The Impact of Modest Price Increases and Single Cigar Restrictions on Youth Cigar Use

INTRODUCTION

In 2011, Boston restricted cigar sales to packages of at least 4 cigars unless sold at a minimum of $2.50 per cigar. Nearly 200 localities in Massachusetts have since adopted policies establishing minimum pack quantities of 2-5 or minimum prices of $2.50-5.00 per cigar. The objective of this study was to examine the impact of these policies on youth cigar use.

METHODS

Biennial data from 1999 to 2019 were obtained from the Massachusetts Youth Risk Behavior Survey and analyzed in 2023. Final analytic samples included 15,674 youth for the Boston analyses and 35,674 youth for the statewide analyses. For Boston, change in use was examined from prepolicy (1999-2011) to postpolicy (2012-2019). For statewide analyses, the percentage of the state covered by a policy was estimated. Multivariable logistic regressions examined the impact of cigar policies on cigar and cigarette use. Analyses were adjusted for sociodemographic characteristics and stratified by sex and race.

RESULTS

Policy enactment was associated with significant decreases in the odds of cigar use in Boston (AOR: 0.28; 95% CI: 0.17-0.47) and statewide (AOR: 0.98; 95% CI: 0.98-0.99), with similar findings for cigarette use. Results were consistent among males and females statewide but only among males in Boston. By race statewide and in Boston, odds of cigar use decreased significantly among White, Black, and Hispanic youth, but not youth of other races.

CONCLUSIONS

These findings indicate small increases in the quantity and price of cigar packs could discourage young people from purchasing and using cigars, providing significant benefits for local tobacco control efforts.

Smartphone Apps Targeting Youth Tobacco Use Prevention and Cessation: An Assessment of Credibility and Quality

Purpose of Review

The goals of this study were to identify smartphone apps targeting youth tobacco use prevention and/or cessation discussed in the academic literature and/or available in the Apple App Store and to review and rate the credibility of the apps. We took a multiphase approach in a non-systematic review that involved conducting parallel literature and App Store searches, screening the returned literature and apps for inclusion, characterizing the studies and apps, and evaluating app quality using a standardized rating scale.

Recent Findings

The negative consequences of youth tobacco use initiation are profound and far-reaching. Half of the youth who use nicotine want to quit, but quit rates are low. The integration of smartphone apps shows promise in complementing and enhancing evidence-based youth tobacco prevention and treatment methods.

Summary

Consistent with prior reviews, we identified a disconnect between apps that are readily accessible and those that have an evidence base, and many popular apps received low quality scores. Findings suggest a need for better integration between evidence-based and popular, available apps targeting youth tobacco use.

A content review of state tobacco pre-emption laws in the US

OBJECTIVES

State ceiling pre-emption laws effectively limit the authority of local governments to regulate numerous public health issues, including tobacco. While general trends in the number of state tobacco pre-emption laws have been well-documented, less is known about the specific content of these laws. This study provides a comprehensive analysis of the content of current state tobacco pre-emption laws and captures the salient features of these laws.

STUDY DESIGN

This was a comparative analysis of tobacco pre-emption laws in the United States.

METHODS

The study team collected data about tobacco pre-emption laws from the Centers for Disease Control and Prevention's State Tobacco Activities Tracking and Evaluation System. Trained legal researchers further verified and reviewed each law's content using the Westlaw database. A coding scheme was developed to capture and analyse these laws' most salient features.

RESULTS

State tobacco pre-emption laws use various terms to indicate the pre-emption of a local authority, including supersede, pre-empt, uniform, exclusive, and consistent. State laws cover numerous general topics and vary widely in explicit terminology of authorities and fields pre-empted. Several state laws included grandfathering exceptions and a few allowed exceptions for particular local jurisdictions.

CONCLUSIONS

State laws that undermine local tobacco control efforts from implementing more stringent laws pose a threat to public health. These laws vary widely in their scope across the U.S., and local jurisdictions should be empowered to enact and maintain tobacco control measures that protect their communities from the harms of tobacco use and exposure.

Longitudinal analysis of cigar use patterns among US youth and adults, 2013-2019

BACKGROUND

Cigars are available in a range of pack quantities, which contrasts regulations requiring cigarettes to be sold in packs of 20 or greater. Smaller packages may be associated with increases in initiation while larger packs may lead consumers to smoke more. The purpose of this study was to inform pack quantity regulations by examining whether usual cigar pack quantity purchased was associated with use, initiation, and discontinuation among youth and adults for four cigar types: premium cigars, large cigars, cigarillos, and filtered cigars.

METHODS

We analyzed waves 1-5 (2013-2019) of the adult and waves 2-5 (2014-2019) of the youth Population Assessment of Tobacco and Health (PATH) Study. Samples included those responding to the item on pack quantity and providing data at all waves (adults: premium cigars [N = 536], large cigars [N = 1,272], cigarillos [N = 3,504], filtered cigars [N = 1,281]; youth: premium cigars [N = 55], large cigars [N = 217], cigarillos [N = 1514], filtered cigars [N = 266]). Generalized estimating equation models examined the population-averaged effects of pack quantity on cigar use, initiation, and discontinuation.

RESULTS

Adult pack quantity was positively associated with the days used per month for premium cigars (b: 0.23, 95% CI: 0.11, 0.34), large cigars (b: 0.17, 95% CI: 0.08, 0.25), cigarillos (b: 0.12, 95% CI: 0.003, 0.24), and filtered cigars (b: 0.07, 95% CI: 0.04, 0.10), and positively associated with amount smoked per day for all cigar types. Youth pack quantity was positively associated with days used per month for premium cigars (b: 0.88, 95% CI: 0.33, 1.43), large cigars (b: 0.79, 95% CI: 0.43, 1.15), and cigarillos (b: 0.17, 95% CI: 0.01, 0.34). Adult initiation was associated with pack quantity for filtered cigars (b: -2.22, 95% CI: -4.29, -0.13), as those who initiated purchased smaller pack quantities compared to those who did not initiate that wave. Pack quantity was not associated with discontinuation for adults or youth.

