Risk factors of persistent adolescent thinness: findings from the UK Millennium Cohort Study

BACKGROUND

Thinness during adolescence can increase the risk of adverse health outcomes across the life-course and impede development. There is limited research examining the prevalence and determinants of persistent adolescent thinness in the United Kingdom (UK). We used longitudinal cohort data to investigate determinants of persistent adolescent thinness.

METHODS

We analyzed data from 7,740 participants in the UK Millennium Cohort Study at ages 9 months, 7, 11, 14 and 17 years. Persistent thinness was defined as thinness at ages 11, 14 and 17; thinness was defined as an age- and sex-adjusted Body Mass Index (BMI) of less than 18.5 kg/m². In total, 4,036 participants, classified either as persistently thin or at a persistent healthy weight, were included in the analyses. Logistic regression analyses were conducted to examine associations between 16 risk factors and persistent adolescent thinness by sex.

RESULTS

The prevalence of persistent thinness among adolescents was 3.1% (n = 231). Among males (n = 115), persistent adolescent thinness was significantly associated with non-white ethnicity, low parental BMI, low birthweight, low breastfeeding duration, unintended pregnancy, and low maternal education. Among females (n = 116), persistent adolescent thinness was significantly associated with non-white ethnicity, low birthweight, low self-esteem, and low physical activity. However, after adjusting for all risk factors, only low maternal BMI (OR: 3.44; 95% CI:1.13, 10.5), low paternal BMI (OR: 22.2; 95% CI: 2.35, 209.6), unintended pregnancy (OR: 2.49; 95% CI: 1.11, 5.57) and low self-esteem (OR: 6.57; 95% CI: 1.46,29.7) remained significantly associated with persistent adolescent thinness among males. After adjustment for all risk factors, not reaching the recommended physical activity levels (OR: 4.22; 95% CI: 1.82, 9.75) remained significantly associated with persistent adolescent thinness among females. No appreciable associations were found between persistent adolescent thinness and sex, premature birth, smoking during pregnancy, income, maternal postnatal depression, mother-infant attachment or socio-emotional difficulties (p > 0.05).

CONCLUSION

Persistent adolescent thinness is not rare and appears to be associated with both physical and mental health factors, with some sex specific differences. Healthy weight initiatives should consider the full weight spectrum. Further research is required to understand thinness at a population level, including among those whose BMI changes during child and adolescent development.

Internalized weight bias in the relationship between mental health and obesity in UK adolescents

Background

It is crucial to promote mental and physical health during adolescence to protect against lifetime risks of mental health problems and obesity. Internalized weight bias (self-directed stigmatizing attitudes about perceived weight status) and bullying are implicated as potential mechanisms in the relationship between mental health and obesity in adolescence. We examined internalized weight bias and bullying as potential mediators of the relationship between mental health and weight status across adolescence in the United Kingdom (UK).

Methods

We analysed data on 8,688 adolescents from the UK Millennium Cohort Study. Weight status was defined using sex and age specific International Obesity Taskforce cut points for body-mass index (not overweight/obese; overweight; obese) at 11 and 17 years. Mental health was defined using parental reported emotional (anxiety and depression), and externalizing (aggression and impulsivity) symptoms at 11 and 17 years (low; moderate; high). Self-reported measures of internalized weight bias captured via body-dissatisfaction and self-esteem and bullying at 14 years were tested as mediators. We used Generalized Structural Equation Models to examine longitudinal pathways between weight status and mental health across 11 and 17 years, whilst accounting for concurrent associations and potential confounders.

Results

Adolescents with high emotional (relative risk (RR) 1.98, 95% CI 1.28 to 3.07) or externalizing symptoms (RR 2.07, 95% CI 1.23 to 3.48) at 11 years were twice as likely to be obese at 17 years compared with those who had low symptoms. The impact of emotional and externalizing symptoms on weight status was found to be partially attributable to internalized weight bias, but not bullying, with significant mediation for body-dissatisfaction and low self-esteem.

Conclusions

Internalized weight bias partially explains the relationship between mental health and weight status across adolescence.

