Laser tongue base mucosectomy is a useful diagnostic tool in the management of unknown primary cancers of the head and neck region

OBJECTIVE

Tongue base mucosectomy identified cancer in 78 per cent of cancers of unknown primary in a recent meta-analysis. The carbon dioxide laser is an alternative technique if there is no access to a robot. This study aimed to describe the steps for undertaking tongue base mucosectomy using the carbon dioxide laser and its diagnostic utility in cancers of unknown primary.

METHOD

This was a prospective feasibility study utilising carbon dioxide laser for tongue base mucosectomy in cancers of unknown primary. Data collected included demographic data and p16 status.

RESULTS

There were 14 cancers of unknown primary with 86 per cent p16 positivity on immunohistochemistry. Laser tongue base mucosectomy alone identified the cancer primary in 7 of 12 (58 per cent) cancers of unknown primary among p16 positive tumours and 0 of 2 (0 per cent) among p16 negative tumours. Combining bilateral tonsillectomy with laser tongue base mucosectomy resulted in identification of the primary cancer in 8 of 12 (67 per cent) p16 positive tumours.

CONCLUSION

In centres without a robot, tongue base mucosectomy using the carbon dioxide laser is a viable alternative, especially in combination with bilateral tonsillectomy in p16 positive cases.

147 ESTABLISHING A PERI-OPERATIVE MEDICAL SERVICE (POMS) FOR OLDER PEOPLE IN UROLOGY

Background

Older adults account for approximately 65% of patients undergoing urological procedures therefore as the population ages the demand is anticipated to rise. The benefits of Comprehensive Geriatric Assessment (CGA) have been proven in ortho-geriatrics and a number of surgical specialties but evidence in urology is lacking. The aim of this study was to assess the impact of a Peri-Operative Medical Service for older people (POMS) on patient outcomes in a urology inpatient population.

Methods

This was a single-centre retrospective study of patients ≥50 years with length of stay (LOS) >1 day admitted over two four month periods in 2018 (Pre-intervention) and 2019 (Intervention). Group differences in LOS and complications were examined using univariate regressions and then adjusted for sex, emergency admission, severity of procedure and Charlson Co-morbidity Index which also accounts for age. Secondary outcomes were to record undiagnosed medical conditions identified and the interventions made by the POMS.

Results

There were a total of 218 admissions from 211 patients with equal numbers of admissions in both the pre-intervention and intervention groups. No significant differences were detected for LOS (median 3 vs 4 days, p=0.11) or complications (32(29%) vs 40(37%), p=0.23) between pre-intervention and intervention groups. A new medical diagnosis was made in 13 (12%) of the pre-intervention v 43(39%) of the intervention group (p<0.001). The POMS recommended a change to management in 102 admissions (94%). The most common intervention was medication review: 64(59%) v 19(17%) (p<0.001).

Conclusion

The Peri-Operative Medical Service for older people can improve patient management by identifying and managing medical issues, complications and geriatric syndromes that may otherwise have been missed.

96 Adult Nasal Chondromesenchymal Hamartoma: A Rare and Benign Tumour with Aggressive Malignant Transformation

Nasal chondromesenchymal hamartoma (NCMH) is an extremely rare benign tumour of the nasal cavity predominantly described in infants. To date, a total of 59 cases have been described. We report a case involving a 48-year-old female who had been diagnosed with NCMH a year earlier and now represented with a short history of progressive nasal blockage, recurrent epistaxis, and orbital apex syndrome.

Histopathology was suggestive of malignant transformation into sinonasal sarcoma. However, following multi-disciplinary team (MDT) discussions including a second and third opinion from external departments, the histological diagnosis was revised to ‘NCMH with bizarre stromal cells. Despite this, clinically the lesion demonstrated malignant features with rapid, invasive growth and was treated with palliative radiotherapy. The patient later developed radiological signs of lung and liver metastases and subsequent pulmonary emboli. Shortly after this she passed away. This case is unique in its diagnostic challenge, with ambiguous histopathological findings, and highlights the importance of an MDT approach when managing complex sinonasal tumours.

The effect of radiological imaging on treatment delay and hospitalisation in patients with peritoneal dialysis-related peritonitis: A secondary analysis of the PROMPT study

BACKGROUND

In peritoneal dialysis-related peritonitis (peritonitis), delayed antibiotic therapy is associated with adverse outcomes. Identifying barriers to timely treatment may improve outcomes.

AIM

To determine the impact of radiological investigations on treatment delay and predictors of hospitalisation and length of stay (LOS).