CONCLUSIONS

Cigar use increased as usual pack quantity purchased increased across cigar types for youth and adults. Small increases in pack quantity (e.g., one additional cigar) are likely to result in consuming less than one additional day per month, though larger increases (e.g., 10 additional cigars per pack) may result in greater use.

Loopholes for Underage Access in E-Cigarette Delivery Sales Laws, United States, 2022

Objectives. To comprehensively catalog and review state e-cigarette delivery sales laws as well as capture their scope and dimensions. Methods. We conducted an in-depth review to determine whether states had at least 1 form of e-cigarette delivery sales law. We coded laws for 5 key policy domains: (1) delivery terminology used in laws, (2) age verification requirements, (3) packaging label requirements, (4) permit or registration requirements, and (5) fines and penalties for violations. Results. Overall, 34 states had e-cigarette delivery sales laws with varying scopes and dimensions. In 27 states, these laws required at least 1 form of age verification requirements. We identified mandatory packaging labels in 12 states, and 7 states where permits were required. There were considerable differences among states on the scale of fines and penalties for violations. Conclusions. Our findings reveal extensive heterogeneity in e-cigarette delivery sales laws among states, particularly regarding the scope and dimensions of these laws. Public Health Implications. The mapping of e-cigarette delivery sales policies showed several potential loopholes that may diminish their effectiveness. (Am J Public Health. 2023;113(5):568-576. https://doi.org/10.2105/AJPH.2023.307228).

E-cigarette preemption laws: Limiting local communities from protecting youth

E-cigarette use is prevalent among youth in the United States. Historically, local communities have been a catalyst for adopting evidence-based tobacco control policies. However, some states have ceiling preemption laws that prevent more stringent statutes from being enacted at the city or county level and inhibit tobacco control efforts. The current study documents state preemption laws regarding e-cigarette advertising, licensure, indoor clean air, and youth access. We conducted a systematic synthesis of state statutes to identify states with e-cigarette preemption laws. Data were collected on four policy categories being preempted: advertising, licensure, clean indoor air, and youth access. Laws were compiled, and the content was verified using the Westlaw legal database. In the US, 25 states preempt stricter local e-cigarette regulations in 55 laws. Of these states, 19 preempt advertising regulations, 11 preempt licensure requirements, four preempt ordinances for indoor clean air, and 21 preempt youth access. A broad range of terms was employed to describe preemption, yet few states explicitly used the term "preempt." E-cigarette ceiling preemption laws inhibit public health progress and prevent local authorities from addressing the popularity of e-cigarettes among adolescents.States without preemption laws should be encouraged to adopt language that expressly saves local authority.

The impact of cigar pack size and pricing policies on youth and adult cigar use in the US

BACKGROUND

Over 250 US localities have adopted cigar pack quantity and price policies. No empirical studies exist on their impact on tobacco use.

METHODS

A quasi-experimental design was used to assess the impact of cigar policies on cigar and cigarette use among (1) Minnesota youth (n=569,528, triennially 2007-2019); (2) New York youth (n=111,236, annually 2000-2020), (3) New York adults (n=62,295, annually 2003-2019), and (4) District of Columbia (DC) adults (n=5027, annually 2015-2019). We estimated the county-level policy coverage for 15 local policies in Minnesota. Differences-in-differences approach was used to compare the policy in NYC with the rest of the state (no policy). We examined changes in DC use before and after policy implementation. Analyses adjust for sociodemographic characteristics.

RESULTS

In Minnesota, youth in counties with a greater proportion of the population covered by a policy had lower odds of cigar use (AOR: 0.51; 95% CI: 0.38-0.69). Similarly, adult cigar use in DC declined following policy enactment (AOR: 0.65; 95% CI: 0.46-0.93). Cigarette use also decreased in both Minnesota and DC following policy enactment. However, in New York, the NYC policy did not have a significant impact on cigar use among youth (AOR: 0.95; 95% CI: 0.47-1.93) or adults (AOR: 1.98; 95% CI: 0.85-1.37) in NYC compared to the rest of the state. The only significant effect in NYC was reduced odds for adult cigarette use (AOR: 0.79; 95% CI: 0.68-0.92).

CONCLUSIONS

Findings suggest regulating cigar packaging could decrease cigar consumption without increasing cigarette consumption, but effects may differ across jurisdictions.

Understanding Primary Care Providers’ Experience with Lifestyle Behavior Change Recommendations and Programs to Prevent Chronic Disease

Prescribing lifestyle behavior change is a recommended strategy for both primary and secondary prevention of disease. Programs that support and encourage lifestyle behavior change are available to patients but are underutilized. The purpose of this study was to understand primary care providers (PCPs) experiences and barriers they experience with referring patients to lifestyle behavior change programs at one academic health care system. In-depth semi-structured interviews were conducted with 7 academic PCPs between November 2020 and January 2021. Qualitative analysis identified major themes. Four themes emerged: (1) guideline awareness and adherence, (2) barriers to lifestyle behavior change recommendations, (3) provider role with respect to lifestyle behavior change recommendations, and (4) suggestions to improve utilization of behavior change support. Specific strategies for improvement include revising referral process, educating providers about programs already offered, integrating a team-based approach, and systemizing healthy lifestyle behaviors interventions. The lessons identified through this study highlight the need for systematic prioritization of lifestyle behavior change to decrease certain barriers that providers face when attempting to integrate lifestyle change consistently into their practice.

Uptake of [68Ga]-NODAGA-E[(cRGDyK)]2 is related to improvement in pump function in rats with chronic ischemic cardiomyopathy treated with cell therapy

Background

An increasing number of patients living with chronic ischemic cardiomyopathy (ICM) are potential candidates for cell therapy, including adipose tissue-derived mesenchymal stromal cells (ASC). However, proper assessment of clinical effects in relation to cellular effector mechanisms, such as angiogenesis, is currently lacking.

