Osteoradionecrosis after treatment of head and neck cancer: a comprehensive analysis of risk factors with a particular focus on role of dental extractions

In head and cancer (HNC), osteoradionecrosis (ORN) is one of the most significant complications of radiotherapy (RT). With an absence of effective non-surgical treatment, prevention of the development of ORN is the best approach. The purpose of this study was to identify the risk factors for the development of ORN in HNC. Records of 1,118 patients with HNC treated with radical RT (≥55Gy) from January 2010 to December 2019 were reviewed. After applying the exclusion criteria, 935 patients were included in the final analysis. In patients with confirmed ORN, exact RT doses were mapped. In total, 91 patients were found (9.7%) with a median (range) time of eight (3-89) months to the development of ORN. Smoking, having a primary site in the oropharynx, bone surgery before adjuvant RT, the addition of concurrent chemotherapy, the presence of xerostomia, dental extraction pre-RT, the time ≤20 days between dental extraction and start of RT, and receiving >55Gy RT dose were significant factors for its development. This comprehensive analysis including the precise RT dose mapping has shown the risk factors for the development of ORN. In practice, every effort should be made to avoid these risk factors without compromising the oncology treatment. The findings of this analysis may provide a basis for future prospective research on this topic.

91 To What Extent are Patients’ Future Care Preferences Shared Between Secondary and Primary Care? A Retrospective Chart Review

Introduction

When a doctor is informed of a patient’s future care preferences if they were to lose capacity, there is an ethical and legal obligation to share this information with the treating medical team. In frail older patients, conversations about treatment preferences often occur during hospital admission. We sought to assess the communication of these preferences to the patient’s GP.

Methods

Retrospective chart review of consecutive discharges from acute geriatric wards across seven hospitals. Records were excluded if the patient was admitted for less than 48 hours, was under orthogeriatric care, or died in hospital.

Results

339 notes were included, 41-50 from each hospital. GPs were informed of the resuscitation status of 28% of all patients. 52% of patients had an inpatient DNACPR, the GP was informed of 54% of these. 36% of patients had an inpatient ceiling of treatment documented, of which GPs were informed of 19%. 53% of hospital DNACPRs were converted into community DNACPRs on discharge: GPs were informed of only 24% of new community DNACRPs. 47% of patients discharged with a new community DNACPR lacked capacity to be involved in that decision; for just 6% of these was the GP asked to review the DNACPR order in the community. Inpatient Advance Care Planning (ACP) discussions were held for 9% of patients, of which the GP was informed in 59% of cases. 49% of ACP conversations involved the next-of-kin but not the patient. Among patients who had a new DNACPR decision made during their admission (n=124), there was documentary evidence in only 25% that the patient or next-of-kin was informed whether this was time-limited or indefinite.

Conclusions

Communication from hospitals to GPs about resuscitation, ceiling of care and ACP discussions is very limited. For patients who have expressed ongoing future care preferences, there is a legal obligation to share this information with the treating medical team, which on discharge is the GP.

There is poor documentary evidence of discussions with patients about whether DNACPR decisions are time-limited or indefinite. Furthermore, many hospitalised frail patients lack capacity to make DNACPR decisions but they may subsequently regain capacity, particularly those with delirium. Despite this, GPs are rarely asked to review new community DNACPRs, including those made for patients without capacity.

95 Goals-Of-Care and Advance Care Planning Discussions with Hospitalised Frail Older People: What is the Evidence?

Introduction

National guidelines suggest that patients in the last year of life should be identified, their prognosis and future care options discussed, with advance care planning (ACP) recorded. Goals-of-care should be discussed with hospitalised patients at risk of deteriorating or with life-limiting conditions. The stated purpose of ACP and goals-of-care discussions is to increase goal-concordant care (i.e. patients receiving treatments they would wish to receive, and not receiving those they would not want). This literature review investigates the evidence-base for these policies and outcomes.

Review question

What is the evidence for goals-of-care and ACP discussions with hospitalised frail older people?

Methods

Systematic literature review and narrative synthesis. Electronic search of MEDLINE, CINAHL, ASSIA, PsycINFO, and Embase databases from January 1990 to September 2017. An updated search until May 2019 is currently underway.