METHODS

Retrospective review of patients with presumed peritonitis in Western Australia.

RESULTS

In 153 episodes of peritonitis, 79 (51.6%) resulted in admission with a median LOS of 3 days (Q1, Q3: 1, 6). In a multivariable model, significant predictors of admission were abnormal exit-site (odds ration (OR) 5.7; 95% confidence interval (CI): 1.4, 23.6; p = 0.02), failure to detect a cloudy bag (OR 11.9; 95%CI: 3.2, 44.7; p < 0.001), female sex (OR 3.3; 95% CI: 1.4, 9.7; p = 0.027), radiological imaging within 24 h (OR 8.8; 95% CI: 2.2, 34.8; p = 0.002) and contact with ambulant care facility (OR 0.32, 95% CI: 0.11, 0.98; p = 0.04). Imaging within 24 h of presentation occurred in 41 (27%) episodes of peritonitis, mostly plain X-rays (91%), of which 83% were clinically irrelevant. Imaging performed within 24 h of presentation increased the median time to antibiotic treatment (2.9 h (Q1, Q3: 1.6, 6.4) vs 2.0 h (Q1, Q3: 1, 3.8; p = 0.046)). Imaging performed prior to administering antibiotics significantly increased the median time to treatment (4.7 h (Q1, Q3: 2.9, 25) vs 1.5 h (Q1, Q3: 0.75, 2.5; p < 0.001)) in those where imaging followed antibiotic treatment.

CONCLUSIONS

Half of all presentations with peritonitis result in hospital admission. Radiological imaging was associated with an increased risk of hospitalisation, potentially contributes to treatment delay, and was mostly clinically unnecessary. When required, imaging should follow antibiotic therapy.

Non-mass versus mass-like ultrasound patterns in ductal carcinoma in situ: is there an association with high-risk histology?

AIM

To review the ultrasound (US) patterns of pure ductal carcinoma in situ (DCIS) using a non-mass-like (NML) versus mass-like (ML) classification and to investigate histopathological associations.

MATERIALS AND METHODS

The present study was a retrospective analysis of sonographically evident pure DCIS lesions detected in a mammographic (MG) screening programme over a 7-year period from 2008. All lesions had undergone US-guided 14 G core biopsies with no upgrades to invasive disease on surgical histopathology. Lesions that were three-dimensional with convex margins were classified as ML and all others as NML. ML lesions were subdivided into solid, cystic, or mixed, and NML lesions into ductal and non-ductal. Imaging and pathological characteristics of NML versus ML lesions were investigated using logistic regression.

RESULTS

There were 78 lesions in 75 participants. NML lesions accounted for 45 (58%) lesions, comprising 27 (60%) ductal and 18 (40%) non-ductal subtypes. There were 33 (42%) ML lesions; the largest subgroup being solid (n=21, 64%). Significant associations between lesion type and lesion size on US (<15 versus ≥15 mm), presence of US and mammographic calcification and posterior shadowing on sonography were identified. NML lesions had fivefold higher odds (OR=5.41 95% confidence interval [CI]: 2.03, 14.39, p=0.001) to be high grade and sevenfold higher odds (OR=7 95% CI: 1.75, 27.99, p=0.006) to have comedo necrosis on histopathology.

CONCLUSION

DCIS lesions can be successfully classified using ML and NML lesion descriptors and NML morphology on US is associated with histological features of "high-risk" DCIS.

Effects of postnatal omega-3 fatty acid supplementation on offspring pro-resolving mediators of inflammation at 6 months and 5 years of age: A double blind, randomized controlled clinical trial

BACKGROUND

Resolution of inflammation is an active process involving specialised pro-resolving mediators (SPMs) generated from the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Omega-3 fatty acid supplementation during infancy may provide an intervention strategy to modify SPMs and reduce oxidative stress. This study evaluates the effect of omega-3 fatty acid supplementation in infancy on SPMs and F₂-isoprostanes from 6 months to 5 years of age.

METHODS

In a double-blind, placebo-controlled, parallel-group study design, 420 infants were randomized to a daily supplement of omega-3 fatty acids (280mg DHA and 110mg EPA) or olive oil (control), from birth to age 6 months. Blood was collected at birth (cord blood), 6 months, 12 months and 5 years. Plasma SPMs included 18-HEPE, E-series resolvins, 17-HDHA, D-series resolvins, 14-HDHA, 10S,17S-DiHDoHE, MaR1 and PD1. F₂-isoprostanes were measured in plasma and urine, as markers of oxidative stress in vivo.

