Evaluation of an ultrasonically guided venepuncture technique for the placement of permanent pacing electrodes

We have evaluated a method of puncturing the subclavian vein in its extrathoracic portion using an ultrasound guidance system. Seventy consecutive patients requiring permanent pacemakers were included in the study. The method was successful in 56 (80%) cases (23 dual chamber systems) and unsuitable or unsuccessful in 14 (20%) cases (2 dual chamber systems). The time taken to achieve a successful cannulation of the vein was similar to that taken with conventional subclavian venepuncture (average time taken for each venepuncture was 31 seconds, range 5-130 seconds). There was a significant "learning curve" in that nearly all of the unsuccessful cases were in the first half of the series. There were no major complications. Computerized Tomography (CT) confirms that the point of entry into the subclavian vein using this technique lies outside the thoracic cavity, thereby minimizing the risk of pneumothorax. This approach to the subclavian vein is an easy technique to learn, with few immediate complications and there may be less chance of lead fracture due to subclavian crush in the longer term.

Catering services. Measuring the wasteline

The study found that overall almost half (46 per cent) of the food served in the hospitals surveyed was wasted. Waste was higher where meals were put onto plates in wards (57 per cent) than where meals were plated in the hospital kitchen (35 per cent). The researchers observed that meals often arrived late and were not well presented.

Pectoral muscle stimulation after falling off a ladder

A-pacemaker that had been implanted correctly was found at follow-up to have "flipped over" as a result of a fall from a ladder. Symptomatic pectoral muscle stimulation ceased immediately when the generator was manually flipped back into the correct position.

Nuclear receptor coactivator ACTR is a novel histone acetyltransferase and forms a multimeric activation complex with P/CAF and CBP/p300

We report here the identification of a novel cofactor, ACTR, that directly binds nuclear receptors and stimulates their transcriptional activities in a hormone-dependent fashion. ACTR also recruits two other nuclear factors, CBP and P/CAF, and thus plays a central role in creating a multisubunit coactivator complex. In addition, and unexpectedly, we show that purified ACTR is a potent histone acetyltransferase and appears to define a distinct evolutionary branch to this recently described family. Thus, hormonal activation by nuclear receptors involves the mutual recruitment of at least three classes of histone acetyltransferases that may act cooperatively as an enzymatic unit to reverse the effects of histone deacetylase shown to be part of the nuclear receptor corepressor complex.

Right hemidiaphragmatic twitching: a complication of bipolar atrial pacing

A patient with an atrioventricular sequential pacemaker developed rhythmic contractions of the right hemidiaphragm. This was found to be the result of right phrenic nerve stimulation, which was directly related to the wide distance between the poles of an ELA atrial lead when pacing in bipolar mode. Pole separation in current atrial leads is discussed.

Population geography

"This is the last of three reports discussing major avenues of progress in the alleviation of population geography's poor reputation. The first examined the route of policy-relevant research, the second considered the importance of sound scholarship and, as promised, this report will explore the part that can be played by improved communication and dissemination of our work...."

Bicalutamide: a new antiandrogen for use in combination with castration for patients with advanced prostate cancer

Maximum androgen blockade, a relatively recent development in the treatment of prostate cancer, combines medical or surgical castration with antiandrogen therapy. A large randomized study comparing the non-steroidal antiandrogen, bicalutamide, with flutamide, each in combination with luteinizing hormone-releasing hormone (LHRH) analogs, showed that after a median follow-up of 49 weeks, the time to treatment failure was significantly longer for the bicalutamide patients compared with the flutamide patients (p = 0.005). After a median follow up to 95 weeks, bicalutamide in combination with LHRH analog therapy produced at least equivalent efficacy with flutamide in combination with LHRH analog therapy in terms of time to treatment failure and equivalent efficacy in terms of survival. The tolerability profile of bicalutamide, as based on reported findings and a literature review, indicates a superior tolerability to that of currently available antiandrogens, particularly with respect to diarrhea with a low incidence of treatment-related withdrawals.

A cluster of cases of feline dysautonomia (Key-Gaskell syndrome) in a closed colony of cats

Twenty-five cases of feline dysautonomia (Key-Gaskell syndrome) occurred in a closed cat colony over a period of three weeks. The clinical and pathological signs were sufficiently similar to those reported during the 1982-1986 outbreak to establish a positive diagnosis. The special epidemiological and environmental circumstances of the outbreak provide a new insight into the cause(s) of the syndrome.

