High dose rate prostate brachytherapy: an overview of the rationale, experience and emerging applications in the treatment of prostate cancer

The technological advances in real-time ultrasound image guidance for high dose rate (HDR) prostate brachytherapy places this treatment modality at the forefront of innovation in radiotherapy. This review article will explore the rationale for HDR brachytherapy as a highly conformal method of dose delivery and safe dose escalation to the prostate, in addition to the particular radiobiological advantages it has over low dose rate and external beam radiotherapy. The encouraging outcome data and favourable toxicity profile will be discussed before looking at emerging applications for the future and how this procedure will feature alongside stereotactic radiosurgery.

Abstract OT1-1-04: ALTERNATIVE: safety and efficacy of lapatinib (L), trastuzumab (T), or both in combination with an aromatase inhibitor (AI) for the treatment of hormone receptor-positive (HR+), human epidermal growth factor receptor 2 positive (HER2+) metastatic breast cancer

Background: Overexpression of the human epidermal growth factor receptor 2 (HER2) gene in breast cancer is associated with an aggressive phenotype, poor prognosis, and resistance to endocrine therapies. Of HER2+ patients, ∼50% are also hormone receptor-positive (HR+). For patients who are both HER2+ and HR+, combining the AI letrozole with the dual tyrosine kinase inhibitor L has been shown to improve outcomes compared with letrozole alone. The combination of L and T, a humanized monoclonal antibody-targeting HER2, has been shown to improve outcomes compared with L alone.

Trial design: The ALTERNATIVE study is a Phase III, randomized, open-label, multicenter trial, which will examine the efficacy of L/T/AI in combination versus T/AI alone. Patients will be randomized to 1 of 3 treatment arms: L 1000 mg po QD plus T (loading dose of 8 mg/kg followed by maintenance with 6 mg/kg IV q3w plus an AI po QD); T plus an AI; or L 1500 mg po QD plus an AI. Choices of AI include letrozole, anastrozole, or exemestane.

Eligibility criteria: Postmenopausal female patients with HER2+/HR+ metastatic breast cancer (MBC) who have received neo/adjuvant T and endocrine therapy, are treatment naïve for MBC, and are not candidates for chemotherapy.

Specific aims: The primary efficacy endpoint is overall survival (OS), defined as the time from randomization until death due to any cause, for L/T/AI compared with T/AI alone. Secondary efficacy objectives include comparisons of OS between T/AI and L/AI as well as between T/L/AI and L/AI in addition to comparisons of progression-free survival, overall response rate, time to response, and duration of response. The safety objective is to evaluate the safety and tolerability for all 3 treatment groups.

A 4-year recruitment is anticipated. More than 200 centers across 37 countries are planned; approximately 110 centers are currently open for enrollment.

Statistical methods: The study is powered to detect a 42% reduction in risk of death (hazard ratio=0.70) in patients who receive L/T/AI (median 28.5 months) versus T/AI (median 20 months) using a 1-sided test for superiority with α=0.025. The required number of total events to achieve a power of 80% is 249. Secondary comparisons are not powered and will be based on the intent-to-treat population.

Present and target accrual: Twenty-six (26) of 525 patients have been randomized. Patients who have participated in previous neo-/adjuvant trials including a T regimen are eligible, provided they meet all other inclusion criteria.

The study is currently recruiting patients, with an anticipated target accrual of 525 patients by March 2016.

Clinical trial registry number: NCT01160211

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT1-1-04.

Transrectal high-intensity focused ultrasonography is feasible as a new therapeutic option for advanced recurrent rectal cancer: report on the first case worldwide

High-intensity focused ultrasonography is the only completely non-invasive thermal therapy. To date its applications have been limited but clinical indications are expanding with enhanced technological advances that have increased the accuracy of targeting and decreased the duration of treatment times. We report its first use for rectal cancer.

Pancreatic cyst in a cat

CASE HISTORY

A 5-year-old neutered male Cornish Rex cat was presented for evaluation with a history of vomiting over the previous 5 days.

CLINICAL FINDINGS

An abdominal mass was palpated, which was shown to be cystic by ultrasound examination. Exploratory surgery revealed this to be associated with the pancreas and it was duly resected. Histopathology was performed on the cystic mass.

DIAGNOSIS

Pancreatic cyst with associated chronic active inflammation.

CLINICAL RELEVANCE

This is the first report of a true pancreatic cyst in a cat.

Radio and Plasma Wave Observations at Saturn from Cassini's Approach and First Orbit

We report data from the Cassini radio and plasma wave instrument during the approach and first orbit at Saturn. During the approach, radio emissions from Saturn showed that the radio rotation period is now 10 hours 45 minutes 45 +/- 36 seconds, about 6 minutes longer than measured by Voyager in 1980 to 1981. In addition, many intense impulsive radio signals were detected from Saturn lightning during the approach and first orbit. Some of these have been linked to storm systems observed by the Cassini imaging instrument. Within the magnetosphere, whistler-mode auroral hiss emissions were observed near the rings, suggesting that a strong electrodynamic interaction is occurring in or near the rings.