Key messages

There is a need for a holistic, early prevention strategy to focus on reducing weight stigma to encourage healthy mental and physical development of children. The relationship between mental health and weight status across adolescence is partly attributable to internalized weight bias.

Occurrence of pulsus alternans during anaesthesia of two dogs and one cat and its treatment

The authors report the occurrence of pulsus alternans, a condition characterised by the alternance of pulses of higher and lower amplitude, in two dogs and one cat under general anaesthesia. The presence of an underlying cardiac disease was confirmed in the cat but not in either dog, which - based on history and clinical findings - had presumably normal cardiovascular function before the anaesthetic. Possible mechanisms, including negative inotropy and haemodynamic and Frank-Starling effects, as well as the role of general anaesthesia as the potential triggering factor, are discussed in this report. Ephedrine resulted in the successful treatment of pulsus alternans, as demonstrated by the return of normal pulse and synchronisation of heart and pulse rates in the cat and in one dog. In the other dog, pulse pattern and frequency returned to normal once the guidewire for central line placement was withdrawn.

Childhood risk factors for lifetime bulimic or compulsive eating by age 30 years in a British national birth cohort

OBJECTIVE

To examine whether previously identified childhood risk factors for bulimia or compulsive eating (BCE) predict self-reported lifetime BCE by age 30 years in a prospective birth cohort.

METHOD

Using data from the 1970 British Cohort Study at birth, 5, and 10 years, associations between 22 putative childhood risk factors and self-reported lifetime BCE at 30 years were examined, adjusting for sex and socioeconomic status.

RESULTS

Only female sex (odds ratio (OR): 9.2; 95% confidence interval (CI): 1.9-43.7; p = 0.005), low self-esteem (OR:2.9; 95%CI: 1.1-7.5; p = 0.03) and high maternal education (OR:5.4; 95%CI: 2.0-14.8; p = 0.001) were significantly associated with higher risk of BCE, whereas high SES at 10 years was significantly protective (OR:0.2; 95%CI: 0.1-0.8; p = 0.022) of BCE in fully adjusted multivariable logistic regression analysis.

DISCUSSION

Our findings do not support a strong role for childhood weight status and eating behaviours in the development of bulimia and compulsive eating pathology, rather suggesting a focus on self esteem may have greater relative importance. Findings in relation to maternal education and SES need further exploration.

Systematic review of psychological and social outcomes of adolescents undergoing bariatric surgery, and predictors of success

The psychological and social outcomes of bariatric surgery in adolescents, together with psychological and social predictors of success, were systematically reviewed. PubMed, EMBASE, ISI Web of Science and PsychInfo were searched on July 2014. Existing data were sparse; 15 were suitable for qualitative review and six for meta-analysis (four quality of life [QOL], two depression). One study was a randomized controlled trial. A total of 139 subjects underwent Roux-en-Y gastric bypass, 202 underwent adjustable gastric band and 64 underwent sleeve gastrectomy. Overall QOL improved after bariatric surgery, regardless of surgical type with peak improvement at 6-12 months. Meta-analysis of four studies showed changed in overall QOL at latest follow-up of 2.80 standard deviation (SD) (95% confidence interval [CI] 1.23-4.37). Depression improved across all studies, regardless of procedure (effect size -0.47 SD [95% CI -0.76, -0.18] at 4-6 months). Two cohorts reported changes in both overall QOL and depression following a quadratic trajectory, with overall improvement over 2 years and deterioration in the second post-operative year. There were limited data on other psychological and social outcomes. There were insufficient data on psychosocial predictors of outcome to form evidence-based recommendations for patient selection for bariatric surgery at this time.

Body composition in young female eating-disorder patients with severe weight loss and controls: evidence from the four-component model and evaluation of DXA

Background/Objectives:

Whether fat-free mass (FFM) and its components are depleted in eating-disorder (ED) patients is uncertain. Dual energy X-ray absorptiometry (DXA) is widely used to assess body composition in pediatric ED patients; however, its accuracy in underweight populations remains unknown. We aimed (1) to assess body composition of young females with ED involving substantial weight loss, relative to healthy controls using the four-component (4C) model, and (2) to explore the validity of DXA body composition assessment in ED patients.