Re-excision operations in nonpalpable breast cancer

We retrospectively reviewed the records of 317 needle-localization (NL) biopsies performed at the Royal Marsden Hospital during 1989-1992. The malignancy yield in our centre, where there is an emphasis on cooperation with an experienced radiologist and breast pathologist, was 48% (151/317), with benign to malignant biopsy ratio of 1:1:1. Analysis of the histopathological findings of the malignant lesions revealed a 45% (68/51) incidence of positive microscopic margins. Of these 68 patients, 50 had re-excisions, including nine patients who required mastectomy. Twenty-eight of the re-excisions (56%) contained residual tumour, of which five (18%) were invasive carcinoma > 3 mm (size range 1-19 mm) and 13 (46%) were residual DCIS > 1 mm (size range 1-40 mm). Our findings suggest a significant incidence of residual disease associated with positive microscopic margins in NL-detected nonpalpable cancers. Therefore, our current practice of performing a wider re-excision for positive margins is justified. Stereotactic fine-needle aspiration cytology was not performed by the radiologist referring these cases, but it should be performed preoperatively and if the test is positive, definitive treatment in the form of wide local excision or quadrantectomy is carried out in the first instance in order to avoid a second-surgical procedure.

Determining factors which predict response to primary medical therapy in breast cancer using a single fine needle aspirate with immunocytochemical staining and flow cytometry

The increasing use of neoadjuvant chemotherapy and endocrine therapy in the management of breast cancer has lead us to evaluate and optimise the standard technique of cytocentrifugation of a single fine needle aspirate (FNA) taken from a breast tumour in-vivo, to determine a range of both immunocytochemical and flow cytometric factors which are predictive of response to primary medical therapy. Some of these factors are also of prognostic significance in early stage disease. An analysis of the cellularity and immunocytochemical staining characteristics of FNAs obtained from a series of 206 patients with palpable breast cancers indicate that in a sample of 46 cases it is possible to measure oestrogen receptor, progesterone receptor and c-erbB-2 providing over 400 cells per slide are obtained, with material obtained in a single FNA prepared by cytocentrifugation, using standard immunocytochemical methods. The staining results obtained were comparable to those obtained using frozen or paraffin embedded tissue sections taken from the same tumour. In addition an estimate of the proliferation indices could be made by flow cytometric analysis of the residual cell suspension fluid with measurement of DNA index and S-phase fraction in 131/164 (80%) and 110/164 (67%) of cases respectively. Providing all FNAs obtained for cytocentrifugation were taken at first presentation rather than immediately following a standard FNA, then it was possible to obtain adequately cellular (> 400 cells/slide) samples in 96 out of 126 (75%) of the last cohort of breast aspirates. These effects may be independent of T stage but not histological type as patients with lobular tumours only produced cellular aspirates in 1/7 (14%) of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluating palliative care education

This paper illustrates the evaluation of some of the effects of a 3-day workshop for principals and trainees in general practice on a number of aspects of palliative care, using pre-, immediate and late post-tests. Further qualitative evaluation is attempted by including a questionnaire with the late post-test. The evaluation is to demonstrate significant shifts, or differences, in confidence in dealing with physical and psychosocial symptoms, and in participants' perceived ability to cope, and to support these findings with qualitative data where appropriate.

A phase II study in advanced gastro-esophageal cancer using epirubicin and cisplatin in combination with continuous infusion 5-fluorouracil (ECF)

PURPOSE

A phase II study was performed in patients with unresectable or metastatic gastric cancer evaluating the efficacy of a new chemotherapy schedule combining epirubicin and cisplatin with a continuous ambulatory infusion of 5-fluorouracil (ECF).

PATIENTS AND METHODS

One hundred thirty-nine consecutive, previously untreated patients were given ECF. Of these, 128 had measurable disease. Epirubicin (50 mg/m2 i.v.) and cisplatin (60 mg/m2 i.v.) were administered every three weeks for 8 cycles during a 21 week continuous i.v. infusion of 5-fluorouracil (200 mg/m2/day). In total 773 cycles of chemotherapy were given.

RESULTS

Objective tumour responses was seen in 91 (71%) of the 128 patients with measurable disease, of which 15 (12%) had a complete response. Twenty patients with locally advanced disease responding to ECF had attempted resection of the primary--11 (55%) were completely removed, 4 of these had no residual tumour in the resected specimen. The overall median survival was 8.2 months with 1 and 2 year survivals of 30% and 10% respectively. Grade 3 or 4 emesis occurred in 13%, stomatitis in 7%, diarrhoea in 4%, infection in 6%, leucopenia in 21% and thrombocytopenia in 8% of patients. Myelosuppression delayed treatment in 39 (5%) of the 773 cycles. Six of the 139 patients (4.3%) had treatment related deaths. There was no measurable reduction in quality of life during chemotherapy, while 67% of the 66 patients with dysphagia had complete resolution of this symptom.