RESULTS

The change in the concentration of 18-HEPE from birth to 6 months was greater in the omega-3 fatty acid group (P_{timepoint*group}=0.04) with levels at 6 months significantly higher than controls (P=0.02). Other SPMs were not different between the groups at any time point. Plasma 18-HEPE concentration were associated with erythrocyte EPA concentrations after age and group adjustments (P<0.001), but not with allergic outcomes at 12 months. There were no between-group differences in plasma and urinary F₂-isoprostanes at any time point.

CONCLUSION

Omega-3 fatty acid supplementation from birth to 6 months of age increased SPM at 6 months but the effects were not sustained after supplementation ceased. Given that 18-HEPE is a biologically active metabolite, future studies should examine how the increase in 18-HEPE relates to potential health benefits of omega-3 fatty acid supplementation in infancy.

Effect of expiratory positive airway pressure on tidal volume during non-invasive ventilation

During non-invasive ventilation (NIV), tidal volume ( V_t) will depend upon the difference between inspiratory and expiratory positive airway pressure (IPAP and EPAP, respectively), provided the respiratory muscles are relaxed and the lungs and chest wall therefore move along their passive pressure-volume curves. To test this hypothesis, we studied the effect of increasing EPAP during pressure-controlled modes of NIV in 30 long-term ventilator users (10 each with scoliosis, obesity hypoventilation or neuromuscular disorders). While maintaining the same IPAP, addition of 5 cmH₂O of EPAP reduced mean V_t by 167 ml; 10 cmH₂O reduced V_t by 367 ml. This pattern was seen in all three patient groups. EPAP has several potential advantages, for example maintaining upper airway patency, preventing basal atelectasis and facilitating triggering. EPAP does, however, appear to reduce V_t. Decreasing EPAP is an alternative to increasing IPAP if measurements of gas exchange during NIV indicate that ventilation is inadequate.

Prenatal omega-3 fatty acid supplementation does not affect offspring telomere length and F2-isoprostanes at 12 years: A double blind, randomized controlled trial

BACKGROUND

Oxidative stress and nutritional deficiency may influence the excessive shortening of the telomeric ends of chromosomes. It is known that stress exposure in intrauterine life can produce variations in telomere length (TL), thereby potentially setting up a long-term trajectory for disease susceptibility.

OBJECTIVE

To assess the effect of omega-3 long chain polyunsaturated fatty acid (n-3 LCPUFA) supplementation during pregnancy on telomere length and oxidative stress in offspring at birth and 12 years of age (12y).

DESIGN

In a double-blind, placebo-controlled, parallel-group study, 98 pregnant atopic women were randomised to 4g/day of n-3 LCPUFA or control (olive oil [OO]), from 20 weeks gestation until delivery. Telomere length as a marker of cell senescence and plasma and urinary F2-isoprostanes as a marker of oxidative stress were measured in the offspring at birth and 12y.

RESULTS

Maternal n-3 LCPUFA supplementation did not influence offspring telomere length at birth or at 12y with no changes over time. Telomere length was not associated with F2-isoprostanes or erythrocyte total n-3 fatty acids. Supplementation significantly reduced cord plasma F2-isoprostanes (P<0.001), with a difference in the change over time between groups (P=0.05). However, the differences were no longer apparent at 12y. Between-group differences for urinary F2-isoprostanes at birth and at 12y were non-significant with no changes over time.

CONCLUSIONS

This study does not support the hypothesis that n-3 LCPUFA during pregnancy provides sustained effects on postnatal oxidative stress and telomere length as observed in the offspring.

Long-term non-invasive ventilation in muscular dystrophy

Long-term non-invasive ventilation (NIV) was introduced in the 1980s, initially mainly for patients with poliomyelitis, muscular dystrophy (MD) or scoliosis. The obesity-hypoventilation syndrome has since become the commonest reason for referral to most centres providing home-NIV. Patients with MD are numerically a much smaller part of the workload, but as their disease progresses the need for ventilatory support changes and they require regular comprehensive assessment of their condition. We have examined the trend in MD use of home-NIV in our unit over the last 25 years. The number of new referrals appears to be stabilizing at around 20-25 over a 5-year period, equivalent to approximately 0.5 per 100,000 of population per year. The mean age at commencement of home-NIV is now 37.5 years, with 5-year survival rates of 70-75%. Ten-year survival rates are just over 40%. The distance of usual place of residence from our unit is fairly stable, currently at a mean of 27 km. Excellent survival rates mean that patients with MD, while numerically small, are likely to remain an important part of the workload of centres providing home-NIV. Our data should prove useful in the planning of future services for this group of patients.