A randomised study comparing peripheral blood progenitor mobilisation using intermediate-dose cyclophosphamide plus lenograstim with lenograstim alone

We conducted a prospective randomised study to compare the efficiency of out-patient progenitor cell mobilisation using either intermediate-dose cyclophosphamide (2 g/m(2)) and lenograstim at 5 micrograms/kg (Cyclo-G-CSF group, n=39) or lenograstim alone at 10 micrograms/kg (G-CSF group, n=40). The end points were to compare the impact of the two regimens on mobilisation efficiency, morbidity, time spent in hospital, the number of apheresis procedures required and engraftment kinetics. Successful mobilisation was achieved in 28/40 (70%) in the G-CSF group vs 22/39 (56.4%) for Cyclo-G-CSF (P=0.21). The median number of CD34+ cells mobilised was 2.3 x 10(6)/kg and 2.2 x 10(6)/kg for G-CSF and cyclo-G-CSF arms following a median of two apheresis procedures. Nausea and vomiting and total time spent in the hospital during mobilisation were significantly greater after Cyclo-G-CSF (P<0.05). Rapid neutrophil and platelet engraftment was achieved in all transplanted patients in both groups. In conclusion, G-CSF at 10 micrograms/kg was as efficient at mobilising progenitor cells as a combination of cyclophosphamide and G-CSF with reduced hospitalisation and side effects and prompt engraftment. When aggressive in-patient cytoreductive regimens are not required to both control disease and generate progenitor cells, the use of G-CSF alone appears preferable to combination with intermediate-dose cyclophosphamide.

The relationship between social networks and occupational and self-care functioning in people with psychosis

BACKGROUND

Relatively few studies have examined relationships between the social networks of people with psychotic disorder and other aspects of their functioning. The aim of this paper is to describe the social networks of people with psychosis and to investigate relationships between social networks and personal and occupational functioning, taking account of illness course.

METHODS

A two-phase epidemiological survey of persons with psychosis was conducted in four predominantly urban areas of Australia. A census and screen for psychosis was followed by a semi-structured interview of a stratified random sample of participants to assess their functioning. Data relating to functioning and social networks from 908 individuals (most with a diagnosis of schizophrenia) were analysed using structural equation modelling (SEM).

RESULTS

The majority of people with psychosis (67 %) had a network comprising of family and friends, 15 % were defined as having a family-dominated network, 11 % a friends-dominated network and 7 % of participants were defined as socially isolated (no family or friends). Participants who had friends and family in their network (12 %) or who had a family-dominated network (7 %) were more likely to be in full-time employment compared with those with a friends-dominated network (4 %) or those who were socially isolated (5 %). Dysfunction in self-care was more frequently reported among socially isolated people (50 %) and those with family-dominated networks (47 %) than among those with friends-dominated networks (35 %) and those who had friends and family in their social network (23 %). SEM revealed a strong association between social integration and functioning (r = 0.71), even after controlling for illness course. Social integration was defined as having contact with family and/or friends and functioning was defined as having employment and no difficulties in self-care. Male gender was associated with poorer self-care, and female gender was slightly, but significantly, associated with a greater likelihood of having friends.

CONCLUSION

There is a strong relationship between social networks and functioning after taking account of course of illness. That is, the presence of family and friends is generally associated with better self-care and employment. Interventions that are targeted at improving social relationships are likely to have a positive impact on self-care and occupational functioning (and vice versa).

The Australian National Survey of Psychotic Disorders: profile of psychosocial disability and its risk factors

BACKGROUND

Knowledge of the level of psychosocial impairment associated with psychosis is important in evaluating the impact of the illness on those affected. When such knowledge is derived from community-based epidemiological surveys, it can help in providing a public health perspective for service planning with information derived from representative samples of patients.

METHODS

A two-phase epidemiological survey of persons with psychosis in four predominantly urban areas of Australia. First phase screening for psychosis (N= 5,710) was followed by a semi-structured interview of a stratified random sample (N = 980) to assess psychopathology (lifetime and current) and psychosocial disability.

RESULTS

Most of the interviewees were unemployed and had never married. There was widespread impairment in sexual and social relationships and in the performance of activities of daily living. Over half expressed dissatisfaction with life in general. Persons with affective psychoses were often as disabled as those with schizophrenia and diagnostic categorizations were not important in the conferment of risk for disability. Rather, poor pre-morbid work or social adjustment and poor course of illness were potent risk factors for diverse forms of disability in persons with psychosis.

CONCLUSION

A large proportion of persons with experience of psychosis living in the community suffers from significant levels of psychosocial disability. Disablement seems to reflect, in part, a diathesis of poor pre-morbid functioning and less than optimal response to treatment of the disorder.

Perceived need for mental health care: influences of diagnosis, demography and disability

BACKGROUND

Recent major epidemiological studies have adopted increasingly multidimensional approaches to assessment. Several of these have included some assessment of perceived need for mental health care. The Australian National Survey of Mental Health and Wellbeing, conducted in 1997, included a particularly detailed examination of this construct, with an instrument with demonstrated reliability and validity.

METHODS

A clustered probability sample of 10641 Australians responded to the field questionnaire for this survey, including questions on perceived need either where there had been service utilization, or where a disorder was detected by administration of sections of the Composite International Diagnostic Interview. The confidentialized unit record file generated from the survey was analysed for determinants of perceived need.

RESULTS

Perceived need is increased in females, in people in the middle years of adulthood, and in those who have affective disorders or co-morbidity. Effects of diagnosis and disability can account for most of the differences in gender specific rates. With correction for these effects through regression, there is less perceived need for social interventions and possibly more for counselling in females; disability is confirmed as strongly positively associated with perceived need, as are the presence of affective disorders or co-morbidity.

CONCLUSIONS

The findings of this study underscore the imperative for mental health services to be attentive and responsive to consumer perceived need. The substantial majority of people who are significantly disabled by mental health problems are among those who see themselves as having such needs.

