Temperament: a consideration of concepts and methods

This paper discusses conceptual issues and begins with a consideration of definitions of temperament. It is suggested that the purposes for which temperament has been studied have, to some degree, dictated methods used and inferences drawn. Those psychopathologists interested in the relationship between temperament and psychiatric disorder, or emotional and behavioural disturbance, have tended to use different methods from those more concerned with delineating the structure of personality. Some issues and problems are common to both approaches, e.g. the definition of behaviour reflecting temperament in terms of style rather than content. Other issues, such as the difficulty involved in drawing a clear distinction between temperamental attributes and mental disorders, are restricted to one approach. The relative contribution of gentic and environmental effects is of interest to both psychopathologists (who wish to examine this issue in relation to the development of the individual), and to psychologists (who are usually more concerned with populations or aggregate effects). The application of biometric genetic models might clarify this issue, and various suggestions are made regarding steps that need to be taken if such models are to be successfully applied.

Reproducibility of sonographic assessment of fetal liver length in diabetic pregnancies

OBJECTIVES

Assessing fetal liver size might be useful in monitoring the effectiveness of the treatment of diabetes in pregnancy. We aimed to assess the reproducibility of fetal liver-length measurement in pregnant women with diabetes.

METHODS

From 3 April 2006 to 5 December 2006, we assessed intraobserver and interobserver variation of fetal liver-length measurements on 55 sonograms in 44 pregnant women with diabetes, 34 of whom had gestational diabetes. The mean maternal age was 33 years, the mean maternal weight was 92 kg and the mean body mass index (BMI) was 33.7 kg/m(-2). The effect of covariates BMI, gestational age and maternal age on the reproducibility of fetal liver length was assessed by calculating intraobserver SD ratios. We compared liver length with abdominal circumference and gestational age. Nine of 12 sonographers scanned, on average, six women (range, 3-12) as the first sonographer, and all 12 sonographers scanned, on average, four women (range, 1-10) as the second sonographer. The data were analyzed using a hierarchical linear model.

RESULTS

Measurement of fetal liver length was reproducible. The intraobserver SD was 3.06 (95% CI, 2.68-3.59) mm; the interobserver SD was 2.17 (95% CI, 0.59-4.83) mm; the intraobserver correlation was 0.77 (95% CI, 0.63-0.87), and the interobserver correlation was 0.84 (95% CI, 0.51-0.99). The covariate effects were minimal, the SD for a 1-unit increase in the covariate was 1.06 for gestational age, 0.98 for BMI, and 0.97 for maternal age.

CONCLUSIONS

Measurement of fetal liver length in the diabetic pregnancy is reproducible. It is worthy of further investigation as a parameter for monitoring the effectiveness of treatment of the diabetic pregnancy.

Novel landmark-guided routes in ants

We review studies in which ants familiar with fixed routes between their nest and a feeding site are displaced from one of these destinations to an unfamiliar site away from the route. Ants can reach their goal from such novel release sites guided by distant landmarks. We suggest that an ant's ability to take such novel landmark-guided routes after displacement is a by-product of the robustness of normal route-following and is unlikely to reflect the ant's use of a map-like knowledge of its surroundings.

Supraclavicular radiotherapy must be limited laterally by the coracoid to avoid significant adjuvant breast nodal radiotherapy lymphoedema risk

This cross-sectional study aimed to investigate the effect of supraclavicular fossa (SCF) radiotherapy volumes as well as patient characteristics and nodal pathology on the development of lymphoedema. Ninety-one women who had received SCF nodal radiotherapy after axillary dissection were evaluated. Lymphoedema was defined by two measurements: limb volume difference 200 mL, or circumference difference 10 cm proximal or distal to the olecranon>2 cm. On univariate analysis, the addition of axillary to SCF radiotherapy, increasing width of the SCF field, increasing age, presence of extracapsular extension of nodal involvement and use of hormone treatment was associated with lymphoedema by either one or both definitions. For both definitions of lymphoedema, on multivariate analysis, increasing nodal radiotherapy volume remained significant (P=0.02 to 0.007), as did increased age (P=0.05 to 0.001). We conclude that conventionally fractionated SCF radiotherapy limited laterally by the coracoid process has a lymphoedema risk similar to that expected from axillary dissection alone and a lower risk than wider SCF fields with or without an axillary boost.

Re-treatment of chronic hepatitis C patients after relapse: efficacy of peginterferon-alpha-2a (40 kDa) and ribavirin

We conducted a randomized multinational study to determine whether 48 weeks of re-treatment with peginterferon-alpha-2a (40 kDa) plus ribavirin would induce a sustained virological response (SVR) in relapsed chronic hepatitis C patients. Patients who had previously relapsed during 24 weeks of untreated follow-up, after having achieved an end-of-treatment virological response with 24 weeks of peginterferon-alpha-2a (40 kDa)/ribavirin combination therapy, within a phase III trial, were studied. Although the recommended dosage was the same as that used at the end of the initial trial, adjustments were permitted. Data on serious adverse events, or adverse events that resulted in dose reductions or discontinuations, were collected. Following re-treatment, the overall SVR rate in the 64 patients was 55%. The SVR rates in patients infected with hepatitis C virus (HCV) genotype 1 and non-1 genotypes were 51% and 63%, respectively. Early (week 12) virological responses were seen in 39 patients (61%) and were predictive of an SVR. Re-treatment was well tolerated. The most frequent adverse events recorded were fatigue (5%) and abdominal pain (3%). Dosages of peginterferon-alpha-2a (40 kDa) and/or ribavirin were modified because of adverse events in 3% and 13% of patients, and because of laboratory abnormalities in 23% and 5% of patients, respectively. Thus, a 48-week course of peginterferon-alpha-2a (40 kDa) plus ribavirin induces an SVR in 55% of patients who relapsed during follow-up after 24 weeks of combination therapy. Physicians should not hesitate to offer re-treatment to patients who relapse after an initial, 24-week course of combination therapy, or who have prematurely stopped treatment because, for example, of laboratory abnormalities.