EBV & HHV6 reactivation is infrequent and not associated with MS clinical course

BACKGROUND

Among the environmental factors associated with multiple sclerosis (MS) causation, some of the strongest associations are with Epstein-Barr virus (EBV), and to a lesser extent human herpesvirus 6 (HHV6). Associations with clinical course are less conclusive, however.

METHODS

We evaluated serum anti-EBV-EA-R IgG and anti-HHV6 IgM, and EBV and HHV6 viral load (VL) for their associations with relapse, disability, and progression in disability in a prospective cohort of 198 participants with clinically definite MS.

RESULTS

Anti-EBV-EA-R IgG was detected in 81.8% of cases at study entry, and titers remained essentially unchanged during the study. Anti-HHV6 IgM was detected in only one participant, and EBV-VL (29%) and HHV6-VL (1.8%) were detected in a minority of samples, and where detected levels were low. Our previously demonstrated association between anti-HHV6 IgG and relapse hazard was not affected by adjustment for parameters of reactivation. We found no evidence that any of the viral markers were associated with disability or progression in disability. In relation to relapse, only EBV-VL was positively associated, although this was strongly influenced by a single individual.

CONCLUSION

Using a prospective cohort design, we found no convincing evidence that reactivation parameters of EBV or HHV6 were associated with subsequent MS relapse hazard or progression in disability, confirming previous findings, and indicating that herpesvirus reactivation is not an important driver of relapse or disability in this established MS population.

Socio-economic inequalities in suicide attempts and suicide mortality in Québec, Canada, 1990-2005

OBJECTIVES

Little research has evaluated changes in the association between area deprivation and suicidal behaviour over time. This study investigated patterns in suicide attempts and suicide mortality according to material deprivation in the province of Québec, Canada between 1990 and 2005.

STUDY DESIGN

Ecological analysis.

METHODS

Data on suicide attempts were extracted from the hospital discharge summary database (n=47,516) and data on suicides were extracted from the Québec death file (n=20,851). Gender- and age-specific (10-24, 25-44, 45-64 and > or = 65 years) suicide attempt and mortality rates were calculated for four time periods (1990-1993, 1994-1997, 1998-2001 and 2002-2005) for the entire Québec population aged 10 years and older residing in 162 communities ranked by decile of material deprivation. Absolute and relative measures of inequality were calculated to summarize differences between the most and least materially deprived areas. Commonly used methods of suicidal behaviour were examined.

RESULTS

Differentials in suicide attempt hospitalization between the most and least deprived areas were present for all age groups, and these decreased slightly among males and increased among females over time. Inequalities in suicide attempts were greatest among young adults (age 25-44 years) for both genders, and were smallest among the elderly (> or = 65 years). For suicide mortality, differentials increased among females but not males; these differentials were greatest among males and 25-44 year olds, and smallest among the elderly. Differentials in commonly used methods were evident for poisoning hospitalizations in both genders and for hanging deaths among males.

CONCLUSIONS

In Québec, differences in suicide attempts and mortality between the most and least materially deprived areas persisted or even increased over time. Inequalities were more pronounced for suicide attempts than for suicide mortality, and were greatest among adults of working age. Strategies to reduce socio-economic differences in suicidal behaviour may be important.

A review of the safety of tooth bleaching

This article considers the safety of tooth bleaching based on a Medline search of clinical, animal and in vitro studies between 1986 and 2007.

CLINICAL RELEVANCE

Bleaching is the least invasive option for improving tooth colour compared to alternatives such as crowns and veneers. However, no dental procedure is without risk and the clinician should be aware of the safety issues and adverse effects of tooth bleaching so that patients can be fully informed.

Determination of suicide in South Africa: medical practitioner perspectives

Decisional processes underlying the determination of a suicide in the largest injury surveillance system currently available in South Africa are assessed through face-to-face semi-structured interviews with 32 medical practitioners involved in the system. Focus is placed on their current work circumstances and practices, and views of operational and empirical criteria proposed by US experts. Common themes and discrepancies in opinions emerged regarding the quality of the data currently available for suicide determinations, and regarding the importance and difficulty in assessing the US-developed criteria in South Africa. A truly standard approach is unlikely without considerable changes to the medico-legal system.

A group randomised trial of two methods for disseminating a smoking cessation programme to public antenatal clinics: effects on patient outcomes

OBJECTIVE

To assess the differential effectiveness of two methods of disseminating a smoking cessation programme to public hospital antenatal clinics.

