The Effect of Increasing Two-Week Wait Referrals for Head and Neck Cancer in East Kent

In 1998 the UK government published its white paper The New NHS: Modern and Dependable, in which it first suggested that patients being referred with a suspicion of cancer should have a maximum wait of two weeks to see a specialist. The rationale for this was that outcomes for late-stage disease are significantly worse when compared with outcomes for early-stage disease (Table 1). It was assumed that reducing the wait to see a specialist would reduce the stage of disease at presentation.

Nursing sisters' satisfaction with the pharmacy service — a survey

A questionnaire was sent to all nursing sisters in Hammersmith and Queen Charlotte's special health authority, a provider of specialist hospital services in London. They were asked for their overall impression of the pharmacy service and staff, for their opinions of specific services and for suggestions for improving the service. Eighty-six per cent of respondents thought the service was good, very good or excellent and 92 per cent thought the service was either the same or better than that of other hospitals in which they had worked.

Just under half the suggestions received were for service improvements related to supply of drugs stocked on the ward. The other main areas commented on were drug delivery, discharge medication and the pharmacy on-call service. The survey provided useful information about the pharmacy service and has enabled the department to implement some of the changes suggested as well as look at the feasibility of other improvements. It is intended to repeat this survey annually.

Fabrication And Characterization of Thermoelectric Generators From SiGe Thin Films

Thermoelectric materials are being important due to their application in both thermoelectric power generation and microelectronic cooling. The thermoelectric power generations convert the heat change to electricity. The waste of heat could be useful if the thermoelectric power generation is applied. Effective thermoelectric materials have a low thermal conductivity and a high electrical conductivity. A high thermal conductivity causes too much heat leakage through heat conduction. The performance of the thermoelectric materials and devices is shown by a dimensionless figure of merit, ZT = S2σT/K, where S is the Seebeck coefficient, σ is the electrical conductivity, T is the absolute temperature and K is the thermal conductivity. ZT can be increased by increasing S, increasing σ, or decreasing K. In this study, we prepared thermoelectric generator devices of SiGe at the thickness of 112 nm using the ion beam assisted deposition (IBAD) system. Rutherford Backscattering Spectrometry (RBS) analysis was used for the elemental analysis. The 5 MeV Si ion bombardment was performed using the AAMU Pelletron ion beam accelerator to make quantum clusters in the film to decrease the cross plane thermal conductivity, increase the cross plane Seebeck coefficient and electrical conductivity. To characterize the thermoelectric generator devices before and after Si ion bombardment we measured the cross plane Seebeck coefficient, electrical conductivity by Van der Pauw method, and thermal conductivity by 3w method for different fluences.

Recurrence risk of stillbirth in a second pregnancy

OBJECTIVE

To examine the risk of recurrence of stillbirth in a second pregnancy.

DESIGN

Retrospective cohort study.

SETTING

Scotland, UK.

POPULATION

All women who delivered their first and second pregnancies in Scotland between 1981 and 2005.

METHODS

All women delivering for the first time between 1981 and 2000 were linked to records of their second pregnancy using routinely collected data from the Scottish Morbidity Returns. Women who had an intrauterine death in their first pregnancy formed the exposed cohort, whereas those who had a live birth formed the unexposed cohort.

MAIN OUTCOME MEASURE

Stillbirth in a second pregnancy.

RESULTS

After adjusting for confounding factors, the odds of recurrence of stillbirth in a second pregnancy were found to be 1.94 (99% CI 1.29-2.92) compared with women who had had a live birth in their first pregnancy. Other factors associated with recurrence of stillbirth in a second pregnancy included placental abruption (adjusted OR 1.96; 99% CI 1.60-2.41), preterm delivery (adjusted OR 7.45; 99% CI 5.91-9.39) and low birthweight (adjusted OR 6.69; 99% CI 5.31-8.42). A Bayesian analysis using minimally informative normal priors found the risk of recurrence of stillbirth in a second pregnancy to be 1.59 (99% CI 1.10-2.33).

