Women's perceptions of PERSPECTIVE: a breast cancer risk stratification e-platform

Background

Breast cancer risk stratification categorizes a woman’s potential risk of developing the disease as near-population, intermediate, or high. In accordance, screening and follow up for breast cancer can readily be tailored following risk assessment. Recent efforts have focussed on developing more accessible means to convey this information to women. This study sought to document the relevance of an informational e-platform developed for these purposes.

Objective

To begin to assess a newly developed breast cancer risk stratification and decision support e-platform called PERSPECTIVE (PErsonalised Risk Stratification for Prevention and Early deteCTIon of breast cancer) among women who do not know their personal breast cancer risk (Phase 1). Changes (pre- and post- e-platform exposure) in knowledge of breast cancer risk and interest in undergoing genetic testing were assessed in addition to perceptions of platform usability and acceptability.

Methods

Using a pre-post design, women (N = 156) of differing literacy and education levels, aged 30 to 60, with no previous breast cancer diagnosis were recruited from the general population and completed self-report e-questionnaires.

Results

Mean e-platform viewing time was 18.67 min (SD 0.65) with the most frequently visited pages being breast cancer-related risk factors and risk assessment. Post-exposure, participants reported  significantly higher breast cancer-related knowledge (p < .001). Increases in knowledge relating to obesity, alcohol, breast density, menstruation, and the risk estimation process remained even when sociodemographic variables age and education were controlled. There were no significant changes in genetic testing interest post-exposure. Mean ratings for e-platform acceptability and usability were high: 26.19 out of 30 (SD 0.157) and 42.85 out of 50 (SD 0.267), respectively.

Conclusions

An informative breast cancer risk stratification e-platform targeting healthy women in the general population can significantly increase knowledge as well as support decisions around breast cancer risk and assessment. Currently underway, Phase 2, called PERSPECTIVE, is seeking further content integration and broader implementation .

Avoir sa santé en main : le sentiment d'habilitation tel que perçu par les jeunes adultes souffrant d'un cancer avancé

Contexte

Le sentiment d'habilitation sur sa santé (health related empowerment) est un concept fondamental des soins centrés sur la personne. Toutefois, on en sait peu sur la manière dont ce concept s'articule chez les jeunes adultes ayant un diagnostic de cancer avancé.

Objectif

Explorer le sentiment d'habilitation à la lumière des expériences de soins de santé vécues par les jeunes adultes en phase de cancer avancé.

Cadre et participants

Douze jeunes adultes (âgés de 21 à 39 ans) ont été recrutés dans un grand centre de cancérologie de Montréal, au Québec.

Méthodologie

Des entretiens en profondeur durant entre 36 et 90 minutes ont été menés individuellement, enregistrés et retranscrits mot pour mot, puis analysés par thèmes.

Résultats

Tout au long de l'expérience du cancer, les participants ont témoigné du désir soutenu de participer activement à leur traitement et à leurs soins. Quatre thèmes sont ressortis des données décrivant les processus d'attente, de prise en charge de la maladie, de mise en action et de recadrage. Sous-jacents à ces thèmes se trouvent les notions de conscience du corps, les obstacles à surmonter pour obtenir des soins, l'optimisation de la santé et la réflexion sur l'héritage qu'on laisse derrière soi.

Conclusions

De façon générale, les participants voulaient demeurer en contrôle de la situation malgré les multiples difficultés inhérentes à un cancer de stade avancé. Si elles sont corroborées par d'autres recherches, ces conclusions pourraient orienter les approches de soins en oncologie afin qu'elles soient véritablement adaptées aux besoins des jeunes adultes.

Taking control over our health: Empowerment as perceived by young adults living with advanced cancer

Background

Health-related empowerment is a key concept in person-centred care. However, little is known of its core elements in young adults diagnosed with advanced cancer.

Objective

To explore empowerment in the context of young adults' healthcare experiences who are now in advanced stages of cancer.

Setting & Participants

Twelve young adults (aged 21 to 39 years) were recruited from a large cancer centre in Montreal, Quebec.

Methods

In-depth interviews lasting between 36 and 90 minutes were conducted individually, audio-recorded, transcribed verbatim, and analyzed using thematic analysis.

