PSA recurrence following radical prostatectomy is comparable for all age groups in the UK

Increasing numbers of men are being diagnosed with prostate cancer and undergo operative curative treatment. It has been suggested that outcome after radical prostatectomy (RP) may vary for different age groups.

OBJECTIVE

To investigate whether PSA recurrence-free survival after RP is related to age at operation for a cohort of English men.

METHODS

A total of 854 patients notes from four Urology units were audited for preoperative staging parameters and follow-up data obtained. The relationship of PSA, age, biopsy Gleason grade, clinical stage, era and institution on PSA recurrence-free survival was competitively assessed with a multivariate model.

RESULTS

Only preoperative PSA (P<0.0001) and biopsy Gleason grade (P < 0.0001) were found to be strongly associated with PSA recurrence-free survival on multivariate analysis. PSA recurrence-free survival probabilities at 5 y for patients aged 45-55 y, 55.1-60 y, 60.1-65 y, 65.1-70 y and 70.1-75 y were 0.59 (CI 0.47-0.71), 0.74 (CI 0.64-0.784), 0.56 (CI 0.44-0.68), 0.61 (CI 0.53-0.69) and 0.60 (CI 0.46-0.74), respectively. No significant difference of PSA recurrence-free survival between any of the age groups was found (Log-rank, P = 0.8567).

CONCLUSION

No significant difference of pathological variables or biochemical recurrence across the age groups was found. The widely held belief of poorer outcome in younger men selected for RP does not seem to be borne out by this study.

Contemporary update of cancer control after radical prostatectomy in the UK

Despite a significant increase of the number of radical prostatectomies (RPs) to treat organ-confined prostate cancer, there is very limited documentation of its oncological outcome in the UK. Pathological stage distribution and changes of outcome have not been audited on a consistent basis. We present the results of a multicentre review of postoperative predictive variables and prostatic-specific antigen (PSA) recurrence after RP for clinically organ-confined disease. In all, 854 patient's notes were audited for staging parameters and follow-up data obtained. Patients with neoadjuvant and adjuvant treatment as well as patients with incomplete data and follow-up were excluded. Median follow-up was 52 months for the remaining 705 patients. The median PSA was 10 ng ml⁻¹. A large migration towards lower PSA and stage was seen. This translated into improved PSA survival rates. Overall Kaplan–Meier PSA recurrence-free survival probability at 1, 3, 5 and 8 years was 0.83, 0.69, 0.60 and 0.48, respectively. The 5-year PSA recurrence-free survival probability for PSA ranges <4, 4.1–10, 10.1–20 and >20 ng ml⁻¹ was 0.82, 0.73, 0.59 and 0.20, respectively (log rank, P<0.0001). PSA recurrence-free survival probabilities for pathological Gleason grade 2–4, 5 and 6, 7 and 8–10 at 5 years were 0.84, 0.66, 0.55 and 0.21, respectively (log rank, P<0.0001). Similarly, 5-year PSA recurrence-free survival probabilities for pathological stages T2a, T2b, T3a, T3b and T4 were 0.82, 0.78, 0.48, 0.23 and 0.12, respectively (log rank, P=0.0012). Oncological outcome after RP has improved over time in the UK. PSA recurrence-free survival estimates are less optimistic compared to quoted survival figures in the literature. Survival figures based on pathological stage and Gleason grade may serve to counsel patients postoperatively and to stratify patients better for adjuvant treatment.

Drug related critical incidents

Drug related incidents are a common form of reported medical errors. This paper reviews the critical incidents related to drug errors reported from the main operating theatre suite in a teaching hospital in a developing country from January 1997 to December 2002. Each report was evaluated individually by two reviewers using a structured process. During this period, 44 874 anaesthetics were administered; 768 critical incidents were reported, 165 (21%) of which were related to drug errors. Underdosage, side-effect/drug reaction and syringe swap were the most common. A total of 76% were classified as preventable; 56% due to human error and 19% due to system error. High risk incidents accounted for 10% of all drug errors and most of these were related to the use of neuromuscular blocking drugs. This analysis has been found useful in addressing some issues about priorities.

