediction model had 86% sensitivity and 84% specificity when applied to the study population. Pericardial fluid IFN-gamma >or=50 pg/ml, concentration had 92% sensitivity, 100% specificity and a positive predictive value (PPV) of 100% for the diagnosis of tuberculous pericarditis; pericardial fluid ADA >or=40 U/l had 87% sensitivity and 89% specificity. A diagnostic model including pericardial ADA, lymphocyte/neutrophil ratio, peripheral leukocyte count and HIV status had 96% sensitivity and 97% specificity; substituting pericardial IFN-gamma for ADA yielded 98% sensitivity and 100% specificity.

DISCUSSION

Basic clinical and laboratory features can aid the diagnosis of tuberculous pericarditis. If available, pericardial IFN-gamma is the most useful diagnostic test. Otherwise we propose a prediction model that incorporates pericardial ADA and differential WBC counts.

Moulds and yeasts in fruit salads and fruit juices

Thirty-eight fruit salad samples including cantaloupe, citrus fruits, honeydew, pineapple, cut strawberries and mixed fruit salads, and 65 pasteurized fruit juice samples (apple, carrot, grapefruit, grape and orange juices, apple cider, and soy milk) were purchased from local supermarkets in the Washington, DC area and tested for fungal contamination. The majority of fruit salad samples (97%) were contaminated with yeasts at levels ranging from <2.0 to 9.72 log10 of colony forming units per gram (cfu/g). Frequently encountered yeasts were Pichia spp., Candida pulcherrima, C. lambica, C. sake, Rhodotorula spp., and Debaryomyces polymorphus. Low numbers of Penicillium spp. were found in pineapple salads, whereas Cladosporium spp. were present in mixed fruit and cut strawberry salads. Twenty-two per cent of the fruit juice samples tested showed fungal contamination. Yeasts were the predominant contaminants ranging from <1.0 to 6.83 log10 cfu/ml. Yeasts commonly found in fruit juices were C. lambica, C. sake, and Rhodotorula rubra. Geotrichum spp. and low numbers of Penicillium and Fusarium spp. (1.70 and 1.60 log10 cfu/ml, respectively) were present in grapefruit juice.

Biopsy of the prostate guided by transrectal ultrasound: relation between warfarin use and incidence of bleeding complications

AIM

To determine the relation between warfarin use and the frequency of bleeding complications after biopsy of the prostate guided by transrectal ultrasound (TRUS).

METHODS

Overall, 1022 consecutive patients with suspected prostatic disease were followed after biopsy. Warfarin and aspirin use was determined on the day of the procedure. A TRUS-guided biopsy was performed and patients were offered a questionnaire to complete 10 days after the procedure, to determine any immediate or delayed bleeding complications. Follow-up telephone calls were made to those who had not replied within the stipulated period.

RESULTS

Of the 1000 patients who replied, 49 were receiving warfarin, 220 were receiving aspirin and 731 were not receiving any anticoagulant drugs. Of the 49 subjects reporting current use of warfarin, 18 (36.7%) experienced haematuria, compared with 440 (60.2%) of the patients receiving no anti-coagulant drugs who reported haematuria. This was statistically significant (p = 0.001). Of the group receiving warfarin, 4 (8.2%) experienced haematospermia whereas 153 (21%) of the group receiving no anticoagulant medication reported haematospermia. This difference also was statistically significant (p = 0.030). Rectal bleeding was experienced by 7 (14.3%) of the group receiving warfarin compared with 95 (13%) in the group without anticoagulant medication, but this was not statistically significant (p = 0.80). We also demonstrated that there was no statistically significant association between the severity of the bleeding complications and medication with warfarin.

CONCLUSION

None of the group receiving warfarin experienced clinically important bleeding complications. Our results suggest that the frequency and severity of bleeding complications were no worse in the warfarin group than in the control group and that discontinuing anticoagulation medication before prostate biopsy may be unnecessary.

Facilitators and barriers to improving the quality of referrals for potential oral cancer

The quality and content of referral letters are important for prioritisation of patients who may have oral cancer. Referrals letters to the Oral Medicine Clinic at Birmingham Dental Hospital were analysed and practitioners interviewed. Whilst acceptable for general purposes, most letters did not contain sufficient information to allow effective prioritisation. Interviews disclosed a misunderstanding amongst practitioners about the way in which referrals were handled. A number of barriers to increasing the information included in letters were identified. Referral guidelines and a standardised proforma might help improve the ability of the service to operate a fast-track system.

