Selective surgery and adjuvant therapy based on risk classifications of well-differentiated thyroid cancer

BACKGROUND

The prognosis of well-differentiated thyroid cancer has been stratified into low- and high-risk groups. These risk groups can be used to predict prognosis and to guide treatment.

METHODS

Retrospective study of 962 patients with well-differentiated thyroid cancer treated from 1940 to 1998. Stratification into low- and high-risk groups based on age, metastases, extent, and size (AMES). Effects on survival of surgery, lymph node dissection, and radiation therapy were examined.

RESULTS

Seven hundred twenty-eight cases were papillary and 234 were follicular carcinoma. Seven hundred-fifty cases were low risk and 207 high risk. Twenty-year survival was 97.4% in the low-risk patients and 54.0% in high-risk patients (P < 0.001); it was 63.2% in the younger high-risk group and 41.0% in the older high-risk group (P < 0.001). Older high-risk patients had a survival advantage with bilateral thyroidectomy. Extent of surgery did not change survival in either the younger high-risk group or the low-risk group. Lymph node dissection and radioactive iodine ablation did not have an impact on survival.

DISCUSSION

Well-differentiated thyroid cancer in low-risk patients has a favorable outcome regardless of treatment. Low-risk patients can be safely treated with unilateral thyroidectomy alone. Risk stratification with a modification of the AMES criteria can be used to guide treatment.

Conduct disorder: new directions in promoting effective parenting and strengthening parent-adolescent relationships

INTRODUCTION

Although it is always preferable to prevent childhood mental health and behavioural problems, it is not always possible to do so early in their developmental trajectory. Adolescence offers another window of opportunity to intervene and reduce risk or prevent the development of late onset conditions. In this paper, we focus on adolescent Conduct Disorder, noting the special challenges of this developmental period and implications for interventions. We briefly discuss the growing evidence of the importance of parent and family targeted interventions.

METHOD

Forty-eight adolescents with severe Conduct Disorder and their caregivers completed questionnaires at the beginning and end of a parent group program (Connect Parent Group). The program is guided by attachment principles and focuses on skill development in the domains of parental attunement, empathy and effective dyadic affect regulation. These skills are the building blocks of secure attachment and important components of effective parenting.

RESULTS

Caregivers' reports revealed significant improvements in their perceived parenting competence and satisfaction; reduced adolescent aggressive behaviour, internalizing and externalizing problems; and reduced levels of avoidance in the caregiver-adolescent relationship.

CONCLUSION

These findings provide further support for the importance of parent and family focused interventions in the treatment of Conduct Disorder in both children and adolescents.

Prevention and treatment of urinary incontinence after stroke in adults

BACKGROUND

Urinary incontinence can affect 40-60% of people admitted to hospital after a stroke, with 25% still having problems on hospital discharge and around 15% remaining incontinent at one year.

OBJECTIVES

To determine the optimal methods for prevention and treatment of urinary incontinence after stroke in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence and Stroke Groups specialised registers (searched 15 December 2004 and 26 October 2004, respectively), CINAHL (January 1982 to November 2004), national and international trial databases for unpublished data, and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials evaluating the effects of interventions designed to promote continence in people after stroke.

DATA COLLECTION AND ANALYSIS

Data extraction and quality assessment were undertaken by two reviewers working independently. Disagreements were resolved by a third reviewer.

MAIN RESULTS

Seven trials with a total of 399 participants were included in the review. Participants were from a mixture of settings, age groups and phases of stroke recovery. No two trials addressed the same comparison. Four trials tested an intervention against usual care, including acupuncture, timed voiding, and two types of specialist professional intervention. One cross-over trial tested an intervention (oestrogen) against placebo. One trial tested a specific intervention (oxybutynin) against another intervention (timed voiding), and one trial tested a combined intervention (sensory-motor biofeedback plus timed voiding) against a single component intervention (timed voiding alone). Reported data were insufficient to evaluate acupuncture or timed voiding versus usual care, oxybutynin versus timed voiding, or sensory motor biofeedback plus timed voiding versus usual care. Evidence from a single small trial suggested that structured assessment and management of care in early rehabilitation may reduce the number of people with incontinence at hospital discharge (1/21 versus 10/13; RR 0.06, 95% CI 0.01 to 0.43), and have other benefits. Evidence from another trial suggested that assessment and management of care by Continence Nurse Practitioners in a community setting may reduce the number of urinary symptoms (48/89 versus 38/54; RR 0.77, 95% CI 0.59 to 0.99), and increase satisfaction with care.

AUTHORS' CONCLUSIONS

There was suggestive evidence that specialist professional input through structured assessment and management of care and specialist continence nursing may reduce urinary incontinence after stroke. Data from trials of other physical, behavioural, complementary and anticholinergic drug interventions are insufficient to guide continence care of adults after stroke.