Quantification of blood flow

Traditionally, Doppler ultrasound has been used to estimate blood flow as the mean velocity multiplied by the vessel area, but this is subject to significant errors and may be difficult to perform accurately. Microbubbles, developed as contrast agents for ultrasound, were initially envisaged as useful for increasing the intensity of echoes and thus rescuing Doppler studies that were technical failures because of attenuated signals or very slow flow. However, they can act as tracers and, by analogy with isotope techniques, can be used to measure blood flow with transit-time methods which exploit both arterial and venous time-intensity data. An acceptable compromise is to acquire both a tissue intensity curve and one from the feeding artery. The transit of microbubbles across an organ or tissue can be used to estimate haemodynamic alterations, e.g. the arterialisation of the supply to the liver in malignancies and cirrhosis and the delayed arterio-venous transit in the transplant kidney during rejection. The fragility of microbubbles can be turned to advantage by being exploited to create a negative bolus by exposing a tissue slice to a high power beam. The rate of refilling of this slice by circulating microbubbles can then be followed with a low-intensity monitoring beam and the resulting rising exponential curve analysed to extract indices of both the reperfusion rate (the slope) and the fractional vascular volume (the asymptote). The product of these is a measure of true tissue perfusion.

True aneurysm of a femoropopliteal vein graft

Aneurysmal dilatation of saphenous vein grafts mostly represent thin-walled pseudoaneurysms at anastomotic sites. True aneurysmal dilatation of femoropopliteal bypass vein grafts is rare. We report this unusual case, which was repaired with a prosthetic graft.

Defining disability in psychosis: performance of the diagnostic interview for psychosis-disability module (DIP-DIS) in the Australian National Survey of Psychotic Disorders

OBJECTIVE

We aimed to use data from the Australian Survey of Mental Health and Wellbeing to examine the psychometric properties of the Diagnostic Interview for Psychosis-Disability Module (DIP-DIS). The DIP-DIS is a semi-structured questionnaire specially designed to assess disability associated with psychotic disorders.

METHOD

The psychometric properties of the instrument were determined by examining its inter-rater reliability, internal structure, as well as its criterion and discriminant validities.

RESULTS

Analysis shows: (1) that it can be rated reliably by trained interviewers, (2) that the items are complementary but tap a number of different domains, (3) that four factors account for over 66% of the variance, and (4) that it is sensitive to differing clinical populations with expected differences in level of disability. Ratings on the DIP-DIS bore significant relationships with a criterion measure of quality of life.

CONCLUSIONS

The DIP-DIS has encouraging psychometric properties for cross-sectional assessment of disability and may be useful in future studies of disablement associated with psychosis. Future work should examine its sensitivity to change.

Validation of an arsenic sequential extraction method for evaluating mobility in sediments

Arsenic (As) mobility and transport in the environment are strongly influenced by arsenic's associations with solid phases in soil and sediment. We have tested a sequential extraction procedure intended to differentiate the following pools of solid phase arsenic: loosely and strongly adsorbed As; As coprecipitated with metal oxides or amorphous monosulfides; As coprecipitated with crystalline iron (oxyhydr)oxides; As oxides; As coprecipitated with pyrite; and As sulfides. Additions of As-bearing phases to wetland and riverbed sediment subsamples were quantitatively recovered by the following extractants of the sequential extraction procedure: As adsorbed on goethite, 1 M NaH2PO4; arsenic trioxide (As2O3), 10 M HF; arsenopyrite (FeAsS), 16 N HNO3; amorphous As sulfide, 1 N HCI, 50 mM Ti-citrate-EDTA, and 16 N HNO3; and orpiment (As2S3), hot concentrated HNO3/H2O2. Wet sediment subsamples from both highly contaminated wetland peat and less As-rich sandy riverbed sediment were used to test the extraction procedure for intra-method reproducibility. The proportional distribution of As among extractant pools was consistent for subsamples of the wetland and for subsamples of the riverbed sediments. In addition, intermethod variability between the sequential extraction procedure and a single-step hot concentrated HNO3/H2O2 acid digestion was investigated. The sum of the As recovered in the different extractant pools was not significantly different than results for the acid digestion.

Compartment syndrome: when it is least expected

Compartment syndrome, if not identified and acted upon early, will result in irreversible damage to neuromuscular soft tissues. Therefore, orthopaedic nurses must be aware of the risks, signs and symptoms, unusual circumstances, and appropriate medical and nursing interventions with this syndrome. Usually compartment syndrome is considered to occur with fractures of the tibia, the forearm, or in vascular injuries or burns where there is significant edema. Not as common are compartment syndromes that occur after intramedullary nailing, in the thigh or upper arm, or in the presence of fracture blisters. These unexpected compartment syndromes each occurred only once in the author's many years as an orthopaedic clinical nurse specialist at a major trauma center. However, in each case, the situation and actions were significant. Compartment syndrome will be reviewed with supporting current literature. Each scenario will then be analyzed in terms of the particular considerations surrounding the diagnosis, treatment and nursing implications with the compartment syndrome.

Prescribing rates for psychotropic medication amongst east London general practices: low rates where Asian populations are greatest

OBJECTIVES

The aim of this study was to examine the contribution of Asian ethnicity to the variation in rates of practice prescribing for antidepressant and anxiolytic medication, taking into account other population and practice organizational factors.