Case Selection for Radical Prostatectomy in the UK

INTRODUCTION

Radical prostatectomy is an increasingly popular treatment option for clinically localised prostate cancer, yet PSA outcome figures are rare in the UK. This makes it difficult to establish appropriate criteria for case selection. We conducted an audit of PSA recurrence of 5 large centres in the south of England and investigated the use of pre-operative PSA to improve case selection and outcome.

METHOD

854 patients notes were audited for pre-operative staging parameters and follow-up data obtained. Patients with neoadjuvant and adjuvant treatment as well as patients with incomplete data and follow-up were excluded.

RESULT

Median follow-up was 52 months for the remaining 663 patients. Median PSA was 10 ng/ml. A large improvement of PSA recurrence free survival rates was observed from 1988 to 1998 as a result of change in case selection and stage migration. Overall Kaplan-Meier PSA recurrence free survival probability at 1, 3, 5 and 8 years was 0.83, 0.69, 0.60 and 0.48, respectively. Five-year PSA recurrence free survival probability for PSA ranges <4 ng/ml, 4.1-10 ng/ml, 10.1-20 ng/ml and >20 ng/ml was 0.82, 0.73, 0.59 and 0.20, respectively (Wilcoxon, p < 0.0001). A simulation of biochemical recurrence free survival for patient cohorts with stepwise reduced inclusion PSAs suggests an improved outcome for patients with a pre-operative inclusion PSA of <12 ng/ml. Further reduction of the inclusion PSA does not improve outcome.

CONCLUSION

Intermediate PSA recurrence free survival has improved over time in England. PSA recurrence free survival estimates are less optimistic compared to frequently quoted American figures. A reduced pre-operative PSA cut-off for case selection may be used to improve outcome.

Low cost quality control human serum: method of preparation, validation of values and its comparison with the commercial control serum

OBJECTIVE

To prepare low-cost quality controls (QC) human serum and scientifically evaluate its advantages/disadvantages when compared with commercially available sera.

METHODS

The home made QC serum was prepared as per WHO recommended protocol from four healthy volunteers. It was screened for HIV, HCV and HBV, pooled together and stabilized with ethylene glycol. The initial 40 values were used for calculation of means, SDs and CVs for seventeen routinely measured analytes and results were compared with those of commercially available lyophilized human sera.

RESULTS

The average concentrations of seventeen commonly analyzed constituents were found to be near the middle of the physiological range of healthy subjects and the home made serum could be a good substitute for the commercial serum of normal range. The narrower CVs of the analytes imply a lesser vial to vial variation in the home made sera. Additional advantages include easy preparation, no need for reconstitution and lower cost.

CONCLUSION

Home made serum is a good substitute for the commercial serum of the normal range especially in developing countries like Pakistan.

Time trends in case selection, stage and prostate-specific antigen recurrence after radical prostatectomy: a multicentre audit

OBJECTIVES

To report an audit of preoperative staging variables, case selection, stage migration and prostate-specific antigen (PSA) recurrence at five large centres in the south of England. To establish PSA outcome values after radical prostatectomy for clinically localized prostate cancer in the UK, and enable appropriate patient counselling.

PATIENTS AND METHODS

The notes of 854 patients were audited for preoperative staging variables and follow-up data obtained. Patients with neoadjuvant and adjuvant treatment, and with incomplete data and follow-up, were excluded.

RESULTS

The median follow-up was 52 months for the remaining 663 patients; the median PSA level was 10 ng/mL. There was a large migration towards lower PSA and stage; this translated into improved PSA survival rates. The overall Kaplan-Meier PSA recurrence-free survival probability at 1, 3, 5 and 8 years was 0.83, 0.69, 0.60 and 0.48, respectively. The 5-year PSA recurrence-free survival probabilities for PSA levels of < 4, 4.1-10, 10.1-20 and > 20 ng/mL were 0.82, 0.73, 0.59 and 0.20, respectively (Wilcoxon, P < 0.001). The PSA recurrence-free survival probabilities for biopsy Gleason grade 2-4, 5 and 6, 7 and 8-10 at 5 years were 0.70, 0.61, 0.55 and 0.21, respectively (Wilcoxon, P < 0.001). Similarly, the 5-year PSA recurrence-free survival probabilities for clinical stages T1a and 1b, T1c, T2a and T2b were 0.79, 0.62, 0.57 and 0.44, respectively (Wilcoxon, P = 0.0012).