A phase II trial of oxaliplatin in patients with advanced melanoma

18016

Background: Oxaliplatin is a platinum derivative without nephrotoxicity with in vitro activity against human melanoma cell lines. (Mohammed, MQ, 2000; Tashiro, T, 1989). A Phase I trial suggested activity in melanoma (Mathe, G, 1986) but Phase II data is lacking. A non-nephrotoxic platinum compound active in melanoma is of interest in the development of combination chemo-or chemoimmunotherapy. Methods: This was a Phase II prospective study of oxaliplatin in patients with previously treated or refractory advanced melanoma. The primary endpoint was to evaluate the response rate, survival, freedom from progression (FFP) and the tolerability of oxaliplatin in this patient population. Key inclusion criteria were: metastatic (stage IV) or unresectable malignant melanoma progressing following treatment with at least one and at most three chemotherapy regimens. ECOG PS 0–2, measurable disease and adequate organ and marrow function were required. Oxaliplatin 130 mg/m2 was given IV in 250–500 mL D5W over 120 minutes every 21 days for at least 2 cycles. Patients were evaluated for response every 2 cycles. Gehan’s two-stage design was utilized. Results: Ten patients were treated between March 2004 and March 2005. Three patients were female and 3 male with a median age of 62.5 years. All patients had PS 0–1. The median number of cycles was 2 (1–6). Three patients had disease stabilization (SD) for median of 3 months. No objective responses were seen; therefore, the study did not progress to the second stage.All patients have progressed and all have expired but one. Median survival from registration was 168 days (128–383). Toxicities included grade 2 fatigue (2 pts) and grade 2 neuropathy (3 pts); one patient had grade 3 diarrhea. Conclusions: Treatment with oxaliplatin in previously treated patients with melanoma is well tolerated at the dose and schedule studied but did not result in objective responses and further development in this population cannot be recommended. Incorporation into combination regimens in previously untreated patients may be of interest.

No significant financial relationships to disclose.

Phase II trial of oxaliplatin and gemcitabine with bevacizumab in first-line advanced non-small cell lung cancer (NSCLC)

17009

Background: Oxaliplatin-Gemcitabine (GemOx) is an active and well tolerated. Bevacizumab (BV) prolongs survival when combined with carboplatin-paclitaxel. This phase II trial evaluates the efficacy of GemOx + BV as 1st line therapy for advanced NSCLC patients. Methods: Pts with stage IIIB (effusion) and IV non-squamous NSCLC, ECOG PS 0 or 1, no CNS metastasis, and no other contraindications to BV, are eligible. Prior therapy for earlier-stage disease allowed if completed at least 12 months before enrollment. Treatment consists of Gem 1000 mg/m2 on d1 and 8, Ox 130 mg/m2 on d1, and BV 15 mg/kg on d1, repeated every 3 wks for a total 4 cycles. Pts who respond or have stable disease receive BV maintenance until progression. Main endpoints are response rate (RR), grade (Gr) 3–4 toxicities, time to progression (TTP), and overall survival (OS). Results: As of 12/05, 26 out of 50 projected pts have been enrolled from 4 institutions. M/F 17/9; median age 65y (45,81); IIIB/IV 3/23; PS 0/1 8/18. Median F/U time is 3.7 months. 24 pts are evaluable for toxicity: 1Gr3 ANC; 1Gr3 and 4 PLT; no FN.3 Gr3 diarrhea and 2 Gr3 N/V; 1Gr3 and 4 hypophosphatemia; 1 pt had ischemic bowel after the 1st cycle, recovered fully and was removed from study; 1 pt died of liver failure in the 1st cycle. No bleeding complications have occurred. 22 pts are evaluable for RR (ITT): 7 PR (31%); 8 SD (36%). TTP and OS data not yet available. Conclusions: This is the first report of GemOx in combination with BV in advanced NSCLC. This regimen has minimal hematologic toxicity but selected non-hematologic toxicities are noted. Activity appears promising and merits further investigation. Accrual is ongoing.