Subjects/Methods:

Body composition of 13 females with ED and 117 controls, aged 10–18 years, was investigated using the 4C model. Accuracy of DXA for estimation of FFM and fat mass (FM) was tested using the approach of Bland and Altman.

Results:

Adjusting for age, height and pubertal stage, ED patients had significantly lower whole-body FM, FFM, protein mass (PM) and mineral mass (MM) compared with controls. Trunk and limb FM and limb lean soft tissue were significantly lower in ED patients. However, no significant difference in the hydration of FFM was detected. Compared with the 4C model, DXA overestimated FM by 5±36% and underestimated FFM by 1±9% in ED patients.

Conclusion:

Our study confirms that ED patients are depleted not only in FM but also in FFM, PM and MM. DXA has limitations for estimating body composition in individual young female ED patients.

Inferior epigastric artery false aneurysm following incisional hernia repair

INTRODUCTION

We report a case of IEA false aneurysm following a mesh repair of a large incisional hernia. We emphasize the importance to consider the diagnosis to help avoid inappropriate interventions which could increase patient morbidity.

CASE REPORT

A 68-year-old male patient, who 4 weeks previously had had a mesh repair of a large incisional hernia, presented with a painful left iliac fossa swelling. This was found to be an IEA false aneurysm. This was treated successfully with percutaneous thrombin injection.

CONCLUSIONS

We feel an inferior epigastric artery false aneurysm must be included in the differential diagnosis when investigating the cause of any lateral swelling following incisional hernia repair. This would help reduce the chance of a missed diagnosis and avoid any inappropriate interventions which may cause increased patient morbidity.

Family-based behavioural treatment of childhood obesity in a UK National Health Service setting: randomized controlled trial

Background

The best outcomes for treating childhood obesity have come from comprehensive family-based programmes. However there are questions over their generalisability.

Objective

To examine the acceptability and effectiveness of ‘family-based behavioural treatment’ (FBBT) for childhood obesity in an ethnically and socially diverse sample of families in a UK National Health Service (NHS) setting.

Methods

In this parallel group, randomised controlled trial, 72 obese children were randomised to FBBT or waiting list control. Primary outcomes were body mass index (BMI) and BMI standard deviation scores (SDS). Secondary outcomes were weight, weight SDS, height, height SDS, waist, waist SDS, fat mass index, fat free mass index, blood pressure, and psychosocial measures. Outcomes were assessed at baseline and post-treatment, with analyses on the 6 month data done on an intent-to-treat (ITT) basis. Follow-up anthropometric data were collected at twelve months for the treatment group.

Results

ITT analyses included all children with baseline data (n=60). There were significant BMI SDS changes (p<0.01) for the treatment and control groups of −0.11 (0.16) and −0.10 (1.6). The treatment group showed a significant reduction in systolic blood pressure (−0.24 (0.7), p<0.05) and improvements in quality of life and eating attitudes (p<0.05), with no significant changes for the control group. However the between-group treatment effects for BMI, body composition, blood pressure and psychosocial outcomes were not significant. There was no overall change in BMI or BMI SDS from 0-12 months for the treatment group. No adverse effects were reported.

Conclusions

Both treatment and control groups experienced significant reductions in level of overweight, but with no significant difference between them. There were no significant group differences for any of the secondary outcomes.

A diagnostic system using broad categories with clinically relevant specifiers: lessons for ICD-11

A diagnostic system for ICD-11 is proposed which commences with broad reorganization and simplification of the current categories and the use of clinically relevant specifiers. Such changes have implications for the positioning of diagnostic groups and lead to a range of possibilities for improving terminology and the juxtaposition of individual conditions. The development of ICD-11 provides the fi rst opportunity in almost two decades to improve the validity and reliability of the international classification system. Widespread change in broad categories and criteria cannot be justified by research that has emerged since the last revision. It would also be disruptive to clinical practice and might devalue past research work. However, the case for reorganization of the categories is stronger and has recently been made by an eminent international group of researchers (Andrews et al., 2009). A simpler, interlinked diagnostic system is proposed here which is likely to have fewer categories than its predecessor. There are major advantages of such a system for clinical practice and research and it could also produce much needed simplification for primary care (Gask et al., 2008) and the developing world (Wig, 1990; Kohn et al., 2004).