DESIGN

Group randomised trial.

SETTING

22 antenatal clinics in New South Wales, Australia.

INTERVENTION

Clinics were allocated to a simple dissemination (SD) condition (11 clinics) which received a mail-out of programme resources or to an intensive dissemination (ID) condition (11 clinics) which included the mail-out plus feedback, training, and ongoing support with midwife facilitator.

MAIN OUTCOME MEASURES

Independent cross sectional surveys of women on a second or subsequent visit undertaken pre-dissemination and 18 months after dissemination. Outcomes were: (1) levels of smoking status assessment by clinic staff; (2) proportion of women identifying as having been smokers at their first visit who reported receiving cessation advice; (3) proportion of these women who had quit (self report and expired air carbon monoxide (CO)); and (4) smoking prevalence among all women (self report and CO).

SUBJECTS

5849 women pre-dissemination (2374 SD, 3475 ID) and weighted sample of 5145 women post-dissemination (2302 SD, 2843 ID).

RESULTS

There were no significant differences between the groups on change on any outcome. Change in either group was minimal. In the post-dissemination survey, the cessation proportions were 6.4% (SD) and 10.5% (ID).

CONCLUSIONS

Relatively modest strategies for encouraging incorporation of smoking cessation activities into antenatal care were not effective in the long term. Alternative strategies should be implemented and evaluated. The findings reinforce the importance of a whole population approach to tobacco control.

The share of suicide in injury deaths in the South African context: sociodemographic distribution

This study describes the sociodemographic distribution of suicide deaths compared with other injury deaths in South Africa. Cross-sectional data for 26,354 cases were extracted from an injury surveillance database. These included all manners of injury death from 10 mortuaries for 1999-2000 (approximately 18-20% coverage of all injury deaths per year). They were used to examine the distribution of suicide across different sex, race and age groupings, and the relative involvement of alcohol across manners of death. The share of suicide as a cause of death was comparable for males and females, but varied considerably across races and age groups. It was twice as high for Whites as for Asians, and four times as high as for Coloureds and Blacks. For all races except Whites, suicides were concentrated in the younger age groups. Only among Whites was the proportion of alcohol-positive suicides higher or comparable with that for other manners of death. While homicides and unitentional injury deaths outnumbered suicides overall, the relative importance of suicide in some social groups is reason for concern. South Africa is a country undergoing profound transformations, and differences in the distribution of suicide across sociodemographic groups deserve attention.

The South African National Non-Natural Mortality Surveillance System--rationale, pilot results and evaluation

BACKGROUND

While individual mortuaries have recorded data for non-natural deaths in time-limited studies, there have been no systematic efforts to draw forensic-medical services and state mortuaries into a nationwide fatal injury surveillance system. Beginning in June 1998, the National Non-Natural Mortality Surveillance System (NMSS) commenced pilot operation.

OBJECTIVE

To evaluate the NMSS and illustrate its utility from sample findings.

DESIGN

Data entered into the system by mortuary staff were checked against a random sample of cases for which separate forms were completed by an independent researcher. Process observations and follow-up with data users were used to assess the system's acceptability, timeliness and data usefulness.

SETTING

Eighteen mortuaries in six provinces representing approximately 35,000 cases per year, or around 50% of all non-natural deaths.

PARTICIPANTS

The National Departments of Health; Safety and Security; and Arts, Culture, Science and Technology; national and provincial forensic medico-legal services; the South African Police Services; universities and science research councils.

MAIN OUTCOME MEASURES

Surveillance system simplicity, flexibility, acceptability, sensitivity, positive predictive value, representativeness, timeliness, data usefulness and resources.

RESULTS

The NMSS was established at 10 target sites. Lack of equipment, personnel resistance, and closure of some mortuaries prevented implementation in the remaining eight mortuaries. Sensitivity was internally assessed and ranged from 65% to 95% for manner of death. Positive predictive value was also internally measured, and ranged from 74% to 80% for manner of death and from 71% to 82% for mechanism of death. Timeliness was good, and basic reports covering most items were available 6 weeks after a case had been examined. While staff found the system simple, acceptability depended on the individuals involved at different mortuaries, and the system was compromised to some extent by bureaucratic barriers. End users found the data to be of great value. NMSS set-up costs totalled approximately R26,000 per mortuary, and it is estimated that maintenance costs will be R8.00 per case registered.

