Babies born at the threshold of viability: attitudes of paediatric consultants and trainees in South East England

AIM

To determine attitudes of paediatric consultants and trainees towards immediate care of babies born at 22-24 weeks gestation.

METHODS

A questionnaire was sent to one consultant and one trainee within each of 63 neonatal units in South East England.

RESULTS

Response rate was 90% (111/123). At 22 weeks gestation, 51% of all respondents would not attend the delivery. At 23 weeks gestation, 63% of respondents would advise against resuscitation during antenatal counselling but 45% would resuscitate despite a parental request for comfort care. Forty-one percent of respondents would provide comfort care for a 23 week gestation baby born in poor condition. If required, 53% of respondents would use chest compressions and/or adrenaline at birth of a 24 week gestation infant (38% consultants, 54% trainees; p = 0.05). More experienced and older paediatricians were more likely to attend 22 week deliveries and be comfortable with parental requests for resuscitation. Fifty-four percent of units had written guidelines on care of these babies. Significantly more consultants (67%) than trainees (25%) correctly classified neonatal deaths.

CONCLUSIONS

Paediatricians with greater experience and age demonstrated more shared decision-making with parents. Nearly half of paediatricians would defy parental wishes at 23 weeks gestation, contrary to ethical recommendations (Nuffield Council on Bioethics, http://www.nuffieldbioethics.org).

Isolation and characterization of the RAD3 gene of Saccharomyces cerevisiae and inviability of rad3 deletion mutants

The RAD3 gene of Saccharomyces cerevisiae is required for nicking of DNA containing pyrimidine dimers or interstrand crosslinks. We have cloned the RAD3 gene and physically mapped it to 2.6 kilobase of DNA. A DNA segment of the cloned RAD3 insert was ligated into plasmid YIp5, which transforms yeast by homologous integration, and shown to integrate at the RAD3 site in chromosome V, thus verifying the cloned DNA segment to be the RAD3 gene and not a suppressor. The RAD3 gene encodes a 2.5-kilobase mRNA, extending between the Kpn I site and the Sau3A1/BamHI fusion junction in plasmid pSP10, and the direction of transcription has been determined. The 2.5-kilobase transcript could encode a protein of about 90,000 daltons. We also show the deletions of the RAD3 gene to be recessive lethals, indicating that the RAD3 gene plays an important role in other cellular processes in addition to incision of damaged DNA.

Parental educational attainment as an indicator of socioeconomic status and risk of childhood cancers

Background:

Little has been reported on socioeconomic (SES) patterns of risk for most forms of childhood cancer.

Methods:

Population-based case–control data from epidemiological studies of childhood cancer conducted in five US states were pooled and associations of maternal, paternal and household educational attainment with childhood cancers were analysed. Odds ratios (ORs) and 95% confidence intervals were estimated using logistic regression, controlling for confounders.

Results:

Although there was no association with parental education for the majority of cancers evaluated, there was an indication of a positive association with lower education for Hodgkin's and Burkitt's lymphoma and Wilm's tumour, with the ORs ranging from 1.5 to >3.0 times that of more educated parents. A possible protective effect was seen for lower parental education and astrocytoma and hepatoblastoma, with ORs reduced by 30 to 40%.

Conclusions:

These study results should be viewed as exploratory because of the broad nature of the SES assessment, but they give some indication that childhood cancer studies might benefit from a more thorough assessment of SES.

Nicotine patch vs. nicotine lozenge for smoking cessation: an effectiveness trial coordinated by the Community Clinical Oncology Program

BACKGROUND

Nicotine replacement therapies are efficacious for treating nicotine dependence. However, limited data exist on benefits of different NRTs and predictors of treatment outcome. This study compared the effectiveness of transdermal nicotine vs. nicotine lozenge for smoking cessation and identified predictors of treatment response.

METHODS

A randomized, open-label effectiveness trial was conducted at 12 medical sites participating in the National Cancer Institute's Community Clinical Oncology Program. The sample consisted of 642 treatment-seeking smokers randomized to 12 weeks of transdermal nicotine or nicotine lozenge.