CONCLUSION

With better case selection the intermediate oncological outcome has improved over time in the UK. PSA recurrence-free survival estimates are less optimistic than the frequently quoted American values. The present values may be used to help in counselling British patients before radical prostatectomy.

Midazolam and thiopentone co-induction: looking for improvement in quality of anaesthesia

OBJECTIVE

To evaluate improvement in quality of anaesthesia induction using thiopentone and midazolam for co-induction of anaesthesia. An additional end point was taken as loss of response to a tetanic stimulation (50 Hz) delivered for 5 seconds after the loss of verbal contact and eyelash reflex.

METHODS

Ninety ASA I and II patients, within the age range of 20-60 years were studied. Patients were randomly divided into three equal groups; A, B and group C.

RESULTS

Onset of induction and loss of response to a tetanic stimulation was achieved earlier in group B as compared to the other study groups (p<0.05).

CONCLUSION

Co-induction with midazolam 0.02 mg x kg(-1) followed by thiopentone 3 mg x kg(-1) was superior to other two groups. Induction of anaesthesia in this group was found to be smoother and faster, provided better hemodynamic stability, better airway maintenance and with lesser incidence of untoward effects.

A comparison of morphine and nalbuphine for intraoperative and postoperative analgesia

INTRODUCTION

Short acting narcotics are not available in Pakistan and the supply of drugs like morphine and pethidine is short and erratic; therefore there is a need for investigating acceptable alternatives for analgesia, to be used for balanced anaesthesia.

OBJECTIVE

We studied the agonist-antagonist narcotic nalbuphine compared to morphine, for intra and postoperative pain relief in total abdominal hysterectomies.

METHODS

In a randomised double blind trial, fifty ASA I and II patients in two groups of twenty five each were given equianalgesic doses of morphine and nalbuphine. Hemodynamic stability, intraoperative analgesia, recovery profiles, incidence of side effects and need for postoperative supplements were compared using standard anaesthesia technique for induction, maintenance and reversal. Postoperative analgesia profile was studied by the need for supplements in twenty four hours using the unidimensional verbal category scale.

RESULTS

We found that patients in the morphine group showed a rise of mean blood pressure and heart rate to 20% above the baseline in response to intubation whereas in the nalbuphine group it remained within 20% of baseline. Twelve out of twenty five patients in the morphine group and four out of twenty five patients in the nalbuphine group needed intraoperative supplements. Recovery profiles were similar in the two groups; postoperative nausea and vomiting and need for postoperative supplements was significantly less in the nalbuphine group.

CONCLUSION

We conclude that nalbuphine provides better haemodynamic stability and better analgesia, recovery profile and postoperative pain relief compared to morphine in patients undergoing total abdominal hysterectomy.

Sonographic prevalence of acquired cystic renal disease in patients receiving haemodialysis

OBJECTIVE

To determine the sonographic prevalence of Acquired Cystic Renal Disease (ACRD) in patients on maintenance haemodialysis and its relationship to the duration on dialysis.

METHODS

All patients with end stage renal disease (ESRD) who were receiving maintenance haemodialysis in Urology Department of Mayo Hospital Lahore between November 1997 to February 1998 were screened by ultrasound for the prevalence of ACRD.

RESULTS

Forty patients with ESRD on maintenance haemodialysis were evaluated. The mean age of patients was 39.9 years. The male to female ratio was 2.3:1. Four patients (10%) had documented ACRD. The proportion of patients with ACRD increased with increasing duration of dialysis; ACRD was found in 60% of patients who had dialysis for more than 3 years, 20% in those who had been dialyzed for 1-3 years, and no patient developed ACRD who was on dialysis for less than one year. All patients remained asymptomatic except one, who had intermittent macroscopic haematuria. There was no evidence of neoplasm in any of these patients on clinical grounds or on ultrasound.