Results

Of 8077 unique articles identified, 17 met inclusion criteria. There is no evidence that goals-of-care discussions lead to increased goal-concordant care; there is observational evidence that they increase the accuracy of documented preferences. Currently, rates of goals-of-care discussions are variable (38-72%), and there is poor concordance between patients’ actual and documented preferences, with agreement in only 31-33% of cases.

Present rates of ACP are very low (0-3%), with mixed evidence for benefits of ACP. One single-centre randomised controlled trial suggests ACP improves outcomes for patients who die within 6 months of discharge, including increased goal-concordant care and reduced family distress.

There is very limited evidence concerning patients’ and family members’ experiences of these discussions, their reasons for wishing (or not) to participate in discussions, or their perceptions of the important outcomes. Most (80%) patients would like to be involved in decisions about their care; 48% consider these conversations very important. The views and experiences of healthcare professionals have been little studied.

Conclusions

The asserted aim of goals-of-care and ACP discussions is to increase goal-concordant care; the extent to which this reflects patients’ priorities is unknown. In younger patient populations, while 40% of patients consider goal-concordant care the most important outcome, one third of patients consider family-related outcomes to be more important. Further research is needed to understand the perspectives of frail older patients, their families and clinicians, in order to make these discussions and subsequent care truly patient-centred.

Withdrawal of anticancer therapy in advanced disease: a systematic literature review

Background

Current guidelines set out when to start anticancer treatments, but not when to stop as the end of life approaches. Conventional cytotoxic agents are administered intravenously and have major life-threatening toxicities. Newer drugs include molecular targeted agents (MTAs), in particular, small molecule kinase-inhibitors (KIs), which are administered orally. These have fewer life-threatening toxicities, and are increasingly used to palliate advanced cancer, generally offering additional months of survival benefit. MTAs are substantially more expensive, between £2-8 K per month, and perceived as easier to start than stop.

Methods

A systematic review of decision-making concerning the withdrawal of anticancer drugs towards the end of life within clinical practice, with a particular focus on MTAs. Nine electronic databases searched. PRISMA guidelines followed.

Results

Forty-two studies included. How are decisions made? Decision-making was shared and ongoing, including stopping, starting and trying different treatments. Oncologists often experienced ‘professional role dissonance’ between their self-perception as ‘treaters’, and talking about end of life care. Why are decisions made? Clinical factors: disease progression, worsening functional status, treatment side-effects. Non-clinical factors: physicians’ personal experience, values, emotions. Some patients continued treatment to maintain ‘hope’, often reflecting limited understanding of palliative goals. When are decisions made? Limited evidence reveals patients’ decisions based upon quality of life benefits. Clinicians found timing withdrawal particularly challenging. Who makes the decisions? Decisions were based within physician-patient interaction.

Conclusions

Oncologists report that decisions around stopping chemotherapy treatment are challenging, with limited evidence-based guidance outside of clinical trial protocols. The increasing availability of oral MTAs is transforming the management of incurable cancer; blurring boundaries between active treatment and palliative care. No studies specifically addressing decision-making around stopping MTAs in clinical practice were identified. There is a need to develop an evidence base to support physicians and patients with decision-making around the withdrawal of these high cost treatments.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-015-1862-0) contains supplementary material, which is available to authorized users.

Is community treatment best? a randomised trial comparing delivery of cancer treatment in the hospital, home and GP surgery

BACKGROUND

Care closer to home is being explored as a means of improving patient experience as well as efficiency in terms of cost savings. Evidence that community cancer services improve care quality and/or generate cost savings is currently limited. A randomised study was undertaken to compare delivery of cancer treatment in the hospital with two different community settings.

METHODS

Ninety-seven patients being offered outpatient-based cancer treatment were randomised to treatment delivered in a hospital day unit, at the patient's home or in local general practice (GP) surgeries. The primary outcome was patient-perceived benefits, using the emotional function domain of the EORTC quality of life (QOL) QLQC30 questionnaire evaluated after 12 weeks. Secondary outcomes included additional QOL measures, patient satisfaction, safety and health economics.