RESULTS

Smoker characteristics were assessed at baseline, and 24-h point prevalence abstinence confirmed with breath carbon monoxide (CO) was evaluated at end of treatment (EOT) and at a 6-month follow-up. There was a trend for higher quit rates for transdermal nicotine vs. nicotine lozenge at EOT (24.3% vs. 18.7%, p=.10) and 6 months (15.6% vs. 10.9%, p=.10). A logistic regression model of EOT quit rates showed smokers who preferred transdermal nicotine, were not reactive to smoking cues, and did not use nicotine to alleviate distress or stimulate cognitive function had higher quit rates on transdermal nicotine. A logistic regression model of 6-month quit rates showed smokers who preferred transdermal nicotine had higher quit rates on transdermal nicotine, and smokers who used nicotine to alleviate distress or stimulate cognitive processes had lower quit rates on nicotine lozenge.

CONCLUSIONS

Transdermal nicotine may be more effective than nicotine lozenge for smokers who prefer transdermal nicotine and do not smoke to alleviate emotional distress or stimulate cognitive function.

Menopausal Hormone Therapy influences Lung Cancer Survival but not Lung Cancer Risk: Results from the California Teachers Study

Purpose: Most studies have shown a protective or null effect of postmenopausal hormone therapy (HT) on lung cancer risk, whereas the recent post-hoc analysis of the Women's Health Initiative (WHI) showed that estrogen+progestin (E+P) decreased lung cancer survival. Given the substantial clinical implications, it is vital that the risk and survival associations be validated.

Methods: We examined the associations between HT use and lung cancer risk and survival among 60,592 postmenopausal women enrolled in the prospective California Teachers Study cohort. Between 1995 and 2007, 727 women (184 never smokers) were diagnosed with lung cancer; 441 of these died as of December 31, 2007. Age-stratified, multivariable Cox proportional hazards regression was used to calculate hazard ratios (HR).

Results: After adjusting for potential confounders, various measures of HT use were not associated with lung cancer risk. However, any HT use (vs. no use) was associated with a statistically significant increase in lung-cancer-specific survival [HR, 0.70; 95% confidence interval (CI), 0.56-0.87]. Among women who only used E, statistically significant increases in lung cancer survival were seen for recent use (HR, 0.59; 95% CI, 0.43-0.80), but not former use; use of only E+P was not associated with survival. Shorter duration of recent E-only use was associated with improved survival (0-5 years of use: HR, 0.29, 95% CI, 0.12-0.68; 5-15 years of use: HR, 0.60, 95% CI, 0.35-1.05; >15 years of use: HR, 0.58, 95% CI, 0.39-0.88) (trend P = 0.005). Similarly, women who reported recently using E-only for 0-5 years had a median survival time of 42.1 months versus women who reported 5-15 years of use (31 months), >15 years of use (19.1 months), or no HT use (15.6 months) (log-rank P = 0.009). Among former users of HT, a statistically significant 63% (95% CI, 0.16-0.87) decrease in lung-cancer-specific death was observed for E-only use <5 years prior to baseline, but not for E-only use >5 years prior to baseline or E+P-only use.

Conclusions: Contrary to the recent finding that lung cancer survival is poorer among women in WHI taking E+P, our results suggest no effect of E+P. By contrast, postmenopausal E-only use, specifically recent use, is associated with increased lung cancer survival.

Correlates of smoking cessation self-efficacy in a community sample of smokers

While numerous studies show that higher levels of smoking cessation self-efficacy predicts motivation to quit smoking and successful smoking cessation, few studies have evaluated factors related to smoking cessation self-efficacy that could be targets of behavioral interventions to promote greater confidence to quit smoking. This study, using a large community sample of smokers enrolled in a smoking cessation treatment program, evaluated potential associations between self-efficacy to quit smoking and demographic (e.g., age, race), smoking-related (e.g., rate, cessation history, past use of treatments), and psychosocial (e.g., stress, cue reactivity, self-medication smoking) variables. The results indicated that Hispanic-American smokers, relative to smokers of other racial/ethnic groups, report significantly lower self-efficacy to quit smoking when facing internal stimuli (e.g., feeling depressed), as do smokers who report that they have little confidence to control abstinence-induced symptoms (F(9,576)=6.9, p<.001). The results also indicated that smokers who reported that they have little confidence to control abstinence-induced symptoms and report high smoking urge reactivity to situations that illicit positive affect (e.g., at a bar, with coffee, at a party) report lower self-efficacy to quit smoking when facing external stimuli (e.g., during a celebration; F[7,600]=9.05, p<.05). These findings can be used to refine behavioral smoking cessation interventions to increase self-efficacy to quit smoking.