Classification of eating disturbance in children and adolescents: proposed changes for the DSM-V

Childhood and adolescence are critical periods of neural development and physical growth. The malnutrition and related medical complications resulting from eating disorders such as anorexia nervosa (AN), bulimia nervosa (BN) and eating disorder not otherwise specified may have more severe and potentially more protracted consequences during youth than during other age periods. The consensus opinion of an international workgroup of experts on the diagnosis and treatment of child and adolescent eating disorders is that (a) lower and more developmentally sensitive thresholds of symptom severity (e.g. lower frequency of purging behaviours, significant deviations from growth curves as indicators of clinical severity) be used as diagnostic boundaries for children and adolescents, (b) behavioural indicators of psychological features of eating disorders be considered even in the absence of direct self-report of such symptoms and (c) multiple informants (e.g. parents) be used to ascertain symptom profiles. Collectively, these recommendations will permit earlier identification and intervention to prevent the exacerbation of eating disorder symptoms.

Classification of child and adolescent eating disturbances. Workgroup for Classification of Eating Disorders in Children and Adolescents (WCEDCA)

OBJECTIVE

: The purpose of this article is to summarize major conceptual and clinical variables related to age-appropriate and developmentally appropriate classification of eating problems and disorders in children and adolescents.

METHOD

A review of current classifications and related literature in child development is provided. Problems with current classification schemes are identified and discussed.

RESULTS

Current classifications are inadequate to address the clinical and research needs of children and adolescents with eating disturbances and disorders.

CONCLUSION

A range of possible changes in classification strategies for eating disorders in children and adolescents are described.

Family-based behavioural treatment of obesity: acceptability and effectiveness in the UK

OBJECTIVE

To assess the acceptability and impact of family-based behavioural treatment (FBBT) for childhood obesity in a clinical setting in the UK.

DESIGN

Pre- and post-treatment assessment for four consecutive treatment groups.

SETTING

Treatment groups took place at Great Ormond Street Hospital, London.

PATIENTS

Participants were 33 families with obese (BMI >or=98th centile for age and sex) children aged 8-13 years.

INTERVENTION

FBBT was delivered over 12 sessions.

MAIN OUTCOME MEASURES

Overweight (percentage BMI), self-esteem, mood and eating attitudes were assessed before and after treatment; overweight was re-assessed at 3-month follow-up for those who completed treatment.

RESULTS

The FBBT programme materials translated easily to the UK setting and the programme was well-liked by participants. Twenty-seven out of 33 families (82%) completed the sessions. Children lost 8.4% BMI over the time of treatment, and this was maintained at 3-month follow-up. Self-esteem and depression improved significantly and there was no change in food pre-occupation, anorexia or bulimia on the ChEAT.

CONCLUSIONS

These results establish that FBBT is feasible and acceptable in a clinical setting in Britain. They indicate that significant loss of overweight can be achieved using the programme without adverse psychological consequences.

Managing obesity in secondary care: a personal practice

Obesity is becoming a common clinical headache for child health professionals, as the increase in professional and media concern has not been matched by effective clinical solutions. Added to this is considerable confusion about both the definitions of obesity and about which groups of children and adolescents actually require treatment. Little guidance exists for paediatricians and other child health specialists on the assessment and management of child and adolescent obesity. Guidelines produced by the American Academy of Pediatrics (AAP) are useful, but require modification for non-American clinical practice. In the UK, the Royal College of Paediatrics and Child Health has recently issued excellent brief guidance on managing obesity in primary care, as has the Scottish Intercollegiate Guidelines Network.

