Critique of a protocol for annual review of older people with diabetes

In this article we present a critical evaluation of the development of a protocol to support district nurses in the domiciliary annual review of older people with diabetes. We discuss the protocol's development, identifying its limitations and making recommendations for its use. We conclude that although the protocol is a useful starting point its validity is challenged by a lack of primary research regarding the care of older people with diabetes. More work is needed to identify appropriate remedial therapy following the annual review. The health education component also requires development to better reflect the different needs of older people.

Intravenous polymethyl methacrylate after cemented hemiarthroplasty of the hip

Current cementing techniques used during hip arthroplasty aim to maximize the bond at the bone-cement interface in an effort to increase the longevity of the prosthesis. To accomplish this, one must generate high intramedullary pressures, which are known to be associated with complications such as cement implantation syndrome. We record a rare complication following cement pressurization of a hip hemiarthroplasty that resulted in intravenous polymethyl methacrylate (PMMA). This complication however, is not associated with a significant morbidity or mortality, but it is important to identify and distinguish from a femoral cortical defect, which can be created during surgery.

Interleukin 21 and its receptor are involved in NK cell expansion and regulation of lymphocyte function

Cytokines are important in the regulation of haematopoiesis and immune responses, and can influence lymphocyte development. Here we have identified a class I cytokine receptor that is selectively expressed in lymphoid tissues and is capable of signal transduction. The full-length receptor was expressed in BaF3 cells, which created a functional assay for ligand detection and cloning. Conditioned media from activated human CD3+ T cells supported proliferation of the assay cell line. We constructed a complementary DNA expression library from activated human CD3+ T cells, and identified a cytokine with a four-helix-bundle structure using functional cloning. This cytokine is most closely related to IL2 and IL15, and has been designated IL21 with the receptor designated IL21 R. In vitro assays suggest that IL21 has a role in the proliferation and maturation of natural killer (NK) cell populations from bone marrow, in the proliferation of mature B-cell populations co-stimulated with anti-CD40, and in the proliferation of T cells co-stimulated with anti-CD3.

The successful use of regional anesthesia to prevent involuntary movements in a patient undergoing awake craniotomy

IMPLICATIONS

The authors demonstrate that the combination of single and continuous peripheral nerve blocks allows the control of involuntary movements in patients undergoing awake craniotomy.

A model of stress-induced geometrical remodeling of vessel segments adjacent to stents and artery/graft anastomoses

The mismatch between the elastic properties and initial geometry of a host artery and an implanted stent or graft cause significant stress concentration at the zones close to junctions. This may contribute to the often observed intimal hyperplasia, resulting in late lumen loss and eventual restenosis. This study proposes a mathematical model for stress-induced thickening of the arterial wall at the zones close to an implanted stent or graft. The host artery was considered initially as a cylindrical shell with constant thickness that was clamped to the stent or graft, which was assumed to be non-deformable in the circumferential direction. It was assumed that the abnormal circumferential and axial stresses due to the bending of the arterial wall cause wall thickening that tends to restore the stress state close to that existing far from the junction. The linear equations of a cylindrical shell with variable thickness were coupled to an evolution equation for the wall thickness. These equations were solved numerically and a parametric study was performed using finite difference method and explicit time step. The results show that the remodeling process is self-limiting and leads to local thickening that gradually decreases with distance from the edge of the stent/graft. Model predictions were tested against morphological findings existing in the literature. Recommendations on stent designs that reduce stress concentrations are discussed.

An insurer's perspective on reform

Individual health insurance markets differ from state to state, and as a result approaches to individual market reforms need to be different. In evaluating approaches, policy makers need to remember that since the decision to purchase health insurance coverage is voluntary, the potential for adverse selection exists. In addition, rather than putting the focus of individual market reforms almost exclusively on access to health insurance for a small number of persons with high-cost health conditions, more attention needs to be put on how to decrease the number of uninsured persons. This includes making the premiums paid for individual health insurance 100 percent tax deductible, similar to those of employer-based health insurance. Finally, market reforms need to treat all types of coverage issued in the individual market the same, whether they are purchased direct for the insurer or through an out-of-state association.