Obesity, waist size and prevalence of current asthma in the California Teachers Study cohort

BACKGROUND

Obesity is a risk factor for asthma, particularly in women, but few cohort studies have evaluated abdominal obesity which reflects metabolic differences in visceral fat known to influence systemic inflammation. A study was undertaken to examine the relationship between the prevalence of asthma and measures of abdominal obesity and adult weight gain in addition to body mass index (BMI) in a large cohort of female teachers.

METHODS

Prevalence odds ratios (ORs) for current asthma were calculated using multivariable linear modelling, adjusting for age, smoking and race/ethnicity.

RESULTS

Of the 88 304 women in the analyses, 13% (n = 11,500) were obese (BMI > or = 30 kg/m(2)) at baseline; 1334 were extremely obese (BMI > or = 40 kg/m(2)). Compared with those of normal weight, the adjusted OR for adult-onset asthma increased from 1.40 (95% confidence interval (CI) 1.31 to 1.49) for overweight women to 3.30 (95% CI 2.85 to 3.82) for extremely obese women. Large waist circumference (>88 cm) was associated with increased asthma prevalence, even among women with a normal BMI (OR 1.37, 95% CI 1.18 to 1.59). Among obese women the OR for asthma was greater in those who were also abdominally obese than in women whose waist was < or = 88 cm (2.36 vs 1.57). Obese and overweight women were at greater risk of severe asthma episodes, measured by urgent medical visits and hospital admissions.

CONCLUSIONS

This study confirms the association between excess weight and asthma severity and prevalence, and showed that a large waist was associated with increased asthma prevalence even among women considered to have normal body weight.

Family history of haematopoietic malignancies and non-Hodgkin's lymphoma risk in the California Teachers Study

Family history of haematopoietic malignancies appears to be a risk factor for non-Hodgkin's lymphoma (NHL), but whether risk varies by family member's gender is unclear. Among 121 216 women participating in the prospective California Teachers Study, NHL risk varied by type of haematopoietic malignancy and gender of the relative.

Hormone therapy use before diagnosis and breast cancer survival in the California teachers study

Abstract #65

Background: Breast cancer survival appears to be improved by pre-diagnostic use of hormone therapy (HT), but it is unclear from existing studies whether this is attributable to a direct beneficial effect of HT or because HT use encourages the development of certain tumor types with better prognosis. It is therefore important to examine whether the association between HT use and survival still remains after adequate adjustment for tumor characteristics.&#x2028; Methods: The California Teachers Study is an ongoing prospective study of female public school teachers and administrators. These analyses included 2,783 postmenopausal women whose use of HT was known and who were diagnosed with an incident primary invasive breast cancer after joining the cohort in 1995-96 and followed until death or the end of 2005. Incident cancers and tumor characteristics were ascertained through annual linkage with the statewide California Cancer Registry. Deaths were ascertained through annual linkage with the California state mortality files, the Social Security Administration Death Master File and the National Death Index. HT and other covariates were self-reported on the baseline questionnaire. We estimated the relative risk (RR) of breast cancer death stratifying by age in years, and using age in days from breast cancer diagnosis as the time scale (censoring deaths from other causes).&#x2028; Results: During the follow-up period, 159 (5.7%) women died of breast cancer. In unadjusted analysis, former and current HT use, specifically current estrogen-progestin (EP) use (RR=0.37; 0.24-0.57) but also current unopposed estrogen (E) use (RR=0.64; 0.43-0.95), was significantly associated with reduced breast cancer mortality, compared with no HT use. In multivariable analysis, taking into account race, body mass index, smoking history, lifetime physical activity, and co-morbidities, the risk estimates were somewhat attenuated (EP RR=0.40; 0.26-0.63 and E RR=0.67; 0.44-1.00). After additional adjustment for tumor characteristics (stage at diagnosis, estrogen receptor status, number of positive lymph nodes, grade and tumor size) and treatment received (surgery type and radiation) the risk estimates were considerably attenuated (EP RR=0.53; 0.33-0.84 and E RR=0.82; 0.53-1.27).&#x2028; Conclusion: Use of EP before diagnosis was associated with a reduced risk of death due to breast cancer. Use of E was also associated with reduced breast cancer mortality, although the association was not statistically significant after adjustment for indicators of general health, characteristics of the tumor and treatment.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 65.