CONCLUSIONS

Women who have stillbirth in their first pregnancy have a higher risk of recurrence in their next pregnancy.

Automatic spike sorting for neural decoding

While various automated spike sorting techniques have been developed, their impact on neural decoding has not been investigated. In this paper we extend previous Gaussian mixture models and expectation maximization (EM) techniques for automatic spike sorting. We suggest that good initialization of EM is critical and can be achieved via spectral clustering. To account for noise we extend the mixture model to include a uniform outlier process. Automatically determining the number of neurons recorded per electrode is a challenging problem which we solve using a greedy optimization algorithm that selects models with different numbers of neurons according to their decoding accuracy. We focus on data recorded from motor cortex and evaluate performance with respect to the decoding of hand kinematics from firing rates. We found that spike trains obtained by our automated technique result in more accurate neural decoding than those obtained by human experts.

Measuring laparoscopic operative skill in a video trainer

BACKGROUND

Laparoscopic surgery requires a unique set of technical skills. More experienced laparoscopic surgeons perform certain tasks more efficiently in a video trainer than less experienced laparoscopic surgeons. The presumption is that the experienced surgeon possesses more of the skill required to complete the task. This study sought to determine the degree to which previous laparoscopic operative experience influenced the performance of selected video trainer tasks of varying complexity.

METHODS

In this study, 19 general surgery residents with varying levels of laparoscopic operative case experience (as defined by operative case logs) were timed performing five tasks in a video trainer. The tasks were rope pass, peg drop, peg exchange, needle pass, and knot tie. All the residents watched a video demonstration of each skill before testing. None of the residents had previous exposure to video trainers, and no practice was allowed before testing. A composite score for all tasks was calculated for each resident as a measure of overall performance.

RESULTS

There was a strong correlation between operative experience and time required for successful completion of each task, with the exception of the rope pass. The magnitude of correlation increased with tasks of increasing complexity. Composite scores were correlated with operative experience. Significant interval improvements in performance were observed for increasing experience up to a level of approximately 100 previous laparoscopic cases.

CONCLUSIONS

Overall composite scores and time required for the completion of each individual video trainer task (with the exception of the rope pass) may be an accurate reflection of laparoscopic surgical skill acquired in the operating room. A resident may need as many as 100 laparoscopic cases for full development of a basic skill set in the operating room. A more efficient and safe method of training, such as a validated skills curriculum conducted in a dry lab, is a desirable alternative to developing skill exclusively in the operating room.

Drug related deaths amongst Glasgow city hostel dwellers

The problems of homelessness and drug misuse are every day issues encountered in today's society. Over the past 2 years the number of hostel residents overdosing within their rooms in the city of Glasgow was shown to increase. Approximately three-quarters of deaths involved heroin, of which 56% also involved at least one benzodiazepine. This paper demonstrates a dearth in the literature relating to drug misuse amongst the homeless population, highlighting an area in need of address by the appropriate authorities.

The impact of past alcohol use on treatment response rates in patients with chronic hepatitis C

BACKGROUND

Studies have shown that past alcohol consumption reduces response rates in patients with chronic hepatitis C treated with interferon monotherapy.

AIM

To clarify the importance of alcohol consumption on response rates in patients undergoing treatment with pegylated interferon and ribavirin.

METHODS

In a single centre, prospective study, median daily alcohol consumption (determined by previously validated method) and quartiles of alcohol consumption were calculated. Univariate and binary logistic regression analyses were performed using treatment response status as the dependent variable.

RESULTS

Overall, in an intention-to-treat analysis, 34 of 115 patients (30%) responded to treatment. In univariate analysis, black patients, especially those with hepatitis C virus genotype 1, high viral load and low alanine aminotransferase were significantly less likely to respond. Predictors of response by regression analysis included alcohol <30 g/day (OR=3.02, 95% CI: 1.02-8.93; P=0.04), non-genotype 1 status (OR=1.98, 95% CI: 1.03-3.80; P=0.04) and non-black race (OR=2.79, 95% CI: 1.33-5.85; P=0.006).