Acute toxicity of chemo-radiotherapy for cervical cancer: the Addenbrooke's experience

AIMS

An audit of acute treatment-related toxicity during chemo-radiotherapy for cervical cancer was carried out to assess its tolerance outside research settings.

MATERIALS AND METHODS

Between May 1999 and April 2003, 74 patients with carcinoma of the cervix were treated with radical radiotherapy given concurrently with weekly cisplatin chemotherapy. Fifty-nine (79.7%) patients received chemo-radiotherapy as primary radical treatment, 10 (13.5%) patients were treated adjuvantly for poor-prognosis features after radical surgery, and the remaining five (6.8%) were given chemo-radiotherapy for pelvic recurrences after previous surgery. Acute treatment-related toxicity was graded prospectively at weekly intervals during chemo-radiotherapy using the National Cancer Institute Common Toxicity Criteria.

RESULTS

The most common adverse effects were diarrhoea (80.6%), malaise (66.7%) and nausea (62.5%). The most common haematological toxicity was anaemia, with 41.7% patients developing grade 1 or 2 toxicity. Only three (4.2%) patients had grade 3 or 4 toxicity. One patient had grade 3 thrombocytopenia, another had grade 4 neutropenia and the third patient had grade 3 diarrhoea. A statistically significant correlation was found between maximum treatment-related toxicity, larger treatment volumes (P = 0.006) and disease stage (P = 0.04). A total of 97.3% of patients completed external beam radiotherapy without any interruptions for treatment-related toxicity. Only two patients (3.4%) experienced a delay in brachytherapy for treatment-related toxicity. Two patients died during external beam radiotherapy, and one patient suffered a fatal pulmonary embolism 1 week after completing brachytherapy treatment. A total of 70.2% patients completed the planned number of chemotherapy cycles, with a further 20.3% receiving at least three cycles. The most common reason for failure to complete chemotherapy as planned was gastrointestinal toxicity. There was no correlation between failure to complete planned chemotherapy and patient age, disease stage, radiotherapy treatment volumes or postoperative treatment.

CONCLUSION

Our study has shown that cisplatin-based chemo-radiotherapy for carcinoma of the cervix is well tolerated when given to a largely unselected population of patients outside research settings. The effectiveness of the treatment should therefore mirror the efficacy obtained in clinical trials.

Does Supervised Exercise Offer Adjuvant Benefit Over Exercise Advice Alone for the Treatment of Intermittent Claudication? A Randomised Trial

OBJECTIVE

Exercise advice is the main treatment for symptom relief in the UK for patients with mild to moderate Intermittent Claudication (IC). Would a weekly exercise and motivation class for 6 months offer adjuvant benefit over written and verbal exercise advice alone?

PATIENTS AND METHODS

Fifty-nine patients attending a regional vascular centre for whom IC was the main factor affecting mobility were randomised to either exercise advice alone (n=30) or exercise advice with a once a week 45 min supervised exercise/motivation class (n=29). The mean age was 68 years. Baseline and 6-month assessment included a Quality of Life Questionnaire--the Short-Form-36, the Charing Cross Symptom Specific Claudication Questionnaire (CCCQ) and treadmill walking distance (3.5 km/h 12%).

RESULTS

At 6-month follow-up the supervised exercise group had improved their treadmill walking by 129% compared to 69% in the advice alone group (p=0.001). This significant improvement was maintained at the subsequent 9 and 12-month follow-up assessments. By the 9-month stage the advice only group CCCQ score had improved 16% from baseline, while the supervised exercise group had a significantly better 43% improvement in base line score (p<0.05). Self reported frequency of walks was higher in the exercise class group being significant for improvement in CCCQ score.

CONCLUSION

A weekly, supervised exercise and motivation class for a 6-month period provides a significant improvement in patients' symptoms, quality of life, and distance walked compared with advice alone and this improvement continues after attendance at class has ceased.

An audit of delays before and during radical radiotherapy for cervical cancer--effect on tumour cure probability

AIM

To evaluate the potential impact of time delay before and during radical radiotherapy for cervical carcinoma at Addenbrooke's Hospital.

MATERIALS AND METHODS

An audit was undertaken which recorded the number of gaps during external beam radiotherapy (EBRT), overall treatment time, and delay between first oncology consultation to start of radiotherapy, for patients receiving primary radical radiotherapy for cervical cancer in 1996, 1998 and 2001. Radiobiological modelling was used to calculate the tumour control probability (TCP). A questionnaire survey of 62 oncology departments in the U.K. was carried out for comparison.