Purpose

To investigate the prognostic value of assessing angiogenesis non-invasively using novel PET imaging in terms of functional outcome after cell therapy in a homologous animal model of ICM.

Methods

Myocardial infarction was induced by permanent ligation of the left anterior descending coronary artery. Four weeks after infarction, the rats were scanned with [18F]-FDG and echocardiography, and based on left ventricular ejection fraction (LVEF) and infarct size randomized to allogeneic ASC treatment (n=14) or saline (n=9). Animals were treated using echo-guided trans-thoracic intramyocardial injections. Follow-up echocardiography was performed four weeks after treatment. Angiogenesis was assessed non-invasively using the [68Ga]-NODAGA-E[(cRGDyK)]2 (RGD) PET-tracer before treatment and two weeks after the treatment (Figure). The output was RGD-uptake by maximum standardized uptake value (SUVmax).

Results

RGD-uptake in the infarct area significantly decreased in the saline group (p=0.04), while this decline was not significant in the ASC group (p=0.58). There was no effect on LVEF of the cell therapy in this study (p=0.70). When the rats were grouped by RGD-uptake post treatment, the high RGD-uptake group (n=8) improved LVEF compared to the rats with medium or low RGD-uptake (n=15, p=0.04) irrespective of the treatment. This could indicate that non-invasive detection of a high degree of myocardial angiogenesis measured using RGD is predictive of improvement in cardiac pump function in ICM.

Conclusions

Following injection of ASC or saline, a high RGD-uptake precluded improvement in pump function. This is the first evidence of how uptake of the novel RGD tracer relates to changes in pump function in ICM and the results could affect the design of future clinical trials using regenerative therapy for ICM patients.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Aase and Ejnar Danielsens FondDoctor Sofus Carl Emil Friis and wife Olga Doris Friis' Scholarship Study design, RGD-uptake, and results

P1215Non-invasive angiogenesis assessment with PET/CT in a rabbit model of myocardial infarction: feasibility and comparison with molecular markers

Background

Translational molecular imaging using Positron Emission Tomography/Computed Tomography (PET/CT) and Transesophageal Echocardiography (TEE) are powerful non-invasive tools for investigation and monitoring of cardiovascular functions. Following myocardial infarction (MI), formation of new blood vessels (angiogenesis) is of importance in the healing process and can be assessed with the PET tracer 68Ga-NODAGA-E[(cRGDyK)]2 (68Ga-RGD).

Purpose

The purpose of the study was to assess angiogenesis in a rabbit model of myocardial infarction using molecular imaging (PET/CT) and furthermore to validate the findings using TEE, immunohistochemistry (IHC) and quantitative PCR (qPCR).

Methods

Ten NZW rabbits were used (MI: n=5, SHAM: n=5). Angiogenesis was assessed with 68Ga-RGD before, 1 and 3 weeks after interventions using PET/CT (Inveon System, Siemens Health Care). TEE was used per-operatively and at termination for assessment of the MI (S8–3T probe, iE33 System, Phillips). Following the final scans, hearts were harvested for ex vivo analyses. Short axis slides were stained for collagen deposition and myocardial differentiation (H&E and Masson's trichrome), endothelial cells (CD31), and macrophage infiltration (RAM11). Gene expression alterations related to wound healing response (inflammation, granulation, and tissue remodeling) were measured using qPCR arrays (84 genes analyzed).

Results

One week after the interventions, 68Ga-RGD uptake, as assessed with PET was increased in the infarct area when compared to the remote zone of the same rabbit as well as compared to the SHAM group. Three weeks after intervention, there was no difference in 68Ga-RGD uptake between groups. High quality TEE images were obtained in all rabbits. Ex vivo analyses at 3 weeks after intervention revealed moderate vessel formation (CD31) in the infarct zone, none in the border zone, whereas surrounding viable myocardium had visible CD31 positive vessels comparable to the SHAM group. Macrophage infiltration (RAM11) and collagenous scaring (Masson's trichrome) was pronounced in the infarcted area. Gene expression alterations in the infarct area (30 of 84 genes upregulated) were dominated by increased expression of collagens (COL1A2, COL5A1, COL5A4), inflammatory chemokines and cytokines (CCL2, IL1A, IL1B, IL6, IL10) and ECM remodeling enzymes (uPAR, TPA, TIMP1, SERPINE1, MMP9) in the MI group compared to the SHAM group, whereas integrins involved in the angiogenesis response (ITGA4, ITGAV) were only moderately changed in the infarction at termination, confirming the in vivo PET findings.

Study outline

Conclusions

In this rabbit MI model, we demonstrate the feasibility of monitoring angiogenesis in the healing process non-invasively with PET. The imaging results were confirmed by IHC and gene expression analysis. Moreover, TEE using a dedicated pediatric probe is feasible in the rabbit model, making this a robust and translational medium-sized animal model of myocardial infarction.

A slow-cycling subpopulation of melanoma cells with highly invasive properties

Melanoma is a heterogeneous tumor with different subpopulations showing different proliferation rates. Slow-cycling cells were previously identified in melanoma, but not fully biologically characterized. Using the label-retention method, we identified a subpopulation of slow-cycling cells, defined as label-retaining cells (LRC), with strong invasive properties. We demonstrate through live imaging that LRC are leaving the primary tumor mass at a very early stage and disseminate to peripheral organs. Through global proteome analyses, we identified the secreted protein SerpinE2/protease nexin-1 as causative for the highly invasive potential of LRC in melanomas.