METHODS

A practice-based cross-sectional survey was carried out of the prescribing of antidepressants and anxiolytics (daily defined dosages) in 164 general practices. The study was set in East London and the City Health Authority, which includes the multiethnic inner London boroughs of Hackney, Tower Hamlets, Newham and the City of London. The main outcome measures were the annual prescribing rates for each group of drugs, calculated as the total annual daily defined dosages divided by the practice population, and the ratio of antidepressant/ anxiolytic annual prescribing rates.

RESULTS

Prescribing rates for antidepressants showed a 25-fold variation between practices; this was greater for anxiolytics. The median annual prescribing rate for all antidepressants combined was 4.13 (interquartile range 2.50-5.88). For all anxiolytics and hypnotics combined the median annual prescribing rate was 3.55 (interquartile range 1.71-6.36). Univariate analysis showed that Asian ethnicity alone accounted for 28% of the variation in antidepressant prescribing and 20.5% of the variation in the anxiolytic prescribing. A backwards multiple regression model using 10 explanatory practice and population variables accounted for 47.7% of the variance in antidepressant prescribing and 34% of the variance in the anxiolytic prescribing.

CONCLUSION

In practices where the proportion of Asian patients is high, both antidepressant and anxiolytic prescribing is low. This is important for understanding interpractice prescribing variation and for setting levels of drug budgets. This study confirms that the low rates of non-psychotic disorders presented by Asian populations is not a selective feature of access to secondary care, but is evident in the prescribing behaviour of GPs. Uncertainty remains as to how much this is due to a lower prevalence rate, "culture-bound syndromes" or practical difficulties in diagnosis and management within the general practice setting.

Attitudes toward the Metric System 15 Years Later

This follow-up study investigated whether attitudes toward the metric system have changed over the last 15 years. 132 subjects ranging in age from 18 to 45 years participated by filling out a 7-item survey designed to measure attitudes toward the metric system. Each survey item was scored using a 5-point rating, e.g., “the change to the metric system will create more problems than it solves,” 1: strongly agree and 5: strongly disagree. Scores were compared to those obtained for a similar sample in 1983. Comparisons using t tests indicated no significant differences between attitude scores from 1983 to 1998 for either men ( t64 = .95) or women ( t133 =.06).

The burden of mental disorders in Victoria, 1996

BACKGROUND

Between 1998 and 1999, a burden of disease assessment was carried out in Victoria, Australia applying and improving on the methods of the Global Burden of Disease Study. This paper describes the methods and results of the calculations of the burden due to 22 mental disorders, adding 14 conditions not included in previous burden of disease estimates.

METHODS

The National Survey of Mental Health and Wellbeing provided recent data on the occurrence of the major adult mental disorders in Australia. Data from international studies and expert advice further contributed to the construction of disease models, describing each condition in terms of incidence, average duration and level of severity, with adjustments for comorbidity with other mental disorders. Disability weights for the time spent in different states of mental ill health were borrowed mainly from a study in the Netherlands, supplemented by weights derived in a local extrapolation exercise.

RESULTS

Mental disorders were the third largest group of conditions contributing to the burden of disease in Victoria, ranking behind cancers and cardiovascular diseases. Depression was the greatest cause of disability in both men and women. Eight other mental disorders in men and seven in women ranked among the top twenty causes of disability.

CONCLUSIONS

Insufficient information on the natural history of many of the mental disorders, the limited information on the validity of mental disorder diagnoses in community surveys and considerable differences between ICD-10 and DSM-IV defined diagnoses were the main concerns about the accuracy of the estimates. Similar and often greater concerns have been raised in relation to the estimation of the burden from common non-fatal physical conditions such as asthma, diabetes and osteoarthritis. In comparison, psychiatric epidemiology can boast greater scientific rigour in setting standards for population surveys.

Minority recruitment in the prostate cancer prevention trial

PURPOSE

African American men have a higher prostate cancer risk profile than that of other men in the United States. The purpose of this manuscript is to summarize the challenges associated with enrolling and randomizing African American and other minority participants in the Prostate Cancer Prevention Trial (PCPT).

METHODS

The PCPT is a randomized trial of finasteride versus placebo for preventing prostate cancer in healthy men age 55 years and older; it is coordinated by the Southwest Oncology Group. The manuscript describes demographic and lifestyle characteristics of the PCPT randomized sample (18,882 men) by four racial and ethnic groups (Caucasian, African American, Hispanic, and other). African American men comprised 4% of the total randomized sample compared to our goal of 8%. Minority recruitment was emphasized through the Study Manual and training that occurred at trial activation. Supplemental minority recruitment activities were initiated a year after study activation and continued through the end of the accrual period. Minority recruitment was emphasized as follows: minority recruitment presentations at PCPT training seminars (held during twice yearly Southwest Oncology Group meetings); distribution of additional minority recruitment materials; engagement of four consultants for minority recruitment; production of a Minority Recruitment Manual; and a small pilot study involving minority outreach recruiters at five PCPT sites.

RESULTS

The consultants were helpful in implementing the pilot project and in suggesting and reviewing materials for minority recruitment. The five-site pilot project did not increase either enrollment or randomization of minorities (with a possible exception at one site).

CONCLUSIONS

We suggest that a long-term perspective is required for successful recruitment of minority participants in clinical trials. Likewise, extensive minority recruitment efforts must be ready to implement at trial activation.

Comparative studies of two-times-daily versus three-times-daily indinavir in combination with zidovudine and lamivudine

OBJECTIVES

To compare the efficacy and safety of two-times-daily versus three-times-daily indinavir in combination with zidovudine and lamivudine.

DESIGN

Two multicenter, open-label, randomized 24-week studies.