[Table: see text]

Placing the boost in breast-conservation radiotherapy: A review of the role, indications and techniques for breast-boost radiotherapy

Randomised trials have established that the addition of a boost dose of radiotherapy to the lumpectomy site after whole-breast adjuvant radiotherapy further improves local control achieved by whole-breast radiotherapy alone. The absolute size of this benefit varies according to the baseline risk of local recurrence. Age is the strongest predictor of benefit. Below the age of 40 years, the absolute benefit of a boost seems to be substantial, and there are no clearly identified groups unlikely to benefit. Above the age of 50 years, the benefit is small, and several additional risk factors for local failure would need to be present to merit boost treatment. These may include tumour size, high grade, high mitotic rate, lymphovascular invasion, extensive and high grade associated with intraduct carcinoma, receptor-positive tumours when avoidance of anti-oestrogen therapy is desired or receptor-negative tumours. Other independent reasonable indications for the use of a boost would be positive margins where further surgery is not indicated. If a boost is indicated, a variety of techniques may be used and toxicity and cosmetic results remain highly acceptable. Overall, there seems to be no substantial differences in boost technique results; however, interstitial techniques may have advantages for deeper targets compared with electrons. Irrespective of technique, accurate localisation will maximise the benefit of a boost. Surgical clips are strongly recommended to facilitate localisation.

Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis

BACKGROUND

Non-invasive positive pressure ventilation (NIPPV), using continuous positive airway pressure (CPAP) or bilevel ventilation, has been shown to reduce the need for invasive mechanical ventilation in patients with acute cardiogenic pulmonary oedema. We assessed additional benefits of NIPPV in a meta-analysis.

METHODS

Meta-analysis comparison in acute cardiogenic pulmonary oedema was undertaken to compare (1) CPAP with standard therapy (oxygen by face-mask, diuretics, nitrates, and other supportive care), (2) bilevel ventilation with standard therapy, and (3) bilevel ventilation with CPAP, incorporating randomised controlled trials identified by electronic and hand search (1966-May, 2005). In 23 trials that fulfilled inclusion criteria, we assessed the effect of NIPPV on hospital mortality and mechanical ventilation, estimated as relative risks.

FINDINGS

CPAP was associated with a significantly lower mortality rate than standard therapy (relative risk 0.59, 95% CI 0.38-0.90, p=0.015). A non-significant trend towards reduced mortality was seen in the comparison between bilevel ventilation and standard therapy (0.63, 0.37-1.10, p=0.11). We recorded no substantial difference in mortality risk between bilevel ventilation and CPAP (p=0.38). The need for mechanical ventilation was reduced with CPAP (0.44, 0.29-0.66, p=0.0003) and with bilevel ventilation (0.50, 0.27-0.90, p=0.02), compared with standard therapy; but no significant difference was seen between CPAP and bilevel ventilation (p=0.86). Weak evidence of an increase in the incidence of new myocardial infarction with bilevel ventilation versus CPAP was recorded (1.49, 0.92-2.42, p=0.11). Heterogeneity of treatment effects was not evident for mortality or mechanical ventilation across patients' groups.

INTERPRETATION

In patients with acute cardiogenic pulmonary oedema, CPAP and bilevel ventilation reduces the need for subsequent mechanical ventilation. Compared with standard therapy, CPAP reduces mortality; our results also suggest a trend towards reduced mortality after bilevel NIPPV.

Oxime therapy and outcomes in human organophosphate poisoning: an evaluation using meta-analytic techniques

OBJECTIVE

The status of oximes in human organophosphate poisoning is controversial. This analysis compares the outcomes of therapy with or without oximes.

DESIGN

Quantitative analysis using meta-analytic techniques.

METHODS

Controlled trials of oximes in human organophosphate poisoning were identified by search of MEDLINE and TOXLINE (1966 to May 2005) and review of published articles.

MEASUREMENTS AND MAIN RESULTS

Of the 3,122 articles on organophosphate poisoning identified by electronic search, 116 related to oxime use in human organophosphate poisoning. Seven trials, including two randomized controlled trials, compared oximes with standard medical care. Varying dosage schedules of pralidoxime or obidoxime were used. The effects of oxime therapy on mortality rate, mechanical ventilation, incidence of intermediate syndrome, and need for intensive care therapy were analyzed and expressed as risk difference (positive values indicating oxime harm). The random effects estimator was reported because of underlying heterogeneity of treatment effects between study types. No statistically significant association of oxime therapy was demonstrated for either mortality (risk difference 0.09, 95% confidence interval -0.08 to 0.27), ventilatory requirements (risk difference 0.16, 95% confidence interval -0.07 to 0.38), or the incidence of intermediate syndrome (risk difference 0.16, 95% confidence interval -0.12 to 0.45), although point estimates of effect suggested harm. An increased need for intensive care therapy (risk difference 0.19, 95% confidence interval 0.01 to 0.36) was apparent with oxime therapy.

CONCLUSIONS

Based on the current available data on human organophosphate poisoning, oxime was associated with either a null effect or possible harm. The lack of current prospective randomized controlled trials, with appropriate patient stratification, mandates ongoing assessment of the role of oximes in organophosphate poisoning.

Rewarming of healthy volunteers after induced mild hypothermia: a healthy volunteer study

OBJECTIVES

The study compares the efficacy of two active and one passive warming interventions in healthy volunteers with induced mild hypothermia.

METHODS

Eight volunteers were studied in a random order crossover design. Each volunteer was studied during re-warming from a core temperature of 35 degrees C with each of: a radiant warmer (Fisher & Paykel); a forced air warmer (Augustine Medical), and a polyester filled blanket, to re-warm.

RESULTS

No significant differences in re-warming rates were observed between the three warming devices. It was found that the subject's endogenous heat production was the major contributor to the re-warming of these volunteers. Metabolic rates of over 350 W were seen during the study.

