Randomized Controlled Trial of Aerobic Exercise for Smoking Cessation Among Individuals With Elevated Depressive Symptoms

INTRODUCTION

Adults with depression have higher rates of cigarette smoking and are more likely to relapse than those without depression. Pharmacological, psychological, and combined interventions have largely yielded small improvements in smoking outcomes for adults with depression. Aerobic exercise (AE) may facilitate smoking cessation in this subpopulation.

METHODS

This study was a 12-week two-arm randomized controlled trial that evaluated the effect of a moderate-intensity AE program compared to a health education contact (HEC) control on smoking cessation in adults with elevated depressive symptoms (mild to severe). Participants (n = 231) were randomized to AE or HEC and received smoking cessation treatment (telephone counseling and nicotine replacement therapy). Primary (biologically confirmed 7-day point prevalence abstinence) and secondary (depressive symptoms, objective and self-reported physical activity, and cardiorespiratory fitness) outcomes were assessed at baseline, 3, 6, and 12 months. Data were analyzed with mixed-effects generalized linear models controlling for age, gender, nicotine dependence, history of major depression disorder, and month of follow-up assessment.

RESULTS

There were no significant differences in primary or secondary outcomes between the AE and HEC groups.

CONCLUSIONS

The AE program was not superior to HEC in facilitating smoking cessation, increases in physical activity, or improved depressive symptoms. Given evidence for the positive acute effects of exercise on mood and smoking urges, future research should consider testing alternative exercise approaches for aiding smoking cessation beyond structured, AE programs.

IMPLICATIONS

This study found that an adjunctive aerobic exercise (AE) program was not superior to a health education contact control for adults with elevated depressive symptoms, all of whom also received standard smoking cessation treatment. This finding adds to the growing body of literature that structured AE programs for smoking cessation may have limited efficacy for cessation outcomes. Future research is needed to test alternative methods of integrating AE into smoking cessation treatment, such as strategically using exercise to manage cravings and low mood in the moment.

Staging cancer of the uterus: a national audit of MRI accuracy

AIM

To report the results of a nationwide audit of the accuracy of magnetic resonance imaging (MRI) staging in uterine body cancer when staging myometrial invasion, cervical extension, and lymph node spread.

MATERIALS AND METHODS

All UK radiology departments were invited to participate using a web-based tool for submitting anonymized data for a 12 month period. MRI staging was compared with histopathological staging using target accuracies of 85, 86, and 70% respectively.

RESULTS

Of the departments performing MRI staging of endometrial cancer, 37/87 departments contributed. Targets for MRI staging were achieved for two of the three standards nationally with diagnostic accuracy for depth of myometrial invasion, 82%; for cervical extension, 90%; and for pelvic nodal involvement, 94%; the latter two being well above the targets. However, only 13/37 (35%) of individual centres met the target for assessing depth of myometrial invasion, 31/36 (86%) for cervical extension and 31/34 (91%) for pelvic nodal involvement. Statistical analysis demonstrated no significant difference for the use of intravenous contrast medium, but did show some evidence of increasing accuracy in assessment of depth of myometrial invasion with increasing caseload.

CONCLUSION

Overall performance in the UK was good, with only the target for assessment of depth of myometrial invasion not being met. Inter-departmental variation was seen. One factor that may improve performance in assessment of myometrial invasion is a higher caseload. No other clear factor to improve performance were identified.

Measuring the accuracy of diagnostic imaging in symptomatic breast patients: team and individual performance

OBJECTIVE

The combination of mammography and/or ultrasound remains the mainstay in current breast cancer diagnosis. The aims of this study were to evaluate the reliability of standard breast imaging and individual radiologist performance and to explore ways that this can be improved.

METHODS

A total of 16,603 separate assessment episodes were undertaken on 13,958 patients referred to a specialist symptomatic breast clinic over a 6 year period. Each mammogram and ultrasound was reported prospectively using a five-point reporting scale and compared with final outcome.

RESULTS

Mammographic sensitivity, specificity and receiver operating curve (ROC) area were 66.6%, 99.7% and 0.83, respectively. The sensitivity of mammography improved dramatically from 47.6 to 86.7% with increasing age. Overall ultrasound sensitivity, specificity and ROC area was 82.0%, 99.3% and 0.91, respectively. The sensitivity of ultrasound also improved dramatically with increasing age from 66.7 to 97.1%. Breast density also had a profound effect on imaging performance, with mammographic sensitivity falling from 90.1 to 45.9% and ultrasound sensitivity reducing from 95.2 to 72.0% with increasing breast density.