CONCLUSIONS

Median daily alcohol use >30 g/day is associated with failure to respond to pegylated interferon and ribavirin for treatment of hepatitis C. Past alcohol use should be evaluated when considering treatment for hepatitis C.

Number II Pemphigus vulgaris

Pemphigus is a group of potentially life-threatening autoimmune diseases characterized by cutaneous and/or mucosal blistering. Pemphigus vulgaris (PV), the most common variant, is characterized by circulating IgG antibodies directed against desmoglein 3 (Dsg3), with about half the patients also having Dsg1 autoantibodies. There is a fairly strong genetic background to pemphigus with linkage to HLA class II alleles and ethnic groups such as Ashkenazi Jews and those of Mediterranean and Indian origin, are especially liable. Oral lesions are initially vesiculobullous but readily rupture, new bullae developing as the older ones rupture and ulcerate. Biopsy of perilesional tissue, with histological and immunostaining examination are essential to the diagnosis. Serum autoantibodies to either Dsg1 or Dsg3 are best detected using both normal human skin and monkey oesophagus or by enzyme-linked immunosorbent assay. Before the introduction of corticosteroids, PV was typically fatal mainly from dehydration or secondary systemic infections. Current treatment is largely based on systemic immunosuppression using corticosteroids, with azathioprine or other adjuvants or alternatives but newer therapies with potentially fewer adverse effects, also appear promising.

Dietary soy protein and isoflavones: no effect on the reproductive tract and minimal positive effect on bone resorption in the intact female Fischer 344 rat

Our previous study evaluating 3 months of feeding soy protein or isoflavones (IF) to intact adult Sprague-Dawley (SD) rats showed no change in bone and the vagina but occasional extensive squamous metaplasia of the uterine glandular epithelium was observed. The current study was designed to characterize further these effects of soy protein or IF on the uterus using the Fischer 344 (F344) rat, a known high responder strain to estrogenic stimuli. Three-month-old intact F344 rats were divided into five groups and fed diets containing either casein, low or high amount of soy protein or casein with low or high amount of IF extract. Body weight, urinary deoxypyridinoline (Dpyr), bone mineral density (BMD) of the femur and lumbar, uterine wet weight and histology of the reproductive tract were evaluated. No significant difference was seen in bone parameters between control and treatment groups except for a lower Dpyr in the high soy and a higher lumbar BMD in the low soy groups. No alteration was seen in the reproductive tract of all treatment groups. Contrary to our hypothesis, the present results suggest that the uterus of the F344 strain is less sensitive to dietary soy protein and IF than that of the SD strain.

Dietary soy protein and isoflavones have no significant effect on bone and a potentially negative effect on the uterus of sexually mature intact Sprague-Dawley female rats

OBJECTIVE

To evaluate the effect of dietary soy protein and isoflavones on bone and the reproductive tract in premenopausal rats.

DESIGN

Three-month-old intact Sprague-Dawley female rats (N = 50) were fed diets containing casein, soy protein, or casein with isoflavone extract for 12 weeks. The amount of casein, soy protein, and extract (per kilogram diet) in each group was: (1) 200 g casein (control); (2) 100 g casein plus 100 g soy protein (low soy); (3) 200 g soy protein (high soy); 4) 200 g casein plus 17.2g extract (low extract); and (5) 200 g casein plus 34.4 g extract (high extract). Diet consumption, body weight, uterine wet weight, urinary deoxypyridinoline concentration, and bone mineral density of the femur and lumbar vertebrae were measured. Femur rigidity was evaluated by histomorphometry. The uterus and vagina were studied histologically.