Subsurface nitrate reduction under wetlands takes place in narrow superficial zones

This study aims to investigate the depth distribution of the Nitrate Reduction Potential (NRP) on a natural and a re-established wetland. The obtained NRP provides a valuable data of the driving factors affecting denitrification, the Dissimilatory Nitrate Reduction to Ammonium (DNRA) process and the performance of a re-established wetland. Intact soil cores were collected and divided in slices for the determination of Organic Matter (OM) through Loss of Ignition (LOI) as well as Dissolved Organic Carbon (DOC) and NRP spiking nitrate in batch tests. The Nitrate Reduction (NR) was fitted as a pseudo-first order rate constant (k) from where NRPs were obtained. NR took place in a narrow superficial zone showing a dropping natural logarithmic trend along depth. The main driving factor of denitrification, besides depth, was OM. Although, DOC and LOI could not express by themselves and absolute correlation with NRP, high amounts of DOC ensured enough quantity and quality of labile OM for NR. Besides, high concentration of LOI but a scarce abundance of DOC failed to drive NR. DNRA was only important in superficial samples with high contents of OM. Lastly, the high NRP of the re-established wetland confirms that wetlands can be restored satisfactorily.

Pressure-actuated microfluidic devices for electrophoretic separation of pre-term birth biomarkers

We have developed microfluidic devices with pressure-driven injection for electrophoretic analysis of amino acids, peptides, and proteins. The novelty of our approach lies in the use of an externally actuated on-chip peristaltic pump and closely spaced pneumatic valves that allow well-defined, small-volume sample plugs to be injected and separated by microchip electrophoresis. We fabricated three-layer poly(dimethylsiloxane) (PDMS) microfluidic devices. The fluidic layer had injection and separation channels, and the control layer had an externally actuated on-chip peristaltic pump and four pneumatic valves around the T-intersection to carry out sample injection. An unpatterned PDMS membrane layer was sandwiched between the fluidic and control layers as the actuated component in pumps and valves. Devices with the same peristaltic pump design but different valve spacings (100, 200, 300, and 400 μm) from the injection intersection were fabricated using soft lithographic techniques. Devices were characterized through fluorescent imaging of captured plugs of a fluorescein-labeled amino acid mixture and through microchip electrophoresis separations. A suitable combination of peak height, separation efficiency, and analysis time was obtained with a peristaltic pump actuation rate of 50 ms, an injection time of 30 s, and a 200-μm valve spacing. We demonstrated the injection of samples in different solutions and were able to achieve a 2.4-fold improvement in peak height and a 2.8-fold increase in separation efficiency though sample stacking. A comparison of pressure-driven injection and electrokinetic injection with the same injection time and separation voltage showed a 3.9-fold increase in peak height in pressure-based injection with comparable separation efficiency. Finally, the microchip systems were used to separate biomarkers implicated in pre-term birth. Although these devices have initially been demonstrated as a stand-alone microfluidic separation tool, they have strong potential to be integrated within more complex systems.

Martian fluvial conglomerates at Gale crater

Observations by the Mars Science Laboratory Mast Camera (Mastcam) in Gale crater reveal isolated outcrops of cemented pebbles (2 to 40 millimeters in diameter) and sand grains with textures typical of fluvial sedimentary conglomerates. Rounded pebbles in the conglomerates indicate substantial fluvial abrasion. ChemCam emission spectra at one outcrop show a predominantly feldspathic composition, consistent with minimal aqueous alteration of sediments. Sediment was mobilized in ancient water flows that likely exceeded the threshold conditions (depth 0.03 to 0.9 meter, average velocity 0.20 to 0.75 meter per second) required to transport the pebbles. Climate conditions at the time sediment was transported must have differed substantially from the cold, hyper-arid modern environment to permit aqueous flows across several kilometers.

Micropollutants in stormwater runoff and combined sewer overflow in the Copenhagen area, Denmark

Stormwater runoff contains a broad range of micropollutants. In Europe a number of these substances are regulated through the Water Framework Directive, which establishes Environmental Quality Standards (EQSs) for surface waters. Knowledge about discharge of these substances through stormwater runoff and combined sewer overflows (CSOs) is essential to ensure compliance with the EQSs. Results from a screening campaign including more than 50 substances at four stormwater discharge locations and one CSO in Copenhagen are reported here. Heavy metal concentrations were detected at levels similar to earlier findings, e.g., with copper found at concentrations up to 13 times greater than the Danish standard for surface waters. The concentration of polyaromatic hydrocarbons (PAHs) exceeded the EQSs by factors up to 500 times for stormwater and 2,000 times for the CSO. Glyphosate was found in all samples whilst diuron, isoproturon, terbutylazine and MCPA were found only in some of the samples. Diethylhexylphthalate (DEHP) was also found at all five locations in concentrations exceeding the EQS. The results give a valuable background for designing further monitoring programmes focusing on the chemical status of surface waters in urban areas.

Osteoprotegerin concentrations and prognosis in acute ischaemic stroke

AIM

Concentrations of osteoprotegerin (OPG) have been associated with the presence of vascular and cardiovascular diseases, but the knowledge of this marker in the setting of ischaemic stroke is limited.

METHODS AND RESULTS

In 244 patients with acute ischaemic stroke (age: 69 +/- 13 years), samples of OPG were obtained serially from presentation to day 5. Patients with overt ischaemic heart disease and atrial fibrillation were excluded. The patients were followed for 47 months, with all-cause mortality as the sole end-point. Multivariable predictors of OPG values at presentation included haemoglobin (T = -2.82; P = 0.005), creatinine (T = 4.56; P < 0.001), age (T = 9.66; P < 0.001), active smoking (T = 2.25; P = 0.025) and pulse rate (T = 3.23; P = 0.001). At follow-up 72 patients (29%) had died. Patients with OPG < or =2945 pg mL(-1) at baseline had a significantly improved survival rate on univariate analysis (P < 0.0001); other time-points did not add further prognostic information. In multivariate analysis, after adjustment for age, stroke severity, C-reactive protein levels, troponin T levels, heart and renal failure concentrations of OPG independently predicted long-term mortality after stroke (adjusted hazard ratio, 2.3; 95% CI: 1.1 to 4.9; P = 0.024).

CONCLUSION

Osteoprotegerin concentrations measured at admission of acute ischaemic stroke are associated with long-term mortality.