Adding high-dose tamoxifen to CHOP does not influence response or survival in aggressive non-Hodgkin's lymphoma: an interim analysis of a randomized phase III trial

PURPOSE

CHOP is the standard regimen currently used in the management of the majority of patients with aggressive non-Hodgkin's lymphoma (NHL). However, CHOP only produces 30-35% long-term survival. We hypothesized that adding high-dose tamoxifen, which is known to have multiple drug resistance-modulatory effects, to the CHOP regimen could increase the response rate, and consequently enhance the survival of patients with NHL.

PATIENTS AND METHODS

In a prospective, controlled, and randomized study, eligible adult patients with aggressive NHL were randomized between CHOP only (Group I), or CHOP plus high-dose tamoxifen (Group II). The primary aim was to assess the effect of tamoxifen on complete response (CR) rate, with the secondary evaluation of tamoxifen potential impact on survival. The interim analysis of this study is presented.

RESULTS

Fifty-one and forty-seven evaluable patients were randomized to Group I and Group II, respectively. The median age of all patients was 53 y (range 18-78 y). The two groups had comparable distributions of the pretreatment prognostic variables. The CR for patients in Group I was 80% (41 patients) as compared with 74% (35 patients) in Group II (P=0.48). Likewise, there was no apparent difference in the partial remission rates between the two groups (6% vs 15%, respectively). Of patients who initially attained CR, 15 (37%) and 10 (29%) subsequently relapsed in Groups II and I respectively (P = 0.45). The NHL International Prognostic Index (IPI) was the only factor that predicted attaining CR. At the time of this interim analysis, the actuarial-estimated overall survival (OS) probability (+/-S.E.) for the entire population at 5 y was 58% (+/-6) with no survival difference between the two groups (P=0.51). Only attaining CR and the IPI predicted OS probability. The probability of remaining event-free at 5 y (+/-SE) for those achieving CR was 72% (+/-9), and there was no significant difference between the two treatment groups (P=0.68). Toxicity profile was similar in the two groups.

CONCLUSION

Based on this interim analysis, combining high-dose tamoxifen, as used in this study, with the CHOP regimen has failed to have any favorable effect on the outcome of patients with aggressive NHL, and therefore cannot be recommended for future trials.

Optimization of oral etoposide dosage in elderly patients with non-Hodgkin's lymphoma using the fraction of dose absorbed measured for each patient

This study was undertaken to investigate the pharmacokinetics of etoposide for optimizing its oral dosage in elderly patients with non-Hodgkin's lymphoma (NHL) using the fraction of dose absorbed calculated from the data generated from first oral and intravenous doses in the same patient. Twenty-three NHL patients (ages 61-95 years) entered this study. Each received 50 mg/m2 of etoposide by 1-hour i.v. infusion, which was repeated every 24 hours for 5 days. The second cycle commenced on day 21, with etoposide being administered by mouth at a dose as close to 50 mg/m2 as possible. Serial blood samples were collected and analyzed for etoposide by HPLC. The fraction of dose absorbed (F) was calculated as F = (AUCor/AUCi.v.) (Di.v./Dor), and etoposide was then given orally for the following 20 days at a daily dose equivalent to Dor/F. After 1 week free of etoposide administration, a second cycle of oral etoposide at the adjusted dose was given for 21 days. The mean +/- SD values for t1/2 beta, tmax, Cmax, CLTor, and MRT observed following the first oral dose were 8.98 +/- 4.84 h, 1.39 +/- 0.96 h, 0.083 +/- 0.046 mg.L-1/mg.m-2, 1.89 +/- 1.2 L.h-1/m2, and 10.37 +/- 2.76 h, respectively, and those observed following the first intravenous dose were 8.05 +/- 5.11 h, 1.57 +/- 0.17 h, 0.142 +/- 0.043 mg.L-1/mg.m-2, 1.25 +/- 0.44 L.h-1/m2, and 7.69 +/- 1.53 h, respectively. The mean +/- SD of F was 0.80 +/- 0.34. The data obtained indicate that optimization of etoposide oral dosage using F yielded good clinical results while keeping the morbidity at a level that is similar to that of the i.v. administration.