Results

Throughout the cancer trajectory, participants reported a sustained desire to be actively involved in their treatment and care. Four themes emerged from the data representing processes of waiting, managing, acting, and revisiting. Subsumed under these were notions of body ownership, facing obstacles to care, optimizing health, and (re)considering their legacy.

Conclusions

Overall, participants wanted to remain in control of their situation despite the multiple challenges related to advanced cancer. If corroborated further, these findings should inform supportive cancer care approaches that are truly tailored to the needs of young adults.

Supportive care needs and distress in patients with non-melanoma skin cancer: Nothing to worry about?

PURPOSE

There is a paucity of psychosocial research on non-melanoma skin cancer (NMSC) despite the fact that these malignancies mainly develop on the head and neck, frequently recur, and are associated with an increased risk for other cancers. The current study aims to respond to this gap in the scholarship by determining the prevalence of supportive care needs and examining the relationship between patients' needs and distress.

METHOD

A cross-sectional research protocol included a consecutive sample of 60 patients with squamous and/or basal cell carcinomas who completed a survey comprised of the Skin Cancer Index (SCI), the Hospital Anxiety and Depression Scale (HADS), the Supportive Care Needs (SCNS) Survey, an inquiry about informational needs regarding skin cancer prevention, and a socio-demographic questionnaire.

RESULTS

More than half of the patients indicated unmet needs, most frequently endorsing moderate and high needs for help with: the prevention of future skin cancers, the health system and informational matters. Psychological needs were strongly associated with skin cancer-specific and general distress. Higher levels of anxious and depressive symptoms were related to greater patient needs across all domains.

CONCLUSIONS

Despite NMSC not being life threatening in most cases, there is a significant proportion of patients, who have unmet supportive care needs and experience heightened distress levels. This study raises awareness for health care professionals to be vigilant about the supportive care needs and the psychological health of patients with non-melanoma skin cancer.

Barriers and facilitators of adherence to medical advice on skin self-examination during melanoma follow-up care

BACKGROUND

Melanoma is the fastest growing tumor of the skin, which disproportionately affects younger and middle-aged adults. As melanomas are visible, recognizable, and highly curable while in early stages, early diagnosis is one of the most effective measures to decrease melanoma-related mortality. Skin self-examination results in earlier detection and removal of the melanoma. Due to the elevated risk of survivors for developing subsequent melanomas, monthly self-exams are strongly recommended as part of follow-up care. Yet, only a minority of high-risk individuals practices systematic and regular self-exams. This can be improved through patient education. However, dermatological education is effective only in about 50% of the cases and little is known about those who do not respond. In the current literature, psychosocial variables like distress, coping with cancer, as well as partner and physician support are widely neglected in relation to the practice of skin self-examination, despite the fact that they have been shown to be essential for other health behaviors and for adherence to medical advice. Moreover, the current body of knowledge is compromised by the inconsistent conceptualization of SSE. The main objective of the current project is to examine psychosocial predictors of skin self-examination using on a rigorous and clinically sound methodology.

METHODS/DESIGN

The longitudinal, mixed-method study examines key psychosocial variables related to the acquisition and to the long-term maintenance of skin self-examination in 200 patients with melanoma. Practice of self-exam behaviors is assessed at 3 and 12 months after receiving an educational intervention designed based on best-practice standards. Examined predictors of skin self-exam behaviors include biological sex, perceived self-exam efficacy, distress, partner and physician support, and coping strategies. Qualitative analyses of semi-structured interviews will complement and enlighten the quantitative findings.

DISCUSSION

The identification of short and long-term predictors of skin self-examination and an increased understanding of barriers will allow health care professionals to better address patient difficulties in adhering to this life-saving health behavior. Furthermore, the findings will enable the development and evaluation of evidence-based, comprehensive intervention strategies. Ultimately, these findings could impact a wide range of outreach programs and secondary prevention initiatives for other populations with increased melanoma risk.

A retrospective audit of long-term lower limb complications following leg vein harvesting for coronary artery bypass grafting

OBJECTIVE

To evaluate the prevalence of leg complications following leg-vein harvest for coronary artery bypass grafting.

METHOD

A questionnaire was sent to patients who had coronary artery bypass surgery between January 1993 and December 1998. Questions addressed pain, numbness, infection, swelling and general healing. The relationship between the risk factors of diabetes, peripheral vascular disease, previous fractures/injuries to legs, previous deep vein clots and arthritis affecting the legs with post operative symptoms of pain, numbness, swelling and general healing was explored with multivariate analysis.