RESULTS

There was no statistically significant QOL difference between treatment in the combined community locations relative to hospital (difference of -7.2, 95% confidence interval: -19·5 to +5·2, P=0.25). There was a significant difference between the two community locations in favour of home (+15·2, 1·3 to 29·1, P=0.033). Hospital anxiety and depression scale scores were consistent with the primary outcome measure. There was no evidence that community treatment compromised patient safety and no significant difference between treatment arms in terms of overall costs or Quality Adjusted Life Year. Seventy-eight percent of patients expressed satisfaction with their treatment whatever their location, whereas 57% of patients preferred future treatment to continue at the hospital, 81% at GP surgeries and 90% at home. Although initial pre-trial interviews revealed concerns among health-care professionals and some patients regarding community treatment, opinions were largely more favourable in post-trial interviews.

INTERPRETATION

Patient QOL favours delivering cancer treatment in the home rather than GP surgeries. Nevertheless, both community settings were acceptable to and preferred by patients compared with hospital, were safe, with no detrimental impact on overall health-care costs.

Prognosticating in patients with advanced cancer--observational study comparing the accuracy of clinicians' and patients' estimates of survival

BACKGROUND

Clinicians' prognoses in patients with advanced cancer are imprecise. The aim of this study was to compare doctors', nurses' and patients' survival predictions and to identify factors which influence accuracy.

PATIENTS AND METHODS

Some 1018 patients with advanced cancer were recruited. Survival estimates were obtained from the attending doctor, nurse, multidisciplinary team (MDT) and patient (n = 829, 954, 987 and 290 estimates, respectively) and were compared with actual survival. Clinician and patient characteristics were recorded.

RESULTS

MDTs', doctors' and nurses' predictions were accurate 57.5%, 56.3% and 55.5% of occasions, respectively. Nurses were less accurate than the MDT (P = 0.007) but were no worse than doctors (P = 0.284). Estimates of clinicians and patients were more optimistic (doctors: 31%; nurses: 34%; MDT: 31.1%; patients: 45.1%) than pessimistic (12.7%, 11%, 11.4% and 2.7%). Nurses' accuracy increased if they had reviewed the patient within 24 h. Most patients (61.4%) wanted to know their prognosis. Only 37.1% were willing to offer an estimate regarding their own survival. Patients' prognostic estimates were less accurate than health care professionals' (P < 0.001).

CONCLUSIONS

MDTs were better at predicting survival than doctors' or nurses' alone. Patients were substantially worse. Among nurses, recency of review was related to improved prognostic accuracy.

Radiological assessment of type II Stafne idiopathic bone cyst in a patient undergoing implant therapy: a case report

This paper is intended to describe the confirmative role of radiology in the diagnosis of Stafne Idiopathic bone Cyst (SIBC) without the need for histopathology especially when dental implants are considered so as to avoid unnecessary invasive surgical exploration of this benign pathology. Other pathologies may present not unlike SIBC and as such it is mandatory to rule out such possibilities especially prior to dental implant therapy. The use of orthopanthomogram and non-sialographic computed tomography (CT) scan in the reported case together with a review of CT scan confirmatory role in the diagnosis of SIBC from the literature was the basis for this clinical report. Based on the CTscan findings of the jaw in this case and review of the literature, the implant procedure was commenced without the need of histopathology and/or for invasive surgical exploration of this pathology. All pathologic lesions of the jawbone seen on the orthopanthomogram should be confirmed prior to commencement of implant procedure even when such pathologies are seen in areas remote from the proposed implant site. The pre-implant radiological assessment utilizing non-sialographic CT scan alone is confirmatory of SIBC.

What are patients' priorities for palliative care research? Focus group study

To elucidate the research priorities of palliative care patients we conducted focus groups with day therapy and hospice in-patients with cancer with an estimated prognosis of 6 months or less. Patients were positive about taking part in this research project identifying five main priorities for future research--talking with patients; help for patients and families; oncology; symptoms; medication/treatments. Patients gave great emphasis to communication issues and little to symptom control. A patient questionnaire was created with these themes which is currently being used in five hospices across East Anglia. This paper describes the qualitative component of the study.

Aggressive infantile (desmoid-type) fibromatosis of the maxilla: a case report and new classification

This paper describes the clinical, radiographic and histologic findings of an aggressive infantile (desmoid-type) fibromatosis of the face in a seven-year-old black Jamaican male. This condition is rare in the head and neck region and its occurrence in the maxilla is exceptional. The differential diagnosis, management and long term follow-up of this case are also mentioned The need for a less aggressive surgical management in this child and long-term follow-up is stressed. Also, its occurrence in someone of African descent has not been reported previously. The absence of recurrence, eight years after surgery is significant. This paper discusses the differential diagnosis and treatment of aggressive infantile fibromatosis and suggests a classification of the condition.