CONCLUSIONS

With minimal resources, the NMSS uses existing investigative procedures to describe and report the epidemiology of fatal injuries. The pilot study demonstrates the feasibility of the system, and identifies the need to remove organisational constraints and individual barriers if it is to be sustained and expanded beyond the pilot sites.

The Southeast Florida AIDS Information Network: a community outreach, specialized information system

In the years ahead, end-user instruction will expand from the current models of curriculum- and institution-based programs for teaching MEDLINE to include outreach programs to unaffiliated users for teaching specialized database searching. The Southeast Florida AIDS Information Network (SEFAIN), a community-based information system targeting health care providers in a tri-county area, is an example of this new model. The components of SEFAIN and the results of the outreach and educational programs are presented. The advantages of these programs to both providers and librarians are highlighted. Comparisons are drawn between end users who take specialized information courses and those who take MEDLINE courses or no courses. These data will assist librarians in the justification and development of specialized information systems.

Perceived needs of women diagnosed with breast cancer: rural versus urban location

OBJECTIVE

To assess the prevalence and predictors of perceived unmet needs among women diagnosed with breast cancer, with a particular focus on the impact of location (rural/urban).

METHOD

A random sample of women in NSW diagnosed with breast cancer was surveyed during 1995-96. The Breast Cancer Patients' Needs Questionnaire (BR-CPNQ) explores patients' perceived needs across five domains: psychological, health information, physical/daily living, patient care/support and interpersonal communication. Items assessing breast cancer specific needs and access to services and resources were included. Of 235 eligible rural women, 134 (57%) consented to participate and 129 (55%) returned completed surveys. Of 196 eligible urban women, 102 (52%) consented to participate and 100 (51%) returned completed surveys.

RESULTS

For 12 of the 52 items, at least one-third of the sample reported ever having a moderate/high need for help. Of the 15 highest moderate or high unmet needs, 10 related to health information and three to psychological needs. There were few differences in the prevalence of needs reported by rural and urban women. Only in the physical/daily living domain were rural women more likely than urban women to report some need for help (OR = 2.59, 95% CI 1.21-5.52).

CONCLUSIONS

Unmet needs, particularly in the information and psycho-social domains, are reported by both rural and urban women with breast cancer, with sub-groups experiencing different types of needs.

IMPLICATIONS

There is a need to develop and trial targeted and innovative strategies to meet the health information and psychological needs of women with breast cancer, and the physical/daily living needs of rural women diagnosed with breast cancer.

Randomized comparative trial of nicotine polacrilex, a transdermal patch, nasal spray, and an inhaler

BACKGROUND

There are several nicotine replacement products on the market, and physicians are likely to be asked with increasing frequency about which of these products their patients should use.

OBJECTIVE

To provide a basis for rational advice by comparing nicotine polacrilex (gum), a transdermal patch, nasal spray, and an inhaler.

DESIGN

Randomized trial with assessments at the quit date and 1, 4, and 12 weeks later.

SETTING

Hospital smokers' clinic.

PATIENTS

Male and female community volunteers (N = 504) smoking 10 or more cigarettes per day and seeking help to stop smoking.

INTERVENTIONS

Patients were given brief advice, and purchased their nicotine replacement treatment at approximately half the regular retail price.

MAIN OUTCOME MEASURES

Nicotine replacement treatment use, ratings of withdrawal symptoms, ratings of product characteristics and helpfulness, and biochemically validated continuous lapse-free abstinence.

RESULTS

The products did not differ in their effects on withdrawal discomfort, urges to smoke, or rates of abstinence. The continuous validated 12-week abstinence rates were 20%, 21%, 24%, and 24% in the gum, patch, spray, and inhaler groups, respectively. Compliance with recommended nicotine replacement treatment use was high for the patch, low for gum, and very low for the spray and the inhaler. The spray was underused because of adverse effects more often than the other products. In the subjects using the spray, the level of use among abstainers at week 1 predicted outcome at week 12. The inhaler was rated as more embarrassing to use than the other products, but provided at least as much nicotine as the gum.

CONCLUSION

When asked about nicotine replacement treatment products available, physicians should note that, despite low compliance with the recommended dose of the spray and inhaler and differences in product ratings, overall, there are no notable differences between the products in their effects on withdrawal discomfort, perceived helpfulness, or general efficacy.

