UK women doctors' use of hormone replacement therapy: 10-year follow up

OBJECTIVES

To determine changes in the prevalence and duration of use of hormone replacement therapy (HRT) by women doctors over 10 years.

METHODS

Questionnaire survey of 1234 UK women doctors (randomized, stratified sample), compared with a similar survey in 1993.

RESULTS

In women aged 50-64 years, the age-standardized prevalence of ever-use of HRT had increased from 53.4% in 1993 to 66.2% in 2003 (p<0.001). There was a marked reduction in uptake by women under 50 years, while the age-standardized prevalence of current use in women aged 50-64 years was unchanged at 38.1%. The discontinuation rate in this age group had increased from 27.8% to 42.4% (p<0.001). Over 20% of women aged 65-74 years were still using HRT. The median duration of HRT use was 8.1 years by current users and 5 years by past users. The major indications were symptom relief and osteoporosis prevention. Current users of HRT tended to have more definite views about the potential risks and benefits of long-term use than past or never-users.

CONCLUSIONS

The proportion of women doctors starting HRT increased after 1993, but uptake and continuation rates have now both declined, consistent with prescription data, probably reflecting the changing nature of the evidence base. However, many women doctors still intended to continue long-term HRT.

Influence of T cell depletion method on circulating gammadelta T cell reconstitution and potential role in the graft-versus-leukemia effect

BACKGROUND

Our laboratory previously reported that leukemia patients who developed > or = 10% gammadelta+ T cells during the first six months after receiving an anti-TCRalphabeta T-cell-depleted (TCD) graft from a partially mismatched related donor (PMRD) had a disease-free survival (DFS) advantage. These gammadelta+ T cells were V81+CD3+CD4-CD8-CD69+HLADR+ and are cytotoxic to K562 cells.

METHODS

In order to determine whether the anti-alphabeta TCD regimen was associated with these findings, we compared the reconstitution of gammadelta+ T cells from patients who received TCD PMRD grafts using the anti-TCRc4 MAb TIOB9-1A31 (previously reported) with similar patients who received grafts using the anti-CD3 MAb OKT3.

RESULTS

Increased cytotoxic Vdelta1+ T cells were seen in 10 of 43 T10B9 TCD patients compared to 7 of 100 in the OKT3 TCD group (23% versus 7%, p = 0.010). T10B9 patients with increased gammadelta+ T cells also exhibited a higher range of increased gammadelta+ T cells and the length of time the gammadelta+ T cells remained high was longer when compared to OKT3 patients. Patients with increased gammadelta+ T cells whose grafts were T-cell depleted with T10B9 showed a significant decrease in relapse (p = 0.038). Similar rates and reduction in relapse were seen in OKT3 TCD patients, although significance was not reached due to the small number of patients with increased gammadelta+ T cells. Estimated 3 year disease-free survival was significantly improved in T10B9 patients with increased gammadelta+ T cells (0.79 versus 0.31, p = 0.009), a trend also seen in OKT3 patients (p = 0.091).

DISCUSSION

These observations indicate that Vdelta1+CD4-CD8-cytotoxic T cells are associated with lower relapse rates and improved survival, and thus may have a role in a graft-versus-leukemia effect.

Self-reported bladder function five years post-hysterectomy

We have examined the contribution of hysterectomy, compared with less invasive surgery, for dysfunctional uterine bleeding (DUB) on the prevalence of bladder problems five years after surgery. We report a prospective cohort study of over 25,000 women treated for benign cause menorrhagia by three types of surgery - transcervical endometrial resection/ablation and hysterectomy with or without bilateral oophorectomy. Postal questionnaires were sent five years after surgery investigating satisfaction with surgery and bladder function. When adjusted for confounders the odds of severe urinary incontinence (OR = 1.59, CI 95%, 1.35 - 1.87), urinary frequency (1.23 (1.04 - 1.45)), and nocturia (1.19, (1.03 - 1.38)) - were increased for women who had a hysterectomy compared with endometrial ablation. Hysterectomy with bilateral oophorectomy was not as strongly associated with severe bladder problems. Women who had the LAVH were most likely to report severe urinary incontinence (2.02, CI 95% 1.32 - 3.07), but not severe frequency or nocturia.

