Repair of left coronary artery aneurysm, recurrent ascending aortic aneurysm, and mitral valve prolapse 19 years after Bentall's procedure in a patient with Marfan syndrome

A 45-year-old female with Marfan syndrome had a Bentall's procedure performed 19 years ago. She presented with a 4-year history of gradually worsening dyspnea and decreasing exercise tolerance. Investigations revealed severe mitral valve prolapse, a left main stem coronary artery (LMSCA) aneurysm, and a recurrent aneurysm of the ascending aorta. The mitral valve was replaced and the aortic aneurysmal sac and the LMSCA aneurysm were then repaired by a modified Bentall procedure. The patient made an uneventful recovery and was discharged home.

The 2004 Canadian recommendations for the management of hypertension: Part III--Lifestyle modifications to prevent and control hypertension

OBJECTIVE

To provide updated, evidence-based recommendations regarding the role of lifestyle modification in the treatment and prevention of hypertension.

OUTCOMES

Lifestyle modification interventions including exercise, weight reduction, alcohol consumption, dietary modification, intake of dietary cations and stress management are reviewed. Antioxidants and fish oil supplements are also reviewed, although specific recommendations cannot be made at present.

EVIDENCE

MEDLINE searches were conducted from January 2002 to September 2003 to update the 2001 recommendations for the management of hypertension. Supplemental searches in the Cochrane Collaboration databases were also performed. Reference lists were scanned, experts were contacted, and the personal files of the subgroup members and authors were used to identify additional published studies. All relevant articles were reviewed and appraised independently using prespecified levels of evidence by content and methodology experts.

RECOMMENDATIONS

Key recommendations include the following: lifestyle modification should be extended to nonhypertensive individuals who are at risk for developing high blood pressure; 30 min to 45 min of aerobic exercise should be performed on most days (four to five days) of the week; an ideal body weight (body mass index 18.5 kg/m2 to 24.9 kg/m2) should be maintained and weight loss strategies should use a multidisciplinary approach; alcohol consumption should be limited to two drinks or fewer per day, and weekly intake should not exceed 14 standard drinks for men and nine standard drinks for women; a reduced fat, low cholesterol diet that emphasizes fruits, vegetables and low fat dairy products, and maintains an adequate intake of potassium, magnesium and calcium, should be followed; salt intake should be restricted to 65 mmol/day to 100 mmol/day in hypertensive individuals and less than 100 mmol/day in normotensive individuals at high risk for developing hypertension; and stress management should be considered as an intervention in selected individuals.

VALIDATION

All recommendations were graded according to the strength of the evidence and voted on by the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. Individuals with irreconcilable competing interests (declared by all members, compiled and circulated before the meeting) relative to any specific recommendation were excluded from voting on that recommendation. Only those recommendations achieving at least 70% consensus are reported here. These guidelines will continue to be updated annually.

Implementation of an osteopathic manipulative medicine clinic at an allopathic teaching hospital: a research-based experience

Mastery of osteopathic palpatory skills and the skilled delivery of osteopathic manipulative treatment is a life-long venture that demands from practitioners increasingly sophisticated manual skills. Specific receptors and neural networks within the brain allow for the gradual development of refined manual skills that parallel responsive alterations and refinements that develop with repeated experience. During clinical training, most graduates of colleges of osteopathic medicine are not given opportunities to hone their palpatory skills. This is unfortunate because there is an increasing public demand for the nonpharmacologic treatment modalities osteopathic physicians could supply. At Berkshire Medical Center in Pittsfield, Mass, a major teaching affiliate of the University of Massachusetts Medical School in Worcester, the authors assembled a team of osteopathic and allopathic physicians to found an osteopathic manipulative medicine clinic. In this article, the authors share their experience in the creation of this research-based osteopathic medical clinic.

Anaesthetic management of a parturient with pulmonary stenosis and aortic incompetence for Caesarean section

Anaesthetic management of Caesarean section in a parturient with severe pulmonary stenosis and aortic regurgitation is described. The valvular sequelae resulted from previous unsuccessful surgical correction (Ross procedure) of congenital aortic stenosis. This case demonstrates the importance of multi-disciplinary assessment and careful anaesthetic planning, to avoid deterioration in perioperative cardiac performance in parturients with complex valvular disease.