RESULTS

The percentage of patients completing EBRT without any interruptions was 22, 67 and 94% in 1996, 1998, and 2001, respectively (P = 0.0009). The median overall treatment time was 49, 42 and 39 days in 1996, 1998 and 2001, respectively (P = 0.001). However, the median waiting time to start of radiotherapy increased from 14 days in 1996 to 18 days in 1998 and 35 days in 2001 (P = 0.007).

CONCLUSION

The results from the national survey showed that this pattern of improved overall treatment times accompanied by deterioration in waiting times was also seen in most other U.K. centres. Radiobiological modelling showed that any potential gain in TCP resulting from shorter overall treatment times could be offset entirely by the adverse effect of increasing waiting times. The calculations suggest that the tumours most likely to be adversely affected by long waiting times are those with shorter volume doubling times or a medium chance of tumour control at the outset of treatment. A system of patient triage, and prioritization of patients deemed most likely to benefit from a reduced waiting time, may be necessary in the current climate of limited radiotherapy resources.

A reassessment of the fat intake of children from meat and meat products and an estimate of haem iron intakes

BACKGROUND

It is possible that fat intake from red meat has declined as a consequence of changes in animal husbandry and butchery practices. In particular, a study of the intake of vegetarian and meat-eating children concluded that their fat intakes were similar, but the most recent information on the fat content of meat was not available. In addition, iron availability is probably as important as the total amount of iron consumed but estimates of haem iron intake are rarely made.

METHODS

The dietary intake of 50 omnivorous children was reanalysed to produce new estimates of fat and haem iron intakes. Fat intake from meat and meat products only was recalculated using supplements to the food tables not available to the initial survey. Haem iron intake was calculated by discriminating between the different types of meat consumed and estimates of the proportion of iron which is in the haem form.

RESULTS

The recalculated diets had significantly lower energy (8.03-7.50 MJ), fat (79-73 g) and carbohydrate (257-237 g) levels. The proportions of energy from fat (36%) and carbohydrate (51%) were unaffected. Meat supplied 3.2 mg (33%) of the iron intake (9.6 mg) of which 1.3-1.5 mg (13-16% of the total) was estimated to be in the haem form. Children may be relatively unaffected by the changes in the composition of meat as such, if they consume highly processed foods which include, for example, rusk, pastry, breadcrumbs and batter.

CONCLUSIONS

The original estimates of the intake of fat of these omnivorous children from meat and meat products do appear to have been overestimates, but only as the weight of fat consumed not as a percentage of energy. Haem iron was found to supply a substantial proportion of the iron intake of these children and may account for their higher haemoglobin values.

Twelve-lead electrocardiography in tuberculous pericarditis

OBJECTIVES

This study is part of an ongoing initiative started in 1995 to investigate the therapeutic efficacy of adjuvant corticosteroids in the management of tuberculosis (TB) pericarditis. In this retrospective, descriptive study we describe the changes found on the 12-lead electrocardiogram (ECG) in patients with TB pericarditis, with and without cardiac tamponade. We determined the diagnostic accuracy of ECG parameters for cardiac tamponade.

METHODS

All patients referred to our department with echocardiographically confirmed large pericardial effusions underwent a thorough clinical assessment followed by pericardiocentesis and drainage using an indwelling pigtail catheter. The amount of drained effusion was measured, and fluid was sent for diagnostic assessment. Patients were grouped into those with or without cardiac tamponade. The following ECG parameters were assessed: rate, rhythm, microvoltage, electrical alternans, PR segment and ST segment abnormalities.

RESULTS

Of the 157 patients assessed, 88 were diagnosed with TB pericarditis All had abnormal ECGs and 83% had changes of chronic pericarditis. Microvoltage in the extremity and/or precordial leads correlated with the presence of large effusions (> 750 ml). None of the studied parameters correlated with the presence of cardiac tamponade.

CONCLUSIONS

Twelve-lead ECG is of supportive but not diagnostic value in cardiac tamponade. The presence of microvoltage suggests the presence of a large effusion. The absence of microvoltage makes the presence of cardiac tamponade unlikely.