Proliferative signals mediated by CD28 superagonists require the exchange factor Vav1 but not phosphoinositide 3-kinase in primary peripheral T cells

Almost all responses of naive T cells require co-stimulation, i.e. engagement of the clonotypic TCR with relevant antigen/MHC and the co-stimulatory molecule CD28. How CD28 contributes to T-cell proliferation remains poorly understood, with widely conflicting reports existing which may reflect different methods of co-ligating receptors. Some CD28 mAb, however, can stimulate T-cell proliferation without the need for TCR co-ligation, and thus provide unique tools to dissect proliferative signals mediated through CD28 alone. Using primary peripheral T cells from CD28-transgenic mice, we show that both the YMNM and Lck-binding motifs, but not the Itk-binding motif, in CD28 are required for proliferation. Given that the YMNM motif recruits both phosphoinositide 3-kinase (PI3K) and the exchange factor Vav1, we investigated the role of these two molecules in CD28-mediated proliferation. In p110delta(D910A/D910A) transgenic T cells, which are defective in PI3K activation following CD28 ligation, proliferation was comparable to that in wild-type cells. By contrast, T-cell proliferation was abolished in Vav1(-/-) cells. Although we did not address the role of Grb2 in CD28 signalling, these results indicate that CD28 can mediate Lck- and Vav1-dependent proliferative signals independently of PI3K.

The efficacy and safety of weekly vinorelbine in relapsed malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is a rapidly progressive invariably lethal tumor. Treatment options remain limited and the outcome in relapsed disease is poor warranting new therapeutic options. Following our previous experience in the first-line setting, we conducted a phase 2 open-label non-comparative study to assess the safety and efficacy of weekly vinorelbine chemotherapy, each cycle consisting of 30 mg/m(2) for 6 weeks, in patients with previous exposure to chemotherapy. In 63 individuals with relapsed MPM who had not received previous vinorelbine, we observed an objective response rate of 16% and an overall survival of 9.6 months (95% confidence interval 7.3-11.8 months). The main grade III/IV toxicity observed was neutropenia and toxicity was similar to weekly vinorelbine when used in the first-line setting. Weekly vinorelbine appeared to have a reasonable response rate with an acceptable toxicity profile in the second-line treatment of MPM. Its use should be prospectively evaluated in a randomised trial in the first or second-line therapy of MPM.

Uterine artery embolisation or hysterectomy for the treatment of symptomatic uterine fibroids: a cost-utility analysis of the HOPEFUL study

OBJECTIVES

To evaluate the relative cost-effectiveness of uterine artery embolisation (UAE) and hysterectomy in women with symptomatic uterine fibroids from the perspective of the UK NHS.

DESIGN

Cost-utility analysis.

SETTING

Eighteen UK NHS hospital trusts. POPULATION OR SAMPLE Women who underwent UAE (n= 649; average follow up of 8.6 years) or hysterectomy (n= 459; average follow up of 4.6 years) for the treatments of symptomatic fibroids.

METHODS

A probabilistic decision model was carried out based on data from a large comparative cohort and the literature. The two interventions were evaluated over the time horizon from the initial procedure to menopause. Extensive sensitivity analysis was carried out to test model assumptions and parameter uncertainties.

MAIN OUTCOME MEASURES

Costs of procedures and complications and quality of life expressed as quality-adjusted life years (QALYs).

RESULTS

Overall, UAE was associated with lower mean cost (2536 pounds sterling versus 3282 pounds sterling) and a small reduction in quality of life (8.203 versus 8.241 QALYs) when compared with hysterectomy. However, when the quality of life associated with the conservation of the uterus was incorporated in the model, UAE was shown to be the dominant strategy--lower costs and greater QALYs.

CONCLUSIONS

UAE is a less expensive option to the health service compared with hysterectomy, even when the costs of repeat procedures and associated complications are factored in. The quality of life implications in the short term are also predicted to favour UAE; however, this advantage may be eroded over time as women undergo additional procedures to deal with recurrent fibroids. Given the hysterectomy is the current standard treatment for symptomatic fibroids, offering women UAE as an alternative treatment for fibroids is likely to be highly cost-effective for those women who prefer uterus-conserving treatment.