METHODS

Adults HIV-1 infection, HIV-1 RNA greater than 10000 copies/ml, and no prior lamivudine or protease inhibitor therapy were eligible. In a pilot study (Study A), patients received indinavir at 800 mg every 8 h, 1000 mg every 12 h, or 1200 mg every 12 h. In a subsequent study (Study B), patients received indinavir at 800 mg every 8 h or 1200 mg every 12 h. All subjects received zidovudine (300 mg) and lamivudine (150 mg) every 12 h. An intent-to-treat analysis was used.

RESULTS

In Study A, which enrolled 88 patients, neither HIV-1 RNA nor CD4 cell responses differed significantly between treatment groups at 24 weeks when corrected for multiple comparisons. Study B enrolled 433 patients, but was prematurely discontinued when interim analysis suggested greater efficacy of three-times-daily indinavir. Of the first 87 patients reaching week 24, HIV-1 RNA was less than 400 copies/ml in 91% receiving three-times-daily versus 64% receiving two-times-daily indinavir (P < 0.01).

CONCLUSION

Three-times-daily indinavir appears more efficacious than two-times-daily dosing when administered with zidovudine and lamivudine. Two-times-daily indinavir dosing should only be considered in situations characterized by favorable pharmacokinetic drug-drug interactions.

Assessing perceived need for mental health care in a community survey: development of the Perceived Need for Care Questionnaire (PNCQ)

BACKGROUND

The Perceived Need for Care Questionnaire (PNCQ) was designed for the Australian National Survey of Mental Health and Wellbeing. The PNCQ complemented collection of data on diagnosis and disability with the survey participants' perceptions of their needs for mental health care and the meeting of those needs. The four-stage design of the PNCQ mimics a conversational exploration of the topic of perceived needs. Five categories of perceived need are each assigned to one of four levels of perceived need (no need, unmet need, partially met need and met need). For unmet need and partially met need, information on barriers to care is collected.

METHODS

Inter-rater reliabilities of perceived needs assessed by the PNCQ were examined in a study of 145 anxiety clinic attenders. Construct validity of these items was tested, using a multi-trait multi-method approach and hypotheses regarding extreme groups, in a study with a sample of 51 general practice and community psychiatric service patients.

RESULTS

The instrument is brief to administer and has proved feasible for use in various settings. Inter-rater reliabilities for major categories, measured by the kappa statistic, exceeded 0.60 in most cases; for the summary category of all perceived needs, inter-rater reliability was 0.62. The multi-trait multi-method approach lent support to the construct validity of the instrument, as did findings in extreme groups.

CONCLUSIONS

The PNCQ shows acceptable feasibility, reliability and validity, adding to the range of assessment tools available for epidemiological and health services research.

Screening techniques to identify people at high risk for diabetic foot ulceration: a prospective multicenter trial

OBJECTIVE

Diabetic foot ulceration is a preventable long-term complication of diabetes. A multicenter prospective follow-up study was conducted to determine which risk factors in foot screening have a high association with the development of foot ulceration.

RESEARCH DESIGN AND METHODS

A total of 248 patients from 3 large diabetic foot centers were enrolled in a prospective study. Neuropathy symptom score, neuropathy disability score (NDS), vibration perception threshold (VPT), Semmes-Weinstein monofilaments (SWFs), joint mobility, peak plantar foot pressures, and vascular status were evaluated in all patients at the beginning of the study. Patients were followed-up every 6 months for a mean period of 30 months (range 6-40), and all new foot ulcers were recorded. The sensitivity, specificity, and positive predictive value of each risk factor were evaluated.

RESULTS

Foot ulcers developed in 95 feet (19%) or 73 patients (29%) during the study. Patients who developed foot ulcers were more frequently men, had diabetes for a longer duration, had nonpalpable pedal pulses, had reduced joint mobility, had a high NDS, had a high VPT, and had an inability to feel a 5.07 SWE NDS alone had the best sensitivity, whereas the combination of the NDS and the inability to feel a 5.07 SWF reached a sensitivity of 99%. On the other hand, the best specificity for a single factor was offered by foot pressures, and the best combination was that of NDS and foot pressures. Univariate logistical regression analysis yielded a statistically significant odds ratio (OR) for sex, race, duration of diabetes, palpable pulses, history of foot ulceration, high NDSs, high VPTs, high SWFs, and high foot pressures. In addition, 94 (99%) of the 95 ulcerated feet had a high NDS and/or SWF which resulted in the highest OR of 26.2 (95% CI 3.6-190). Furthermore, in multivariate logistical regression analysis, the only significant factors were high NDSs, VPTs, SWFs, and foot pressures.

CONCLUSIONS

Clinical examination and a 5.07 SWF test are the two most sensitive tests in identifying patients at risk for foot ulceration, especially when the tests are used in conjunction with each other. VPT measurements are also helpful and can be used as an alternative. Finally, foot pressure measurements offer a substantially higher specificity and can be used as a postscreening test in conjunction with providing appropriate footwear.

Perceived need for mental health care, findings from the Australian National Survey of Mental Health and Well-being

BACKGROUND

The Australian National Survey of Mental Health and Well-being was designed to detect and describe psychiatric morbidity, associated disability, service use and perceived need for care. The survey employed a single-phase interview methodology, delivering a field questionnaire to a clustered probability sample of 10,641 Australians. Perceived need was sampled with an instrument designed for this survey, the Perceived Need for Care Questionnaire (PNCQ). This questionnaire gathers information about five categories of perceived need, assigning each to one of four levels of perceived need. Reliability and validity studies showed satisfactory performance of the instrument.