Validation of the Dutch Eating Behaviour Questionnaire parent version (DEBQ-P) in the Italian population: a screening tool to detect differences in eating behaviour among obese, overweight and normal-weight preadolescents

OBJECTIVE

To validate the Dutch Eating Behaviour Questionnaire Parent version (DEBQ-P) in the Italian population and investigate the differences in eating behaviour among Italian normal-weight, overweight and obese preadolescents.

DESIGN

A cross-sectional validation study. Participants were measured and the approved translation of the questionnaire was administered to their parents.

SETTING

: Three school communities in the province of Bergamo, Northern Italy.

SUBJECTS

A total of 312 preadolescents (mean age 12.9 y; s.d. 0.8, both sexes) from three secondary schools of the province of Bergamo, Northern Italy, and their parents were invited to participate to the study. Informed written consent was obtained from each subject and their parents. Students were measured and their parents filled in the approved translation of the DEBQ-P. Recruitment was opportunistic and school based.

RESULTS

Factor and internal consistency analysis confirmed the factor structure of the DEBQ-P and the high internal consistency of its three scales. Variance analysis showed that eating behaviour of Italian normal-weight, overweight and obese preadolescents differs significantly only in regards to the 'restrained eating' scale (F 19.29, P < 0.001), with overweight and obese scoring higher.

CONCLUSIONS

The DEBQ-P can be used for screening projects regarding eating behaviour in the Italian population. The association between restrained eating and weight status was confirmed for both sexes, but the relationship between external eating and emotional overeating and overweight requires further exploration.

Ciclopiroxolamine cream for treating seborrheic dermatitis: a double-blind parallel group comparison

BACKGROUND

The aim of this study was to compare the efficacy and tolerability of topically applied ciclopiroxolamine cream with that of the corresponding vehicle in patients with seborrheic dermatitis of the face.

PATIENTS AND METHODS

The study was conducted as a multicenter prospective, randomized, double-blind parallel group comparison at 14 centers in Australia and New Zealand. 189 patients with clinically diagnosed seborrheic dermatitis participated in the study. Each patient applied ciclopiroxolamine 1% cream or the corresponding vehicle twice daily as a thin film to the affected skin areas and to clinically unaffected skin areas surrounding the lesions for 29 days.

RESULTS

The rate of treatment success was significantly higher with ciclopiroxolamine than with vehicle (73.9 vs 53.6%; p = 0.003). Treatment with ciclopiroxolamine reduced the sum score of the clinical signs of seborrheic dermatitis to a greater extent than the vehicle (p </= 0.001).

CONCLUSION

This study confirms that topical treatment with ciclopiroxolamine is effective and well tolerated in patients with seborrheic dermatitis.

Body composition in early onset eating disorders

BACKGROUND

Body mass index (BMI) or equivalent weight for height indices are the most widely used measures of body composition in early onset and adolescent eating disorders. Although of value as screening instruments the limitation in disease states is their inability to discriminate fat and fat-free components of body weight.

OBJECTIVE

To compare height-adjusted fat and fat-free components of body composition in children and young adolescents with different types of eating disorders with those of age matched reference children.

DESIGN

Weight, height, triceps and subscapular skinfold thickness were measured in 172 children (aged 7-16 y) with eating disorders receiving specialist treatment. Fat mass index (FMI) and fat-free mass index (FFMI) were calculated using Slaughter's and Deurenberg's equations and normalisation for height. Using data from 157 normal children, representative of the UK 1990 growth reference data, reference curves for FMI and FFMI+/-2 s.d. were derived. Results for patient groups were superimposed on these reference curves.

RESULTS

FMI and FFMI were both reduced in eating disorders associated with malnutrition, including anorexia nervosa (AN). AN subjects did not differ from other subjects with comparable degrees of malnutrition. Children with eating disorders of normal weight, such as bulimia nervosa and selective eating, did not differ significantly from reference children in their relative FM and FFM.

CONCLUSIONS

FM and FFM merit independent consideration in disorders of malnutrition in children, rather than expressing data as percentage body fat or percentage BMI. The implications of loss of FFM on growth and development merit further investigation.