Non-syndromal multiple buried supernumerary teeth: report of two cases from the English-speaking Caribbean and a review of the literature

Multiple supernumerary teeth affecting all four quadrants of the jaw are a rare dental anomaly which has become a chance finding on routine dental panoramic tomography (DPT). In this paper, two cases from the English-speaking Caribbean are reported. The role of radiography in the diagnosis and management of this rare developmental dental anomaly is emphasized. The paper stresses the importance of ruling out associated syndromes such as Gardner's Syndrome, cleidocranial dysostosis and cleft lip and palates, as multiple supernumerary teeth are usually related to such conditions. There is a review of the literature as it relates to supernumerary teeth.

Critical incidents contributing to the initiation of substance use and abuse among women attending drug rehabilitation centres in Trinidad and Tobago

The aim of this study was to determine the critical incidents that contribute to the initiation of substance use and abuse among women in Trinidad and Tobago. Twenty women were randomly selected from 46 women currently attending 43 drug rehabilitation centres, Narcotics Anonymous and Alcoholics Anonymous groups in Trinidad and Tobago. In-depth semi-structured interviews using the critical incident technique were conducted. Interviews were recorded, transcribed and analyzed. Concepts, categories and themes were determined by team study and group discussion. The critical incidents that influenced women to initiate the use and abuse of substances fell into eight major themes: factors intrinsic to the individual woman, family factors, social and environmental factors, life stresses, relationship issues, abuse, peer pressure and substance use and abuse as a coping mechanism. The results imply that the factors contributing to the initiation of substance use and abuse among women in Trinidad and Tobago are many and complex. As such any attempt to address this issue requires a broad-based approach. Such an approach should address family use of such substances, societal acceptance of them, availability, the self-esteem of the individual woman and her ability to cope with peer and internal stresses.

Is late diagnosis of lung cancer inevitable? Interview study of patients' recollections of symptoms before diagnosis

BACKGROUND

A study was undertaken to explore the pathway to diagnosis among a group of patients recently diagnosed with lung cancer.

METHODS

A directed interview study triangulating patients' accounts with hospital and GP records was performed with 22 men and women recently diagnosed with lung cancer at two cancer centres in the south and north of England. The main outcome measures were the symptoms leading up to a diagnosis of lung cancer and patient and GP responses before diagnosis.

RESULTS

Patients recalled having new symptoms for many months, typically over the year before their diagnosis, irrespective of their disease stage once diagnosed. Chest symptoms (cough, breathing changes, and pain in the chest) were common, as were systemic symptoms (fatigue/lethargy, weight loss and eating changes). Although symptoms were reported as being marked changes in health, these were not in the main (with the exception of haemoptysis) interpreted as serious by patients at the time and not acted on. Once the trigger for action occurred (the event that took patients to their GP or elsewhere in the healthcare system), events were relatively speedy and were faster for patients who presented via their GP than via other routes. Patients' beliefs about health changes that may indicate lung cancer appeared to have played a part in delay in diagnosis.

CONCLUSION

Further investigation of the factors influencing the timing of diagnosis in lung cancer is warranted since it appears that patients did not readily attend GP surgeries with symptoms. Insight into patients' perspectives on their experience before diagnosis may help medical carers to recognise patients with lung cancer more easily so that they can refer them for diagnosis and treatment. Encouragement to present early with signs of lung cancer should be considered alongside other efforts to speed up diagnosis and treatment.

Defining patients as palliative: hospital doctors' versus general practitioners' perceptions

There appears to be a lack of consensus on the classification of individual patients as 'for palliative care', although the extent of this is unknown. General practitioners (GPs) of 213 patients with a palliative diagnosis of lung or colo-rectal cancer were sent a one-page questionnaire to assess information sent by hospital doctors, and to establish the GPs' perception of patients' palliative status. A total of 185 questionnaires were returned (87% response rate). Of those GPs receiving information from the hospital, one in four rated the adequacy as less than positive; 26% reportedly received no information or received it 'too late'. In 20% of cases, GPs did not perceive patients as palliative, although hospital records suggested that they were, and death certificates received later potentially confirmed this. There was, however, no significant difference between GPs allocating a patient to palliative status or not, in terms of the promptness or adequacy of information received from the hospital, as rated by the GP. There was a significant difference in survival between patients whom GPs perceived as for palliative care and those they did not ('palliative' patients died, on average, 117 days earlier). Possible explanations of the differing perceptions of patients' palliative status are discussed. The findings have implications for patient care in the community, patients' informed choices, and palliative care research.