Extreme DNA sequence variation in isolates of Aspergillus fumigatus

DNA sequence analysis of the alkaline protease gene was used to investigate two Aspergillus fumigatus strains isolated from ostriches (QLD1 and NSW3) and one environmental isolate (FRR 1266) that have shown genetic variation in previous analyses. The results showed that the QLD1 sequence was virtually identical to the published sequences for three human isolates but NSW3 differed in > 6% and FRR 1266 in > 10% of the nucleotides that were analysed. An RFLP assay was designed to determine the distribution of these (and other) genetic variants among environmental and clinical isolates of A. fumigatus.

Control of porcine lacrimal gland secretion by non-cholinergic, non-adrenergic nerves: effects of electrical field stimulation, VIP and NPY

This study employs the technique of electrical field stimulation (EFS) to characterise the effects of endogenous neurotransmitters on protein secretion in the in vitro pig lacrimal gland. The effects of exogenous applications of neurotransmitters on protein output and peroxidase secretion were also investigated for comparative purposes. EFS evoked frequency-dependent (5-20 Hz) increases in protein secretion. The EFS-evoked protein output was abolished with the nerve blocking drug tetrodotoxin (10(-6) M, TTX). Elevated potassium (100 mM KCl) can stimulate protein output in the presence of TTX. Exogenous application of either acetylcholine (ACh, 10(-9)-10(-4) M) or noradrenaline (NA, 10(-8)-10(-4) M) can also result in protein secretion, but they have no detectable effect on peroxidase secretion. In the presence of the cholinergic antagonist, atropine (10(-5) M) the EFS-induced protein output was reduced but not abolished. This atropine-resistant and non-cholinergic nerve-mediated component was further reduced in the combined presence of atropine, phentolamine, and propranolol (all 10(-5) M). When vasoactive intestinal polypeptide (VIP) receptor antagonist (10(-6) M [4-Cl-D-Phe6-Leu17]-VIP) was combined with the cholinergic and adrenergic antagonists, EFS caused a small but detectable increase in protein output. Exogenous application of either 10(-9) M VIP or 10(-9) M neuropeptide-Y (NPY) resulted in protein secretion. Combination of both VIP and NPY only induced an additive effect on protein output. Theophylline (10(-4) M), a phosphodiesterase inhibitor, evoked a small increase in protein output and had no significant effect on the secretory responses elicited by either VIP or NPY. In contrast, theophylline potentiated the non-cholinergic, non-adrenergic EFS-induced protein secretion. The results indicate that protein secretion from the porcine lacrimal gland may be controlled by cholinergic, adrenergic and non-cholinergic, non-adrenergic nerves. The peptidergic neurotransmitters may be VIP and other related neuropeptide(s). In addition to these neurophysiological studies, our results confirm previous findings that the porcine lacrimal nerves contain abundant quantity of NPY and VIP.

Outpatient pulmonary rehabilitation in severe chronic obstructive pulmonary disease

BACKGROUND

This is a study of an outpatient programme for rehabilitation of patients with severe ventilatory impairment due to chronic obstructive pulmonary disease (COPD). Its main purpose was to assess the feasibility of such a programme and so no control group was included.

METHODS

The study included 44 patients (28 men) of mean age 66 years with COPD. They all had severe ventilatory impairment as defined by a forced expiratory volume in 1 second (FEV1) less than 40% of predicted. Initial assessment included a shuttle walking test, the Chronic Respiratory Disease Questionnaire (CRDQ), the Hospital Anxiety and Depression scale (HAD) and the Sickness Impact Profile (SIP). The patients then entered a 6-week outpatient programme during which they attended twice weekly for a 2 1/2 hour session. Assessment was repeated on completion of the study (the 3 1/2 month assessment) and at 6 months.

RESULTS

The shuttle walking distance improved significantly and was maintained at the improved level for 6 months. The improvement in all four dimensions of the CRDQ was statistically significant and reached clinical significance for fatigue and for mastery. On entry, a notable level of depression was found in 32% of patients, and of anxiety in 40%. There was significant reduction in both of these which was maintained at 6 months. There was no improvement in the SIP at 3 months, but significant improvement was found at 6 months.

CONCLUSIONS

This study shows that a successful outpatient programme can be conducted in patients with severe ventilatory impairment, and that apparent benefit in physical ability and in health-related quality of life can be achieved. The improvements were maintained at 6 months.