CONCLUSION

We found a low prevalence of ACRD in the population studied compared to previously published series. This can be explained by the fact that most of our patients were on dialysis for less than one year. A further study is suggested with greater numbers in a center where patient stay on dialysis for longer period and patient turnover is low.

Comparison of fentanyl and nalbuphine in total intravenous anaesthesia (TIVA)

OBJECTIVE

To compare Nalbuphine and fentanyl as total intravenous anaesthesia with propofol infusion in laproscopic cholecystectomy cases.

STUDY DESIGN

Double blind randomised.

METHODS

Changes in haemodynamic variables greater than twenty percent above or below the baseline and recovery profile were observed.

RESULTS

Blood pressure remained within 20% of baseline in either group. Nine patients in fentanyl and fifteen in nalbuphine group required an additional bolus of propofol intraoperatively. Heart rate response after tracheal intubation was significantly higher in the nalbuphine group (25%). No difference was observed in the incidence of nausea and vomiting in the recovery room. Twenty-seven percent patients in the nalbuphine group required analgesia in the recovery in comparison to 87% in the fentanyl group. Patients in the fentanyl group required analgesia earlier (37 minutes vs. 62 minutes).

CONCLUSION

Fentanyl provided better intraoperative haemodynamic stability in comparison to nalbuphine when used as the analgesic component in total intravenous anaesthesia with propofol. The recovery profile with both drugs was similar. Lesser number of patients required analgesia in the recovery in the nalbuphine group.

Effect of age on haemodynamic response to tracheal intubation. A comparison of young, middle-aged and elderly patients

The effect of age on the haemodynamic response to tracheal intubation was studied. Ninety ASA 1 or 2 patients were divided into three groups of 30 each based on age; ie., young (18-25 years), middle-aged (40-50 years) and elderly (65-80 years). The haemodynamic response after tracheal intubation was observed as percentage change in heart rate and blood pressure compared to the baseline. Inter-group comparison was also done at different time points. The greatest percentage change in the systolic arterial pressure after tracheal tube insertion was seen in the elderly group (15%). The increase in systolic arterial pressure was significantly less in theyounggroup compared with the two older groups at one, two, three and four minutes post-intubation. The greatest percentage increase in the diastolic blood pressure compared to the baseline was seen in the middle aged group (24%). The elderly and young patients showed a significant difference in the diastolic blood pressure response only at one minute post-intubation. The heart rate response was greatest in the middle-aged patients (40%) and least in the elderly (16%). These differences may have clinical significance and should be considered in assessing and performing research into the haemodynamic response to intubation.

Calcium-activated K+ channels of mouse beta-cells are controlled by both store and cytoplasmic Ca2+: experimental and theoretical studies

A novel calcium-dependent potassium current (K(slow)) that slowly activates in response to a simulated islet burst was identified recently in mouse pancreatic beta-cells (Göpel, S.O., T. Kanno, S. Barg, L. Eliasson, J. Galvanovskis, E. Renström, and P. Rorsman. 1999. J. Gen. Physiol. 114:759-769). K(slow) activation may help terminate the cyclic bursts of Ca(2+)-dependent action potentials that drive Ca(2+) influx and insulin secretion in beta-cells. Here, we report that when [Ca(2+)](i) handling was disrupted by blocking Ca(2+) uptake into the ER with two separate agents reported to block the sarco/endoplasmic calcium ATPase (SERCA), thapsigargin (1-5 microM) or insulin (200 nM), K(slow) was transiently potentiated and then inhibited. K(slow) amplitude could also be inhibited by increasing extracellular glucose concentration from 5 to 10 mM. The biphasic modulation of K(slow) by SERCA blockers could not be explained by a minimal mathematical model in which [Ca(2+)](i) is divided between two compartments, the cytosol and the ER, and K(slow) activation mirrors changes in cytosolic calcium induced by the burst protocol. However, the experimental findings were reproduced by a model in which K(slow) activation is mediated by a localized pool of [Ca(2+)] in a subspace located between the ER and the plasma membrane. In this model, the subspace [Ca(2+)] follows changes in cytosolic [Ca(2+)] but with a gradient that reflects Ca(2+) efflux from the ER. Slow modulation of this gradient as the ER empties and fills may enhance the role of K(slow) and [Ca(2+)] handling in influencing beta-cell electrical activity and insulin secretion.