CONCLUSION

The sensitivity ranges widely between radiologists (53.1-74.1% for mammography and 67.1-87.0% for ultrasound). Reporting sensitivity was strongly correlated with radiologist experience. Those radiologists with less experience (and lower sensitivity) were relatively more likely to report a cancer as indeterminate/uncertain. To improve radiology reporting performance, the sensitivity of cancer reporting should be closely monitored; there should be regular feedback from needle biopsy results and discussion of reporting classification with colleagues.

One-stop diagnostic breast clinics: how often are breast cancers missed?

The aim of this study was to estimate the number of patients discharged from a symptomatic breast clinic who subsequently develop breast cancer and to determine how many of these cancers had been ‘missed’ at initial assessment. Over a 3-year period, 7004 patients were discharged with a nonmalignant diagnosis. Twenty-nine patients were subsequently diagnosed with breast cancer over the next 36 months. This equates to a symptomatic ‘interval’ cancer rate of 4.1 per 1000 women in the 36 months after initial assessment (0.9 per 1000 women within 12 months, 2.6 per 1000 women within 24 months). The lowest sensitivity of initial assessment was seen in patients of 40–49 years of age, and these patients present the greatest imaging and diagnostic challenge. Following multidisciplinary review, a consensus was reached on whether a cancer had been missed or not. No delay occurred in 10 patients (35%) and probably no delay in 7 patients (24%). Possible delay occurred in three patients (10%) and definite delay in diagnosis (i.e., a ‘missed’ cancer) occurred in only nine patients (31%). The overall diagnostic accuracy of ‘triple’ assessment is 99.6% and the ‘missed’ cancer rate is 1.7 per 1000 women discharged.

National audit of provision of MRI services 2006/07

In 2003 the Royal College of Radiologists Clinical Radiology Audit Sub-Committee began an audit process evaluating the standards of provision of magnetic resonance imaging (MRI) services. This was prompted by the publication of the 2002 Audit Commission Report, which had identified that lack of MRI provision was responsible for more than half of the total waiting times for diagnostic imaging investigations. The audit found that the time from request to report did not meet the standard for cancer staging examinations, but nationally, was within the target set for routine orthopaedic examinations. However, national mean waiting times were longer than recommended for both cancer and orthopaedic MRI. Since then, there has been massive investment in MRI capacity, both from installation of MRI systems in NHS Trusts, and in England, from outsourcing of routine MRI cases through the Department of Health contract with an independent provider. A re-audit in 2006/7 shows that there has been a significant improvement in waiting times for routine orthopaedic examinations, but the position with cancer staging examinations has deteriorated. Control chart methodology shows that underperformance is due to common cause variation, i.e., improvements need to be made to the overall process from receiving the request for MRI to the issue of the report. Follow-up with participating departments demonstrated there were some common themes for underperformance, and suggestions for improvement are made from departments with best performance.

The Service Review Committee: Royal College of Radiologists. Philosophy, role, and lessons to be learned

The Service Review Committee (SRC) was established by the Board of the Faculty of Clinical Radiology in 2000. At the time, the RCR identified a clear need to respond appropriately and swiftly to requests for review of service provision in clinical radiology departments where trusts were concerned about standards or performance issues. It was recognized by the College that the poorly performing radiologist is often part of a department that is itself dysfunctional, and that sub-optimal performance may often reflect inadequate management, lack of support, overwhelming workload, or inadequate facilities. Following the completion of a range of service reviews during its first 6 years, the SRC recognized that among the reviews there were recurring themes and causes for poorly functioning departments. The committee felt it appropriate to share these with the wider radiological community. In doing so, it is hoped that other departments may recognize their own problems at an early stage and take appropriate steps to prevent any escalation of difficulties.

Specificity of phosphatidylserine-containing membrane binding sites for factor VIII. Studies with model membranes supported by glass microspheres (lipospheres)

Factor VIII functions in an enzyme complex upon the activated platelet membrane where phosphatidylserine exposure correlates with expression of receptors for factor VIII. To evaluate the specificity of phosphatidylserine-containing membrane binding sites for factor VIII, we have developed a novel membrane model in which phospholipid bilayers are supported by glass microspheres (lipospheres). The binding of fluorescein-labeled factor VIII to lipospheres with membranes of 15% phosphatidylserine was equivalent to binding to phospholipid vesicles (KD = 4.8 nM). Purified von Willebrand factor (vWf), a carrier protein for factor VIII, decreased membrane binding of factor VIII with a Ki of 10 micrograms/ml. Likewise, normal plasma decreased bound factor VIII by more than 90% whereas plasma lacking vWf decreased the binding of factor VIII by only 20%. Proteolytic activation of factor VIII by thrombin, which releases factor VIII from vWf, increased liposphere binding in the presence of vWf and in the presence of normal plasma. Although factor V is homologous to factor VIII and binds to lipospheres with the same affinity, purified factor V was not an efficient competitor for the membrane binding sites of factor VIII. These results indicate that phosphatidylserine-containing membrane sites have sufficient specificity to select thrombin-activated factor VIII from the range of phospholipid-binding proteins in plasma.