CONCLUSIONS

For patients with mild hypothermia and in whom shivering is not contraindicated our data would indicate that the rate of re-warming would be little different whether a blanket or one of the two active devices were used. In the field, this may provide the caregiver a useful choice.

Vitamin C supplementation in very preterm infants: a randomised controlled trial

OBJECTIVE

To determine whether regulating vitamin C (ascorbic acid: AA) intake to achieve higher or lower plasma concentrations was associated with improved clinical outcome.

DESIGN

A double blind, randomised controlled trial.

SETTING

Neonatal intensive care unit at Christchurch Women's Hospital.

PATIENTS

Infants with birth weight <1500 g or gestation <32 weeks, admitted to the unit within 48 hours of birth.

INTERVENTION

Infants were randomised to one of three protocols with regard to AA supplementation for the first 28 days of life: group LL received low supplementation throughout; group LH received low until day 10 and then high: group HH received high throughout.

MAIN OUTCOME MEASURES

Primary outcome measures were oxygen requirement at 28 days and 36 weeks postmenstrual age, total days supplemental oxygen, and retinopathy of prematurity. AA concentrations were measured at study entry (day 2), and days 10, 21, and 28.

RESULTS

A total of 119 infants were enrolled over 24 months (mean gestation 28.4 weeks; birth weight 1161 g). Six infants died, and these had significantly higher AA concentrations before randomisation than surviving infants (116 micromol/l (95% confidence interval 90 to 142) v 51 micromol/l (45 to 58), p<0.0001). There were no significant differences in primary outcomes between the groups. However, the proportion of surviving infants with an oxygen requirement at 36 weeks postmenstrual age in group HH (19%) was half that in group LL (41%) (p=0.06).

CONCLUSIONS

In a randomised controlled trial, no significant benefits or harmful effects were associated with treatment allocation to higher or lower AA supplementation throughout the first 28 days of life.

Absence of adverse early quality of life outcomes of radiation therapy in breast conservation therapy for early breast cancer

The New South Wales Breast Radiation Oncology Group has completed a prospective multicentre study of the impact of radiation therapy (RT) on acute toxicity and quality of life (QoL) in women with early breast cancer treated with breast conservation therapy. The patient group received adjuvant breast tangential RT after wide local excision of breast cancer. Acute toxicity and cosmesis was assessed quantitatively and qualitatively. European Organization of Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-30) and Perceived Adjustment to Chronic Illness Scale (PACIS) were the QoL instruments used. Of 175 women, 34.3% described lethargy leading to a significant disruption to normal activity during RT. At week 6, this had reduced to 7.5% reporting significant lethargy. No negative effects on QoL were noted over the time period of RT; EORTC demonstrated no difference (P = 0.79). PACIS recorded a significant improvement in functioning (P < 0.001) from baseline to week 6. Univariate analysis on potential predictive patient, tumour and treatment factors demonstrated an association of baseline pre-RT breast discomfort with worse lethargy (P = 0.03), EORTC (P < 0.01) and PACIS (P < 0.01) measures. This study confirms the minimal impact of RT on patient functioning at 6 weeks post-treatment.

Impact of phosphorus application and sheep grazing on the botanical composition of sown pasture and naturalised, native grass pasture

Botanical composition (basal cover) was measured in 4 replicated pasture treatments based on Phalaris aquatica and Trifolium subterraneum at Hall, ACT (unfertilised with low and high stocking rate; fertilised with low and high stocking rate) and in 2 unreplicated pasture treatments based on native perennial grasses (Austrodanthonia spp. and Microlaena stipoides) and T. subterraneum at Bookham, NSW (unfertilised and low stocking rate; fertilised and high stocking rate). Current economic pressures are encouraging graziers to increase their use of phosphorus (P) fertiliser and to adopt higher stocking rates. The objective of the research was to determine the changes in botanical composition that may result from these changes in grazing systems management. At Hall, annual species differed in their responses to P fertility. Notably, basal cover of Bromus spp. increased significantly with P application, whereas Vulpia spp. decreased significantly. Basal cover of T. subterraneum also increased significantly with P application when stocking rate was high, but was reduced by P application if stocking rate was low. Basal cover of perennial grasses (P. aquatica and Holcus lanatus) was significantly higher at low stocking rate when P was applied. The botanical composition of high stocking rate treatments was relatively stable over time, which contrasted with less stable composition at low stocking rate. At Bookham, fertilised pasture in unreplicated paddocks appeared to have a higher basal cover of productive annual species (i.e. Bromus spp. and T. subterraneum), but native perennial grasses appeared to have lower basal cover in comparison with the unfertilised area. These results indicated that in some cases, the influence of P fertiliser and high stocking rates on botanical composition was favourable (i.e. increased basal cover of P. aquatica and T. subterraneum) and in others it could be detrimental (i.e. lower basal cover of native perennial grasses).

An in vitro Flaviviridae replicase system capable of authentic RNA replication

We have established an in vitro replication system for bovine viral diarrhea virus (BVDV), a surrogate for the closely-related hepatitis C virus. In an in vitro reaction, BVDV replication complexes synthesize vRNA and replicative form (RF) and replicative intermediate (RI) RNAs. Kinetic and heparin trapping experiments demonstrate the recycling of RF and RI products and the initiation of vRNA synthesis in this system. Consistent with this, quantitative hybridization reveals the asymmetric synthesis of positive and negative strand RNA products. These findings support the notion that RF serves as a template and RI as a precursor in the synthesis of vRNA. Furthermore, the antiviral activity of an NS5B inhibitor was similar in BVDV replicase and infectivity assays. Together, these results indicate that the in vitro activity of BVDV replicase complexes recapitulates RNA replication that occurs in infected cells, providing a system in which to study both mechanisms and inhibitors of Flaviviridae replication.