Takayasu arteritis and atherosclerosis: illustrating the consequences of endothelial damage

The excess of cardiovascular morbidity associated with chronic vasculitic disease has become a focus of considerable research, particularly regarding the link between endothelial damage and the development of atherosclerosis. We describe a case of Takayasu arteritis treated sub-optimally by today's standards, giving rise to an 11 year history of progressive, stepwise decline associated with cerebrovascular events and leading to early death. Postmortem findings presented a picture of chronic atherosclerotic disease but in a distribution consistent with lesions of Takayasu arteritis.

Children into DSM don't go: a comparison of classification systems for eating disorders in childhood and early adolescence

OBJECTIVE

To evaluate the reliability of diagnostic classification systems for eating disorders when applied to children and young adolescents.

METHOD

Eighty-one patients were randomly selected from a population of 226 children (age 7-16) presenting with eating difficulties to a specialist clinic. Diagnoses were assigned according to three classification systems: the 10th edition of the International Classification of Diseases (ICD 10), the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), and Great Ormond Street (GOS) criteria. Ratings were performed by two clinicians blind to the diagnosis of the other.

RESULTS

Interrater reliability values (kappa) for the three systems were 0.357 (ICD 10), 0.636 (DSM-IV), and 0.879 (GOS). Using DSM criteria, more than 50% of children were classified as eating disorder not otherwise classified (EDNOS) or could not be classified.

DISCUSSION

DSM-IV and ICD 10 criteria are of little value in the classification of the eating difficulties of children. The GOS criteria, which were developed for this age range, are more reliable. The classification of eating disorders in childhood needs reevaluation.

Transcription pattern of a FIM homologue in Impatiens during floral development and reversion

Flowering and reversion in Impatiens are characterised by gradual transitions of organ identity and constitute a unique system for the molecular and physiological study of floral organogenesis. The authors have isolated an Impatiens homologue of the FIM gene of Antirrhinum (UFO in Arabidopsis), Imp-FIM, and analysed its expression in three states of the terminal meristem: vegetative, floral, and reverted. In floral meristems, Imp-FIM transcription is associated with petal identity, as in Antirrhinum and Arabidopsis, but this is achieved through a novel transcription pattern, characterised by a high level of transcript within petal primordia. This novel transcription pattern could contribute to the more diffuse boundaries between organ types in Impatiens. In vegetative meristems, Imp-FIM is expressed in the axils of leaf primordia which are arranged in a spiral. A similar pattern is observed in reverted meristems in which leaf primordia are initiated in a whorled arrangement. This result indicates that the maintenance of floral phyllotaxis is not associated with a specific pattern of Imp-FIM transcription. Transcription of Imp-FIM in a non-reverting line is no different from that in the reverting line. Therefore, the lack of floral commitment in the reverting line does not seem to be responsible for Imp-FIM transcription within petals. The novel transcription pattern in petals, together with features of Impatiens that are reminiscent of fim and ufo mutant phenotypes suggest an evolutionary divergence for Imp-FIM regulation in this species.

A pilot study of needs assessment in acute psychiatric inpatients

The needs of acute psychiatric patients have been less studied than those of long-term patients. A pilot study of needs assessment using the MRC Needs for Care Assessment Schedule is reported in 35 consecutive acute inpatients who had been in hospital for 1 month or more. Unmet clinical needs included treatment of drug side effects and dangerous and socially embarrassing behaviour. Unmet social needs were widespread and included household shopping, cooking meals, occupation and money management. Although the MRC Needs for Care Assessment was found unsuitable for assessing needs in very acutely ill patients whose mental status was rapidly changing, we did find it a useful instrument in more stable acute patients, both on an individual basis and for identifying service underprovision.