Is a vegetarian diet adequate for children

The number of people who avoid eating meat is growing, especially among young people. Benefits to health from a vegetarian diet have been reported in adults but it is not clear to what extent these benefits are due to diet or to other aspects of lifestyles. In children concern has been expressed concerning the adequacy of vegetarian diets especially with regard to growth. The risks/benefits seem to be related to the degree of restriction of he diet; anaemia is probably both the main and the most serious risk but this also applies to omnivores. Vegan diets are more likely to be associated with malnutrition, especially if the diets are the result of authoritarian dogma. Overall, lacto-ovo-vegetarian children consume diets closer to recommendations than omnivores and their pre-pubertal growth is at least as good. The simplest strategy when becoming vegetarian may involve reliance on vegetarian convenience foods which are not necessarily superior in nutritional composition. The vegetarian sector of the food industry could do more to produce foods closer to recommendations. Vegetarian diets can be, but are not necessarily, adequate for children, providing vigilance is maintained, particularly to ensure variety. Identical comments apply to omnivorous diets. Three threats to the diet of children are too much reliance on convenience foods, lack of variety and lack of exercise.

Effects of hyaluronic acid/carboxymethylcellulose gel on bowel anastomoses in the New Zealand white rabbit

Intra-abdominal adhesions form in more than 90% of patients undergoing major abdominal surgery and can lead to significant complications. Application of a bioresorbable gel consisting of chemically modified hyaluronic acid (HA) and carboxymethylcellulose (CMC) has shown promise as a means of preventing intra-abdominal adhesions, but there have been concerns that the presence of the gel might interfere with the integrity and healing of bowel anastomoses. We tested the effects of HA/CMC gel on adhesion formation and anastomotic healing in 60 New Zealand white rabbits after transection and complete (100%) or incomplete (90%) anastomosis of the ileum. Half of the animals underwent application of HA/CMC gel and half served as control subjects. Animals were killed at 4, 7, or 14 days after surgery. Anastomotic adhesions were scored in a blinded fashion. Integrity of the anastomosis was tested by measuring bursting pressure at the anastomotic site and in an adjacent section of intact bowel. With complete anastomosis, HA/CMC gel significantly reduced adhesion formation at 7 and 14 days after surgery (P<0.05), but gel application did not inhibit adhesion formation when the anastomosis was incomplete. Anastomosed segments of bowel burst at a lower pressure than intact bowel 4 days after surgery, but bursting pressures were normal at 7 and 14 days. Burst pressures of anastomoses receiving an application of HA/CMC gel were nearly identical to control anastomoses at all three time points. HA/CMC gel did not interfere with the normal healing process of bowel anastomoses. Furthermore, HA/CMC gel decreased adhesion formation after complete anastomoses, yet it did not affect adhesion formation in the presence of anastomotic disruption.

A hyaluronate based gel for the prevention of postsurgical adhesions: evaluation in two animal species

OBJECTIVE

To assess in two animal surgery models, the efficacy of a bioabsorbable gel to prevent postoperative adhesions.

DESIGN

A randomized, prospective, blinded study using animal abdominal surgery models.

SETTING

Two animals species with surgical traumas to induce adhesion formation.

INTERVENTIONS

A chemically modified hyaluronate and carboxymethylcellulose-based gel formulation.

MAIN OUTCOME MEASURES

The number of animals with no adhesions, mean number of adhesions, and total adhesion score.

RESULTS

Treatment with the bioabsorbable gel increased the number of animals without any adhesion by 70% in a rat cecal abrasion model and by > 90% in a rabbit sidewall defect-bowel abrasion model when compared with nontreatment control animals. Other outcome measures showed similar efficacy.

CONCLUSION

The modified hyaluronate-carboxymethylcellulose gel was effective in two animal species after surgery in the abdominal cavity. The gel appears to act as a physical barrier between damaged peritoneal tissue and may be appropriate for human clinical trials in open and laparoscopic surgical procedures.

Mixed-sex wards--the NT survey results

The practice of rigidly separating men and women in hospital has broken down in recent years; the RCN estimates that half of all acute hospital wards are now mixed. In January, NT invited readers to give their opinions on mixing males and females in the same wards and to describe their own areas of work. Chief areas of concern that emerged were: patients not being informed about the ward being mixed before admission; lack of privacy (especially in bathroom and lavatory areas); and in patients' unhappiness with the proximity of patients of the opposite sex. Although complaints were common, most were informal. Further research, preferably from a 'neutral' source, is needed.