Why a breast boost should remain a controversial aspect of routine breast conservation management in Australia and New Zealand in 2002

Two randomized trials have recently shown a statistically significant improvement in local control when a boost is employed in the conservative treatment of early breast cancer. However, unresolved issues of cost effectiveness, potentially increased toxicity and the inability to automatically generalize these results to Australian and New Zealand practice remain. In view of these unresolved controversies, the St George and Wollongong hospitals breast boost trial (SGW trial) will continue to recruit.

Open mesh versus non-mesh for repair of femoral and inguinal hernia

BACKGROUND

Inguinal hernia repair is the most frequent operation in general surgery. Until recently the standard procedure has been open musculo-aponeurotic repair using sutures under tension to close the defect but 'tension-free' repair using prosthetic mesh is becoming increasingly common in many countries.

OBJECTIVES

The purpose of this review is to evaluate open mesh techniques in comparison with open non-mesh techniques for the surgical repair of groin hernia.

SEARCH STRATEGY

Electronic databases were searched and further trials were sought from the reference lists of reports of known trials. Through the EU Hernia Trialists Collaboration authors of identified randomised controlled trials were asked for information on any other trials known to them. There was no language restriction.

SELECTION CRITERIA

Studies were eligible for inclusion if they were randomised or quasi-randomised trials comparing either a) open mesh with open non-mesh repair of groin hernia or b) open flat mesh repair with plug and mesh repair of groin hernia.

DATA COLLECTION AND ANALYSIS

For each outcome the results were derived using data from the best available source. The majority of data for this review came from individual patient data (IPD) supplied by the trialists. When these were unavailable data came from additional aggregated information or from published trial reports. All trials were analysed using the 'intention to treat' principle.

MAIN RESULTS

Twenty trials comparing open mesh with open non-mesh repair were identified. Open mesh methods, on average, took 7-10 minutes less to perform than Shouldice procedures, but took 1-4 minutes longer than other non-mesh methods. There were no clear differences between mesh and non-mesh groups for haematomas, seromas or wound/superficial infections. Three serious operative complications were reported after open mesh repair and three following non-mesh repair. Overall, those in the mesh groups had a shorter length of hospital stay and quicker return to usual activities, but this pattern was not observed for all trials. There was a suggestion that persisting pain was less frequent after mesh repair than after non-mesh repair but this result was dependent on one trial and data were not available for 11 trials. There was no evidence of a difference between the groups with respect to persisting numbness. Fewer hernia recurrences were reported after mesh repair (Peto OR: 0.37, 95% CI: 0.26 to 0.51). There were too few data to reliably address differential effects for patients with recurrent, bilateral or femoral hernias. Two trials comparing flat mesh with plug and mesh were identified. There was no clear evidence of differences between the groups.

REVIEWER'S CONCLUSIONS

There is evidence that the use of open mesh repair is associated with a reduction in the risk of recurrence of between 50% and 75%. Although the trials were heterogeneous there is also some evidence of quicker return to work and of lower rates of persisting pain following mesh repair.

Plesiomonas shigelloides sepsis and splenic abscess in an adolescent with sickle-cell disease

Plesiomonas shigelloides is a rare cause of self-limiting gastroenteritis. We report a case of extraintestinal P. shigelloides infection in an adolescent with sickle-cell disease who presented with bacteremia complicated by a splenic abscess. Despite the high mortality rate reported in extraintestinal P. shigelloides infection, the patient survived after drainage of the abscess and treatment with antibiotics.

The effect of oral sucralfate on the acute proctitis associated with prostate radiotherapy: a double-blind, randomized trial

PURPOSE

Acute rectal complications occur in the majority of patients receiving external-beam radiotherapy for carcinoma of the prostate. Sucralfate has been proposed to reduce radiation-induced mucosal injury by forming a protective barrier on ulcer bases, binding local growth factors, and stimulating angiogenesis. However, there is conflicting clinical evidence as to whether sucralfate, taken prophylactically during radiotherapy, can ameliorate the symptoms of acute radiation proctitis.

METHODS AND MATERIALS

A double-blind randomized trial was conducted at four Radiation Oncology Departments in Sydney, Australia, between February 1995 and June 1997. A total of 338 patients with clinically localized prostate cancer receiving small volume radiotherapy, of whom 335 were evaluable, were randomized to receive either 3 g of oral sucralfate suspension or placebo twice a day during radiotherapy. Patients kept a daily record of their bowel symptoms and were graded according to the RTOG/EORTC acute toxicity criteria.