RESULTS

Of 700 questionnaires sent out 497 were returned, of which 422 (60%) were suitable for analysis. Numbness or tingling related to the wound was reported by 256 (61%), of whom 94 (37%) improved within 3 months. However, 105 (41%) had persistent numbness beyond 2 years. Pain in the wound was reported by 193 (46%), of whom 149 (77%) reported that this had improved by 3 months and only 19 (10%) had pain persisting beyond 2 years. A leg wound infection was reported by 126 (32%) patients, with 82 (65%) of these receiving antibiotics. A total of 336 (87% of 387 responses) described their wound as completely healed at 3 months. Unilateral leg swelling was reported by 175 (41%) with 98 of these (56% of those with swelling) improving by 3 months and 41 (23%) with swelling persisting beyond 2 years. There was no relation of wound problems to examined risk factors diabetes (P-values for numbness 0.31, wound healing 0.15, swelling 0.21, pain 0.22) and peripheral vascular disease (P-values for numbness 0.8, wound healing 0.21, swelling 0.18, pain 0.09). There was insufficient data to comment on the influence of fractures/injuries to legs, previous deep vein clots and arthritis affecting the legs.

CONCLUSIONS

Wound complications are common following leg vein harvest. Prevalence of infection was higher than has previously been reported. Few people suffer long-term pain from saphenous nerve damage although paraesthesia and swelling were common long-term complications. We did not identify either diabetes or peripheral vascular disease as a risk factor for pain, numbness, swelling or problems with general healing. There is a need for a large multicentre prospective study.

CT fluoroscopy guidance for transbronchial needle aspiration: an experience in 35 patients

OBJECTIVE

To demonstrate the usefulness of real-time guidance with CT fluoroscopy to improve the yield of transbronchial needle aspiration (TBNA).

DESIGN

Prospective, observational.

SETTING

A tertiary-care, university-affiliated medical center.

METHODS

From December 1998 to April 2000, 35 patients underwent CT fluoroscopy-guided TBNA. Patients with subcarinal and precarinal lymph nodes were only included if a previous attempt was nondiagnostic, as the initial yield in this setting with conventional TBNA is high. TBNA was performed using standard technique in a CT-scan suite. Needle location was confirmed with fluoroscopy without IV contrast being used. Specimens were evaluated on-site for adequacy.

RESULTS

The procedure had to be aborted in three patients before TBNA could be performed. Samples were obtained in 32 patients. Samples were nondiagnostic in four patients. Adequate tissue was obtained in 28 of 32 patients (87.5%). Twenty-two patients had a specific benign or malignant diagnosis made, and 6 patients had lymphocytes only on the specimen. In follow-up, only one of these six patients proved to have a malignancy. All procedures were performed within a regular interventional CT time slot of 1 h. No TBNA side effects were noted.

CONCLUSION

TBNA under CT fluoroscopic guidance is easy to perform. The yield in all accessible lymph node stations is high.

Peripheral blood CD4 + T-lymphocyte counts during Pneumocystis carinii pneumonia in immunocompromised patients without HIV infection

STUDY OBJECTIVES

To assess the potential use of peripheral blood CD4 + T-lymphocyte counts (CD4 + counts) as a clinically useful biological marker to identify specific immunocompromised patients (without HIV infection) at high risk for Pneumocystis carinii pneumonia (PCP).

DESIGN

Prospective observational study.

SETTING

Three hundred seventy-five-bed tertiary-care urban referral teaching hospital, and 250-bed community-based referral hospital.

PATIENTS

One hundred seventy-one consecutive confirmed HIV-seronegative hospitalized and ambulatory adults, including 22 patients with active PCP, 8 patients with bacterial pneumonia, 24 persons in two groups considered at high clinical risk, 38 persons in two groups considered at low or undefined risk, and 79 persons in four groups considered not at risk for PCP (including healthy individuals).