Inter‐ and intralaboratory variation of in vitro diffusion cell measurements: An international multicenter study using quasi‐standardized methods and materials

In vitro measurements of skin absorption are an increasingly important aspect of regulatory studies, product support claims, and formulation screening. However, such measurements are significantly affected by skin variability. The purpose of this study was to determine inter- and intralaboratory variation in diffusion cell measurements caused by factors other than skin. This was attained through the use of an artificial (silicone rubber) rate-limiting membrane and the provision of materials including a standard penetrant, methyl paraben (MP), and a minimally prescriptive protocol to each of the 18 participating laboratories. "Standardized" calculations of MP flux were determined from the data submitted by each laboratory by applying a predefined mathematical model. This was deemed necessary to eliminate any interlaboratory variation caused by different methods of flux calculations. Average fluxes of MP calculated and reported by each laboratory (60 +/- 27 microg cm(-2) h(-1), n = 25, range 27-101) were in agreement with the standardized calculations of MP flux (60 +/- 21 microg cm(-2) h(-1), range 19-120). The coefficient of variation between laboratories was approximately 35% and was manifest as a fourfold difference between the lowest and highest average flux values and a sixfold difference between the lowest and highest individual flux values. Intralaboratory variation was lower, averaging 10% for five individuals using the same equipment within a single laboratory. Further studies should be performed to clarify the exact components responsible for nonskin-related variability in diffusion cell measurements. It is clear that further developments of in vitro methodologies for measuring skin absorption are required.

Multistable pulselike solutions in a parametrically driven Ginzburg-Landau equation

It is well known that pulselike solutions of the cubic complex Ginzburg-Landau equation are unstable but can be stabilized by the addition of quintic terms. In this paper we explore an alternative mechanism where the role of the stabilizing agent is played by the parametric driver. Our analysis is based on the numerical continuation of solutions in one of the parameters of the Ginzburg-Landau equation (the diffusion coefficient c), starting from the nonlinear Schrödinger limit (for which c=0). The continuation generates, recursively, a sequence of coexisting stable solutions with increasing number of humps. The sequence "converges" to a long pulse which can be interpreted as a bound state of two fronts with opposite polarities.

Development and validation of the Diabetes Bowel Symptom Questionnaire

BACKGROUND

Although gastrointestinal symptoms occur frequently, there is no validated measure of gastrointestinal symptoms in patients with diabetes mellitus.

AIM

To develop the Diabetes Bowel Symptom Questionnaire.

METHODS

A questionnaire derived from previously validated symptom measures was compiled to assess all relevant gastrointestinal and diabetes items. Face and content validity were ascertained by expert review. One hundred and sixty-eight patients with diabetes mellitus completed the instrument, and reliability was evaluated by a test-re-test procedure 1 week later. Concurrent validity was evaluated by an independent physician interview (n = 33). Measures of glycaemic control (glycated haemoglobin and plasma glucose) were compared with self-reported glycaemic control on a five-point Likert scale in diabetic out-patients (n = 166).

RESULTS

The questionnaire had adequate face and content validity. There was good to excellent test-re-test reliability for the gastrointestinal and diabetes items (median kappa: 0.63 and 0.79, respectively); concurrent validity was good to excellent (median kappa: 0.47 and 0.65, respectively), except for the items assessing the severity of gastrointestinal symptoms. Both glycated haemoglobin (P < 0.0001) and plasma glucose (P = 0.005) correlated significantly with self-reported glycaemic control.

CONCLUSION

The Diabetes Bowel Symptom Questionnaire appears to be a useful measure of gastrointestinal symptoms and glycaemic control in diabetes mellitus, and should have applicability in epidemiological and clinical studies.

Discovering resources--making global connections, international networking

PURPOSE

To describe the key objectives, aims, activities and vision for the International Nurse Practitioner/Advanced Practice Nursing Network (INP/PNN).

DATA SOURCES

Selected publications and documents, personal experience, and commentary.

CONCLUSIONS

Advanced practice nursing and NP roles are prevalent in the United States and are now emerging in numerous countries throughout the world. There is a heightened interest among APNs and NPs internationally to share knowledge, expertise, and resources to enhance the presence of nursing in primary healthcare worldwide. The INP/APNN proposes to be an option for supporting the diversity of international networking in this field.

IMPLICATIONS FOR PRACTICE

Nurse practitioner and APN roles are emerging globally. Globalization and global health issues impact all health care practitioners. Collaboration, partnering, and networking have the potential of enhancing and advancing practice for both experienced practitioners and countries that are initiating APN roles.

Asthma inhalation delivery systems: the patient's viewpoint

International guidelines for asthma management state that inhalation is the preferred route of drug delivery. Consequently, it is important to select an appropriate delivery device and to take account of a patient's preference and lifestyle, as incorrect inhaler use may lead to treatment failure. A large number of devices are available from which to select, but it may be difficult for healthcare professionals to provide guidance to the patient unless they are familiar with the characteristics and correct use of each device. Many factors affect the success of a device in a patient's hands: the device's features; the patient's psychosocial status, cultural beliefs, and language skills; and consistent instruction on inhalation technique. Constant education is essential to establish and maintain the patient's confidence in the treatment regimen. It is important that at least one member of the respiratory healthcare team should remain abreast of medical and pharmaceutical developments in the respiratory field. In this way, the choice of delivery device can be reviewed and changed to suit the changing needs of the patient.