Ciliary dyskinesia associated with hydrocephalus and mental retardation in a Jordanian family

OBJECTIVE

To describe the presentation and genetic transmission of ciliary dyskinesia syndrome associated with hydrocephalus and mental retardation in 3 generations of a family.

PATIENTS AND METHODS

A large Jordanian family included 9 individuals in 3 generations with recurrent pulmonary infections; 4 male siblings have been diagnosed as having mental retardation, and a maternal uncle was believed to have been similarly affected. Chromosome analysis of the family showed a normal karyotype.

RESULTS

Electron microscopy of the nasal cilia from 3 affected siblings showed features of primary ciliary dyskinesia. Computed tomographic scans of the brains of all 4 affected siblings showed hydrocephalus.

CONCLUSIONS

The recurrent pulmonary infections and hydrocephalus in this large Jordanian family are likely related to ciliary dyskinesia, which appears to follow an autosomal recessive mode of inheritance. The unusual presentation of ciliary dyskinesia, hydrocephalus, and mental retardation may be due to a new genetic mutation.

Insulin activates ATP-sensitive K(+) channels in pancreatic beta-cells through a phosphatidylinositol 3-kinase-dependent pathway

Insulin is known to regulate pancreatic beta-cell function through the activation of cell surface insulin receptors, phosphorylation of insulin receptor substrate (IRS)-1 and -2, and activation of phosphatidylinositol (PI) 3-kinase. However, an acute effect of insulin in modulating beta-cell electrical activity and its underlying ionic currents has not been reported. Using the perforated patch clamp technique, we found that insulin (1-600 nmol/l) but not IGF-1 (100 nmol/l) reversibly hyperpolarized single mouse beta-cells and inhibited their electrical activity. The dose-response relationship for insulin yielded a maximal change (mean +/- SE) in membrane potential of -13.6 +/- 2.0 mV (P < 0.001) and a 50% effective dose of 25.9 +/- 0.1 nmol/l (n = 63). Exposing patched beta-cells within intact islets to 200 nmol/l insulin produced similar results, hyperpolarizing islets from -47.7 +/- 3.3 to -65.6 +/- 3.7 mV (P < 0.0001, n = 11). In single cells, insulin-induced hyperpolarization was associated with a threefold increase in whole-cell conductance from 0.6 +/- 0.1 to 1.7 +/- 0.2 nS (P < 0.001, n = 10) and a shift in the current reversal potential from -25.7 +/- 2.5 to -63.7 +/- 1.0 mV (P < 0.001 vs. control, n = 9; calculated K(+) equilibrium potential = -90 mV). The effects of insulin were reversed by tolbutamide, which decreased cell conductance to 0.5 +/- 0.1 nS and shifted the current reversal potential to -25.2 +/- 2.3 mV. Insulin-induced beta-cell hyperpolarization was sufficient to abolish intracellular calcium concentration ([Ca(2+)](i)) oscillations measured in pancreatic islets exposed to 10 mmol/l glucose. The application of 100 nmol/l wortmannin to inactivate PI 3-kinase, a key enzyme in insulin signaling, was found to reverse the effects of 100 nmol/l insulin. In cell-attached patches, single ATP-sensitive K(+) (K(ATP)) channels were activated by bath-applied insulin and subsequently inhibited by wortmannin. Our data thus demonstrate that insulin activates the K(ATP) channels of single mouse pancreatic beta-cells and islets, resulting in membrane hyperpolarization, an inhibition of electrical activity, and the abolition of [Ca(2+)](i) oscillations. We thus propose that locally released insulin might serve as a negative feedback signal within the islet under physiological conditions.