MEASUREMENTS AND RESULTS

Compared to counts in healthy individuals, median CD4 + counts were significantly decreased in patients with active PCP (61 cells/microL vs 832 cells/microL; p = 0.001) where 91% of patients had a CD4 + count < 300 cells/microL at the time of PCP diagnosis. Median CD4 + counts were also reduced in the high clinical risk groups of recent organ transplant recipients (117 cells/microL; p = 0.007), 64% with < 300 cells/microL, and patients receiving chemotherapy (221 cells/microL; p<0.01), 80% with < 300 cells/microL. For the low or undefined clinical risk groups, the median CD4 + counts were not significantly reduced, although 39 to 46% of individuals receiving long-term corticosteroid therapy (alone or in combination with other agents) had CD4 + counts < 300 cells/microL. Median CD4 + counts in individuals considered not at risk for PCP were similar to those in healthy subjects. Compared to counts in patients with active PCP, median CD4 + counts were significantly higher in bacterial pneumonia patients (486 cells/microL; p<0.05), but similar to those in healthy subjects.

CONCLUSIONS

These data suggest that for immunosuppressed persons without HIV infection (especially in low or undefined PCP risk groups), CD4 + counts may be a useful clinical marker to identify specific individuals at particularly high clinical risk for PCP and may help to guide chemoprophylaxis.

Management and outcome patterns for adult Pneumocystis carinii pneumonia, 1985 to 1995: comparison of HIV-associated cases to other immunocompromised states

STUDY OBJECTIVES

Encompassing periods preceding and following major advances in the diagnosis and management of HIV-related Pneumocystis carinii pneumonia (PCP), the purpose of this study was to determine whether management and outcome patterns of non-HIV PCP parallel the management and outcomes of AIDS-related PCP.

DESIGN

Retrospective review of medical records.

SETTING

A 375-bed tertiary-care urban teaching hospital and referral center.

PATIENTS

All adult patients with morphologically confirmed PCP from 1985 to 1995.

MEASUREMENTS AND RESULTS

From 1985 to 1995, 638 confirmed cases of PCP were identified, including 605 cases in 442 HIV-positive persons (HIV + PCP), and 33 cases in 33 non-HIV patients (non-HIV PCP). For HIV + PCP cases, a peak of 104 cases occurred in 1987, with a gradual decline to 23 in 1995. The proportion of cases requiring hospitalization declined from a peak of 91.6% in 1987 to a low of 51.6% in 1992. ICU admission was required for 6.3 to 8.2%, and mechanical ventilation for 4.7 to 5.7%. Overall mortality improved from 11.7 to 6.6%, although mortality for intubated patients remained at 50 to 60%. For the non-HIV PCP cases, 97% occurred from 1989 to 1995 with similar annual frequency, 97% required hospitalization, 69% required ICU admission, and 66% required intubation. Overall mortality was 39%, and mortality for intubated patients was 59%.

CONCLUSIONS

Despite major advances in diagnosis and management, PCP remains a significant problem in non-HIV-infected patients, and respiratory failure remains associated with a high mortality rate for patients with both HIV + PCP and non-HIV PCP.

Safety of bedside percutaneous dilatational tracheostomy in obese patients in the ICU

STUDY OBJECTIVE

To examine the safety of bedside percutaneous dilatational tracheostomy in obese patients.

DESIGN

Case series of consecutive obese patients (body mass index > or = 27 kg/m(2)) with acute respiratory failure in a medical, cardiac, or surgical ICU unit who required tracheostomy for failure to wean and continued mechanical ventilatory support.

RESULTS

Thirteen obese patients were identified and consented to the procedure. Bedside percutaneous dilatational tracheostomy was successfully performed in the ICU for all 13 patients. Procedural complications were limited to paratracheal tracheostomy tube placement in one patient, with immediate identification and appropriate correction. Postprocedural complications were limited to a cuff leak in one patient.

CONCLUSION

Bedside percutaneous tracheostomy can be safely performed in obese patients.

Insulin-induced vascular endothelial growth factor expression in retina

PURPOSE

Clinical studies have demonstrated that intensive insulin therapy causes a transient worsening of retinopathy. The mechanisms underlying the initial insulin-induced deterioration of retinal status in patients with diabetes remain unknown. Vascular endothelial growth factor (VEGF) is known to be operative in the pathogenesis of diabetic retinopathy. The current study was conducted to characterize the effect of insulin on retinal VEGF gene expression in vitro and in vivo.