METHODS

Perceived need for mental health care in the Australian population has been analysed using PNCQ data, relating this to diagnostic and service utilization data from the above survey.

RESULTS

The survey findings indicate that an estimated 13.8% of the Australian population have perceived need for mental health care. Those who met interview criteria for a psychiatric diagnosis and also expressed perceived need make up 9.9% of the population. An estimated 11.0% of the population are cases of untreated prevalence, a minority (3.6% of the population) of whom expressed perceived need for mental health care. Among persons using services, those without a psychiatric diagnosis based on interview criteria (4.4% of the population), showed high levels of perceived met need.

CONCLUSIONS

The overall rate of perceived need found by this methodology lies between those found in the USA and Canada. The findings suggest that service use in the absence of diagnosis elicited by survey questionnaires may often represent successful intervention. In the survey, untreated prevalence was commonly not accompanied by perceived need for mental health care.

Effects on protein kinase C and gene expression in a human mast cell line, HMC-1, following microwave exposure

We used a resonant cavity which delivered a continuous wave exposure at 864.3 MHz at an average specific absorption rate (SAR) of 7 W/kg to determine non-thermal biological effects of microwave exposure. A human mast cell line, HMC-1, was used as the biological target. Cells were given three exposures each of 20-min duration daily for 7 days. The temperature of the cell culture medium during the exposure fell to 26.5 degrees C. Effects were seen on localization of protein kinase C, and expression of three genes of 588 screened. The affected genes included the proto-oncogene c-kit, the transcription factor Nucleoside diphosphate kinase B and the apoptosis-associated gene DAD-1. Stress response genes were variably upregulated. No significant effect on morphology or on F-actin distribution was detected. We conclude that low-power microwave exposure may act on HMC-1 cells by altering gene expression via a mechanism involving activation of protein kinase C, and at temperatures well below those known to induce a heat shock response.

Psychotic disorders in urban areas: an overview of the Study on Low Prevalence Disorders

OBJECTIVE

This paper reports on a study designed within the framework of the National Survey of Mental Health and Wellbeing to: estimate the prevalence of psychoses in urban areas of Australia; identify profiles of symptomatology, impairments and disabilities; collect information on services received and needed; and explore quality of life issues in a broadly representative sample of people with psychotic illnesses.

METHOD

The study was conducted over four areas in the Australian Capital Territory, Queensland, Victoria and Western Australia, as a two-phase survey: (i) a census and screening for psychosis of all individuals who made contacts with mental health services during a period of 1 month in 1997; and (ii) interviews with a stratified random sample (n=980) of the screen-positive individuals (n=3800) using a standardised instrument.

RESULTS

The point prevalence (1 month) of psychotic disorders in the urban population aged 18-64 is in the range of 4-7 per 1000 with a weighted mean of 4.7 per 1000. People with psychotic disorders experience high rates of functional impairments and disability, decreased quality of life, persistent symptoms, substance-use comorbidity and frequent side effects of medication. Although the utilisation of hospital-based and community mental health services, as well as of public and non-governmental helping agencies, is high, the majority live in extreme social isolation and adverse socioeconomic circumstances. Among the many unmet needs, the limited availability of community-based rehabilitation, supported accommodation and employment opportunities is particularly prominent.

CONCLUSIONS

The so-called 'low-prevalence' psychotic disorders represent a major and complex public health problem, associated with heavy personal and social costs. There is a need for a broad programmatic approach, involving various sectors of the community, to tackle the multiple dimensions of clinical disorder, personal functioning and socioeconomic environment that influence the course and outcome of psychosis and ultimately determine the effectiveness of service-based intervention.

Do practice-based preventive child health services affect the use of hospitals? A cross-sectional study of hospital use by children in east London

BACKGROUND

Acute paediatric admissions have risen steadily over the past 20 years. During the same period, practice-based child health clinics have increased, although provision is less common in areas of deprivation where hospital use is greatest.

AIM

To investigate the contribution of practice-based, preventive child health services to rates of hospital utilisation in children under five years of age.

METHOD

A cross-sectional retrospective study examining practice variations in paediatric acute admissions, outpatient referrals, and accident and emergency (A&E) department attendances in the East London and the City Health authority, including all 164 practices in the inner-city boroughs of Hackney, Newham, Tower Hamlets, and the City of London. The main outcome measures were practice-based paediatric hospital attendance rates, for discrete age and sex bands, for the year to 31 March 1996.

RESULTS

Hospital use varied with age and sex, with the rates being highest for the youngest children and for boys. The median A&E attendance rate (including reattendances) for boys up to one year of age was 897 per thousand children per practice. In east London, 62% of practices are registered for child health surveillance and 71% provide a child health clinic. Practice approval for child health surveillance, and the provision of child health clinics, did not account for differences between practices in hospital use, but proportionally greater health visiting hours were significantly related to lower rates of emergency hospital admission by young children. Multivariate analyses revealed that up to 23% of the variation between practice admission rates could be explained by health visiting hours.

CONCLUSIONS

We found significant associations between the amount of health visiting time available to the practice population and rates of acute admission and outpatient referral among children up to five years of age. These findings suggest that increasing health visitor provision could contribute to lower paediatric emergency admission and outpatient referral rates. A small change would have a significant effect, particularly among the youngest children, given that during the study year 10,000 children under two years of age in east London were either admitted or referred to hospital.