Lead pollution and amelioration measures in the community of Frazers Content, St Catherine, Jamaica

Lead poisoning, especially in children, is a preventable disease. Many children are exposed to this hazard, especially in poor communities, because of a paucity of information on lead poisoning and increasing economic hardships. In 1994, the case of the poor suburban community of Frazers Content, St Catherine, Jamaica, came to the public attention because of the high frequency of hospital admissions, or outpatient treatment, of children for lead poisoning. This paper reviews a Blue Cross of Jamaica-led-initiative aimed at the clean up and education of the Frazers Content community. The following four-pronged approach was employed: environmental and biological sampling and sample analysis, health education, decontamination and community clean up and entrepreneurial activities. The project outputs included: training of 17 community wardens and 22 schoolteachers; the clean up of 64 residences which had lead levels in excess of 500 ppm; the establishment of an entombment site for the contaminated soil in accordance with the Jamaica Natural Resources Conservation Authority and training of residents in entrepreneurial skills, chicken and rabbit rearing and nursery establishment. The paper includes discussion of the lessons learnt and recommendations for future action.

AVAPROMISE: A randomized clinical trial for increasing adherence through behavioural modification in essential hypertension

BACKGROUND

Patients with hypertension often do not adhere to their medications.

OBJECTIVE

To improve medication adherence in patients with essential hypertension by modifying their behaviours.

PATIENTS AND METHODS

From general practice settings, 4864 patients with essential hypertension were recruited and randomly assigned to receive the angiotensin receptor blocker irbesartan (Avapro) with (intervention group) or without (nonintervention group) a behavioural modification program (Avapromise) based on a model of change. Patients were followed up for 12 months. Patients were subgrouped based on their stage of change in the behavioural change continuum, and the intervention was tailored to address the needs of the particular subgroup. The primary efficacy measure was rate and time to discontinuation with irbesartan.

RESULTS

At the end of the study, there was no significant difference in the discontinuation rates between the intervention (25.4%, 95% CI 23.7 to 27.2) and nonintervention (25.5%, 95% CI 23.8 to 27.3) groups (P=0.94). The time to discontinuation (P=0.87) and the extrapolated rate of discontinuation estimated from the Kaplan-Meir curve (intervention 23.1%, 95% CI 21.3 to 24.8; nonintervention 23.5%, 95% CI 21.8 to 25.3) were not different between the groups.

CONCLUSIONS

This behavioural modification intervention based on a model of change was not efficacious at increasing rates of adherence in patients with essential hypertension in this setting. More individualized interventions may be required to increase adherence in this population.

The 2000 Canadian recommendations for the management of hypertension: Part one--therapy

OBJECTIVE

To provide updated, evidence-based recommendations for the therapy of hypertension in adults.

OPTIONS

For patients with hypertension, there are a number of lifestyle manoeuvres and antihypertensive agents that may control blood pressure. Randomized trials evaluating first- line therapy with thiazides, beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors, calcium channel blockers, alpha-blockers, centrally acting agents or angiotensin II receptor antagonists were reviewed.

OUTCOMES

The health outcomes considered were changes in blood pressure, cardiovascular morbidity, and cardiovascular and/or all-cause mortality rates. Economic outcomes were not considered due to insufficient evidence.

EVIDENCE

Medline searches were conducted from the period of the last revision of the Canadian Recommendations for the Management of Hypertension (May 1998 to October 2000). Reference lists were scanned, experts were polled, and the personal files of the subgroup members and authors were used to identify other studies. All relevant articles were reviewed and appraised, using prespecified levels of evidence, by content experts and methodological experts.

VALUES

A high value was placed on the avoidance of cardiovascular morbidity and mortality.

BENEFITS, HARMS, AND COSTS

Various lifestyle manoeuvres and antihypertensive agents reduce the blood pressure of patients with sustained hypertension. In certain settings, and for specific classes of drugs, blood pressure lowering has been associated with reduced cardiovascular morbidity and/or mortality.

RECOMMENDATIONS

The present document contains detailed recommendations pertaining to all aspects of the therapy of patients with hypertension, including lifestyle modifications proven to lower blood pressure, treatment thresholds, target blood pressures, choice of agents in various settings and strategies to enhance adherence. Lower thresholds for blood pressure treatment are advocated for people with other cardiovascular risk factors or established hypertensive target organ damage. Implicit in the recommendations for therapy is the principle that treatment should be individualized for each patient and the choice of agent should be dictated by coexistent conditions. For the treatment of uncomplicated essential hypertension, thiazides, beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors or calcium channel blockers may be appropriate, depending on individual circumstances.

VALIDATION

All recommendations were graded according to strength of the evidence and voted on by the Canadian Hypertension Recommendations Working Group. Only those recommendations achieving high levels of consensus are reported here. These guidelines will be updated annually.