A comparison of OHIP 14 and OIDP as interviews and questionnaires

OBJECTIVE

To assess the completion rates and concurrent validity of the Oral Impacts on Daily Performance (OIDP) and the short form of the Oral Health Impact Profile (OHIP 14) in both questionnaire and interview formats.

BASIC RESEARCH DESIGN

Cross sectional social and clinical study. Clinical setting Dental teaching hospital primary care department in London UK. Participants Two week consecutive sample of 183 patients attending setting.

PARTICIPANTS

came from 19 ethnic groups, 53% were men and 32% had attended for a dental emergency.

MAIN OUTCOME MEASURES

Completion rates and concurrent validity for each instrument and in each format.

RESULTS

Completion rates for OHIP 14 and OIDP were similar in interview format. In questionnaire format usable data were provided on 92.9% of the OHIP 14 but only 86.5% of the OIDP questionnaires. Completion of both questionnaires was related to ethnicity. The number of impacts for both measures and total impact scores for OHIP 14 were related to the age of the participants, the presence of oral disease and the order of administration of the instruments. Analysis of the total score for OIDP was weakened by the severe skewness of these data.

CONCLUSIONS

The psychometric properties of OHIP 14 and OIDP were not related to the method of administration. However, the use of OIDP in this questionnaire format may result in loss of data, particularly from people who are not White English.

Neonatal lead poisoning from maternal pica behavior during pregnancy

Lead toxicity has gained increasing attention in the public media because of its ubiquitous distribution in the environment and the potentially serious medical complications that it can induce, particularly in children. We present a case of an asymptomatic Hispanic woman who exhibited a unique form of pica during her pregnancy. By serendipity, she agreed to enroll into a lead screening study at our medical center when she presented to deliver her child. Her blood lead level was 119.4 microg/dL at delivery, and simultaneous measurement of the neonate's cord blood lead level was 113.6 microg/dL. The infant underwent an exchange transfusion, and the mother was treated with oral 2,3-dimercaptosuccinic acid. Both demonstrated dramatic biochemical improvement.

Patella lead x-ray fluorescence measurements are independent of sample orientation

In vivo x-ray fluorescence bone lead measurements assess long-term lead exposure. Tibia, calcaneus, and patella are the most commonly sampled bones. Patella measurements also include lead signals from the distal femur, proximal tibia, and synovium. It is therefore important to know whether the orientation of the patella relative to the measurement system substantially affects the measured patella lead concentrations and their measurement uncertainties. This study examined whether these parameters exhibited a dependence on the orientation of the patella with respect to the measurement system, a dependence that could arise from varying nonpatella contributions. There was no effect of orientation on measured patella lead concentration, but there was a highly significant effect of orientation on the measurement uncertainty. These data do not conclusively show that there are no nonpatella contributions to a patella lead measurement; rather, that any such contributions are not a function of measurement orientation over the range of orientations considered. Further study is required if the contribution of nonpatella tissues to a patella lead XRF-measured concentration is to be fully addressed. This study also filled a gap in the literature by quantifying the within-patella (29%) and between-patella (71%) variability of measured patella lead concentrations from replicate measures of nine patellae.

Anthelmintic resistance on an organized sheep farm in India

Monitoring anthelmintic resistance in strongyle nematodes by the faecal egg count reduction test and a commercial larval development assay on an organized sheep farm in the semi-arid area of Rajasthan revealed the emergence of resistance to benzimidazoles and rafoxanide and a potential risk of the development of levamisole/tetramisole resistance. A benzimidazole/levamisole combination, avermectins and closantel were each found to be efficacious.

Comparison of spontaneous with controlled mode of ventilation in tonsillectomy

METHODS

This randomized study compares spontaneous versus controlled ventilation in 60 ASA I and II patients undergoing tonsillectomy as regards haemodynamic stability, recovery characteristics, intra- and immediate postoperative complications and surgical impressions.