What really matters to patients living with chronic obstructive pulmonary disease? An exploratory study

There is limited published research into what really matters to people living with chronic obstructive pulmonary disease (COPD). Most previous research in this area focuses on the impact of the symptoms of COPD, rather than on the issues defined as important by patients themselves. This paper describes an exploratory study investigating what is most important to people living with COPD. A qualitative approach employing in-depth interviews with COPD patients was chosen. Thematic analysis was used to code and categorize data. Six patients with 'moderate' to 'very severe' COPD were recruited. They considered engagement in specific activities to be very important (walking, household maintenance and driving), even though these activities were mainly centred around the home environment, or within confined spaces, due to their physical limitations. This restriction led to feelings of social isolation that these patients tried to overcome through social participation (holidays, social interaction). People with COPD often experience physical restrictions, which can lead to reduced community mobility and social isolation. In this study, despite their physical limitations, these patients had a strong desire to participate and be engaged in various activities. The importance of enabling patients to 'participate' rather than just 'do' should be considered when planning and delivering patient-centred interventions across the whole spectrum of severity of COPD.

Active and passive smoking and the risk of breast cancer in women aged 36-45 years: a population based case-control study in the UK

Active smoking has little or no effect on breast cancer risk but some investigators have suggested that passive smoking and its interaction with active smoking may be associated with an increased risk. In a population based case-control study of breast cancer in women aged 36-45 years at diagnosis, information on active smoking, passive smoking in the home, and other factors, was collected at interview from 639 cases and 640 controls. Women were categorised jointly by their active and passive smoking exposure. Among never smoking controls, women who also reported no passive smoking exposure were significantly more likely to be nulliparous and to be recent users of oral contraceptives. Among those never exposed to passive smoking, there was no significant association between active smoking and breast cancer, relative risk (RR) of 1.12 (95% confidence interval (CI) 0.72-1.73) for past smokers and RR of 1.19 (95% CI 0.72-1.95) for current smokers, nor was there an association with age started, duration or intensity of active smoking. Compared with women who were never active nor passive smokers, there was no significant association between passive smoking in the home and breast cancer risk in never smokers, RR of 0.89 (95% CI 0.64-1.25), in past smokers, RR of 1.09 (95% CI 0.75-1.56), or in current smokers, RR of 0.93 (95% CI 0.67-1.30). There was no trend with increasing duration of passive smoking and there was no heterogeneity among any of the subgroups examined. In this study, there was no evidence of an association between either active smoking or passive smoking in the home and risk of breast cancer.

Arsenic bioaccessibility and speciation in clams and seaweed from a contaminated marine environment

The bioaccessible concentration and speciation of arsenic (soluble in a gastrointestinal medium and available for absorption into the bloodstream) were determined in softshell clams (Mya arenaria), harvested by local residents until 2005, and in seaweed (Fucus sp.) from an arsenic-contaminated marine site in Seal Harbour, Nova Scotia, Canada. Bioaccessibility extractions to simulate the human gastrointestinal environment (pH 1.5 and glycine for 1h followed by pancreatin, bile extract and pH adjustment to 7 for an additional 4h) and speciation of arsenic in extracts (HPLC-HG-AAS to target inorganic arsenic species) and whole samples (XANES) were carried out. Total arsenic for the clams from the contaminated area ranged from 218 to 228 ppm wet weight, with a bioaccessible fraction of 34-46%, and the major bioaccessible species of arsenic were inorganic. The seaweed from the contaminated area contained 27-43 ppm wet weight total arsenic, with the bioaccessible fraction ranging from 63% to 81%, and inorganic arsenic was also predominant. The predominantly inorganic nature of arsenic in the whole samples was confirmed by XANES. In concurrence with the closure of the area for clam harvesting, the clams and seaweed from Seal Harbour should probably not be used for human consumption.

Snoezelen multi-sensory environments: task engagement and generalization

These experiments explored whether behavioral improvements observed during Snoezelen OT treatment sessions carried over to two different settings for three people with moderate/severe intellectual disability, autism and severe challenging behaviors. Experiment 1 explored engagement during a functional task immediately following the treatment sessions while experiment 2 explored changes in the frequencies of challenging behaviors on the days after treatment sessions. Investigators found carryover for two of the three participants to both post-session engagement as well as to the daily frequency of challenging behaviors on days following the OT sessions.