CONCLUSIONS

The ECF regimen displays high anti-tumour activity with moderate toxicity in patients with gastric cancer and in some cases enabled resection of previously inoperable tumours.

The effects of magnitude and direction of stimulus change on auditory event-related potentials elicited by deviant signal stimuli

The present study sought to identify components of the auditory event-related potential (ERP) elicited by stimuli that serve as signals for overt discriminative responses. Sokolov's view of a selective neural filter for deviant stimuli predicts that responses to deviant signal stimuli will be graded in proportion to the amount of change from the standard and independent of the direction of that change. The demonstration of a bi-directional and graded ERP response requires at least two levels of stimulus change in each direction. The present study incorporated two deviants that were lower in pitch (lowest, low) and two that were higher in pitch (high, highest) in order to evaluate the degree (linear, quadratic, etc.) of the function relating ERP response to tonal deviance. Stimulus changes on both the direction and magnitude dimensions were also varied on a trial-by-trial, rather than on a block-by-block, basis which eliminated potential confounds with block or session differences, and discriminative responses were required to both standard and deviant tones, thereby investing both categories of stimuli with signal value. The amplitude of the P3 component associated with deviant stimuli showed close correspondence to the (quadratic) function predicted from the selective filter model. A late negative slow wave (NSW) at Fz and a positive slow wave (PSW) at Pz differentiated deviant tones from the standard but did not distinguish between the deviants themselves. A fronto-central NSW observed at Fz and Cz for initial standard tones was greater than the predominantly frontal NSW elicited by the deviant tones. The topographical differences in NSW elicited by the initial standard tone and by all deviant tones suggest that different processes are reflected in the NSW response to these stimuli.

Reasons for referral to a palliative nursing team

Referral patterns to a palliative nursing team are examined within the context of the developing role of the service. Reasons for referral are identified and a checklist developed to encourage specificity in statement of need on referral. Comparison is made with the assessment of the Macmillan nurse on assessment. Use of the checklist encouraged greater awareness of need. There was no correlation between the referrers' perceived needs and the Macmillan nurses' assessments on visiting. The literature supports the need for more explicit referral criteria based on needs assessment. There are implications for greater awareness of roles, better communication regarding intervention, and organizational review.

Referring patients for domiciliary care

This article attempts to identify some of the reasons why patients who meet the referral criteria of domiciliary palliative nursing care services are not referred. A study was conducted among district nurses and GPs which highlighted that a 'conspiracy of silence' still existed between patients, professionals and families. A desire to manage patients themselves and a misunderstanding of the work of Macmillan nurses were also reported. Some recommendations for change are made.

Terminal care in the community--an evaluation of residential workshops for general practitioner/district nurse teams

This paper describes the development and content of palliative care residential workshops for general practitioner/district nurse pairs from the same practice. Pre- and post-testing self-rating scales were completed by the participants of five workshops. A retrospective questionnaire identified perceived effects on practice in terms of patient and family care, and the impact of having attended with a professional colleague. Demographic data are presented followed by respondents' perceived changes in practice following the workshop. These are supported by clinical examples. Respondents were able to identify specific effects of having attended with a colleague and offered supporting examples from their practice. The difficulties and limitations in the use of self-rating scales are discussed along with the possible effects of such methods on course content and development. Recommendations are made for further study.

Adjuvant aminoglutethimide for postmenopausal patients with primary breast cancer: analysis at 8 years

PURPOSE

The study purpose was to evaluate aminoglutethimide (AG) as adjuvant therapy in patients with primary node-positive breast cancer in a randomized double-blind placebo-controlled trial.

PATIENTS AND METHODS

In a multicenter trial, 354 postmenopausal women with early breast cancer and histologically confirmed positive axillary lymph nodes were randomized after surgery to received aminoplac. Patients were prescribed either AG 250 mg four times per day and hydrocortisone 20 mg twice per day or placebos of identical appearance for 2 years.

RESULTS

After a median follow-up of 8.1 years, there has been no overall benefit for AG in terms of either event-free survival or overall survival (OS). However, the results are consistent with interim analyses with a significantly improved event-free survival for patients who received AG for up to 4 years, although this benefit subsequently disappears. Similarly, there is an improved OS for patients who received AG for up to 4 years, but this also subsequently disappears. There was a marginal advantage for estrogen receptor (ER)-positive patients who received AG (n = 74; P = .054). There was no difference in the sites of relapse. There was a significant increase in toxicity for patients who received AG.

CONCLUSION

The lack of survival benefit with long-term follow-up for AG may indicate that aromatase inhibitors have less of an impact on early breast cancer than tamoxifen and may imply different biologic mechanisms of action.