Congenital chylothorax

The objective of this paper is a retrospective study of all infants treated for congenital chylothorax at the Royal Children's Hospital (RCH), Melbourne, Australia and King Fahad National Guard Hospital (KFNGH), Riyadh, Kingdom of Saudi Arabia. The charts of all infants with congenital chylothorax admitted to RCH over a period of 13 years, June 1982-August 1994, and admissions to KFNGH over a 7-year period, June 1992-August 1998 inclusive, were reviewed including management outcome and complications. There were 19 infants, 13 from RCH and 6 from KFNGH; 11 females and 8 males. Three infants were managed antenatally. Fifteen infants presented immediately after birth. Seven were born with hydrops fetalis, 6 infants had syndromes and 10 infants were born prematurely. Regular infant feeding formula and/or breast milk were used successfully in 12 infants, while in 7 infants medium chain triglycerides (MCT) rich formula was used. Sixteen infants were mechanically ventilated with 75% of them ventilated for < or = 28 days. Fifteen infants received total parenteral nutrition (TPN), and in 80% for < or = 32 days. Hydropic infants had longer duration of mechanical ventilation and hospital stay with mean (range) of 33.9 (3-120) and 115 (23-225) days, respectively, compared with 18 (1-62) and 34.3 (14-88) days for nonhydropic infants. Five infants underwent surgery with failure in four. Sepsis and bronchopulmonary dysplasia were the main complications. The survival rate was 100% regardless of the mode of therapy. The prognosis of Isolated congenital chylothorax in term, and preterm infants is good even in the presence of hydrops. Breast milk and/or regular infant feeding formula should be used initially before proceeding to MCT-rich formula, which may be necessary in some cases. Surgery should be considered if conservative management of congenital chylothorax fails after 4-5 weeks.

Canadian national high blood pressure prevention and control strategy

Despite major efforts to prevent and control high blood pressure, it is one of the most common and important health problems facing Canadians. To address this issue, Health Canada, in collaboration with the Canadian Coalition for High Blood Pressure Prevention and Control, established an Expert Working Group to prepare a national strategy. The present report outlines a strategy to prevent and control high blood pressure. It is directed at policy makers at the local, provincial, and/or territorial and national levels in both the health and nonhealth sectors. The strategy is based on current research and expertise. A multifaceted, comprehensive approach is proposed because there is no one intervention that will accomplish the goal of improving the health of Canadians through high blood pressure prevention and control. The present report focuses on the general population. It does not address the unique needs of children, pregnant women or aboriginal peoples. Each of these groups needs to be studied in its own right, and, in particular, with the involvement of aboriginal people themselves. An implementation committee has been established to realize this strategy, and the Canadian Hypertension Society is a key stakeholder in this effort. Several initiatives are underway. Strong advocates are necessary to increase public awareness and to support the system changes required for a successful public health approach to reduce the prevalence of hypertension and its complications.

1999 Canadian recommendations for the management of hypertension. Task Force for the Development of the 1999 Canadian Recommendations for the Management of Hypertension

OBJECTIVE

To provide updated, evidence-based recommendations for health care professionals on the management of hypertension in adults.

OPTIONS

For patients with hypertension, there are both lifestyle options and pharmacological therapy options that may control blood pressure. For those patients who are using pharmacological therapy, a range of antihypertensive drugs is available. The choice of a specific antihypertensive drug is dependent upon the severity of the hypertension and the presence of other cardiovascular risk factors and concurrent diseases.

OUTCOMES

The health outcomes considered were changes in blood pressure and in morbidity and mortality rates. Because of insufficient evidence, no economic outcomes were considered.

EVIDENCE

MEDLINE searches were conducted from the period of the last revision of the Canadian Recommendations for the Management of Hypertension (January 1993 to May 1998). Reference lists were scanned, experts were polled and the personal files of the authors were used to identify other studies. All relevant articles were reviewed, classified according to study design and graded according to levels of evidence.

VALUES

A high value was placed on the avoidance of cardiovascular morbidity and premature death caused by untreated hypertension.

BENEFITS

Harms and costs: The diagnosis and treatment of hypertension with pharmacological therapy will reduce the blood pressure of patients with sustained hypertension. In certain settings, and for specific drugs, blood pressure lowering has been associated with reduced cardiovascular morbidity and mortality.

RECOMMENDATIONS

This document contains detailed recommendations pertaining to all aspects of the diagnosis and pharmacological therapy of hypertensive patients. With respect to diagnosis, the recommendations endorse the greater use of non-office-based measures of blood pressure control (i.e., using home blood pressure and automatic ambulatory blood pressure monitoring equipment) and greater emphasis on the identification of other cardiovascular risk factors, both in the assessment of prognosis in hypertension and in the choice of therapy. On the treatment side, lower targets for blood pressure control are advocated for some subgroups of hypertensive patients, in particular, those with diabetes and renal disease. Implicit in the recommendations for therapy is the principle that for the vast majority of hypertensive patients treated pharmacologically, practitioners should not follow a stepped-care approach. Instead, therapy should be individualized, based on consideration of concurrent diseases, both cardiovascular and noncardiovascular.