The induction and maintenance of flowering in Impatiens

The mechanisms that establish the floral meristem are now becoming clearer, but the way in which flowering is maintained is less well understood. Impatiens balsamina provides a unique opportunity to address this question because reversion to vegetative growth can be obtained in a predictable way by transferring plants from inductive to non-inductive conditions. Following increasing amounts of induction, reversion takes place at progressively later stages of flower development. Partial flower induction and defoliation experiments show that a floral signal is produced in the cotyledon in response to inductive conditions and that this signal progressively diminishes after transfer to non-inductive conditions, during reversion. Therefore reversion in Impatiens is most likely due to the failure of leaves to become permanent sources of inductive signal in addition to the lack of meristem commitment to flowering. Analysis of the expression of the Impatiens homologues of the meristem identity genes floricaula and squamosa indicates that a change in floricaula transcription is not associated with the establishment or maintenance of the floral meristem in this species. Squamosa transcription is associated with floral development and petal initiation, and is maintained in existing petal or petaloid primordia even after the meristem has reverted. However, it is not expressed in the reverted meristem, in which leaves are initiated in whorled phyllotaxis and without axillary meristems, both characteristics usually associated with the floral meristem. These observations show that squamosa expression is not needed for the maintenance of these floral characters. The requirement for the production of the floral signal in the leaf during the process of flower development may reflect an additional function separate to that of squamosa activation; alternatively the signal may be required to ensure continued transcriptional activation in the meristem.

A study of general practitioners' skin surgery in Canterbury

AIMS

To evaluate skin surgery done by general practitioners in Christchurch.

METHODS

Twenty-eight general practitioners performing regular skin surgery were studied. Their clinical accuracy and completeness of excision was analysed. Skin lesions referred for specialist treatment were also studied.

RESULTS

Three hundred and three lesions were sent to the laboratory for analysis by participating practitioners. Sixty-one malignancies were present comprising 29 basal cell carcinomas, 28 squamous cell carcinomas, three malignant melanomas and one cutaneous lymphoma. Nineteen of the 61 malignant lesions were incompletely excised. Twenty eight further lesions were referred to specialists for treatment.

CONCLUSIONS

General practitioners in Canterbury perform more skin surgery and remove more malignant lesions than their British counterparts. Although the adequacy of their skin surgery is better than other groups studied overseas there is considerable room for improvement.

The development of Ca2+ channel responses and their coupling to exocytosis in cultured cerebellar granule cells

Using single-cell imaging, we investigated developmental changes in the modulation of KCl-evoked Ca2+ entry by various voltage-dependent Ca2+ channels and the coupling of these channels to exocytosis in cultured cerebellar granule neurons. A component of the KCl-evoked Ca2+ elevation sensitive to nifedipine and localized at cell somata, decreases with culture age. A component blocked by 200 nM omega-Agatoxin-IVA increases with age and whilst localized primarily at the cell somata, also becomes evident at the neurites. The change in activity between nifedipine-sensitive Ca2+ channels and omega-Agatoxin-IVA-sensitive Ca2+ channels occurs at 13 days in vitro at cell somata. A component of Ca2+ entry insensitive to nifedipine and 200 nM omega-Agatoxin-IVA is localized primarily at the neurites and is apparent at all ages. Single-cell imaging of exocytosis using FM1-43 destaining indicates that the residual, but not the nifedipine- or omega-Agatoxin-IVA-sensitive components of Ca2+ entry, modulates exocytosis. However cells cultured for 20-26 days develop a component of Ca2+ entry at the neurites which is sensitive to 200 nM omega-Agatoxin-IVA and omega-Conotoxin-MVIIC and which partially controls release. Immunolocalization studies reveal that binding sites for omega-Conotoxin-GVIA are present throughout development, even though this toxin does not inhibit KCl-evoked [Ca2+]c elevations or exocytosis. 300 nM omega-Agatoxin-IVA labels both somata and, at later developmental stages, neurites, consistent with the functional studies.

The incidence of deep venous thrombosis after laparoscopic cholecystectomy

OBJECTIVE

To determine the incidence of deep venous thrombosis (DVT) after laparoscopic cholecystectomy.

DESIGN

Prospective cross-sectional analysis, with a one-month follow-up, conducted in 1994.

SETTING

University teaching hospital.

SUBJECTS

20 patients undergoing elective or urgent laparoscopic cholecystectomy, consecutively recruited.

INTERVENTIONS

Patients received thromboprophylaxis according to the normal practice of the attending surgeon and underwent laparoscopic cholecystectomy. A venous duplex scan was performed before the operation and on Day 1, 7 and 30 after the operation.