RESULTS

One hundred sixty-four patients received sucralfate and 171 received placebo. Both groups were well balanced with regard to patient, tumor, treatment factors, and baseline symptoms, except that the placebo group had a significantly more liquid baseline stool consistency score (p = 0.004). Patients kept a daily diary of symptoms during radiotherapy. After adjusting for baseline values, there was no significant difference between the two groups with regard to stool frequency (p = 0.41), consistency (p = 0.20), flatus (p = 0.25), mucus (p = 0.54), and pain (p = 0.73). However, there was more bleeding in the sucralfate group, with 64% of patients noticing rectal bleeding, compared with 47% in the placebo group (p = 0.001). There was no significant difference between the two groups with respect to RTOG/EORTC acute toxicity (p = 0.88; sucralfate 13%, 44%, 43% and placebo 15%, 44%, 40% for grade 0, 1, and 2, respectively).

CONCLUSION

This study suggests that oral sucralfate taken prophylactically during radiotherapy does not ameliorate the symptoms of acute radiation proctitis and may increase acute bleeding. The cause of the increased bleeding in the sucralfate group is unclear. As the pathogenesis of acute and late reactions are different, late follow-up, which includes sigmoidoscopic evaluation, is currently being performed on this cohort of patients.

Notification of gastrointestinal illness by Canterbury and West Coast general practitioners

AIM

To identify factors influencing notification of enteric diseases by general practitioners (GPs).

METHODS

The 'laboratory-based notification rate' was calculated for each GP by dividing the number of cases they notified by their number of laboratory detected cases of selected enteric diseases during 1997 and 1998. The 'annual full time equivalent (FTE) notification rate' was defined as the number of notifications received during the study period adjusted for the proportion of that time spent in clinical practice. These measures were compared with responses to a questionnaire posted to 395 Canterbury and West Coast GPs.

RESULTS

82% responded to the questionnaire. Higher 'laboratory-based notification rates' and 'annual FTE notification rates' were associated with the practice nurse being responsible for notifying and with GPs who were more recent graduates or who practised in rural areas. Few respondents identified high risk groups in their criteria for requesting a specimen.

CONCLUSIONS

Communicable disease control could be enhanced by emphasising the importance of specimen collection in high risk groups, encouraging delegation of notification to practice nurses and encouraging the development of public health based guidelines to determine the need for specimen request

A comparison of primary and proxy respondent reports of habitual physical activity, using kappa statistics and log-linear models

BACKGROUND

Many epidemiological studies rely in part on proxy informants. There is little published information on the reliability of proxy-respondent reports of physical activity.

METHODS

Self-reported data on vigorous and moderate physical activity, from a representative sub-sample of participants in a community-based case-control study of coronary heart disease, were compared with information collected from their next-of-kin.

RESULTS

Relative to primary respondents, proxy respondents under-reported activity by approximately 10 percentage points, for both leisure and work-time activity. On a simple three point scale (inactivity/moderate activity/physical activity), 70% of primary-proxy pairs were in exact agreement with regard to leisure time activity and 67% of pairs were in exact agreement on work-time activity. The corresponding values for the weighted kappa statistic were 0.66 [95% confidence interval (CI) 0.59-0.72] and 0.62 (0.54-0.72). Log-linear modelling provided evidence for superior agreement on worktime activity when the proxy was not the primary respondent's spouse.

DISCUSSION

Overall levels of primary-proxy respondent agreement on physical activity seem somewhat lower than has been reported for smoking and alcohol-drinking frequency. There seems little reason to prefer spouse proxies when endeavouring to elicit information on work-time physical activity. Log-linear modelling provides an efficient means of exploring covariate effects in observer-agreement studies.

Medical complications of female genital mutilation

More than 130 million women are subjected to genital mutilation. Despite increasing efforts to reduce the practice, there are many obstacles to eliminating this 2,000-year-old practice, which is based on strong cultural traditions. As college health clinicians provide care to more international students from countries where female genital mutilation is performed, increased awareness and knowledge of the procedure will enable clinicians to understand and manage its complications. We report a case of obstructive uropathy resulting in hydronephrosis secondary to female genital mutilation and review the medical literature regarding this and other complications of genital mutilation "surgery."

Patterns of alcohol use and misuse among elderly rest home residents in Christchurch

AIMS

To determine the prevalence of alcohol use and misuse among elderly rest home residents in Christchurch.

METHODS

A cross-sectional prevalence survey was conducted among 175 residents aged 65 years and over, randomly selected from 30 rest homes in Christchurch, in 1998. Hazardous patterns of alcohol consumption in the past twelve months were determined by the Alcohol Use Disorders Identification Test (AUDIT) questionnaire, and alcohol dependence in the past 12-months and lifetime was determined by a strctured clinical interview using DSM-IV criteria.

RESULTS

Of 246 eligible participants, 175 (71.1%) residents were interviewed, 115 women and 60 men, mean age, 82.6 years (SD=7.8) compared with 83.2 years (SD=6.3) for non-participants. The prevalence of hazardous patterns of alcohol consumption in the past twelve months by the AUDIT (cut-off score 8) was 5.1% (95% CI = 1.8-8.4). According to DSM-IV criteria, the prevalence of lifetime alcohol dependence was 20.5% (95% CI = 13.5-27.6) and for the past twelve months was 0.5% (95% CI = 0-1.7). The prevalence of lifetime alcohol dependence was significantly higher in men 36.7% (95% CI = 23.2-50.1) than women 12.2% (95% CI = 5.6-18.8) (p = 0.0001).

CONCLUSIONS

In spite of advanced age, a small proportion of elderly rest home residents consumed quantities of alcohol that put them at risk of future damage to physical or mental health. Lifetime prevalence of alcohol dependence was comparable to the general population estimates and was higher in men than women.