METHODS

The effect of insulin on VEGF expression in vivo was examined by in situ hybridization studies of rat retinal VEGF transcripts. To examine the mechanisms by which insulin regulates VEGF expression, human retinal pigment epithelial (RPE) cells were exposed to insulin, and VEGF mRNA levels were quantified with RNase protection assays (RPAs). Conditioned media from insulin-treated RPE cells were assayed for VEGF protein and capillary endothelial cell proliferation. The capacity of insulin to stimulate the VEGF promoter linked to a luciferase reporter gene was characterized in transient transfection assays.

RESULTS

Insulin increased VEGF mRNA levels in the ganglion, inner nuclear, and RPE cell layers. In vitro, insulin increased VEGF mRNA levels in human RPE cells and enhanced VEGF promoter activity without affecting transcript stability. Insulin treatment also increased VEGF protein levels in conditioned RPE cell media in a dose-dependent manner with a median effective concentration of 5 nM. The insulin-conditioned RPE cell media stimulated capillary endothelial cell proliferation, an effect that was completely blocked by anti-VEGF neutralizing antibody.

CONCLUSIONS

Insulin increases VEGF mRNA and secreted protein levels in RPE cells through enhanced transcription of the VEGF gene. Intensive insulin therapy may cause a transient worsening of retinopathy in patients with diabetes through increased retinal VEGF gene expression.

Enhanced in vivo human immunodeficiency virus-1 replication in the lungs of human immunodeficiency virus-infected persons with Pneumocystis carinii pneumonia

The relationship of serum human immunodeficiency virus-1 (HIV-1) RNA levels to HIV-1 RNA levels in other compartments, such as the lungs, is not well characterized. The purpose of this study was to determine the viral burden of HIV-1 in the lungs by comparing HIV-1 RNA in cell-free bronchoalveolar lavage fluid (BALF) with that in serum. Specimens were examined from 77 HIV-seropositive adults (CD4(+) cell counts: 0 to 700 cells/mm(3); 48% receiving prescribed antiretroviral agents), comprising 43 asymptomatic individuals who were compared with 34 persons with active lung disease caused by Pneumocystis carinii (n = 26), bacteria (n = 3), Mycobacterium avium complex (n = 2), Nocardia sp. (n = 1), Aspergillus sp. (n = 1), or pulmonary Kaposi's sarcoma (n = 1). For serum HIV-1 RNA, the proportion of subjects with detectable levels and the mean values were similar for asymptomatic individuals and persons with active lung disease (85% versus 86%, respectively) (6.64 x 10(4) versus 1. 81 x 10(5) HIV-1 RNA copies/ml; p = 0.13). In contrast, HIV-1 RNA in BALF was more often detected (16% versus 62%; p = 0.001), and mean values were higher (1.04 x 10(5) versus 3.31 x 10(6) HIV-1 RNA copies/ml; p = 0.032), in subjects with active lung disease than in asymptomatic subjects, independent of early or advanced clinical stages of HIV-related disease. For both study groups, HIV-1 RNA levels in BALF exceeded those in serum in 56% of cases by up to 66-fold, and did not correlate with local levels of tumor necrosis factor-alpha, granulocyte-macrophage colony-stimulating factor, or interleukin-16. HIV-1 proviral DNA in cells from BALF was detected in up to 86% of subjects, more frequently in persons with advanced HIV disease (p = 0.0496), and often involved > 10% of BALF cells, but did not correlate with HIV-1 RNA detected in BALF. These data provide evidence for active HIV-1 replication in the lungs. HIV-1 replication is compartmentalized relative to serum, may be restricted, is independent of HIV-1 proviral DNA and clinical stage of HIV, and may be influenced by pulmonary disease such as P. carinii pneumonia or by other local or lung-specific factors. The lungs represent a large reservoir for HIV-1, and may present a source of persistent HIV-1 replication even during periods of apparent clinical latency of HIV-1 infection.

Suppression of hypoxia-associated vascular endothelial growth factor gene expression by nitric oxide via cGMP

PURPOSE

To investigate the suppressive effect of nitric oxide (NO) on vascular endothelial growth factor (VEGF) gene expression and to elucidate its mechanism of action.