Extended use of cranial CT in the evaluation of patients with stroke and transient ischaemic attacks

The hypothesis was explored that patterns of ischaemic brain damage shown by CT may be of greater value in estimating the relevance of angiographic stenosis in the carotico-vertebral arteries in some patients than presenting clinical features. Five angiographic and six CT abnormalities were defined and charted independently in a blinded manner in 312 patients whom clinical features and subsequent management were known. Charts were combined for statistical analysis. Statistically significant associations were found between two types of CT lesion and angiographic abnormalities, but these were present in only 18% of cases. The distribution of clinical features did not differ significantly within this subset compared to the whole population, from which it was concluded that the hypothesis was upheld. Furthermore significantly more patients in this subset were subjected to carotid endarterectomy, suggesting that management decisions may have been modulated by CT findings in some patients.

Relative safety of intravenous digital subtraction angiography over other methods of carotid angiography and impact on clinical management of cerebrovascular disease

Data from a multicentre survey based on three London teaching hospitals on the relative safety and clinical utility of intravenous carotid digital subtraction angiography (DSA) over intra-arterial DSA and conventional carotid angiography are presented. The incidence of stroke during intra-arterial DSA was 0.7% (n = 538) and during conventional angiography was 0.8% (n = 780). The incidence of stroke during intravenous DSA was zero (n = 3710). When it constituted the initial investigation, intravenous DSA achieved a 93.8% replacement value over intra-arterial studies as a whole (n = 474) and 89% replacement value for patients having carotid endarterectomy (n = 99). It was also noted that the installation of DSA equipment at one unit coincided with a sixfold increase in the number of carotid angiographic examinations and an almost threefold increase in carotid endarterectomies.

Radiology of sarcoidosis

This review of the radiology of sarcoidosis encompasses intrathoracic involvement, upper respiratory tract sarcoidosis, pleural disease, and involvement of bone, joint, neurological system, heart, kidney and alimentary tract. Attention is drawn to the value of CT scans, magnetic resonance imaging, gallium, and neutron activation analysis.

Magnetic resonance imaging in central nervous system sarcoidosis

We performed brain MRIs on 21 patients with CNS sarcoidosis. Brain CTs were performed in 18 of these. Parenchymal lesions were seen in 17 of 21 with MRI, compared with 9 of 18 with CT. MRI detected a greater number of parenchymal lesions in cases where both CT and MRI were positive, and some lesions appeared more extensive with MRI than with CT. The most common MRI pattern was one of periventricular and multifocal white matter lesions (14 cases). Such a pattern is not specific, and other recognized causes for it were identified in four cases. It is likely, however, that sarcoid tissue causes this pattern in some cases, and confirmation was obtained from cerebral biopsy in one. In six patients, the white matter changes were indistinguishable from those seen in multiple sclerosis. Contrast-enhanced CT in two patients showed diffuse meningeal involvement not seen with MRI. MRI is the investigation of choice in detecting parenchymal changes in the brain of patients with CNS sarcoidosis and may prove useful in monitoring treatment in such cases.

The radiology of AIDS

Radiology has an important role to play in the management of patients with AIDS. This article will illustrate the radiological aspects that are seen commonly in AIDS rather than cataloguing every conceivable X-ray abnormality that may be found. The aim has been to indicate those findings which are useful pointers in diagnosing the AIDS-related diseases and conditions.