Rural and remote Australian general practitioners' educational needs in radiology

BACKGROUND

The Australian College of Rural and Remote Medicine (ACRRM) was funded by the Commonwealth Department of Health and Aged Care to set up a quality assurance and continuing medical education program for rural and remote general practitioners in radiology to begin in January 2001. An extensive literature search failed to uncover any previous publications on the specific educational or quality assurance needs for rural general practitioners in radiology. Broader educational needs assessments of rural general practitioners in Australia had identified radiology as an important skill for which improvement was desired.

METHOD

A national steering committee consisting of four rural general practitioners and three radiologists, with the assistance of a program manager, developed and piloted a self-administered postal questionnaire to determine the educational and quality assurance needs of rural and remote general practitioners. The questionnaire was sent to all rural and general practitioners holding a remote radiology exemption using the Health Insurance Commission database.

RESULTS

A total of 287 completed questionnaires were returned from all states in the country, except the Australian Capital Territory. The information gave a comprehensive picture of the self-reported radiology education needs of these doctors, who practice in isolation from radiologists and other specialists. The three areas in which the general practitioners were least confident in radiology were chest, cervical spine, and skull radiology. Their highest priority areas of need for education were chest radiology, film interpretation, and spinal radiology. The top preferred quality assurance activity was image review with a radiologist, followed by clinical audit, image review by peers, and measuring practice against guidelines.

FINDINGS

Local ownership of education is important to successful program development and evaluation. Information obtained from the educational needs assessment was used to develop the Radiology Quality Assurance and Continuing Medical Education Program for Rural and Remote General Practitioners.

Three-dimensional dose distribution of tangential breast irradiation: results of a multicentre phantom dosimetry study

BACKGROUND AND PURPOSE

One aspect of good radiotherapeutic practice is to achieve dose homogeneity. Dose inhomogeneities occur with breast tangent irradiation, particularly in women with large breasts.

MATERIALS AND METHODS

Ten Australian radiation oncology centres agreed to participate in this multicentre phantom dosimetry study. An Alderson radiation therapy anthropomorphic phantom with attachable breasts of two different cup sizes (B and DD) was used. The entire phantom was capable of having thermoluminescent dosimeters (TLD) material inserted at various locations. Nine TLD positions were distributed throughout the left breast phantom including the superior and inferior planes. The ten centres were asked to simulate, plan and treat (with a prescription of 100 cGy) the breast phantoms according to their standard practice. Point doses from resultant computer plans were calculated for each TLD position. Measured and calculated (planning computer) doses were compared.

RESULTS

The dose planning predictability between departments did not appear to be significantly different for both the small and large breast phantoms. The median dose deviation (calculated dose minus measured dose) for all centres ranged from 2. 3 to 5.3 cGy on the central axis and from 2.1 to 7.5 cGy for the off-axis planes. The highest absolute dose was measured in the inferior plane of the large breast (128.7 cGy). The greatest dose inhomogeneity occurred in the small breast phantom volume (median range 93.2-105 cGy) compared with the large breast phantom volume (median range, 100.1-107.7 cGy). There was considerable variation in the use (or not) of wedges to obtain optimized dosimetry. No department used 3D compensators.

CONCLUSION

The results highlight areas of potential improvement in the delivery of breast tangent radiotherapy. Despite reasonable dose predictability, the greatest dose deviation and highest measured doses occurred in the inferior aspects of both the small and large breast phantoms.

Meeting the International Conference on Harmonisation's Guidelines on Validation of Analytical Procedures: quantification as exemplified by a near-infrared reflectance assay of paracetamol in intact tablets

This Perspective explains how the International Conference on Harmonisation's Guidelines on Validation of Analytical Procedures for quantitative methods can be met by near-infrared (NIR) assays of intact pharmaceutical products. Each of the validation characteristics (accuracy, precision, specificity, detection limit, quantification limit, linearity, range, robustness and system suitability testing) is defined, examined for their relevance to quantitative methods and examples given on how they may be used to demonstrate that near-infrared assays are fit for purpose. Methods for preparing samples for calibration are given in detail. The intention is to provide information so that a pharmaceutical manufacturer could validate a method suitable for an application for a variation of a marketing authorisation for an existing product and use a NIR assay instead of the previous method. The perspective is illustrated in detail using a NIR reflectance assay of paracetamol in intact tablets. This proven assay gives results comparable to the British Pharmacopeia ultraviolet assay for paracetamol, the standard errors of calibration and prediction for the NIR method being 0.48% w/w and 0.71% w/w respectively. The method is also precise, the standard deviation and coefficient of variation for six NIR assays on the same day being 0.14% w/w and 0.16% w/w respectively, while measurements over six consecutive days gave 0.31% w/w and 0.36% w/w respectively.

Armrest versus vacuum bag immobilization in the treatment of breast cancer by radiation therapy: a randomized comparison

Thirty patients in randomized sequence were simulated in both an arm-rest and a vacuum bag immobilization device and also randomized to treatment in one of the two devices. Overall patient comfort significantly favoured the use of the arm-rest, although both were acceptable. Lung exposed in the tangential beams was less in the vacuum bag device. Supraclavicular skin folding was greater in the vacuum bag, but this is probably related to the angle of arm abduction. Treatment times and stability of the setups were not significantly different. This is a small study piloting a technical comparison and the findings require confirmation in a larger sample.