Educational opportunities in palliative care: what do general practitioners want?

It is important to support general practitioners (GPs) in maintaining and developing their palliative care skills as most of the final year of a patient's life is spent at home under the care of the primary health care team. The training needs and uptake of GPs have been explored, but little is known about how GP educational preferences vary. The aim of this study was to explore the current educational preferences of GPs in different geographical locations as part of an evaluation of an educational intervention. The methods used included postal questionnaires sent to 1061 GPs. Results from 640 (60%) of GPs revealed that half (51%) wanted education in symptom control for non-cancer patients. More inner-city GPs wanted education in opiate prescribing (43%), controlling nausea and vomiting (45%), and using a syringe driver (38%) than their urban and rural colleagues (26%, 29% and 21%, respectively). Increased educational preference and increased difficulty in accessing information was associated with reduced confidence in symptom control. To maximize educational uptake it will be important for educational strategies to be developed and targeted according to variations in demand, and in particular to respond to the need for palliative care education in symptom control for patients suffering from advanced non-malignant disease.

Providing palliative care in primary care: how satisfied are GPs and district nurses with current out-of-hours arrangements?

The complex needs of palliative care patients require an informed, expert, and swift response from out-of-hours general medical services, particularly if hospital admission is to be avoided. Few general practitioners (GPs) reported routinely handing over information on their palliative care patients, particularly to GP co-operatives. District nurses and inner-city GPs were least satisfied with aspects of out-of-hours care. Most responders wanted 24-hour availability of specialist palliative care. This indicates a need to develop and evaluate out-of-hours palliative care procedures and protocols, particularly for GP co-operatives, and to improve inter-agency collaboration.

Primary care group commissioning of services: the differing priorities of general practitioners and district nurses for palliative care services

BACKGROUND

General practitioners (GPs) have become more responsible for budget allocation over the years. The 1997 White Paper has signalled major changes in GPs' roles in commissioning. In general, palliative care is ranked as a high priority, and such services are therefore likely to be early candidates for commissioning.

AIM

To examine the different commissioning priorities within the primary health care team (PHCT) by ascertaining the views of GPs and district nurses (DNs) concerning their priorities for the future planning of local palliative care services and the adequacy of services as currently provided.

METHOD

A postal questionnaire survey was sent to 167 GP principals and 96 registered DNs in the Cambridge area to ascertain ratings of service development priority and service adequacy, for which written comments were received.

RESULTS

Replies were received from 141 (84.4%) GPs and 86 (90%) DNs. Both professional groups agreed that the most important service developments were urgent hospice admission for symptom control or terminal care, and Marie Curie nurses. GPs gave greater priority than DNs to specialist doctor home visits and Macmillan nurses. DNs gave greater priority than GPs to Marie Curie nurses, hospital-at-home, non-cancer patients' urgent hospice admission, day care, and hospice outpatients. For each of the eight services where significant differences were found in perceptions of service adequacy, DNs rated the service to be less adequate than GPs.

CONCLUSION

The 1997 White Paper, The New NHS, has indicated that the various forms of GP purchasing are to be replaced by primary care groups (PCGs), in which both GPs and DNs are to be involved in commissioning decisions. For many palliative care services, DNs' views of service adequacy and priorities for future development differ significantly from their GP colleagues; resolution of these differences will need to be attained within PCGs. Both professional groups give high priority to the further development of quick-response clinical services, especially urgent hospice admission and Marie Curie nurses.

How common is medical training in palliative care? A postal survey of general practitioners

BACKGROUND

General practitioners (GPs) have a central role in palliative care, yet research continues to reveal room for improvement in symptom control at home. There is a need to evaluate how well-prepared GPs are for this task of caring for the dying at home.