The influence of anaemia on stroke prognosis and its relation to N-terminal pro-brain natriuretic peptide

Anaemia is a negative prognostic factor for patients with heart failure and impaired renal function, but its role in stroke patients is unknown. Furthermore, anaemia has been shown to influence the level of N-terminal pro-brain natriuretic peptide (NT-proBNP), but this is only investigated in patients with heart failure, not in stroke patients. Two-hundred-and-fifty consecutive, well-defined ischemic stroke patients were investigated. Mortality was recorded at 6 months follow-up. Anaemia was diagnosed in 37 patients (15%) in whom stroke severity was worse than in the non-anaemic group, whilst the prevalence of renal affection, smoking and heart failure was lower. At 6 months follow-up, 23 patients were dead, and anaemia had an odds ratio of 4.7 when adjusted for age, Scandinavian Stroke Scale and a combined variable of heart and/or renal failure and/or elevation of troponin T using logistic regression. The median NT-proBNP level in the anaemic group was significantly higher than in the non-anaemic group, and in a multivariate linear regression model, anaemia remained an independent predictor of NT-proBNP. Conclusively, anaemia was found to be a negative prognostic factor for ischemic stroke patients. Furthermore, anaemia influenced the NT-proBNP level in ischemic stroke patients, an important aspect when interpreting NT-proBNP in these patients.

Serial Measurements of N-Terminal pro-Brain Natriuretic Peptide after Acute Ischemic Stroke

BACKGROUND

The exact time-course of N-terminal pro-brain natriuretic peptide (NT-proBNP) and the prognostic importance in the immediate phase of ischemic stroke have not been established.

METHODS

NT-proBNP was measured daily from admission to day 5 and again at 6-month follow-up in 250 consecutive patients with acute ischemic stroke.

RESULTS

NT-proBNP peaked the day after onset of symptoms (p = 0.007) followed by a decrease until day 5 (p = 0.001, ANOVA). At 6-month follow-up the difference in the level of NT-proBNP was unchanged compared to day 5 (p = 0.42). NT-proBNP levels > or =615 pg/ml at day 2 after onset of symptoms was associated with 6-month mortality.

CONCLUSION

NT-proBNP peaks the day after onset of symptoms in patients with acute ischemic stroke. A single measurement of NT-proBNP appears to be an indicator of 6-month mortality.

Safety and efficacy of combined high-dose treatment with calcipotriol ointment and solution in patients with psoriasis

BACKGROUND

In the vast majority of psoriatic patients, psoriatic lesions are localised on the body as well as on the scalp. Therefore, safety data on the combined use of calcipotriol in lotion and calcipotriol in ointment are needed.

OBJECTIVE

This study investigated the effect of high-dose treatment with a combination of calcipotriol ointment and scalp solution on calcium metabolism, indices of bone turnover and PASI in patients with extensive psoriasis.

METHODS

Following a 2-week wash-out period, 88 patients were randomised to 4 weeks of treatment with either calcipotriol ointment/scalp solution (80-100 g/week and 30-50 ml/week, respectively; n = 41) or with a dithranol/tar regimen (n = 47). Patients were seen at weeks 1, 2 and 4 during treatment and 1 week following cessation of treatment.

RESULTS

No significant differences at the end of treatment were found between the 2 groups with respect to 24-hour urinary excretion of calcium (expressed as calcium/creatinine ratio), phosphate or pyridinoline, serum concentrations of calcium (albumin corrected), creatinine, phosphate, parathyroid hormone, 25-hydroxyvitamin D(3), 1,25-dihydroxyvitamin D(3), osteocalcin, alkaline phosphatase (total and bone-specific iso-enzymes) or 1-collagen telopeptide. At the end of treatment, the psoriasis area and severity index had decreased by 57.4% in the calcipotriol group and by 36.1% in the dithranol/tar group (p = 0.004). Investigators' and patients' assessments of overall efficacy also favoured treatment with calcipotriol (p < 0.001).

CONCLUSION

The combined use of calcipotriol ointment/scalp solution did not affect the indices of calcium metabolism or bone turnover and was significantly more effective than dithranol/tar in reducing disease severity and extent in patients with extensive psoriasis.

[Acute myocardial infarction associated with a mild blunt thoracic trauma]

A case of acute myocardial infarction associated with a mild blunt thoracic trauma in a 60-year-old woman with normal coronary angiography is described. The underlying potential pathophysiological mechanisms are discussed. Lastly, the clinical and practical consequences of the new consensus document for the redefinition of acute myocardial infarction are briefly commented on.

[Smoking and admission to a department of internal medicine at a county hospital]

On a random day in 1998 all hospitalized unselected patients on the ward of internal medicine, Silkeborg County Hospital were evaluated in relation to possible tobacco-related disease. A total of 56 (71%) of 79 had a smoking-related main diagnosis and of these 23 (29%) of 79 were statistically diseased as a direct consequence of their present and previous use of tobacco.

Stress urinary incontinence at rest

We retrospectively identified 37 cases in which urinary incontinence occurred at rest during urodynamic testing in the absence of a coincident detrusor contraction or urethral relaxation. This phenomenon, genuine stress incontinence at rest, was observed during 9.6% of multichannel cystometrograms performed at our institution. The observed urine loss occurred at bladder volumes between 145 ml and 800 ml. Loss occurred with bladder overdistension (overflow incontinence) in only 3 subjects (8%). Decreased bladder compliance was observed in 11 (30%) and decreased outlet resistance was demonstrated in 24 (65%). Our findings suggest that genuine stress incontinence at rest is relatively common in a referred population of incontinent women. This phenomenon is associated with impaired urethral function and/or decreased bladder compliance.