Treatment interventions and findings from research: bridging the chasm in child psychiatry

BACKGROUND

Along with all other branches of medicine, child and adolescent psychiatry is faced with the need to consider its evidence base and justify its activities accordingly.

AIMS

To consider critically the use of the term 'evidence', to suggest limits to the value of conventionally defined evidence and to point to possible ways forward to bridge the gap between research findings and clinical practice.

METHOD

A review of the literature relating to the use of evidence-based methods.

RESULTS

The term 'evidence' needs to be used more widely than is conventionally the case. Substantial evidence exists from controlled trials, but there are barriers to its use.

CONCLUSIONS

A move away from nonvalidated methods of intervention is both desirable and feasible. The use of qualitative methods of enquiry, both in situations where controlled trials are unlikely to be feasible and as adjuncts to quantitative methods, should be considered more seriously.

Bayesian inference for a generalized population attributable fraction: the impact of early vitamin A levels on chronic lung disease in very low birthweight infants

In this paper, the population attributable fraction is studied using the potential responses framework of Rubin's causal model. This framework facilitates definition of a general measure of population attributable effect which can accommodate many-valued and multivariate exposures as well as many-valued responses. Inferential issues are considered from the Bayesian perspective. Finite population inference is emphasized with inference in the case of a fully observed population given particular attention. The key inferential issue concerns computation of the posterior distribution of unobserved potential responses, given observed responses, exposures and covariates. A dependency on model parameters about which observed data are uninformative is highlighted and this reflects the unobservable nature of causal effects. In an application to a small cohort study of respiratory problems in very low birthweight infants, posterior inferences were found to be insensitive to assumptions concerning the joint distribution of potential response variables but sensitive to the assumption of weak ignorability, a weaker form of the more familiar assumption of no confounding by omitted covariates. In a model-based set-up, the weak ignorability assumption is identified with setting a model parameter to zero, and consequently uncertainty concerning this assumption can, in principle, be handled via the prior distribution for the model parameters.

Heart or heart-lung transplantation: psychosocial outcome

The psychosocial outcome of 23 heart and 21 heart-lung transplant recipients, aged 5-17 yrs, was determined and compared with the psychosocial outcome of a group of 46 children and adolescents who underwent conventional cardiac surgery. Preoperatively, and 12 months post-operatively, the patients' physical health status, mental state (ICD-9) and level of psychosocial functioning (GAF scale, DSM-IIIR) were assessed. There was an improvement in physical health in all groups. Preoperatively, psychiatric disorder, including anxiety and phobic states, depression and adjustment reaction, was noted in 6/23 (26%) children assessed for heart transplantation, 6/21 (28.5%) children assessed for heart-lung transplantation, and 12/46 (26%) children undergoing conventional cardiac surgery. The prevalence of psychiatric disorder remained in the transplant group but decreased in the non-transplant comparison group (6.5%). Improvement in overall levels of psychosocial functioning were found in all groups, but over 40% of all the participants were still functioning below normal levels. In summary, children with end-stage cardio-respiratory disease benefit physically and psychologically from heart or heart-lung transplantation treatment but there is a need for systematic psychosocial support both before and after transplantation.

Tattoo allergy in patients receiving adjuvant radiotherapy for breast cancer

Tattooing is routinely employed prior to radiotherapy treatment but allergies to tattoos are rare. New information on the incidence of tattoo allergy at St George Hospital is presented with details of two clinical cases. The literature on tattoo allergy has been unable to estimate the incidence of allergic reaction to tattoos because the total number of patients treated is unknown and not all patients were followed up. Our radiation oncology population for the first time has provided a known denominator, but wide confidence intervals prevent an accurate estimate of the incidence. Salient issues about tattoo allergy are highlighted based on a review of the published literature from 1966 to 1998.

Health expectancy in New Zealand, 1981-1991: social variations and trends in a period of rapid social and economic change

STUDY OBJECTIVE

To assess social variations and trends in health expectancy over a period of rapid social and economic change.

DESIGN

Cross sectional survey data on the association between social status--gender, socioeconomic class and ethnic group--and measures of health status at two points in time approximately a decade apart. The Sullivan method of calculating health expectancy was used.

SETTING

The adult population of New Zealand in the periods 1980-81 and 1992-93.

PARTICIPANTS

Representative samples of the adult civilian non-institutionalised population of 6,891 (1980-81) and 5,873 (1992-93) respectively.

MAIN RESULTS

In comparison with life expectancy, adjusting for health status narrowed the gender gap but widened socioeconomic and ethnic differentials. These results were replicated for three measures--self reported health, mobility, and handicap--suggesting a robustness of outcome to specific indicators. Comparable data over the period of study were only available for the mobility measure. Increases in longevity appeared to be fully absorbed by minor disability. Ethnic and socioeconomic disadvantages remained static or widened for the 15-64 age group, suggesting a potential social polarisation in the disability transition.

CONCLUSIONS

The operationalization of health expectancy appears to be rather robust to specific indicators. Health expectancy may provide a sensitive health impact assessment of social and economic policy. Existing theories of the disability transition may need to be modified to take account of social variation, at least in the special case of disability free health expectancy over the 15-64 age range.