RESULTS

Rats in all treatment groups had lower body weights and lower deoxypyridinoline concentrations compared with controls, but none of the differences was statistically significant. There was no significant difference in femur and lumbar bone mineral density, uterine wet weights, or histomorphometry between the control and treatment groups. Histologically, uteri and vaginae were normal in all groups except that 1 of 10 rats in the high-soy group and 2 of 10 rats in the high-extract group showed extensive squamous metaplasia in the uterine gland.

CONCLUSION

These results suggest that dietary isolated soy protein and isoflavones have no effect on bone and the vagina during premenopausal period, but may have an adverse effect on the uterus.

Number 1Epithelial biology

The oral mucous membrane has features similar to skin but also differs in several ways. This paper reviews the aspects of epithelial biology necessary for an understanding of the vesiculoerosive disorders.

Dietary soy protein and isoflavones: minimal beneficial effects on bone and no effect on the reproductive tract of sexually mature ovariectomized Sprague-Dawley rats

OBJECTIVE

The present study was conducted to determine the effects of dietary soy protein and isoflavones on bone and the reproductive tract in the absence of the ovary.

DESIGN

Three-month-old Sprague-Dawley rats (n = 56) were either sham-operated or ovariectomized and then fed diets containing casein or soy protein +/- isoflavone extract for 12 weeks. The amounts of casein, soy protein, and extract (per kg diet) in each group were as follows: (1) Ovariectomy, 200 g of casein; (2) Ovariectomy+low soy, 100 g of casein + 100 g of soy protein; (3) Ovariectomy+high soy, 200 g of soy protein; (4) Ovariectomy+low extract, 200 g of casein + 17.2 g of extract; (5) Ovariectomy+high extract, 200 g of casein + 34.4 g of extract; (6) Ovary intact, 200 g of casein; (7) Ovariectomy+estradiol-17beta, 200 g of casein. Diet consumption, body weight, uterine weight, urine deoxypyridinoline, and bone mineral density of the femur and lumbar vertebrae were measured. The femur rigidity was evaluated by histomorphometry. The reproductive tract (uterus, vagina, and cervix) was studied histologically.

RESULTS

The Ovariectomy group showed significant increases in body weight, diet consumption, and deoxypyridinoline, decreases in uterine weight and bone mineral density, and negative changes in histomorphometry compared with the Ovary intact group. Neither soy protein nor extract diets abrogated these alterations, except for the Ovariectomy+high extract group that showed statistically significant positive changes in histomorphometric parameters. There were no histological differences in the reproductive tract among Ovariectomy, Ovariectomy+soy, and Ovariectomy+extract groups. The estradiol-17beta replacement abrogated ovariectomy-induced alterations.

CONCLUSION

Dietary intake of isoflavones by sexually mature ovariectomized rats has a minimal beneficial effect on bone with no effect on the reproductive tract.

Non-traumatic forensic neuropathology

The practicing Forensic Pathologist is likely to encounter case material in which either the cause of death or a major contribution to the cause of death is underlying damage to or disease of the central nervous system. While it is good practice in many instances to have a working relationship with a Department of Neuropathology, from which advice and practical help can be sought, there may be instances when the Forensic Pathologist needs to proceed on a basis of a working knowledge of Forensic Neuropathology up to and including how to examine the specimen and take tissue blocks for processing and subsequent histological examination. Some of the more common conditions of the central nervous system such as damage consequent to hypoxia-ischaemia, hypoglycemia and epilepsy, the encephalopathies associated with altered sodium concentration, deficiency due to Vitamin B(1) and various neurodegenerative diseases that manifest as dementia and include Alzheimer's disease, cortical Lewy body disease and the prion disorders, are outlined in this article.

Results of a feasibility study for a psycho-educational intervention in head and neck cancer

BACKGROUND

With survival rates for people with head and neck (H&N) cancers static during the past 30 years and the enormous burden of psychosocial impacts they suffer well documented, the testing of psychosocial interventions in this group is a priority.

OBJECTIVE

To test the feasibility of providing a psycho-educational intervention for people with H&N cancer.