Atm knock-in mice harboring an in-frame deletion corresponding to the human ATM 7636del9 common mutation exhibit a variant phenotype

ATM, the gene mutated in the human immunodeficiency disorder ataxia-telangiectasia (A-T), plays a central role in recognizing ionizing radiation damage in DNA and in controlling several cell cycle checkpoints. We describe here a murine model in which a nine-nucleotide in-frame deletion has been introduced into the Atm gene by homologous recombination followed by removal of the selectable marker cassette by Cre-loxP site-specific, recombination-mediated excision. This mouse, Atm-DeltaSRI, was designed as a model of one of the most common deletion mutations (7636del9) found in A-T patients. The murine Atm deletion results in the loss of three amino acid residues (SRI; 2556-2558) but produces near full-length detectable Atm protein that lacks protein kinase activity. Radiosensitivity was observed in Atm-DeltaSRI mice, whereas the immunological profile of these mice showed greater heterogeneity of T-cell subsets than observed in Atm(-/-) mice. The life span of Atm-DeltaSRI mice was significantly longer than that of Atm(-/-) mice when maintained under nonspecific pathogen-free conditions. This can be accounted for by a lower incidence of thymic lymphomas in Atm-DeltaSRI mice up to 40 weeks, after which time the animals died of other causes. The thymic lymphomas in Atm-DeltaSRI mice were characterized by extensive apoptosis, which appears to be attributable to an increased number of cells expressing Fas ligand. A variety of other tumors including B-cell lymphomas, sarcomas, and carcinomas not seen in Atm(-/-) mice were observed in older Atm-DeltaSRI animals. Thus, expression of mutant protein in Atm-DeltaSRI knock-in mice gives rise to a discernibly different phenotype to Atm(-/-) mice, which may account for the heterogeneity seen in A-T patients with different mutations.

Reiswigins A and B, novel antiviral diterpenes from a deepwater sponge

The structures of reiswigins A(1) and B(2), new reduced azulene diterpene enones have been determined by combined one and two dimensional NMR and mass spectral techniques.

Confidentiality within physiotherapy: perceptions and attitudes of clinical practitioners

OBJECTIVES

This study examined the issue of confidentiality in relation to i) undergraduate curriculum content in physiotherapy, and ii) the awareness, experiences and attitudes of clinical physiotherapists.

DESIGN

Postal survey of universities and focus group interviews with physiotherapists.

SETTING

Twenty-five universities in the UK and Ireland and 44 therapists in five hospitals in southern England.

RESULTS

The survey of universities indicated that legal and ethical aspects of confidentiality featured in virtually all preregistration courses that responded. However, whereas its inclusion was rated as extremely important, the degree of coverage of confidentiality varied considerably between courses. Within the focus groups, 35 informants recollected coverage of confidentiality in their preregistration education, and 12 in postregistration in-service training; in neither case was this coverage in great detail. Informants identified environmental factors and working practices as barriers to preserving confidentiality. Disclosure to others also gave rise to difficulties. Informants were only aware in general terms of the relevant sections of the Chartered Society of Physiotherapy's Rules of Professional Conduct.

CONCLUSIONS

Aspects of hospital-based physiotherapy practice were seen to create specific problems in relation to confidentiality. More detailed sources of education and guidance on this issue appear to be required.

Seven-year follow-up of blood pressure in the Healthy Old People in Edinburgh (HOPE) cohort

The relationship between blood pressure and health in old age is complex and influenced by socio-economic factors. The Healthy Old People in Edinburgh cohort were initially disease-free and untreated, providing a sample in which directionality in this relationship could be examined. Subjects' health status, medication use and blood pressure was ascertained at baseline, after 4 years, and again after 7 years. Socio-demographic and socio-economic data were also collected. A total of 603 subjects were seen at baseline, 429 at 4 years and 301 at 7 years; complete blood pressure data were available for 294. Mean blood pressures were 157/85 mm Hg, 159/87 mm Hg and 162/86 mm Hg at baseline, 4 years and 7 years respectively. When subjects with diagnosed hypertension were excluded, the presence of disease (P = 0.009) and medication use (P = 0.047) at 7 years were associated with a relative reduction in blood pressure over time. For these subjects disease was predicted by deprivation index of residential area (OR 1.24, 95% CI 1.10-1.40 per Carstairs unit) and occupational group (OR 0.85, 95% CI 0.74-0.97 per major group). In this cohort disease, excluding hypertension itself, significantly attenuated the age-related rise in systolic blood pressure; the longer disease has been present the less the increase. In addition, socio-economic variables are important predictors of blood pressure change in those with disease. Deprivation index of residential area was a better predictor of disease than previous occupation in these subjects who had retired over a decade previously. Journal of Human Hypertension (2000) 14, 773-778