VALIDATION

All recommendations were graded according to the strength of the evidence and the consensus of all relevant stakeholders.

SPONSORS

The Canadian Hypertension Society and the Canadian Coalition for High Blood Pressure Prevention and Control.

The intestinal epithelial cell: processing and presentation of antigen to the mucosal immune system

The immunologic tone of the intestinal tract is one of suppressed or highly regulated responses. While there are several components (intrinsic and extrinsic to the gut-associated lymphoid tissue) responsible for this immunologically suppressed tone, the intestinal epithelial call (IEC) has been proposed as a key player in this process. IECs can take up and process antigen but distinct surface molecules and restriction elements allow them to present these antigens to unique regulatory T cells. These include the expression of the class Ib molecule CD1d as well as a novel CD8 ligand, gp180. These molecules come together to activate a subpopulation of CD8+ regulatory cells whose function is to suppress immune responses in an antigen non-specific fashion most likely through cognate interactions. This form of regulation may be unique to the gut-associated lymphoid tissue which is consistent with the unusual demands upon this part of the immune system.

Continuing Professional Education and Interacting Variables Affecting Behavioral Change in Practice: Instrument Development and Administration

BACKGROUND

Instruments were developed to measure variables identified by Cervero that evaluate the complex processes and effectiveness of continuing professional education.

METHOD

Content validity was established with a panel of experts. Four studies were conducted to determine reliability. Data were merged to conduct factor analysis.

RESULTS

Reliability was confirmed across studies using Cronbach's alpha. Stability was confirmed in a test-retest study. Factor analysis confirmed instrument items measure the concepts of Cervero's Model.

CONCLUSION

The reliable and valid instruments may be useful for continuing education and staff development nurses to measure the effectiveness of education on behavioral change in practice.

A problem for the idea of voluntary euthanasia

I question whether, in those cases where physician-assisted suicide is invoked to alleviate unbearable pain and suffering, there can be such a thing as voluntary euthanasia. The problem is that when a patient asks to die under such conditions there is good reason to think that the decision to die is compelled by the pain, and hence not freely chosen. Since the choice to die was not made freely it is inadvisable for physicians to act in accordance with it, for this may be contrary to the patient's genuine wishes. Thus, what were thought to be cases of voluntary euthanasia might actually be instances of involuntary euthanasia.

Classification of human liposarcoma and lipoma using ex vivo proton NMR spectroscopy

Prognostication in patients with liposarcoma is a complex and controversial subject based on recognition of lipoblasts, adipocyte nuclear atypia, and qualitative estimations of cellularity and cell size. We show here that for 30 patients with liposarcoma and 5 patients with lipoma, spectral differences on high-resolution, magic angle spinning proton nuclear magnetic resonance (hr-MAS 1H-NMR) spectroscopy relate to known biochemical changes and correlate with adipocyte tissue differentiation, histologic cell type, and cellularity. The NMR-visible level of triglyceride is shown to correlate with liposarcoma differentiation, since the triglyceride level in well-differentiated liposarcoma is 33-fold higher on average than for myxoid/round cell liposarcoma, which in turn is 6-fold higher than the dedifferentiated and/or pleomorphic subtypes. The NMR-visible phosphatidylcholine level serves as an estimate of total tissue cell membrane phospholipid mass and was found to correlate with liposarcoma subtype. Pleomorphic liposarcoma, the most aggressive and metastatic subtype, was found to have a threefold increase in NMR-visible phosphatidylcholine level compared with dedifferentiated liposarcoma. The level of NMR-visible phosphatidylcholine was twofold greater in well-differentiated liposarcoma compared with lipoma and was threefold larger for the hypercellular myxoid/round cell subtype compared with the pure myxoid histology. Thus, NMR-derived parameters of tissue lipid may be used for objective distinction of liposarcoma histologic subtype/grade and lipoma from liposarcoma. These biochemical parameters may ultimately improve prognostication in patients with liposarcoma.