RESULTS

The patients in the balanced anaesthesia (B) group showed less haemodynamic variability compared to baseline after tracheal intubation, mouth gag application and removal and incision. Two patients had dysrhythmias in the B group compared to six in the spontaneous breathing (S) group. Six patients in the S group had a rise in endtidal carbon dioxide concentration above 7.8 kPa (60 mmHg). Recovery scores were higher in the B group at 10 and 20 min into recovery. The surgical impression of bleeding and jaw relaxation was similar with both groups. The incidence of postoperative nausea and vomiting and agitation was higher in the S group but did not achieve statistical significance.

CONCLUSION

Use of balanced anaesthesia offered more haemodynamic stability and a rapid recovery.

A prospective survey of intra-operative critical incidents in a teaching hospital in a developing country

Critical incident monitoring has the advantage of identifying a potential risk to the patient without it necessarily resulting in morbidity. An added advantage in developing countries is the low cost involved in introducing the programme. This paper analyses the incidents reported from the operating room suite in a teaching hospital in a developing country from August 1997 to 31 December 1999. During the period, 20 819 anaesthetics were administered and 329 incidents were reported (1.58% of the cases). Seventy-three per cent of the incidents were reported in patients of ASA grade 1 or 2. Thirty-nine per cent occurred during induction, 51% during maintenance and 10% during emergence. Human error was the cause in 41%, equipment error in 50% and system error in 8.5%. Twenty-two per cent of the incidents resulted in minor, and 13% in major physiological disturbance. The technique has been found useful in identifying trends and selecting issues to be discussed in departmental quality assurance meetings, but requires persistent motivation of the reporting staff.

The effect of measurement location on tibia lead XRF measurement results and uncertainty

The aims of this study were to determine whether the location on the tibia measured by 109Cd-based K-shell x-ray fluorescence (XRF) affected the measurement result and its uncertainty, and whether higher tibia lead levels at the extremities of the tibia and/or inhomogeneity in the distribution of lead in the tibia could be inferred therefrom. Replicate XRF measurements were performed at multiple locations on ten adult cadaver intact legs and on nine bare tibiae dissected from them. Mean lead levels in the bare tibiae ranged from 16 to 48 microg Pb per g of bone mineral. Bare tibia measurements showed that both the XRF result and its uncertainty increased towards the proximal and distal ends of the tibia. The XRF result decreased away from the medial-lateral mid-point of the tibia, but XRF uncertainty was not significantly affected. Intact leg measurements showed no effect of proximal distal location on XRF result but did show an effect on XRF uncertainty. We conclude that the XRF method used can determine the differences in bone lead level resulting from the more trabecular composition at the ends of the tibia, and we present limited evidence for localized regions of low tibia lead level.

En bloc heterotopic auxiliary liver and bilateral renal transplant in a patient with homozygous protein C deficiency

An 8-year-old girl with homozygous protein C deficiency who had undergone maintenance dialysis since birth because of renal veins with thrombosis was treated with an en bloc heterotopic auxiliary liver and bilateral renal transplantation. The reconstitution of protein C activity by auxiliary liver transplantation facilitated successful renal transplantation.

Provision of dental care for medically compromised children in the UK by General Dental Practitioners

The aim of this study was to investigate the views of General Dental Practitioners (GDPs) regarding their provision of dental treatment for medically compromised children. A questionnaire to assess confidence, experience and willingness to treat eight specific groups of medically compromised children was sent to 524 GDPs. Information is based on 271 completed questionnaires. The median number of children treated by GDPs in each of the eight groups over the previous 5 years was 0-2. Eighty percent of respondents stated that they would value further training in the provision of dental care for medically compromised children. Confidence was highest in providing dental treatment for children with three conditions: congenital heart disease (37% very confident), diabetes (39% very confident) and epilepsy (41% very confident). These were also the conditions that the GDPs reported as presenting most frequently in the dental surgery. GDPs reported least confidence in providing dental care for children with haemophilia (12% very confident) and organ transplants (14% very confident). Only 30% of GDPs wanted to be routinely involved with the provision of dental care for medically compromised children. The results indicate that medically compromised children may have problems accessing dental care and expertise. A system of integrated medical and specialised dental care is suggested.