AIM

To evaluate the training in palliative care GPs have received throughout their careers.

METHOD

Postal survey of 450 randomly selected East Anglian GP principals, investigating training in five areas of palliative care (pain control, control of other symptoms, communication skills, bereavement care, use of syringe driver), as clinical students, junior hospital doctors, GP trainees (registrars), and GP principals.

RESULTS

A response rate of 86.7% was obtained. While GPs were clinical students, training was uncommon, (32% reported no training in pain control, and 58% no training in bereavement care), although there has been a significant increase in more recent years. Training as junior doctors was particularly uncommon (over 70% report no training in communication skills or bereavement care); there was some evidence of an increase in more recent years. During the GP trainee year, training was much more common. For GP principals, most areas had been covered, although over 20% reported no training in communication skills and bereavement care. During the community-based years as trainee and principal, training was significantly more common than during the hospital-based years of training as clinical student and junior doctor.

CONCLUSIONS

There is a continuing need for medical education in palliative care. Particular attention should be paid to the basic medical education of clinical students and the training of junior doctors, especially regarding communication skills and bereavement care.

Knowledge of lymphoedema among primary health care teams: a questionnaire survey

Lymphoedema usually develops following surgery or radiotherapy for cancer, but can also occur in advanced malignant disease or be primary in origin. Lower limb lymphoedema may present particular difficulties in diagnosis, treatment and management. All types of lymphoedema can seriously impair quality of life for those affected. This study aimed to determine the level of knowledge among primary health care team members concerning the identification and management of patients at risk of developing lymphoedema, the current treatment options available for patients with established lymphoedema, and the awareness of local services available within the Cambridge Health District. A postal questionnaire survey obtained an 84.3% response rate. Many primary health care professionals were not aware of some important issues in the prevention and management of lymphoedema. This information proved useful in enabling the specialist service to develop appropriate educational initiatives.

Low incidence of red cell and HLA antibody formation by bone marrow transplant patients

BACKGROUND

Bone marrow transplant (BMT) patients, although immunosuppressed, are at risk for the development of red cell (RBC) and HLA antibodies, and they often are given filtered blood in an effort to prevent the latter complication. This study attempts to determine the rate of formation and the specificity of both RBC and HLA alloantibodies in this patient population.

STUDY DESIGN AND METHODS

BMT patients (148 received autologous marrow; 45 received allogeneic marrow) from an 18-month period, including patients with leukemia (57 patients), lymphoma (54), breast cancer (68), myeloma (8), myelodysplastic syndrome (5), and aplastic anemia (1), were studied to determine the rate of alloantibody formation to RBC and HLA antigens. A total of 2,410 RBC antibody screens were performed. The patients received 3,921 packed RBCs and 5,915 single-donor platelet units; all were irradiated and administered via white cell-reduction filters.

RESULTS

Seven (3.6%) of 193 patients had RBC antibodies upon hospital admission. Four (2.1%) of 193 developed RBC antibodies during the course of BMT: 3 patients had one RBC antibody and 1 patient had two RBC antibodies. RBC antibodies included anti-E (n = 2), anti-M (n = 1), anti-Jkb (n = 1), and anti-Lu14 (n = 1). Thus, 98 percent of patients (189/193) did not develop new (182/186) or additional (7/7) RBC antibodies during BMT. BMT patients were also screened weekly for HLA antibody formation (60-cell panel). Upon admission, 170 (85%) patients were negative. Of these, 8 (4.7%) developed persistent HLA antibodies (mean panel-reactive antibody score, 33 +/- 29%) and 9 (5.3%) were variably positive. Thus, in our setting and population, RBC antibody formation was 0.1 percent per unit transfused, and the HLA alloimmunization rate was 5 to 10 percent.

CONCLUSION

As RBC antibody screens are done every Monday, Wednesday, and Friday on this BMT service and as RBC antibody formation is low in these patients, screening for unexpected antibodies might be possible on a more infrequent basis. Also, the rate of HLA alloimmunization in this population receiving filtered blood components is low.