Induction of solid tumor differentiation by the peroxisome proliferator-activated receptor-gamma ligand troglitazone in patients with liposarcoma

Agonist ligands for the nuclear receptor peroxisome proliferator-activated receptor-gamma have been shown to induce terminal differentiation of normal preadipocytes and human liposarcoma cells in vitro. Because the differentiation status of liposarcoma is predictive of clinical outcomes, modulation of the differentiation status of a tumor may favorably impact clinical behavior. We have conducted a clinical trial for treatment of patients with advanced liposarcoma by using the peroxisome proliferator-activated receptor-gamma ligand troglitazone, in which extensive correlative laboratory studies of tumor differentiation were performed. We report here the results of three patients with intermediate to high-grade liposarcomas in whom troglitazone administration induced histologic and biochemical differentiation in vivo. Biopsies of tumors from each of these patients while on troglitazone demonstrated histologic evidence of extensive lipid accumulation by tumor cells and substantial increases in NMR-detectable tumor triglycerides compared with pretreatment biopsies. In addition, expression of several mRNA transcripts characteristic of differentiation in the adipocyte lineage was induced. There was also a marked reduction in immunohistochemical expression of Ki-67, a marker of cell proliferation. Together, these data indicate that terminal adipocytic differentiation was induced in these malignant tumors by troglitazone. These results indicate that lineage-appropriate differentiation can be induced pharmacologically in a human solid tumor.

Classification of human liposarcoma and lipoma using ex vivo proton NMR spectroscopy

Prognostication in patients with liposarcoma is a complex and controversial subject based on recognition of lipoblasts, adipocyte nuclear atypia, and qualitative estimations of cellularity and cell size. We show here that for 30 patients with liposarcoma and 5 patients with lipoma, spectral differences on high-resolution, magic angle spinning proton nuclear magnetic resonance (hr-MAS 1H-NMR) spectroscopy relate to known biochemical changes and correlate with adipocyte tissue differentiation, histologic cell type, and cellularity. The NMR-visible level of triglyceride is shown to correlate with liposarcoma differentiation, since the triglyceride level in well-differentiated liposarcoma is 33-fold higher on average than for myxoid/round cell liposarcoma, which in turn is 6-fold higher than the dedifferentiated and/or pleomorphic subtypes. The NMR-visible phosphatidylcholine level serves as an estimate of total tissue cell membrane phospholipid mass and was found to correlate with liposarcoma subtype. Pleomorphic liposarcoma, the most aggressive and metastatic subtype, was found to have a threefold increase in NMR-visible phosphatidylcholine level compared with dedifferentiated liposarcoma. The level of NMR-visible phosphatidylcholine was twofold greater in well-differentiated liposarcoma compared with lipoma and was threefold larger for the hypercellular myxoid/round cell subtype compared with the pure myxoid histology. Thus, NMR-derived parameters of tissue lipid may be used for objective distinction of liposarcoma histologic subtype/grade and lipoma from liposarcoma. These biochemical parameters may ultimately improve prognostication in patients with liposarcoma.

Adherence to management of high blood pressure: recommendations of the Canadian Coalition for High Blood Pressure Prevention and Control

Adherence or compliance, in the context of medical treatment, refers to how well a patient follows and sticks to the management plan developed with her/his health care provider, which may include pharmacologic agents as well as changes in lifestyle. Adherence is of great concern in asymptomatic conditions such as hypertension, where lack of control may have serious ramifications including end organ damage and premature mortality. To address this issue, the Canadian Coalition for High Blood Pressure Prevention and Control established a national Advisory Committee on Adherence to the Management of High Blood Pressure. The Advisory Committee consisted of 11 members from different disciplines of health care providers. The Committee reviewed all evidences to date and drew up four practical recommendations with respect to patient, provider and environment. Based on Canadian Task Force on Periodic Health Examination's guidelines, all four recommendations can be classified as 'level C' with a quality of evidence of II.

Adherence to pharmacologic management of hypertension

Adherence to pharmacologic therapy of hypertension is low (in the range of 50-70%) and has important implications both for blood pressure control and cardiovascular complications. Based on a review of the literature using the levels of evidence grading technique, determinants of adherence to the pharmacologic therapy of hypertension have been assessed. Additionally, interventions to improve compliance were evaluated. Patient-centred, health care provider-centred and drug-specific factors have all been shown to affect adherence rates. We conclude that the extent of adherence to pharmacologic therapy is modifiable. Measurable improvements in adherence can be obtained from simplified medication regimens and a combination of behaviour strategies, including the tailoring of pill-taking to patients' daily habits and rituals, the advocacy of self-monitoring of pills and blood pressure, and the institution of reward systems.

Aorto-atrial fistula without aneurysm formation in Behçet's disease

Cardiac disease is known to occur in patients with the multisystemic inflammatory disorder Behçet's disease. An aorto-atrial fistula secondary to Behçet's disease without a sinus of Valsalva aneurysm has not been previously reported. A 30 year old man with a four year history of symptoms and signs consistent with Behçet's disease presented with an aorto-atrial fistula and a large left to right shunt. At operation the defect was repaired with a bovine pericardial patch. There was no evidence of aneurysm formation. The patient made a good recovery and was well at one year follow up.