The relationship of body mass index to intra-abdominal pressure as measured by multichannel cystometry

The aim of the study was to identify the possible relationship between body mass index and intra-abdominal pressure as measured by multichannel cystometry. A retrospective chart review of patients presenting for urodynamic evaluation between January 1995 and March 1996 was carried out. Variables identified included weight, height, intra-abdominal pressure and intravesical pressure as recorded on multi-channel cystometrogram at first sensation in the absence of detrusor activity. Body mass index was defined as weight in kilograms divided by height in square meters. Intra-abdominal pressure was measured intravaginally except in those cases of complete procidentia or severe prolapse, where it was measured transrectally. Adequate data were available on 136 patients. The mean age was 60.6 years (range 30-91); mean body mass index was 27.7 kg/m2 (range 12.7-47.7); and mean intra-abdominal pressure was 27.5 cmH2O (range 9.0-48.0). A strong association between intra-abdominal pressure and body mass index was demonstrated, with a Pearson coefficient correlation value of 0.76 (P<0.0001). Strong correlation was still demonstrated when those patients who had had the intra-abdominal pressure measured transrectally were separated out, thus eliminating any possible confounding factors between measurements of intra-abdominal pressure measured transvaginally versus transrectally. In addition a strong correlation between intravesical pressure and body mass index was also demonstrated, with a Pearson coefficient correlation value of 0.71 (P<0.0001). Of the 136 patients, 65 (47.8%) were ultimately diagnosed as having genuine stress urinary incontinence (GSUI), 35 (25.7%) with GSUI and a low-pressure urethra (maximum urethral closure pressure of less than 20 cmH2O), and 18 (13.2%) with detrusor instability. The remaining 13.2% had severe prolapse. Our data demonstrate a significant correlation between body mass index and intra-abdominal pressure. These findings suggest that obesity may stress the pelvic floor secondary to chronic state of increased pressure, and may represent a mechanism which supports the widely held belief that obesity is a common factor in the development and recurrence of GSUI.

Banked human fascia lata for the suburethral sling procedure: a preliminary report

OBJECTIVE

To report our initial experience with allogenic (human cadaver donor) fascia lata for the suburethral sling procedure.

METHODS

Allogenic fascia lata for the suburethral sling procedure has been used in our practice since July 1994. Fascial grafts were obtained from licensed tissue banks. Women who underwent this procedure were followed prospectively to determine the incidence of perioperative complications, the incidence of local wound complications at the sling insertion site, and the subjective and objective cure rates.

RESULTS

Sixteen women underwent the suburethral sling procedure with allogenic fascia. Fourteen had genuine stress urinary incontinence and two required replacement of a previously placed synthetic graft because of chronic infection. Follow-up ranged from 6 months to 1 year. No patient developed sinus tract formation or persistent granulation tissue. Two of 16 patients (12%) developed abdominal wound infections, which resolved with local care. The mean duration of postoperative bladder drainage was 29 days. One patient continued to require intermittent catheterization at 187 days. Among the 14 women with preoperative genuine stress incontinence, the subjective cure rate was 86% and the objective cure rate was 79%. The two patients who required replacement of a chronically infected synthetic graft remained subjectively continent.

CONCLUSIONS

These preliminary data suggest that allogenic fascia lata is an acceptable material for the suburethral sling procedure. This material may be considered as an alternative to autologous fascia, which must be harvested from the patient intraoperatively, and to synthetic materials, which have been associated with local complications in up to 40% of cases.

The effect of patient position on proximal urethral mobility

OBJECTIVE

To determine the effect of patient position on the mobility of the urethrovesical junction.

METHODS

Q-tip tests in the supine and standing positions were performed on forty-six consecutive female patients with a variety of urogynecologic complaints. Wilcoxon signed-rank test and McNemar test were used to compare urethral mobility in the supine and standing positions.

RESULTS

Both the maximum straining Q-tip angle and the difference between the resting and straining angles were significantly greater in the supine position than in the standing position (P < .01). Thirty-four subjects had a positive Q-tip test in the supine position (defined as a maximal straining angle of at least 30 degrees), but only 24 (71%) of these women had a positive Q-tip test in the standing position.

CONCLUSION

Patient position has a significant effect on mobility of the urethrovesical junction, in that the female urethra is more mobile in the supine than in the standing position. Because the selection of a surgical procedure for a woman with genuine stress incontinence depends in part on the presence or absence of urethral hypermobility, this observation has important implications for the evaluation of women with genuine stress incontinence.

Assessment of exposure to EMF in a Danish case-control study of childhood cancer

In Denmark it is permitted to draw overhead lines across residential areas. In connection with a Danish case-control study we developed a method for estimating the historical values of magnetic fields at residences. The study included 1,707 cases with childhood cancer and 4,788 matched population controls. A total of 16,082 different addresses had been occupied by the families from the time of conception until the date of diagnosis. The values of the extreme, maximum, middle and minimum 50 Hz magnetic field strengths originating from a 50-400 kV high-voltage installation were estimated for each of the dwellings included in a potential exposure area. 30 children were exposed to an average level of magnetic fields of 0.1 microT or more. The evaluated Danish method of exposure assessment was compared with the method for residential wiring codes developed by Wertheimer and Leeper /1/. We concluded that the US wiring codes are inappropriate for use in connection with the Danish electricity transmission system.

The role of patient history in the diagnosis of urinary incontinence

OBJECTIVE

To assess the clinical usefulness and validity of patient history in the diagnosis of genuine stress incontinence and detrusor overactivity.

DATA SOURCES

A literature search was performed for publications addressing the clinical evaluation of urinary incontinence between 1975-1992.

METHODS OF STUDY SELECTION

Nineteen of 29 articles during this period reported data in such a manner as to allow statistical comparison of patient history to the diagnosis based on urodynamic evaluation.

DATA EXTRACTION AND SYNTHESIS

Each article was assessed for the following information: inclusion and exclusion criteria, method of obtaining patient history, clinical evaluation, and diagnostic criteria. Patients in each article were classified according to their history and urodynamic diagnosis. Sensitivity, specificity, and predictive values were calculated for each article, as well as for the combined data from all articles. Combined data from all 19 articles produced a total of 3092 and 2950 patients evaluated for genuine stress incontinence and detrusor overactivity, respectively. A clinical history consistent with stress incontinence, when compared to a urodynamically based diagnosis, showed a sensitivity of 0.906, a specificity of 0.511, a positive predictive value of 0.749, and a negative predictive value of 0.771. A comparison of clinical history suggestive of an overactive detrusor and urodynamic evidence of spontaneous bladder activity revealed a sensitivity of 0.735, specificity of 0.552, positive predictive value of 0.561, and negative predictive value of 0.728.