Comparative cytotoxicity of aflatoxin B1 and saxitoxin in cell cultures

Human and animal cell cultures were evaluated for their susceptibility to two environmental toxins found as contaminants in human food supplies: aflatoxin B1, a hepatotoxin produced by the mold Aspergillus flavus, and saxitoxin, a paralytic neurotoxin produced by the marine dinoflagellate Gonyaulax catenella. Both toxins cause food poisoning in humans and other animals. The acute cytotoxicity of both toxins was measured and compared by inhibition of cell growth and by progressive cytopathogenicity resulting in cell destruction. Aflatoxin B1 was cytotoxic to all of the 11 primary kidney cultures derived from susceptible animals. The cell growth inhibition 10% values (TD10) ranged from 0.02 to 6.0 micrograms/ml: mouse (TD10 = 0.02 micrograms), guinea pig (0.03 micrograms), rat (0.07 micrograms), hamster (0.16 micrograms), monkey (0.1 microgram), human (0.7-1.5 micrograms), chick (0.05 micrograms), and duck (6.0 micrograms). The corresponding TD50 levels were about 10 times higher concentrations and caused cell destruction within 2 d. Saxitoxin did not induce cytotoxicity manifestations in cultures derived from susceptible species--mouse kidney, human carcinoma HeLa line, chick embryo, and goldfish fin (CAR) cell line--at high concentration levels up to 5 micrograms/ml. When the same toxin preparation at only 1 microgram was injected into mice, the animals died immediately. The results indicate that animal cell cultures are useful for studies of general cytotoxins that affect common essential metabolism but cannot be used to detect environmental toxins that cause toxic manifestations by an interference with specific physiological functions of organ systems.

Comparison of ultrasonography, computed tomography and 99mTc liver scan in diagnosis of Budd-Chiari syndrome

Ultrasonography, computed tomography and 99mTc liver scanning are all useful in diagnosis of patients with the Budd-Chiari syndrome. In a study to determine their comparative value characteristic findings were recorded in all nine patients at ultrasonography and in seven patients at computed tomography. In contrast 99mTc liver scan showed a characteristic pattern in only one of eight patients. In our experience intrahepatic venous abnormalities were seen better at ultrasonography than at computed tomography. In addition, abnormality in the direction of blood flow could be detected by pulsed Doppler examination. Ultrasonography is relatively inexpensive, readily accessible, does not require administration of radiation or contrast agents and therefore should be the primary non-invasive investigation of patients with Budd-Chiari syndrome, or those at risk of developing it.

Activated eosinophils in familial eosinophilic gastroenteritis

Two siblings with eosinophilic gastroenteritis who presented with severe iron deficiency anemia and hypoalbuminemia associated with varying degrees of mucosal damage are described. Using a monoclonal antibody to the secreted form of eosinophil cationic protein, we demonstrated activated degranulating eosinophils in the gastrointestinal mucosa that correlated with the degree of histologic damage. This finding suggests that eosinophils may have a primary role in the tissue damage in this condition. Oral disodium cromoglycate (Nalcrom) failed to alter the clinical, radiologic, and histologic abnormalities. Prednisolone, however, was beneficial in 1 case but did not completely reverse the abnormalities.

Polymorphonuclear and mononuclear leucocyte function in necrobiosis lipoidica and granuloma annulare

Neutrophils and monocytes from patients with necrobiosis lipoidica (NL) and granuloma annulare (GA) were studied in vitro in order to detect functional abnormality. Phagocytosis of latex particles and zymosan-induced release of beta-glucuronidase were similar in patients and controls. Plasma from these patients did not enhance or inhibit phagocytosis or enzyme release from normal cells. Our studies suggest that peripheral blood leucocyte function in patients with GA and NL is normal, but this does not exclude a functional abnormality in the lesions.

Sarcoidosis of the upper respiratory tract (SURT)

A series of eight hundred and eighteen patients with histologically-confirmed multisystem sarcoidosis was analysed; within this series were 53 (6 per cent) patients with sarcoidosis of the upper respiratory tract (SURT). Two-thirds presented with predominantly upper respiratory tract symptoms when the systemic disorder was minimal or unrecognized. Women were affected twice as often as men. SURT is commonly associated with lupus pernio and other manifestations of chronic fibrotic sarcoidosis, and it follows the same indolent course. When granulomas are found on biopsy of the upper respiratory tract, there should be a management plan to determine whether they are due to multisystem sarcoidosis or other granulomatous disorders including tuberculosis, Wegener's granulomatosis and leprosy. About one-half of patients with SURT will need oral steroids, either alone or in combination with topical steroids or chloroquine.

Serum alpha 2 globulin levels in granuloma annulare and necrobiosis lipoidica

Alpha 2-macroglobulin, caeruloplasmin and haptoglobin were measured in the sera of patients with necrobiosis lipoidica, granuloma annulare and diabetes. Alpha 2 Macroglobulin and caeruloplasmin were significantly raised in diabetes, and caeruloplasmin was raised in necrobiosis lipoidica without diabetes. The ratio of alpha 2-globulin to serum albumin was significantly high for all three proteins in diabetes, and for haptoglobin and caeruloplasmin in necrobiosis lipoidica. None of these proteins was abnormally raised in non-diabetic patients with granuloma annulare. There is good evidence that the plasma protein changes in diabetes contribute to the development of microangiopathy by their influence on blood viscosity. The altered plasma protein profile in necrobiosis lipoidica may therefore be of relevance to the development of the vascular lesions in this disorder.