Fluctuations in blood lipid levels during furosemide therapy: a randomized, double-blind, placebo-controlled crossover study

BACKGROUND

Acute decreases in intravascular volume are associated with increases in lipid levels. Furosemide causes acute changes in intravascular volume during prolonged therapy but is thought to have little effect on lipid levels.

METHODS

To determine if there are daily acute rises in lipid and lipoprotein levels associated with changes in intravascular volume during long-term furosemide ingestion therapy, we performed a randomized, double-blind, placebo-controlled crossover study in 10 patients.

RESULTS

In the 8 hours after furosemide ingestion there were increases in levels of plasma cholesterol (10.1%; P = .001), high-density lipoprotein cholesterol (9.0%; P = .006), and apolipoprotein B (9.8%; P = .003). The increases in levels of triglycerides (11.5%; P = .17) and apolipoprotein A-1 (13.3%; P = .051) were of similar magnitude but more variable and did not achieve statistical significance. There was no substantial change in the total cholesterol-high-density lipoprotein cholesterol ratio (0.6%; 95% CI,-0.74% to 8.6%; P =.88).

CONCLUSION

This study indicates that there are acute increases in lipid levels after furosemide ingestion during prolonged therapy, which could affect the interpretation of lipid levels and cardiovascular risk in patients.

Gradient, high-resolution, magic angle spinning 1H nuclear magnetic resonance spectroscopy of intact cells

The application of new gradient, high-resolution, magic angle spinning (MAS) 1H nuclear magnetic resonance (NMR) spectroscopy to the study of intact undifferentiated and differentiated NIH 3T3 F442A cells demonstrated improved spectral resolution and sensitivity compared with static studies. MAS of cells permits the detection and quantitation of many cellular metabolites that are not clearly resolved in nonspinning measurements and provides an improved visibility of phospholipids. Gradient, MAS enables the use of diffusion weighting for compartment assignment and the determination of mobility for many metabolites which are incompletely resolved using static techniques. The smaller, undifferentiated preadipocytes show no microscopic evidence of cell lysis after 2 h of MAS at 3.5 kHz and 82% of these cells remain viable by trypan blue exclusion. In contrast, 15-19% of the larger, lipid-laden differentiated adipocytes were found to suffer some degree of cell lysis with MAS. This new method is an attractive alternative to either nonspinning perfusion or extraction techniques for NMR studies of cells.

Factors influencing blood loss in transurethral resection of the prostate (TURP): auditing TURP

OBJECTIVES

To assess the blood loss accompanying TURP and investigate its association with the resected weight of prostatic tissue, type of anaesthesia, type of presentation, histology, different surgeons and their differing techniques, and thus to reduce the morbidity associated with blood loss and transfusion.

PATIENTS AND METHODS

All prostatectomies carried out in a district general hospital were audited prospectively, recording the pre- and post-operative haemoglobin concentration (Hb), blood transfusions and the variables listed above. The audit was repeated a year later.

RESULTS

The peri-operative blood loss, as assessed by various indicators, was equivalent to a decrease in Hb of 10-15 g/L (8-11%). The weight of the resected prostatic tissue was the most important measurable factor in determining blood loss. Regional anaesthesia was associated with less blood loss than general anaesthesia. The added use of a suprapubic catheter for irrigation appeared to have a marginal advantage in large resections. The type of presentation, elective or otherwise, and the histological nature of the prostate did not influence blood loss. Smaller transfusions were probably avoidable in patients having smaller resections and a normal pre-operative Hb. On re-auditing, the overall transfusion rate was reduced from 10.8% to 8.2% and from 4.4% to 1% in patients having resections of < 30 g.

CONCLUSION

Blood transfusion can be reduced and rationalized. Patients with a normal pre-operative Hb and undergoing resections of < 30 g do not usually require transfusion. Regional anaesthesia is associated with less blood loss but its advantage is overshadowed in practice by the weight of the resected tissue. An audit of this type is repeatable and is useful in raising awareness, objectively assessing differences and advocating and assessing any changes made.

Closed kinetic chain tarsal mechanics of subtalar joint arthroereisis

The weightbearing biomechanics of the tarsus with and without subtalar joint arthroereisis was investigated in 11 fresh frozen cadaver specimens using a three-dimensional (3-D) radiowave tracking system. Specimens, consisting of the distal half of the tibia and fibula and the intact ankle and foot, were mounted on a nonmetallic loading frame test system that allowed positioning of the foot to simulate midstance position of gait. The tibia was axially loaded to 756 N (one bodyweight) with 15% of the total load diverted through the fibula. Receiving transducers were attached to the talus, navicular, calcaneus, and cuboid bones. Tarsal movements were monitored as the specimen was loaded with and without subtalar joint arthroereisis. Three-dimensional data sets of osseous positions and orientations were collected and analyzed. Significant rotational differences were detected with and without subtalar joint arthroereisis for all four tarsal bones (p < or = 0.05). Tarsal translational position changes were small and not statistically significant.