METHODS

Immortalized human retinal epithelial (RPE) cells, H-ras-transfected murine capillary endothelial cells, and nuclear factor-kappaB (NF-kappaB) RelA knockout 3T3 fibroblasts had VEGF gene expression stimulated by hypoxia, TPA (phorbol ester 12-O-tetradecanoylphorbol-13 acetate), and ras-transfection. The dose response and time course of inhibition of VEGF gene expression by NO were characterized by northern blot analysis, ribonuclease protection assay, and enzyme-linked immunosorbent assay. The effects of NF-kappaB and cGMP in the NO-induced suppression of VEGF gene expression were quantitated. cGMP production was inhibited by LY 83583 (6-anilino-5,8-quinolinedione), a specific inhibitor of guanylate cyclase production, and cGMP accumulation was quantitated by immunoassay. RelA knockout 3T3 fibroblasts were used to assess the contribution of NF-kappaB to the downregulation of VEGF by NO.

RESULTS

The NO donor sodium nitroprusside (SNP) decreased hypoxia-induced VEGF gene expression in a dose- and time-dependent manner. One hundred fifty micromolar SNP completely suppressed hypoxia-induced VEGF mRNA levels for at least 24 hours. Constitutive VEGF expression was not altered by SNP. The SNP-mediated decreases in VEGF expression were associated with increases in intracellular cGMP and were blocked by LY 83583. Sodium nitroprusside was able to decrease hypoxia-induced VEGF mRNA increases in fibroblasts deficient in the RelA subunit of NF-kappaB. Nitric oxide was also effective at suppressing increased VEGF expression secondan, to mutant ras and TPA.

CONCLUSIONS

These data indicate that NO decreases hypoxia-induced VEGF via a cGMP-dependent mechanism and suggest that NO may serve as an endogenous inhibitor of both hypoxia- and non- hypoxia-enhanced VEGF expression in vivo.

Use of adjunctive corticosteroids in severe adult non-HIV Pneumocystis carinii pneumonia

STUDY OBJECTIVE

To examine the use of adjunctive corticosteroids in cases of severe Pneumocystis carinii pneumonia (PCP) in non-HIV-infected adult patients.

DESIGN

Retrospective review of medical records.

SETTING

Tertiary care urban teaching hospital.

PATIENTS

Review identified 31 consecutive histologically confirmed primary cases of adult non-HIV-related PCP. Complete records were available for 30 patients, including 20 male and 10 female patients with a mean age of 58.3+/-15 years (+/-SD). Underlying conditions included organ transplantation (n=13), long-term immunosuppressive therapy (n=9), and chemotherapy for malignancy (n=8). All patients had documented PO2 <65 mm Hg or arterial oxygen saturation <90% on room air.

INTERVENTIONS

Following the identification of P carinii, in addition to trimethoprim-sulfamethoxazole or pentamidine therapy, 16 patients received increased steroids (> or =60 mg prednisone daily equivalent; increased high-dose steroid group), whereas 14 patients were maintained on a regimen of low doses (< or =30 mg prednisone equivalent daily) or had steroid therapy tapered (low-dose steroid group).

RESULTS

The increased high-dose steroid group demonstrated a shorter required duration for mechanical ventilation (6.3+/-6 days vs 18.0+/-21 days; p=0.047), a shorter duration of ICU admission (8.5+/-7 days vs 15.8+/-8 days; p=0.025), and a shorter duration of supplemental oxygen use (10.0+/-4 vs 32.2+/-33; p=0.05). The hospital duration to discharge for the nine survivors in each group favored the use of corticosteroids (15.4+/-5 days vs 36.3+/-33 days; p=0.077). Similar rates were observed for intubation (75% vs 57%; p=0.442) and in-hospital mortality (44% vs 36%; p=0.722).

CONCLUSIONS

These preliminary data suggest that high-dose adjunctive corticosteroids may accelerate recovery in cases of severe adult non-HIV PCP.

Coming out at night-performing as the lesbian vampire rosie lugosi

Abstract Rosie Lugosi is the lesbian vampire queen of Manchester, an electrifying performance poet, a fang-in-cheek compere and a sultry chanteuse. This article examines what has led to her creation and development: her past incarnations as a Wicked Queen and screaming Goth; the impact of coming out; the discovery of feminism and the importance of the image of the lesbian vampire as defiant rebel.

Aerosolized pentamidine as alternative primary prophylaxis against Pneumocystis carinii pneumonia in adult hepatic and renal transplant recipients

STUDY OBJECTIVE

To examine the safety and efficacy of aerosolized pentamidine (AP) as alternative primary prophylaxis against Pneumocystis carinii pneumonia (PCP) in adult liver and kidney transplant recipients.

DESIGN

Retrospective review of medical records.