Sequence variation of cytotoxic T cell epitopes in different isolates of Epstein-Barr virus

Previous results have identified two distinct cytotoxic T lymphocyte (CTL) epitopes encoded by Epstein-Barr virus (EBV), TETA (ORF BLRF3/BERF1 residues 329-353) and EENL (ORF BERF3/BERF4 residues 290-309). Measurement of the specificities of CTL clones (TETA-specific clone 13 and EENL-specific clone 7) directed against these epitopes indicated that the EENL epitope is conserved in all strains of EBV tested while the TETA epitope varied between individual virus strains. Sequencing of the DNA regions encoding these two CTL epitopes in different EBV isolates confirmed these interpretations and demonstrated that different TETA epitope sequences were encoded by B-type EBV strains and by the B95-8 isolate of EBV compared to the other A-type EBV strains. Titration of synthetic variants of the TETA epitope revealed that the epitope encoded by B95-8 was 15-fold less efficient as a T cell epitope than the sequence encoded by other A-type viral strains while the TETA variant encoded by the B-type strains displayed essentially no activity as a T cell epitope.

An intrapreneurial approach to integrating information production services into an academic medical center library

The many challenges faced by health sciences libraries of all types and sizes often require innovative solutions. When an innovative solution involves calculated risk taking, the approach is called intrapreneurial. At the University of Miami School of Medicine, an intrapreneurial approach solved the fiscal problems of the biomedical communications unit. The Louis Calder Memorial Library inherited these problems when the Department of the Library and Biomedical Communications was created in the early 1980s. In this paper, two intrapreneurial programs are described, and the benefit and suitability of this management style to information services are demonstrated.

Lymphokine-activated killer (LAK) cells discriminate between Epstein-Barr virus (EBV)-positive Burkitt's lymphoma cells

We have generated in vitro lymphokine-activated killer (LAK) cells from healthy donors by stimulating their mononuclear leukocytes with recombinant interleukin-2 (rIL-2) (100 U/ml). After 6 days in culture, the lytic properties of the LAK cells were analyzed in the 51Cr-release assay by utilizing a target panel of 6 paired lines consisting of an Epstein-Barr virus (EBV)-positive Burkitt's lymphoma (BL) cell line and an EBV-transformed lymphoblastoid cell line (LCL) from the same donor, the Raji BL line and the natural killer (NK) cell-sensitive K562 line. The patterns of lysis showed that the LAK cells discriminated between two categories of BL cell lines. Group I/II BL tumor cells which expressed the common acute lymphoblastic leukemia antigen (CALLA), the BL-associated glycolipid antigen (BLA) and phenotypically resembled biopsy cells were strongly lysed whereas group III BL cells which had assumed an LCL-like phenotype during culture and lacked the CALLA and BLA surface markers were only poorly lysed. The LCL targets were generally resistant to lysis but the K562 cell line was particularly sensitive. The outcome of cell depletion and monoclonal antibody (MAb) studies indicated that the LAK cell populations were phenotypically and functionally heterogeneous and consisted of at least 2 subpopulations of effector cells; a tumor-specific component and an NK-cell-mediated component.

Effect of glucose tablets on craving for cigarettes

Clients attending a smokers clinic were randomly allocated to two groups to assess the effects of glucose tablets in reducing craving for cigarettes. Smokers who had already been abstinent for 1 week were eligible to take part in the study. All subjects completed rating relating to urge to smoke and craving. Then subjects in one group were given packets of dextrose tablets and those in the other group were given packets of tablets containing sorbitol (a low calorie sweetener). Ratings of urges to smoke and craving were taken after 1 week, during which time the subjects had been asked to chew their tablets ad lib. Eight out of ten smokers in each group maintained abstinence. The remaining two smokers either did not abstain or did not turn up for the second measurement session. There was a significant reduction in ratings of urges to smoke and craving in the glucose group compared with the sorbitol group. These results support a theory postulating a link between glucoregulation and cigarette craving. If the results are replicated and it is shown that the reduction in craving translates into improved abstinence rates, oral glucose could be of assistance to smokers wishing to give up.

A strategy for curriculum integration of information skills instruction

The ever increasing need of health professionals for information and the inclusion of active learning experiences in the medical school curriculum require that students learn the effective use of health information tools. Curriculum integration is gaining acceptance as an effective approach to teaching information skills in this setting. At the University of Miami School of Medicine, information skills components taught by library faculty are integrated into the Freshman Orientation Program and two sophomore curriculum courses. Beginning with a core set of skills and basic information management tools, more complex and subject-specific skills are introduced sequentially throughout the basic sciences curriculum. During the first two years, a wide range of information skills are taught, and students receive many opportunities to seek and identify information using both printed sources and computerized bibliographic databases. This paper describes how curriculum integration of information skills instruction was achieved and the many benefits of this approach. Included are a description of the information skills components, evaluation data, and future plans.