Image Region Labelling by Humans and by an Artificial Neural Network

We reported (Troscianko et al, 1995 Perception24 Supplement, 18) that a neural network has been developed which is capable of labelling objects in natural scenes by first segmenting a scene, then obtaining a description of each segment in terms of a set of features. A neural net is then trained to label the segments on the basis of the feature set. The question we are now addressing is: how important is each of these features to overall performance, both in human and machine vision?

We carried out an experiment in which human subjects were trained in the same labelling task as the neural net. Individual segments of scenes (sometimes corresponding to a whole object, eg a car, and sometimes an incomplete region, eg part of the sky) were presented on a screen, and the subject asked to label the scene as one of eleven possible types of object (sky, vegetation, vehicle …). Feedback was given and the learning curve monitored. When the learning curve was flat, each subject's performance was investigated with both intact and degraded stimuli. The degradation consisted of partial representation of the information, such as presenting just the outer boundary, or the average colour, or the average luminance, or randomising the size, position, and texture of the segment.

The results suggest that this degradation produces significant changes in performance (F9,7=4.4, p=0.0005). A posteriori analysis indicates that certain attributes (particularly texture, boundary-only, colour-averaging) are particularly influential in mediating performance. A similar set of results was obtained by training the network on similarly degraded data. The results imply: (1) that a neural net can provide a useful model of human object labelling processes, and (2) that certain features are more important than others in mediating such performance.

A phase II study of single agent paclitaxel in patients at first relapse following initial chemotherapy for breast cancer

This study was initiated to evaluate the safety and efficacy of 3-weekly paclitaxel given at 225 mg/m2 over 3 hours without colony stimulating factor support in patients at their first relapse following adjuvant therapy for breast cancer. Thirty patients were entered into the study; all were assessable for response and toxicity. All patients had received adjuvant/neo-adjuvant chemotherapy; 22 patients had had prior hormonal therapy and 26 previous adjuvant radiotherapy. The group was characterized by a short time to first relapse (median 7.5 months (range 2-43)) and widespread disease, with 22 patients having multiple disease sites including: nodes (43%), skin and soft tissue (43%), liver (40%), lung (37%) and bone (50%). A total of 219 cycles of paclitaxel were given, with a median of eight per patient. The major non-haematological toxicities were: grade 3 alopecia (82% cycles), grade 2/3 arthralgia/myalgia (26%), grade 2/3 fatigue (16%) and grade 2/3 peripheral nervous system toxicity (12%). Haematological toxicity was mainly neutropenia of short duration, with grade 4 counts documented in 16% of cycles. Thrombocytopenia was minimal and there were no significant hypersensitivity reactions. The objective response rate was 60% (95% CI 42.5-77.5) with one complete response and 17 partial responses. The median duration of overall response was 30 weeks (range 15-75+ (95% CI 25-33)) with a median survival time for all patients of 42 weeks (range 1-124+). This study demonstrates that paclitaxel 225 mg/m2 is well tolerated as a 3-hour infusion and can be given safely in an outpatient setting without routine use of granulocyte colony stimulating factor. The response rate is encouraging and shows that this regimen is effective in this poor prognosis patient population.

A comparison of two transcutaneous monitors for the measurement of arterial PO2 and PCO2 in neonates

We examined the ability of two transcutaneous devices (Fastrac, Sensormedics Corporation, Yorba Linda, California, U.S.A. and Hewlett Packard M1018A, Hewlett Packard Component Monitoring System, Hewlett Packard, North Hollywood, U.S.A.) to measure arterial PCO2 and PO2 in neonates. Thirty-seven neonates had transcutaneous oxygen measured with the Hewlett Packard (HPO2 group), 38 neonates had transcutaneous carbon dioxide measured with the Hewlett Packard (HPCO2 group) and the Fastrac was used on 27 neonates (FTCO2 group). Both devices were operated with electrode temperatures of 43.5 degrees C although an additional ten subjects were studied using the Fastrac with an electrode temperature of 43.0 degrees C. The mean differences (transcutaneous--arterial) and upper and lower limits of agreement were calculated for each group. For the HPO2 group they were 3.78 mmHg (-12.23 to 19.80 mmHg), for the HPCO2 group they were 0.40 mmHg (-4.50 to 5.30 mmHg) and for the FTCO2 they were -0.96 mmHg (-7.85 to 5.92 mmHg). For the Fastrac group at an electrode temperature of 43.0 degrees C the mean difference and limits of agreement were -1.00 mmHg and -4.58 mmHg to 2.58 mmHg. The average sensitivity and specificity for both machines for the detection of hypocarbia were 82% and 92% respectively while for hypercarbia they were 90% and 94% respectively. For hypoxaemia, the sensitivity and specificity were 40% and 94% while for hyperoxaemia the sensitivity and specificity were 83% and 97%. We conclude that both machines provide a useful supplement to arterial PCO2 measurements and the Fastrac performs better at 43.0 degrees C. The measurement of PO2 is less accurate but is still of clinical use.