Lactoferricin, a new antimicrobial peptide

Lactoferricin B (LF-B) is a peptide derived from acid-pepsin digestion of bovine lactoferrin, which has antimicrobial properties. In order to assess the antimicrobial spectrum of LF-B and its possible in vivo uses, the minimum inhibitory and microbicidal concentrations of pure lactoferricin B were determined for a range of bacterial species and under varying conditions of growth including growth phase and size of the inoculum, pH and ionic strength of the medium. Lactoferricin B was bactericidal against a wide range of bacteria and Candida albicans. Proteus spp., Pseudomonas cepacia and Serratia spp. were resistant. The bactericidal activity of LF-B was inhibited by increasing ionic strength and bacterial inoculum and at acid pH. The activity of lactoferricin B was completely inhibited by the addition of 5% whole cow's milk and was reduced in the presence of increasing concentrations of mucin. These results indicate the potential of LF-B to reduce the numbers of organisms in a simple medium, but raise doubts about its role in vivo because of its sensitivity to changes in physical variables. It may be that lactoferricin exerts a transient antimicrobial effect at mucosal surfaces.

Oncology focus. Facing the reality of head and neck cancer

There are many facets and ideas surrounding the concept of body image, which are of particular importance to patients with defects of the head and neck who may have had to suffer extensive alterations to their appearance and bodily functions. This article discusses how nursing models can be used to help patients cope with their altered body image and the attitudes of society and the media to their disfigurement.

An epidemic of massive proportions: Smoking and the health of the nation

The number of deaths from smoking-related illness is still unacceptably high. The government aims to reduce cigarette consumption by the year 2000, but this can only be achieved if the social, psychological and political factors that induce people to start smoking are addressed.

Differential radiosensitization by the poly(ADP-ribose) transferase inhibitor 3-aminobenzamide in human tumor cells of varying radiosensitivity

Four newly-established human tumor cell lines, have been irradiated at dose rates of 150 and 3.2 cGy/min to compare their capacity to repair radiation damage. They included a neuroblastoma, a germ-cell carcinoma of the testis, a large cell carcinoma of the lung, and a carcinoma of the cervix. The four lines varied in their sensitivity to high dose-rate irradiation, with the neuroblastoma being most radiosensitive and the lung and cervix tumors the most radioresistant. The extent of dose sparing associated with lowering the dose rate to 3.2 cGy/min was similar in three of the lines but somewhat greater in the case of the cervix carcinoma cell line. The presence of non-toxic concentrations of the poly(ADP-ribose) transferase inhibitor, 3-aminobenzamide (3-AB), enhanced the response of 3 of the 4 tumors to irradiation; it failed to modify the sensitivity of a lung carcinoma cell line. The extent of sensitization was generally similar at high and low dose rate. Measurement of poly(ADP-ribose) transferase activity in control and irradiated cells showed the neuroblastoma cells to contain much higher initial levels than the other three lines but there were no significant differences in the extent of stimulation in enzyme levels after irradiation. Survival curves obtained at low dose-rate help define the initial slope of the acute curve and it appears that 3-AB may exert a differential effect among human tumors in modifying this component.

Hospice in transition: Kentucky 1982-85

The ratio of hospice patients to 100 Kentuckians dying of cancer was 8 in 1982 and 12 in 1985. The primary increase occurred in the number of patients served by three hospices which became Medicare-certified during that time period. During this period, the average age of hospice patients increased, and patients became more likely to die at home. Hospices in some counties may have served about 40 per cent of terminally ill cancer patients.

Characterization of four new cell lines derived from human squamous carcinomas of the uterine cervix

Four continuous cell lines were established from 15 biopsies of human squamous carcinomas of the uterine cervix, two from women less than 35 years old. All four lines grew as adherent monolayers and had epitheloid morphology. All required initial 3T3 feeder layer support and hydrocortisone and insulin for growth and have now been grown in vitro for at least 12 months. The individual lines possessed unique isozyme patterns and were distinct from the HeLa cell line. All were tumorigenic in nude mice. In vitro colony forming efficiencies ranged from 2 to 30% in a monolayer anchorage dependent assay but were only from 0.0025 to 0.6% when assayed in soft agar. The lines were all aneuploid with mean chromosome numbers ranging from 71 to 75. Analysis of intermediate filament expression showed that all lines were positive for cytokeratin expression and two were positive for vimentin expression. These low-passage cell lines represent a panel of new in vitro models of carcinoma of the cervix. They should be useful for the investigation of chemosensitivity, of the involvement of human Papillomavirus in this disease, and as models of squamous cell differentiation.