CONCLUSION

Patient history alone is not an accurate tool in the diagnosis of genuine stress incontinence or detrusor overactivity, and should not be the sole determinant of diagnosis or treatment.

[Electromagnetic fields from high-voltage installations and cancer in childhood]

The objective of this population-based case-control study has been to investigate whether residence before and after birth near 50 Hz high voltage installations increases a child's risk of cancer and whether risk correlates with the strength of the magnetic field. One thousand seven hundred and seven children under the age of 15 with either leukaemia, a tumour of the central nervous system, or malignant lymphoma diagnosed in 1968-86 were identified in the Danish Cancer Registry and matched with 4788 population controls. Measures of exposure were proximity before and after birth to existing or former 50-400 kV electrical transmission connections and substations and associated historical electromagnetic fields calculated on the basis of current load on line, phase ordering of line, and distance from the dwelling. A significant association was seen between all major types of childhood cancer combined and exposure to magnetic fields from high voltage installations of > or = 0.4 microT (odds ratio 5.6). At > or = 0.25 microT no significant association was seen (odds ratio 1.5). A possible association was also seen with cases of Hodgkin's disease separately at > or = 0.1 microT. On the basis of these results and additional descriptive data on electricity consumption and incidence of childhood cancer in Denmark since the 1940s it was concluded that the proportion of childhood cancer possibly caused by 50 Hz electromagnetic fields must be small.

Radiology of the continent ileostomy reservoir: II. Findings in patients with late complications

During an 8-year period, 238 barium double-contrast studies performed in 162 patients with continent ileostomy reservoirs who had signs and symptoms of late complications (malfunction of the valve, nonspecific inflammation of the mucosa, stenoses, hernias, and fistulas) showed radiologic abnormalities. The aim of the present study is to depict the radiologic findings in patients with late complications of continent ileostomy reservoirs. With radiologic examination, the correct diagnosis of valve malfunction was made in 96% of patients with surgically proven valve defects. We were able to differentiate between various types of valve dysfunction and complications related to the fixation of the reservoir to the abdominal wall. Inflammatory mucosal changes and fistulas of the reservoir and the afferent ileal segment were depicted with a high degree of accuracy. Barium double-contrast radiologic examination proved to be very valuable in the work-up of patients with dysfunction of continent ileostomy reservoirs. The method was of particular value in assessing the cause of valve dysfunction and in the appraisal of the afferent ileal segment.

Radiology of the continent ileostomy reservoir: I. Method of examination and normal findings

The aim of the present study is to describe the radiologic methods used to study continent ileostomy reservoirs and to depict the normal radiologic features and variations identified by these procedures. During an 8-year period, 408 double-contrast studies were performed in 261 patients. The present study comprises 170 examinations in 99 patients with normal findings. A high-density barium contrast medium and air were used. Modes variation in the size and shape of the reservoirs was observed. The mucosal pattern of the reservoirs resembled that of the ileum but the folds were slightly wider. The continence-providing valves were 3-5 cm long and had a diameter of 2.5-4.0 cm. The diameter of the afferent ileal segments was usually slightly larger than that of more proximal ileal segments, with an upper limit of approximately 4 cm. The efferent ileal segments generally had a straight course without widening or out-pouches. Retrograde barium double-contrast examination is a satisfactory method for the evaluation of continent ileostomy reservoirs. Here we define the range of normal variations of such reservoirs as seen on retrograde double-contrast radiologic examinations.

[Occurrence of housedust mites in dwellings. Relation to ventilation and humidity]

The concentration of house-dust mites (Der. spp.) was investigated in 96 Danish dwellings and bedroom air-exchange rates, humidity and temperature was measured contemporaneously in all the dwellings. A positive correlation was found between indoor air humidity and mite concentration, and an inverse correlation was found between house-dust mite concentration and indoor air-exchange. Dwellings of mite-allergic persons had a higher concentration of house-dust mites compared with those of the non-mite-allergic group. House-dust mite concentration was above the proposed limit in 76% of the homes of mite allergic persons and in 48% of the homes of non-sensitive persons. The high proportion of dwellings infested with house-dust mites, when compared with previous measurements, suggests an increased prevalence of house-dust mites in Danish dwellings. The results support the concept that reduced ventilation in dwellings involves a risk of increased house-dust mite exposure.

Suprapubic needle cystoscopy: a new technique to detect iatrogenic injuries to the lower urinary tract

Latrogenic injury to the lower urinary tract, specifically the ureter and bladder, is a potential risk of any pelvic surgery. According to the available literature, the incidence of injury to the ureter ranges from 0.5-2.5% for routine pelvic operarions. In actuality, the incidence of ureteral injury during pelvic surgery may even be higher, as many cases are not reported, not detected or are asymptomatic. Injury to the bladder during pelvic surgery most commonly occurs in the form of inadverant laceration or placement of sutures through the bladder wall. Previous pelvic surgery, including Cesearean section, hysterectomy and bladder suspension procedures, and gynecologic conditions such as malignancy, endometriosis and pelvic inflammatory disease increase the risk for bladder trauma.

Comparison between radiologic and endoscopic evaluation of the continent ileostomy reservoir

The present study was performed to compare the results of radiologic examination and endoscopy in 156 patients with continent ileostomy reservoirs. Data from clinical follow-up and findings at revisional surgery were used for confirmation of diagnosis. One hundred and one patients had the clinical diagnosis nonspecific inflammation, 48 had symptoms of valve dysfunction, and 7 were studied because of suspected valve-shunting fistulas. For moderate and severe inflammation the findings on radiographs and at endoscopy were in accordance, whereas slight inflammation was more frequently reported by radiology than endoscopy. Radiology overdiagnosed slight inflammation. One disadvantage of endoscopy in patients with inflammation was that the afferent ileal segment could be reached in only 56%. By radiology 41 of 44 defective valves were identified (93%), whereas endoscopy disclosed only 24 defective valves (55%). The combined efforts of radiologic examination and endoscopy only managed to diagnose three of the seven patients with valve-shunting fistulas (two by radiologic and one by endoscopic examination). In conclusion, the retrograde double-contrast examination is a valuable complement in the assessment of patients with continent ileostomies and appears to be superior to endoscopy in the diagnosis of valve dysfunction and in depicting the afferent ileal segment.