Breast self-examination: knowledge and practices of Hispanic women in two southwestern metropolitan areas

The breast self-examination (BSE) practices of 1,453 Hispanic women in Phoenix, Arizona and San Diego, California were the focus of this study. Variables proposed as factors that influence the frequency and proficiency of BSE were demographic variables, particularly language and level of acculturation, having been taught BSE by a health professional, and experience with the disease. Results indicate that even though the majority of the women at both the Phoenix (78.1%) and San Diego (83.7%) sites had been taught BSE by a professional and most women in Phoenix (62.5%) and San Diego (63.4%) reported performing BSE within the past month, only 0.7% of the women at both sites were found to be proficient in the technique of BSE. Further, results indicate that language and acculturation were correlated with whether or not a woman performed BSE. These findings suggest that BSE education classes must provide information and techniques that promote proficiency in BSE, and must be designed to meet the unique needs of Hispanic women, particularly those of low acculturation levels.

Guidelines for measurement of blood pressure, follow-up, and lifestyle counselling. Canadian Coalition for High Blood Pressure Prevention and Control

As part of the Coalition's mandate to promote the prevention and control of high blood pressure in Canada, an interdisciplinary Workgroup was established to review and update the existing standards (1987) for blood pressure measurement and referral guidelines. The intent was to prepare a scientifically based document which contained practical guidelines for the measurement of blood pressure and criteria for follow-up, and one which promoted the concept of cardiovascular health in the assessment and interpretation of blood pressure readings. These guidelines were primarily developed to assist primary health care providers and/or clinicians to assess, monitor, counsel, refer, and develop treatment plans for adults-at-risk for high blood pressure or those with the confirmed diagnosis of hypertension. Readers are referred to The Canadian Hypertension Society Consensus Conference series (Canadian Medical Association Journal 1993) for specific guidelines on the evaluation, diagnosis, and treatment of hypertension. The document is divided into three sections: 1. Measurement of blood pressure 2. Criteria for follow-up 3. Guidelines for lifestyle counselling Each section cites the references used in developing the guidelines and where relevant, identifies other resources which can be used in clinical practice.

Conflict with physician pregnancy revisited

A 10-year follow-up survey found medical school physicians (N = 200) at one institution were more interested in and accepting of pregnancy among colleagues. A greater number of physicians in 1990 than in 1980 reported that pregnant colleagues maintained their work efficiency and interest in medicine. Fewer physicians in 1990 reported being inconvenienced during a colleague's pregnancy, and fewer perceived hiring women of childbearing age to be a risk to the optimal functioning of their departments.

The prevalence of suicidal behavior among preadolescent children who are psychiatric inpatients

The prevalence of suicidal behavior displayed by preadolescent children hospitalized on inpatient psychiatric units is estimated to range between 18% and 80% of the population. The current study provides an independent estimate of the prevalence of this problem. A semistructured interview was used to assess suicidal behavior displayed by 61 admissions to a child psychiatric inpatient unit between April 1988 and September 1989. According to the Pfeffer Spectrum of Suicidal Behavior Scale, 63% of the sample engaged in some form of suicidal behavior. Preadolescents and their parents reported similar rates of suicidal thoughts, threats and attempts. The dangerousness of recent suicidal behavior was not found to differ by age, sex, legal custody status or socioeconomic status.

Vaccination of sheep with purified cysteine proteinases of Fasciola hepatica decreases worm fecundity

There has been some evidence from several parasite systems that proteinases might have potential as protective antigens against parasitic infection. A cysteine proteinase complex identified in the regurgitant of adult F. hepatica was examined in this context. The thiol-cathepsin-related proteinases of M(r) 28,000 were purified and tested in vaccine trials of sheep infected with liver fluke. Ten animals were immunised with the purified proteinases and developed antibodies to the cysteine proteinases prior to challenge with F. hepatica metacercariae. Infection appeared to cause a boost in antibody response by Week 4 into infection, and antibody levels were generally sustained throughout infection. The cysteine proteinases are not novel antigens, since low-level antibody titres were also detected in nonimmunised controls by late infection. On completion of the trial, there was no difference in worm burden between the two groups. However, faecal egg counts and therefore worm fecundity were significantly decreased.