METHODOLOGY

A prospective non-randomised design was used. Subjects were patients with H&N cancer. They were offered the Nucare coping strategies program in one of three formats: small group and one-to-one formats with therapists; and a home format, with material for home use, without a therapist. Outcomes measures (quality of life (QOL) and anxiety and depression) were collected at baseline and following the intervention. Analyses were performed using non-parametric statistics.

RESULTS

Of 128 people invited to participate, 66 agreed, 59 completed the intervention and 50 had outcomes data. Following the intervention, there were significant improvements in physical and social functioning and global QOL, and reduced fatigue, sleep disturbance and depressive symptoms.

CONCLUSIONS

These data suggest that the intervention is desired by the target group, feasible to deliver after cancer therapy and may have some beneficial effects, although an appropriately designed study is required to confirm this.

Teaching head and neck cancer patients coping strategies: results of a feasibility study

To test the feasibility of providing a psycho-educational intervention for people with head and neck (H&N) cancer. A prospective non-randomized design was used. Subjects were patients with H&N cancer. They were offered the Nucare coping strategies program in one of three formats: small group and one-to-one formats with therapists; and a home format, with material for home use, without a therapist. Outcomes measures (quality of life (QOL) and anxiety and depression) were collected at baseline and following the intervention. Analyses were performed using non-parametric statistics. Of 128 people invited to participate, 66 agreed, 59 completed the intervention and 50 had outcomes data. Following the intervention, there were significant improvements in physical and social functioning and global QOL, and reduced fatigue, sleep disturbance and depressive symptoms. These data suggest that the intervention may have some beneficial effects, although an appropriately designed study is required to confirm this.

Randomised, double blind, placebo controlled trial of interferon, ribavirin, and amantadine versus interferon, ribavirin, and placebo in treatment naïve patients with chronic hepatitis C

BACKGROUND AND AIM

In this study, we compared the efficacy of triple therapy (interferon alfa, ribavirin, and amantadine) with standard therapy (interferon alfa and ribavirin) in treatment naïve patients with chronic hepatitis C virus (HCV).

METHODS

In this prospective, randomised, double blind, placebo controlled, multicentre study, 85 patients (amantadine group) received a three drug regimen of interferon alfa-2b 3 million units three times per week, ribavirin 1000-1200 mg daily in divided doses, and amantadine 100 mg twice daily, and 86 patients (placebo group) received interferon alfa-2b, ribavirin, and identical placebo. Treatment was discontinued at 24 weeks if patients had detectable HCV RNA by polymerase chain reaction (PCR). All patients were followed for 24 weeks after completion of treatment. The primary end point was undetectable HCV-RNA by PCR at 24 weeks (sustained viral clearance) after completion of treatment.

RESULTS

At the end of treatment, HCV RNA clearance was seen in 32.9% of the amantadine group and 38.4% of the placebo group (p=0.3). Sustained virological response was seen in 24.7% of the amantadine group and in 27.9% of the placebo group by intention to treat analysis; response rate was 30.4% and 34.8%, respectively, in those who completed 24 weeks of treatment. Poor response was seen in both groups among cirrhotics, African-Americans, genotype 1, and those with a higher viral load. By multivariate analysis, genotype 1, high viral load, and low serum albumin were the only predictors of poor response. Addition of amantadine to the standard regimen did not result in any unexpected side effects.

CONCLUSION

Response to triple therapy of interferon alfa, ribavirin, and amantadine was similar to standard therapy of interferon alfa and ribavirin. Our results suggest that amantadine has no role in the management of HCV.

Sudden unexplained death in adults caused by intracranial pathology

Sudden unexplained deaths as a result of intracranial lesions in adults are an important component of medicolegal practice and are best examined as a combined effort by a forensic pathologist, or a histopathologist experienced in coroner's necropsies, and a neuropathologist. Analysis of case material on file in the University of Glasgow's departments of forensic medicine and science, and neuropathology showed that the principal causes were sudden unexplained death in epilepsy (SUDEP), intracranial haemorrhage, either natural or after trauma, purulent meningitis or an abscess, and tumours. The mechanisms of death are considered to be the rapid increase of intracranial pressure caused by bleeding into the various compartments of the brain, or an acute obstructive hydrocephalus, and in cases where death is very rapid, autonomic and/or neurochemical dysfunction.