To drain or not to drain: a retrospective study of closed-suction drainage following radical hysterectomy with pelvic lymphadenectomy

The records of 115 patients were reviewed following radical hysterectomy with pelvic lymphadenectomy for early stage (IA2 to IIB) cervical cancer to determine the effectiveness of closed-suction drainage in decreasing postoperative morbidity. In Group 1 (n = 67), closed-suction (Jackson-Pratt) drains were placed bilaterally in the pelvic lymphadenectomy sites, whereas in Group 2 (n = 48), no drains were utilized. The groups were similar for mean age, tumor histology, disease stage, and preoperative serum albumin and total protein. There was no difference in the mean operative time, mean estimated blood loss, or transfusion rate. Likewise, febrile morbidity rates, incidence of pelvic cellulitis, length of postoperative ileus, and total hospital stay were similar. Group 1 had an increased rate of rehospitalization and morbidity directly related to the presence of the drains. The data suggest that prophylactic surgical drainage may not be necessary to prevent postoperative morbidity following radical hysterectomy with pelvic lymphadenectomy and on occasion contributes to postoperative complications.

Individual differences in auditory capabilities. I

Twenty-eight audiometrically normal adult listeners were given a variety of auditory tests, ranging from quiet and masked thresholds through the discrimination of simple and moderately complex temporal patterns. Test-retest reliability was good. Individual differences persisted on a variety of psychoacoustic tasks following a period of training using adaptive threshold-tracking methods, and with trial-by-trial feedback. Large individual differences in performance on temporal-sequence-discrimination tasks suggest that this form of temporal processing may be of clinical significance. In addition, high correlations were obtained within given classes of tests (as, between all tests of frequency discrimination) and between certain classes of tests (as, between tests of frequency discrimination and those of sequence discrimination). Patterns of individual differences were found which support the conclusion that individual differences in auditory performance are, in part, a function of patterns of independent abilities.

The efficacy of intraoperative autologous transfusion in major orthopedic surgery: a regression analysis

Perioperative blood loss associated with 89 cases of major orthopedic surgery was compared with that of a control group of 89 to determine the effectiveness of intraoperative autologous transfusion. Volume of banked blood transfused and hematocrit change were used to determine total blood loss. The orthopedic cases consisted of cemented "virgin" total hip replacement, cemented virgin tricompartmental knee replacement, and spine fusion. Use of an autotransfusion device (Cell Saver) intraoperatively was associated with significantly smaller volumes of transfused banked blood and significantly smaller hematocrit drops in the groups of patients who underwent total hip replacement or spine fusion, but not in the group of patients who underwent total knee replacement. One potential source of bias in the study stems from the fact that four days were allotted for equilibrium from perioperative blood loss in the hip and knee replacement groups, while, for reasons of data availability, equilibrium time in the spine fusion groups was two days.

Nonverbal intelligence and English language ability in deaf children

The relationship between nonverbal intelligence and English language ability in a sample of 25 deaf children between the ages of 6-10 was examined. Intelligence measure included the Performance Scale of the Wechsler Intelligence Scale for Children-Revised (Wechsler, 1974) and the Hiskey-Nebraska Test of Learning Aptitude (Hiskey, 1966). Language measures were the Test of Language Development (Newcomer & Hammill, 1977) and the Reynell Developmental Language Scales (Reynell, 1977). Average correlations of .45 were obtained between nonverbal IQ and the language measures. The average multiple correlation between the individual subtests from the intelligence scales and language scores was .68. Subtests which require visual memory consistently entered the multiple regression equations as the best predictors of language performance. Language performance was attenuated in this sample and did not correlate with chronological age. The finding of significant correlations between nonverbal IQ and English language, in spite of the attenuated language performance, suggests that nonverbal intelligence and visual memory skills, in particular, may be important in understanding the success of some hearing-impaired children in acquiring English and the failure of others.

Blood pressure response to administration of local anaesthetics with noradrenaline in craniotomies

Infiltration with local anaesthetics with addition of adrenaline or noradrenaline has been used since 1910 prior to skin incision for craniotomy. In a controlled series of patients scheduled for intracranial operations, systemic blood pressure was measured intra-arterially after infiltration with 15-20 ml 0.5% lignocaine with nonradrenaline 1 mu gr/ml. A marked increase in systemic blood pressure was seen (125% of values prior to infiltration). In a control series, where saline was injected, a slight fall in blood pressure was registered (p smaller than 0.01). As hypertensive episodes increase intracranial pressure in patients with impaired cerebral autoregulation, or promote the risk of haemorrhage in aneurysm surgery, this technique is considered a hazard to patients undergoing intracranial operations.

Cameco anaesthetic ventilator with a modified Mapleson D circuit

A modified Mapleson D circuit has been used in connection with a Cameco anaesthetic ventilator during neuroradiological procedures in general anaesthesia. In order to increase mobility of the patient, two or three lengths of corrugated rubber tubing were used to connect the patient to the ventilator. Blood gas analysis was carried out in 20 patients after ventilation to steady state with both circuits. The respiratory minute volume and fresh gas flow were preset in Bain's (Bain & Spoerel 1975) predictions. No significant difference could be detected in respect to Paco2 or Po2, whether 2 or 3 lengths of tubing were used. Mean values of Paco2 were higher compared with the results of Bain (0.37 kPa s.d. 0.50). It is concluded that this system gives maximum mobility of the patient during the radiological procedure and offers reliable adjustment of Paco2, even in patients with apparent increase of intracranial pressure.