Americans' view of cancer

This paper presents the concept of the town hall meeting and discusses how it can be used as a forum for those who have been touched by cancer. It can be a platform for people to express their views about cancer, not only in the community but also nationally. Empowerment is the hallmark of a town hall meeting. Those who are in leadership positions in health care and elected officials and community leaders are given the opportunity to hear the opinions of people who represent a broad-based constituency of individuals affected by cancer. The idea of holding a town hall meeting was first introduced in the cancer community by the National Coalition for Cancer Survivorship NCCS) as a means of identifying issues, exchanging information and considering creative solutions to problems. The first town hall meeting was held in 1994 in conjunction with the NCCS annual assembly. Since then, utilizing the guidelines set forth by the NCCS, 30 or more town hall meetings have been held across the United States. Cancer survivors have, by and large, been responsible for garnering the necessary support for conducting a town hall in their local area. Organizations such as the American Cancer Society, the Leukemia Society of America, hospitals, clinics, pharmaceutical and healthcare companies and also noncancer groups, such as the YMCA, churches, and radio/T.V. stations, join with the cancer survivors in organizing the meeting, planning related displays, and advertising the event. In 1998, seven town hall meetings were sponsored jointly by OnCare and NCCS in advance and support of the upcoming THE MARCH- Coming Together To Conquer Cancer, a national rally held in Washington, D.C. in September 1998. Attendees at the meetings included not only cancer survivors and their families, but also healthcare professionals, local and state legislators, community leaders and the media. Results of the 1998 town hall meetings are discussed and compared with the topics identified during the meetings held in 1994-1996. Town hall participants were outspoken about what is needed in America if cancer is truly to become the nation's healthcare priority. They are asking for equal access to quality care, increases in financial backing for research, and more support for cancer advocacy efforts. Benefits of holding town hall meetings are identified.

TP53 mutation and haplotype analysis of two large African American families

Two large apparently unrelated African American families with a high incidence of breast cancer and other tumors characteristic of Li-Fraumeni breast sarcoma cancer family syndrome were studied. Mutation screening revealed that in both families the affected members carried a germline mutation of the TP53 gene at codon 133 (ATG--> ACG, M133T). In order to determine whether an ancestral haplotype was shared by these two families, polymorphic markers within and flanking the TP53 gene were studied. Haplotype analysis using five markers revealed an identical haplotype shared by the two families. Loss of heterozygosity at the TP53 locus in the probands' tumor tissues from each family was observed; in each case, the retained allele carried the common haplotype. The frequency of this haplotype in the general African American population is <0.003. This unique haplotype, combined with the rare TP53 mutation, suggests that these African American families share a common ancestry. This finding suggests that other African Americans may be carriers of this mutation and thus may be at risk of early-onset breast cancer or other cancers characteristic of the Li-Fraumeni breast sarcoma cancer family syndrome. The finding of recurring mutations in African Americans may facilitate carrier screening and identification in this population.

Prevalence of asthma and respiratory symptoms in south-central Durban, South Africa

The prevalence of asthma and respiratory symptoms in south-central Durban, one of the most heavily polluted areas of South Africa, has been determined using a cross-sectional survey of 213 households in the communities of Merewent (97% Indians) and Austerville (98% coloreds). The study population consisted of 367 children (less than 17 years old) and 693 adults. About 10% of the children and 12% of adults reported doctor diagnosed asthma. The self-reported prevalence rates for wheezing (3740%) and attacks of shortness of breath with wheeze (16-28%) were much higher than that for doctor diagnosed asthma and common co-occurrence of the three symptoms is found. The prevalence rates for other respiratory symptoms include 33-35% for chronic cough, 31-32% for chronic phlegm, 44-50% for frequent blocked-runny nose, and 16-27% for sinusitis. Factors in the community that were associated with asthma, wheeze and shortness of breath with wheeze among the adult population included cigarette smoking, use of insecticides (coils and pump spray) and home ownership. An association between asthma among children and a number of household risk factors including dampness, carpet, pets or use of pesticides was not apparent in the community. Asthma prevalence was strongly correlated with missing of school by children (odds ratio (OR): 44; 95% confidence interval (CI): 13-141). The study serves to draw attention to a growing but neglected public health problem in urban areas of Africa.

Imaging of tumour therapy responses by dynamic CT

The objective of this study was to investigate whether functional CT with Patlak analysis could be used to demonstrate acute changes associated with radiotherapy. Patlak analysis yields fractional vascular volume and contrast clearance per unit volume (a measure of permeability). Four tumour types (prostate, bronchus, breast and cervix) were studied pre-radiotherapy and at 1-2 weeks and 6-12 weeks post-therapy. Significant rises in fractional vascular volume and contrast clearance were shown at 1-2 weeks. These indices were still significantly elevated at 6-12 weeks post-therapy. In the prostates perfusion values were also elevated reflecting a hyperemic response to radiotherapy. Dynamic CT with Patlak analysis can be used to measure important pathophysiological indices which may prove useful in assessing response to therapy of tumours.

The utility of CT in imaging chest infections in HIV-negative patients

This article focuses on the recent developments in CT imaging of chest infections in patients who are immunocompetent or immunosuppressed, but not infected with HIV. Although simple viral and bacterial infections predominate, more "exotic" infections are now being encountered. First, a re-emergence of mycobacterial disease has occurred. Second, a growing population of transplant recipients (i.e., lung, solid organ, and bone marrow) is susceptible to a wide range of pathogens. These trends are reflected in the forthcoming discussion. In particular, several important articles on immunosuppressed (HIV-negative) patients and on imaging fungal disease have been written within the past year.