Early events in macrophage killing of Aspergillus fumigatus conidia: new flow cytometric viability assay

Detailed investigations of macrophage phagocytosis and killing of Aspergillus fumigatus conidia have been limited by technical difficulties in quantifying fungal uptake and viability. In order to study early events in cell pathogen ingestion and killing, we developed a new flow cytometry assay that utilizes the fungus-specific viability dye FUN-1. Metabolically active A. fumigatus conidia accumulate orange fluorescence in vacuoles, while dormant or dead conidia stain green. After incubation within THP-1 cells, recovered conidia are costained with propidium iodide (PI) to discriminate between dormant and dead cells. Flow cytometric measurements of FUN-1 metabolism and PI uptake provide indicators of conidial viability, dormancy, and death. Conidial phagocytosis and killing are also assessed by measurement of green and orange FUN-1 fluorescence within the THP-1 cell population. Compared to previously described methods, this assay has less error introduced by membrane permeability changes and serial dilution of filamentous fungal forms. Results suggest that the THP-1 cells kill conidia rapidly (within 6 h) after exposure. Conidia that are preexposed to human serum are ingested and killed more quickly than are nonopsonized conidia.

Drug related deaths in the Strathclyde region of Scotland, 1995-1998

The misuse of drugs, both illicit and prescribed has increased dramatically in the west of Scotland over the last few decades. Consequently, the number of drug related deaths has risen as a direct result. Since, discrepancies exist between data collected by the Department of Forensic Medicine and Science, University of Glasgow and official statistics, this project, was funded to investigate all known drug related deaths that occurred within the Strathclyde region of Scotland in an effort to improve the accuracy of statistics and the dissemination of information pertaining to them. Changes in medical treatment, legislation and patterns of drug taking were noted and the effects of these on the year-by-year death tolls evaluated.

The role of dihydrocodeine in causing death among drug users in the west of Scotland

There has been a wealth of information relating to the role of methadone in fatalities over the past decade. However, a dearth exists in the literature of deaths involving dihydrocodeine, a substitute that is being increasingly prescribed by general practitioners for drug harm reduction purposes. Over the past five years in the Strathclyde region of Scotland there has been an increase in the number of drug related deaths involving dihydrocodeine with the largest increase occurring in the latter two years. This in combination with a general acceptance for this drug as a substitute for methadone amongst general practitioners highlights its potential abuse factor which is addressed in this paper. As the number of methadone deaths in relation to the total number of accidental drug related deaths per annum decrease, those related to dihydrocodeine are shown to be increasing.

Results of steroid-based therapy for the hepatitis C-autoimmune hepatitis overlap syndrome

OBJECTIVE

Overlap syndromes in which persons manifest clinical, histological, or immunological features of both hepatitis C infection and autoimmune hepatitis are well described. The discordant forms of treatment for hepatitis C and autoimmune hepatitis have made medical management of these patients difficult. We report our experience in using corticosteroids as first line therapy for the hepatitis C-autoimmune hepatitis overlap syndrome.

METHODS

Seven patients with this overlap syndrome (diagnosis based on the presence of serum hepatitis C antibody by RIBA and serum hepatitis C RNA by polymerase chain reaction, and serum hypergammaglobulinemia, elevated ANA or ASMA titers, or histological findings consistent with autoimmune hepatitis) were treated with prednisone with or without azathioprine or cyclosporine, and followed for a median duration of 44.5 months.