Regurgitant heart valve flow from 2-D proximal velocity field: continued search for the ideal method

It has been suggested that flow through a leaking heart valve can be determined by studying the proximal velocity field. Normally, only the centre-line velocity is studied as a potential method. The aim of the study is to improve this method by using information from the entire reconstructed proximal velocity field. Four methods are compared: use of the centre-line velocity; use of velocities at three different angles; integration of velocities over a hemisphere; and integration of velocities over an estimated hemi-elliptical isovelocity line. Measurements are performed in a hydraulic model with 4, 6 and 8 mm circular orifices, and these are compared with those from computer simulation. From the results presented in the study, it is suggested that the velocities should be integrated over a hemisphere within a best zone. This zone is dependent on the instrument settings, but in this case it is positioned 1.2-1.4 orifice diameters from the orifice inlet, with an angle of up to +/- 45 degrees from the centre axis, and contains velocities in the range 0.15-0.45 ms-1.

The incidence and severity of nifedipine-induced gingival overgrowth

The gingival health of 19 patients with cardiovascular problems who were medicated with nifedipine was compared with a similar cohort treated with atenolol and a control group of healthy patients. In the nifedipine and atenolol groups, patients had been taking their respective medication for a minimum period of 6 months. Plaque scores were similar for all three groups. However, patients medicated with nifedipine had a significantly higher gingival index (P less than 0.005), gingival overgrowth scores (P less than 0.02) and probing sites greater than 3 mm (P less than 0.005) when compared with the atenolol and control groups. 4 patients in the nifedipine group experienced clinically significant gingival overgrowth which required surgical excision. Gingival changes in the nifedipine patients were not related to drug dosage or plaque scores. It is concluded that nifedipine therapy results in significant gingival changes, an effect which may be mediated by the drug's action on calcium transport.

Iron for the suckling

Knowledge of the metabolism of iron by young infants is incomplete but combining practical studies based on detecting the onset of iron depletion with isotopic studies of iron economy may improve our understanding of iron metabolism in infants and our strategies for ensuring their iron supply. The iron accumulated by the fetus is enough to delay the risk of iron deficiency until four, and two months of age in term and preterm infants respectively. Breast fed term infants may not need extra iron until they are six months or older; but whereas low iron formulas are adequate for other infants until about four months of age, thereafter infants need extra iron which can be provided effectively in iron fortified formulas. Breast fed low birth weight infants need iron supplements from two months of age but those fed specific low birth weight formulas which are iron fortified should not need extra iron.

The LFA-1 antigen in human B lymphocyte activation

Human tonsil B cells include a subpopulation (30 per cent) of cells which lack LFA-1 antigen. Activation of tonsil B cells by culture with anti-IgM and interleukin-4 led to an increase in staining intensities and in the proportion of cells staining, until by 48 h the majority of B cells were positive. Culture of activated cells with low-molecular weight B cell growth factor, which induces a proportion of cells to proliferate, led to a minor further increase in expression of the LFA-1 antigen. Inclusion of a monoclonal antibody against the LFA-1 beta chain in culture did not affect either proliferation or immunoglobulin secretion. The expression of LFA-1 by B cells thus changes as B cells are activated, perhaps reflecting the changing requirements of B cells for interaction with other cells and tissue components. On the other hand, our results did not provide any support for the idea that the LFA-1 antigen is directly involved in the interaction of B cells with lymphokines which control proliferation and differentiation.

The p24 leucocyte membrane antigen: modulation associated with lymphocyte activation and differentiation

Monoclonal antibodies of the CD9 cluster recognize a 24 kD protein (p24) found on platelets and endothelium, and expressed by lymphocytes at restricted stages of maturation and activation. In this study, we explore the possibility that p24 is involved in the response of lymphocytes to signals delivered by lymphokines. p24 is expressed only very weakly by resting B lymphocytes. We found no increase in expression when cells were activated with anti-immunoglobulin together with interleukin-4, or induced to proliferate by low-molecular weight B cell growth factor (LMW-BCGF). Culture of activated B cells with B cell differentiation factor was associated with an increased mean expression of p24. In cells from a patient with chronic lymphocytic leukaemia (CLL), culture with LMW-BCGF up-regulated p24 expression. Resting T cells (p24-negative) were induced to express p24 strongly when activated with antibody against CD3. CD9 antibody did not modulate B or T cell responses to activation stimuli. The results suggest that the p24 molecule is not involved in the primary interaction of cells with lymphokine, but rather may be involved in a secondary reaction, such as ion flux, which follows as a consequence of the action of lymphokines on cells.