Role of neuropathy and high foot pressures in diabetic foot ulceration

OBJECTIVE

High plantar foot pressures in association with peripheral neuropathy have been ascertained to be important risk factors for ulceration in the diabetic foot. Most studies investigating these parameters have been limited by their size and the homogeneity of study subjects. The objective of this study was therefore to ascertain the risk of ulceration associated with high foot pressures and peripheral neuropathy in a large and diverse diabetic population.

RESEARCH DESIGN AND METHODS

We studied a cross-sectional group of 251 diabetic patients of Caucasian (group C) (n=121), black (group B) (n=36), and Hispanic (group H) (n=94) racial origins with an overall age of 58.5+/-12.5 years (range 20-83). There was an equal distribution of men and women across the entire study population. All patients underwent a complete medical history and lower extremity evaluation for neuropathy and foot pressures. Neuropathic parameters were dichotomized (0/1) into two high-risk variables: patients with a vibration perception threshold (VPT) > or =25 V were categorized as HiVPT (n=132) and those with Semmes-Weinstein monofilament tests > or =5.07 were classified as HiSWF (n=190). The mean dynamic foot pressures of three footsteps were measured using the F-scan mat system with patients walking without shoes. Maximum plantar pressures were dichotomized into a high-pressure variable (Pmax6) indicating those subjects with pressures > or =6 kg/cm2 (n=96). A total of 99 patients had a current or prior history of ulceration at baseline.

RESULTS

Joint mobility was significantly greater in the Hispanic cohort compared with the other groups at the first metatarsal-phalangeal joint (C 67+/-23 degrees, B 69+/-23 degrees, H 82+/-23 degrees, P=0.000), while the subtalar joint mobility was reduced in the Caucasian group (C 21+/-8 degrees, B 26+/-7 degrees, H 27+/-11 degrees, P=0.000). Maximum plantar foot pressures were significantly higher in the Caucasian group (C 6.7+/-2.9 kg/cm2, B 5.7+/-2.8 kg/cm2, H 4.4+/-1.9 kg/cm2, P=0.000). Univariate logistic regression for Pmax6 on the history of ulceration yielded an odds ratio (OR) of 3.9 (P=0.000). For HiVPT, the OR was 11.7 (P=0.000), and for HiSWF the OR was 9.6 (P=0.000). Controlling for age, diabetes duration, sex, and race (all P < 0.05), multivariate logistic regression yielded the following significant associations with ulceration: Pmax6 (OR=2.1, P=0.002), HiVPT (OR=4.4, P=0.000), and HiSWF (OR=4.1, P=0.000).

CONCLUSIONS

We conclude that both high foot pressures (> or =6 kg/cm2) and neuropathy are independently associated with ulceration in a diverse diabetic population, with the latter having the greater magnitude of effect. In black and Hispanic diabetic patients especially, joint mobility and plantar pressures are less predictive of ulceration than in Caucasians.

Role of interleukin-12 in primary influenza virus infection

The effect of endogenous interleukin-12 (IL-12) on the influenza virus immune response in BALB/c mice was evaluated. Following primary influenza virus infection, IL-12 mRNA and protein are detected in the lung, with live virus being required for cytokine induction. Endogenous IL-12 contributes to early NK cell-dependent gamma interferon (IFN-gamma) production (days 3 and 5) but not late T-cell-dependent IFN-gamma secretion (day 7). IL-12 contributes to the inhibition of early virus replication but is not required for virus clearance. IL-12 also modestly contributes to the activation of cytotoxic T lymphocytes. Thus, in this model of experimental influenza virus infection, endogenous IL-12 contributes primarily to the early development and activation of the innate immune response.

Role of UEV-1, an inactive variant of the E2 ubiquitin-conjugating enzymes, in in vitro differentiation and cell cycle behavior of HT-29-M6 intestinal mucosecretory cells

By means of differential RNA display, we have isolated a cDNA corresponding to transcripts that are down-regulated upon differentiation of the goblet cell-like HT-29-M6 human colon carcinoma cell line. These transcripts encode proteins originally identified as CROC-1 on the basis of their capacity to activate transcription of c-fos. We show that these proteins are similar in sequence, and in predicted secondary and tertiary structure, to the ubiquitin-conjugating enzymes, also known as E2. Despite the similarities, these proteins lack a critical cysteine residue essential for the catalytic activity of E2 enzymes and, in vitro, they do not conjugate or transfer ubiquitin to protein substrates. These proteins constitute a distinct subfamily within the E2 protein family and are highly conserved in phylogeny from yeasts to mammals. Therefore, we have designated them UEV (ubiquitin-conjugating E2 enzyme variant) proteins, defined as proteins similar in sequence and structure to the E2 ubiquitin-conjugating enzymes but lacking their enzymatic activity (HW/GDB-approved gene symbol, UBE2V). At least two human genes code for UEV proteins, and one of them, located on chromosome 20q13.2, is expressed as at least four isoforms, generated by alternative splicing. All human cell types analyzed expressed at least one of these isoforms. Constitutive expression of exogenous human UEV in HT-29-M6 cells inhibited their capacity to differentiate upon confluence and caused both the entry of a larger proportion of cells in the division cycle and an accumulation in G2-M. This was accompanied with a profound inhibition of the mitotic kinase, cdk1. These results suggest that UEV proteins are involved in the control of differentiation and could exert their effects by altering cell cycle distribution.

Excess adipose and heartburn

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