RESULTS

Five patients (71%) showed improvement of median serum ALT level from 162 U/L to 38 U/L (p = 0.04) and median serum gamma-globulin from 2.1 g/dl to 1.4 g/dl (p = 0.04) by 6 months of therapy. The mean modified histological activity index score also decreased from 11.4 +/- 2.5 to 6.6 +/- 2.6 (p = 0.04) by at least 1 yr of therapy. One patient discontinued prednisone while taking azathioprine and experienced a rebound elevation of serum ALT that did not respond to retreatment with prednisone. Antiviral therapy was subsequently administered and resulted in biochemical and virologic response. Hepatitis C virus RNA remained detectable in all other patients.

CONCLUSION

Corticosteroids are beneficial as a first line therapy for some patients with the hepatitis C-autoimmune overlap syndrome, resulting in appreciable biochemical and histological response but without viral eradication.

A review of gunshot deaths in Strathclyde--1989 to 1998

The case files of the Department of Forensic Medicine and Science at the University of Glasgow were searched for deaths involving gunshot injuries for the years 1989 to 1998. Seventy-one such deaths were identified. These were overwhelmingly males (93%) with a median age of 31 (range 17-80 years). Information surrounding the deaths was retrieved from sudden death reports compiled by the Strathclyde Police and the deaths were classified as suicide, homicide or accident. Fifty-one of the 71 deaths (72%) were classified as homicide, 17 deaths (24%) as suicide with insufficient information in three cases. The number of deaths for each year for suicides remained relatively constant at between nought and three cases per year, but figures for homicides varied at between three and ten cases per year, with a pronounced increase in the last four years of the study. The median age of the suicide cases was higher (50 years) than the homicide cases (30 years). The weapon used was predominately a shotgun in the suicide cases (accounting for 65%), but in homicide rifled weapons were the preferred weapons (59%). The site of injury was predominately the head in suicides, with a wider distribution in homicides, 32 per cent involving the head and 33 per cent also involving the chest. Alcohol intoxication was associated with a greater number of homicides than suicides. Homicides were noted to occur most frequently during the evening and early hours of the morning. The majority of suicides occurred at the victim's home address, while 72 per cent of homicides took place in the city of Glasgow.

Passive smoking and lung cancer: a cumulative meta-analysis

OBJECTIVE

To review the epidemiological evidence for the association between passive smoking and lung cancer.

METHOD

Primary studies and meta-analyses examining the relationship between passive smoking and lung cancer were identified through a computerised literature search of Medline and Embase, secondary references, and experts in the field of passive smoking. Primary studies meeting the inclusion criteria were meta-analysed.

RESULTS

From 1981 to the end of 1999 there have been 76 primary epidemiological studies of passive smoking and lung cancer, and 20 meta-analyses. There were 43 primary studies that met the inclusion criteria for this meta-analysis; more studies than previous assessments. The pooled relative risk (RR) for never-smoking women exposed to environmental tobacco smoke (ETS) from spouses, compared with unexposed never-smoking women was 1.29 (95% CI 1.17-1.43). Sequential cumulative meta-analysed results for each year from 1981 were calculated: since 1992 the RR has been greater than 1.25. For Western industrialised countries the RR for never-smoking women exposed to ETS compared with unexposed never-smoking women, was 1.21 (95% CI 1.10-1.33). Previously published international spousal meta-analyses have all produced statistically significant RRs greater than 1.17.

CONCLUSIONS

The abundance of evidence in this paper, and the consistency of findings across domestic and workplace primary studies, dosimetric extrapolations and meta-analyses, clearly indicates that non-smokers exposed to ETS are at increased risk of lung cancer.

IMPLICATIONS

The recommended public health policy is for a total ban on smoking in enclosed public places and work sites.