Thinking ethically about genetic inheritance: liberal rights, communitarianism and the right to privacy for parents of donor insemination children

The issue of genetic inheritance, and particularly the contradictory rights of donors, recipients and donor offspring as to the disclosure of donor identities, is ethically complicated. Donors, donor offspring and parents of donor offspring may appeal to individual rights for confidentiality or disclosure within legal systems based on liberal rights discourse. This paper explores the ethical issues of non-disclosure of genetic inheritance by contrasting two principle models used to articulate the problem--liberal and communitarian ethical models. It argues that whilst the latter provides a more constructive avenue to providing an ethics for donation than the competing and contradictory positions represented in a liberal rights approach, it raises issues of ethical judgement and authority that remain problematic. This ethical discussion is supported by a field study, funded by the Wellcome Trust, exploring the perceptions and experiences of recipients of donor sperm and their partners towards donor anonymity. The field study provides the empirical basis of an argument for making ethical judgements on the grounds of the community good rather than individual rights, that nevertheless recognises that both are inherently problematic.

Evidence-based care and the curriculum

An evidence-based (EB) approach has been a significant driver in reforming healthcare over the past two decades. This change has extended across a broad range of health professions, including oral healthcare. A key element in achieving an EB approach to oral healthcare is educating our practitioners, both current and future. This involves providing opportunities integrated within simulated and actual clinical settings for practitioners to learn and apply the principles and processes of evidence-based oral healthcare (EBOHC). Therefore, the focus of this discussion will be on ways in which EBOHC and associated research activities can be implemented into curricula, with the aim of improving patient care. This paper will initially define the scope of EBOHC and research, what these involve, why they are important, and issues that we need to manage when implementing EBOHC. This will be followed by a discussion of factors that enable successful implementation of EBOHC and research into curricula. The paper concludes with suggestions on the future of EBOHC and research in curricula. Key recommendations related to curricula include strengthening of the culture of a scientific approach to education and oral healthcare provision; complete integration of EBOHC into the curriculum at all levels; and faculty development to implement EBOHC based on their needs and evidence of effective approaches. Key recommendations to support implementation and maintenance of EBOHC include recognition and funding for high-quality systematic reviews and development of associated methodologies relevant for global environments; building global capacity of EBOHC researchers; research into improving translation of effective interventions into education and healthcare practice, including patient-reported outcomes, safety and harms, understanding and incorporation of patient values into EB decision-making, economic evaluation research specific to oral healthcare and effective methods for changing practitioner (faculty) behaviours; and extend access to synthesized research in 'user friendly' formats and languages tailored to meet users' needs. Realizing these recommendations may help to improve access to effective healthcare as a basic human right.

Volume Flow Rate of Common Carotid Artery Measured by Doppler Method and Color Velocity Imaging Quantification (CVI-Q)

BACKGROUND

Common carotid artery (CCA) volume flow rate (VFR) is clinically useful for study of cerebrovascular disease. Color Velocity Imaging Quantification (CVI-Q; Philips Ultrasound International, Irvine, CA), previously reported as accurate and reliable, tracks the flow lumen over the cardiac cycle, as well as mean spatial velocity, which is multiplied by vessel area to obtain VFR. VFR can also be obtained by Doppler sampling for mean velocity, and vessel area based on static B-mode lumen diameter. We compared CCA VFR by CVI-Q and Doppler method (DM), since knowledge of how they compare is crucial when both are used clinically.

METHOD

We prospectively studied patients having clinical carotid duplex exams and healthy controls. All had CCA VFR measured by both methods in the same exam session.

RESULTS

Thirty-four studies were reviewed. CCA VFR by CVI-Q in those without ICA stenosis was 337 +/- 96 mL/m, and by DM 359 +/- 130 mL/m; P = .33. There was no difference between methods for 50-75% or 75-95% ICA stenosis. In 7 patients with ICA occlusion, and 3 with 95-99% stenosis, VFR was higher by DM than by CVI-Q (Occlusion: 125 vs 58 mL/m, P = .007; 95-99%: 152 vs 63 mL/m, P = .038). There was no statistically significant difference between methods for measurement of the ratio of VFR between right and left CCA.

CONCLUSION

In patients with 0-95% ICA stenosis, VFR by CVI-Q and DM showed no difference. For 95-100% ICA stenosis the methods differ; with higher VFR by DM. Side-to-side VFR ratios remain constant, irrespective of VFR method, and can still provide clinically useful information.