Expression of a novel human pan leucocyte differentiation antigen on leukaemic cells

A murine monoclonal antibody has been produced which identifies a novel surface membrane antigen present on virtually all normal human leucocytes and leukaemic cells. The antibody, designated WM-65, reacted with over 95% of peripheral blood, tonsil and thymic lymphocytes, and with a similar proportion of monocytes and granulocytes. A majority of nucleated normal bone marrow cells were also reactive with WM-65; however, these included only a small proportion of myeloid progenitor cells. WM-65 reacted with a wide range of acute and chronic leukaemias of both myeloid and lymphoid types, and with corresponding cell lines, but did not react with non-haemopoietic cells. By immunoprecipitation and SDS-PAGE, WM-65 identifies a heavily glycosylated surface protein of molecular weight between 40 and 50 kD. This property, and the broad non-lineage-specific distribution of the antigen on haemopoietically-derived cells, indicates that WM-65 is different from other monoclonal antibodies with "leucocyte common" reactivity patterns. The extensive reactivity of WM-65 with leukaemic cells raises the possibility of therapeutic applications of the antibody in haematological malignancies.

B lymphocyte/carcinoma antigen (BLCa): functional study in B cells

BLCa is an antigen expressed on the surface of B lymphocytes and certain carcinomas. In this study we have demonstrated that BLCa is distinct from known B cell antigens classified by 'clusters of differentiation' (CD). In particular, the monoclonal antibody MA6, which identifies BLCa, can be distinguished from antibodies of the CDw40 group, which detect an antigen of similar molecular weight expressed also on B cells and certain carcinomas. The expression of BLCa on B cells was measured as tonsil B cells were activated (by anti-Ig and interleukin-4 (IL-4)), induced to proliferate (by low molecular weight B Cell Growth Factor (LMW-BCGF), and induced to differentiate (by B Cell Differentiation Factor, BCDF). Expression of BLCa increased in response to LMW-BCGF. The effect of inclusion of MA6 antibody in cultures with the B cell stimuli was also investigated. MA6 showed an anti-proliferative effect which was antibody-dose dependent, but did not otherwise inhibit or co-operate with anti-Ig. IL-4, LMW-BCGF or BCDF.

Acquired hypoprothrombinemia due to non-neutralizing antibodies to prothrombin: mechanism and management

A patient developed bleeding due to an acute acquired specific prothrombin deficiency. Unlike previously described patients, this patient had no evidence of an associated lupus anticoagulant. Prothrombin activity and antigen were decreased concordantly and the patient's plasma did not neutralize the activity of added prothrombin or interfere with its measurement by electroimmunoassay. Nevertheless, immunoelectrophoresis and experiments using 125I-prothrombin revealed a prothrombin-binding antibody. The residual prothrombin in the patient's plasma was in the form of a prothrombin-antibody complex. Administration of adrenal corticosteroids was associated with a rise in prothrombin activity and cessation of bleeding, but circulating prothrombin was still bound to the antibody. This suggests that non-neutralizing antibodies to prothrombin cause plasma prothrombin deficiency because of a rapid clearance of prothrombin-antibody complexes, which is slowed by adrenal corticosteroids. The antibody had a relatively low affinity for prothrombin (Kd 5 to 8 X 10(-7)) and was transient. It is possible, therefore, that the antibody arose not to prothrombin itself, but to an antigen sharing an epitope with prothrombin.

Psychosocial impact of craniofacial deformities before and after reconstructive surgery

Pre- and post-operative body image, self-confidence and individual and family adjustment were compared in 250 patients (aged 6 weeks to 39 years) with severe craniofacial deformities. Major congenital deformities of genetic or idiopathic etiology were present in 178 patients and 72 had tumours or other late-onset deformities. The patients and/or parents were interviewed by a child psychiatrist and a social worker as part of the routine pre-operative assessment. In addition to a semistructured interview protocol, the patients and parents were asked to rate the deformity according to Hay's Scale and, when appropriate, to complete the Piers-Harris Self-esteem Inventory. One and two year post-operative reevaluations followed the same protocol. The results indicated that the age of the patient, pre-operative expectations and origin of the decision for surgery (particularly in adolescents) are the most significant predictive factors of post-operative psychosocial improvement.