Granulomatous Liver Disease

In the United States, the majority of patients with granulomatous liver disease do not have an identifiable cause. When a specific diagnosis can be made, therapy should be directed at eradicating the cause. A plan of management must recognize the drug history and nationality of the patient, chest radiograph, slit lamp examination of the eyes, skin tests, special stains of liver biopsies, and serum antibodies. In those patients for whom a specific diagnosis cannot be established, the use of corticosteroids requires that the patient have a clinical justification for treatment or manifest important changes in findings of liver biopsies. Patients selected for steroid treatment should be subjected to close laboratory monitoring, and the decision to continue therapy should be based on objective parameters. Treatment of steroid-resistant disease might require methotrexate, chloroquine, cyclosporine, azathioprine, or ursodeoxycholic acid.

Cerebral hyperthermia in children after cardiopulmonary bypass

BACKGROUND

Cerebral hyperthermia after hypothermic cardiopulmonary bypass has been poorly documented for adults and never in children. This study was designed to monitor brain temperature during and up to 6 h after cardiopulmonary bypass in infants and children.

METHODS

Fifteen infants and children, between 3 months and 6 yr of age, were studied. A right retrograde jugular bulb catheter was used to measure the jugular venous bulb temperature (JVBT) during the procedure and the first 6 h in the critical care unit. The temperature of the blood from the bypass machine was measured at the aorta through the cannula using an indwelling temperature probe. All data were acquired every minute.

RESULTS

The age of the patients ranged from 3 to 71 months (median, 15 months). The mean weight was 11.5 +/- 8.4 kg. The mean JVBT recorded at the end of cardiopulmonary bypass was 36.9 +/- 1.4 degrees C but reached 39.6 +/- 0.8 degrees C after six h (P < 0.01). The kinetics of brain rewarming was determined by the slope of the mean JVBT and corresponded to y +/- 0.006x + 37.21 (r2 = 0.97). The JVBT differed from the tympanic temperature after 200 min (P < 0.01) and the lower esophageal (P < 0.05) and rectal (P < 0.001) temperatures after 300 min. After 6 h, the tympanic, rectal, and lower esophageal temperatures were 37.8 +/- 0.9, 37.7 +/- 0.6, and 38.4 +/- 0.7 degrees C, respectively, whereas the JVBT was 39.6 +/- 0.8 degrees C (P < 0.001). However, the correlation coefficients between the JVBT and the tympanic, rectal, and esophageal temperatures were 0.98, 0. 85, and 0.97, respectively. No complications were recorded with placement of the jugular bulb catheter.

CONCLUSIONS

Mean JVBT was significantly increased over the mean core temperature at all times from rewarming by cardiopulmonary bypass onward. Although the lower esophageal, rectal, and tympanic temperatures correlated well with JVBT, all three failed to reflect JVBT during recovery. This observation might help to elucidate factors involved in the functional and structural neurologic injury known to occur in pediatric patients.

Three-dimensional esophageal varix model quantification of variceal volume by high-resolution endoluminal US

BACKGROUND

The purpose of this study was to evaluate the accuracy and reproducibility of three-dimensional volume measurements by high-resolution endoluminal ultrasound in an esophageal varix model.

METHODS

An esophageal varix model was made by filling three esophageal dilatation catheters with various volumes of water. A 20 MHz ultrasonography transducer was then pulled along the length of the catheters at a constant rate (1.25 mm/sec) while videotaping the procedure. Cross-sectional surface area measurements of each catheter were taken every second and the cross-sectional surface area was multiplied by the length of each catheter, as determined by high-resolution endoluminal ultrasound, to determine the volume in each catheter. Interobserver variability was calculated, and three-dimensional reconstruction was performed.

RESULTS

The measured volumes corresponded closely with the actual volumes with an error ranging from 0% to 15.4%. The correlation between actual and measured volumes was r = 0.988. The interobserver variability ranged from r = 0.951 to r = 0.994. Actual esophageal varices were then imaged in a similar fashion to determine the feasibility of this method in patients with esophageal varices.

CONCLUSIONS

High-resolution endoluminal ultrasound is an accurate and reproducible method of measuring volumes in an esophageal varix model and can be used in a clinical setting to determine variceal volume. Volume studies are now underway in human subjects.