MAIN OUTCOME MEASURE

The presence of postoperative DVT.

RESULTS

All patients were given graduated compression stockings to wear and 16 received electrical stimulation of the calf during the operation. Only 16 patients received pharmacological thromboprophylaxis before the operation, but all patients received this after the operation. The median duration of pneumoperitoneum was 80 minutes (40-160 minutes). Eleven of 19 patients completing all the required scans developed venous thrombosis (incidence, 55%); in three the thromboses involved major axial veins. In one patient the Day 7 and Day 30 scans were not performed, but the Day 1 scan was negative. Seven of the 11 thromboses were detected on the Day 1 scan. None of the DVTs were suspected clinically.

CONCLUSIONS

This extremely high incidence of venous thrombosis correlates with the haemodynamic changes which occur in the venous system during pneumoperitoneum. Laparoscopic cholecystectomy should not be considered a procedure with a low risk of DVT, and further studies are needed to determine optimal DVT prophylaxis for laparoscopic surgery.

Medicinal azides. Part 8. The in vitro metabolism of p-substituted phenyl azides

1. A series of p-substituted aromatic azides was synthesized and their metabolism investigated in suspensions of mouse liver microsomes and mouse hepatocytes. Metabolite analysis was performed by h.p.l.c. 2. On incubation with microsomes under anaerobic conditions p-nitro, p-cyano- and p-chlorophenyl azide afforded metabolites which co-chromatographed with the respective aromatic amines. The rate at which p-nitrophenyl azide was metabolically reduced was approximately 20-fold that observed for p-cyano- and p-chlorophenyl azide. 3. Phenyl azide, p-methoxyphenyl azide and the aliphatic congener, phenethyl azide, did not furnish detectable amounts of metabolites on incubation with microsomes under anaerobic conditions. When phenyl azide and p-methoxyphenyl azide were incubated with hepatocytes or microsomes under aerobic conditions the resulting chromatograms furnished peaks which co-eluted with authentic p-hydroxyphenyl azide. 4. The microsomal reduction of p-nitrophenyl azide was dependent upon the presence of viable microsomes and NADPH, and on the absence of oxygen above the incubation medium.

Multidisciplinary management of vascular access devices

Many problems associated with the use of vascular access devices (VADs) can be circumvented with an organized, systematic approach to management. This paper describes an approach that includes several key components: 1) A nurse coordinator of parenteral therapy (CPT) follows all patients with a VAD; records demographic and clinical data on an ongoing basis; monitors complications and outcomes; serves as a consultant for VAD-related questions; develops policies, procedures, and guidelines for catheter care; and oversees inservice nursing and basic patient education. 2) A data coordinator enters all data into a data base management system, compiles complication and other statistics on a periodic basis, and retrieves selected data for specific purposes. 3) A VAD Committee, composed of the above two individuals, a nurse epidemiologist, and physicians representing medical oncology, hematology, transplantation, pediatrics, and surgery, meets monthly to collectively evaluate and assign cause for complications, consider new products, and discuss policy changes regarding VADs. As a result of this multidisciplinary process, responsibility and accountability for VAD insertion and care are appropriately placed, statistics on complications are compiled, and treatment and policy decisions are made. These outcomes have resulted in a significant reduction in complications, an increase in average catheter life, enhancement of quality assurance, and overall improved patient care.

The release and uptake of excitatory amino acids

In this article, David Nicholls and David Attwell describe recent advances in our understanding of the mechanisms by which excitatory amino acids are released from cells, and of the way in which a low extracellular glutamate concentration is maintained. Glutamate can be released from cells by two mechanism: either by Ca2(+)-dependent vesicular release or, in pathological conditions, by reversal of the plasma membrane uptake carrier. The contrasting pharmacology and ionic dependence of the glutamate uptake carriers in the vesicle membrane and in the plasma membrane explain how glutamate (but probably not aspartate) can function as a neurotransmitter, and why the extracellular glutamate concentration rises to neurotoxic levels in brain anoxia.