SETTING

Tertiary care urban teaching hospital with active liver and kidney transplant programs.

PATIENTS

Adult liver and kidney transplant recipients intolerant of trimethoprim-sulfamethoxazole (TMP-SMX) therapy and referred to the AP clinic between June 1991 and December 1994.

INTERVENTIONS

Each patient received monthly AP, 300 mg, delivered by a nebulizer (Respirgard-II), preceded by inhaled albuterol, 180 micrograms. During the period of follow-up, information related to side effects of AP and incidence of PCP was recorded.

RESULTS

A total of 35 patients were identified, 18 liver and 17 kidney transplant recipients. Fourteen patients received AP as initial prophylaxis because of prior sensitivity to TMP-SMX. In another 19 patients, initial TMP-SMX therapy was discontinued for leukopenia (5), elevated liver function test values (4), rash (3), nausea (2), renal failure (2), seizure (2), and thrombocytopenia (1). In addition, two patients received AP in the setting of organ rejection. Liver transplant recipients received AP for an average of 4.28 +/- 1.6 months, and renal transplant recipients received AP for an average of 5.71 +/- 4.3 months. Adverse effects of AP included bronchospasm (two), dyspnea (one), cough (one), and nausea (one). AP therapy was discontinued in only one patient due to severe bronchospasm. There were no cases of PCP in the 35 patients receiving AP.

CONCLUSIONS

These observations suggest that AP is well tolerated and may be an effective alternative for PCP prophylaxis in adult liver and kidney transplant recipients intolerant to TMP-SMX therapy.

Quantitative culture of HIV-1 from bronchoalveolar lavage cells

Determination of the infectious virus burden at the organ level is critical for understanding the pathophysiology of human immunodeficiency virus type 1 (HIV-1) infection. To evaluate the burden of HIV-1 in the lung, quantitative cultures were performed on bronchoalveolar lavage (BAL) cells from 11 HIV-1 seropositive subjects without respiratory infections and compared with peripheral blood mononuclear cells (PBMC) obtained from the same subjects. Fifty percent (50%) of subjects had positive BAL cell cultures while 82% had positive PBMC cultures. There was much less virus cultured from BAL cells than from PBMCs, whether using phytohemagglutinin (PHA)-stimulated peripheral blood lymphocyte (PBL) targets (p < 0.05) or adherent monocyte targets (p < 0.02). There was no significant difference between the HIV-1 titers obtained for BAL cells whether using PHA-stimulated PBL or adherent monocyte targets (p = 0.13). These studies demonstrate that BAL cell cultures for HIV-1 in subjects without respiratory infections are less frequently positive than PBMC cultures, that less virus can be recovered from BAL cells than from PBMC, and that HIV-1 isolates from BAL cells replicate in both PHA-stimulated PBL targets and adherent monocyte targets. Quantitative assessment of virus burden in the lung is important for future studies of HIV-1 pathogenesis and for evaluating potential antiretroviral therapies aimed at altering the natural history of organ dysfunction associated with retroviral replication.

The effects of covert sensitization on preference for sexual stimuli: a preliminary analogue experiment

Although covert sensitization is a widely and diversely employed clinical technique, there is no generally accepted conceptual guideline for its implementation. Consequently, there is considerable variability in the way covert sensitization procedures are employed, which may account for the reported inconsistency in its clinical effectiveness. The present study is an analogue experimental test of a conceptual account of covert sensitization that is based upon classical conditioning. The classical conditioning procedure is viewed as affecting operant target behaviors by altering the reinforcer effectiveness of target stimuli. This was explicitly tested by examining the effects of covert sensitization on subjects' preference for sexual stimuli in an operant choice paradigm. The results support the conceptual account.

Images of health and medical science conveyed by television

Content analysis was carried out on medical programmes on BBC television over a three-month period. Television medical programmes were shown to concentrate on hospital-based, technological and expert-dependent issues at the expense of primary care and community health. Images of technology, the hospital and the hospital specialist were found to predominate. Issues such as the family, preventive care, housing and the environment were rarely raised. Doctors appeared and spoke in 94 per cent of programmes, whereas nurses were seen (although not necessarily heard) in 30 per cent. Of 70 doctors interviewed on television, nearly three quarters were hospital doctors or scientists. Only one doctor was explicitly referred to as a general practitioner.