Improving substance abuse treatment for indigent clients in Detroit

It has been clearly established that substance abuse treatment works (De Leon 1988). Thus, activities which increase the proportion of indigent clients in Detroit who actually get into treatment and activities which help indigent clients stay in treatment are likely to significantly improve treatment outcomes. The Target Cities projects in general and the Detroit Target Cities project in particular represent some of the few efforts currently underway to determine intervention activities which significantly improve treatment outcomes for indigent substance abusing clients. Subsequent evaluation has shown that the proportion of clients referred by the CDRS who were actually admitted into a treatment program increased significantly after full implementation of the Detroit Target Cities screening and pretreatment case management activities. Furthermore, the average time between referral by the CDRS and admission into a treatment program decreased significantly (Tucker 1997). Evaluation of the Detroit Target Cities jail-based substance abuse treatment program also showed a significant increase in the proportion of clients who remained drug free after full implementation of the program (Tucker 1998).

Elevated expression of FGF-2 does not cause prostate cancer progression in LNCaP cells

BACKGROUND

Androgen-independent (AI) prostate cancer (CaP) resulting from progression of disease is untreatable. Such progression may relate to upregulation and autocrinicity of growth factor expression. We studied one candidate growth factor, basic fibroblast growth factor (FGF-2).

METHODS

LNCaP cells made autocrine for FGF-2 by stable transfection with FGF-2 were examined for cancer progression, measured by 1) altered response to androgen, 2) ability to grow more quickly when cocultured with bone cells in vitro or to form tumors when coinoculated with bone cells in vivo, or 3) increase in metastatic ability.

RESULTS

Stably transfected lines differed in FGF-2 protein expression. LNCaP-HF (high production of FGF-2) expressed more FGF-2 than LNCaP-LF (low production of FGF-2); controls were negative. In vitro, compared with LNCaPs, LNCaP-HF cells showed a slightly increased growth rate, reduced proliferation in response to androgen but not to estrogen or progesterone, and a decreased proliferative response to epidermal growth factor (EGF) and FGF-2. Although giving a slightly faster take rate, LNCaP-HF cells without Matrigel only formed small, fast-regressing tumors in male nude mice, and with Matrigel, did not differ from LNCaPs in growth rate or tumor size. No metastases occurred. No tumors grew in females. Mixed growth of FGF-2 transfectants with human fetal osteoblasts failed to cross-stimulate in vitro, or to allow tumor formation in vivo.

CONCLUSIONS

Although FGF-2 is overexpressed in AI CaPs, our experiments show that upregulation of FGF-2 expression is not sufficient to cause androgen independence, tumorigenicity, or metastases production (i.e., prostate cancer progression) in LNCaP cells.

Effect of injected versus iontophoretic corticosteroid on the rabbit tendon

BACKGROUND

The etiologic role of corticosteroid therapy in tendon rupture is controversial. This study compared the effects of injected versus iontophoretically delivered corticosteroid on the normal rabbit Achilles tendon.

METHODS

Rabbits were divided into three treatment groups: (1) corticosteroid injections, (2) iontophoretically delivered corticosteroid, and (3) no treatment. One tendon of each rabbit in the treatment groups was treated with either drug injection or iontophoresis; the tendon of the other leg served as a control. Some tendons were used for testing elastic modulus, ultimate load, and ultimate stress, while the remaining tendons were evaluated histologically.

RESULTS

Injections of either corticosteroid or saline into the tendon sheath resulted in short-term changes in tendon biomechanical characteristics and somewhat higher histologic severity scores; however, iontophoretic delivery of corticosteroid or saline did not affect either significantly.

CONCLUSIONS

Iontophoresis using sterile water or corticosteroid resulted in minimal or no biochemical and histologic changes in the tendon compared with injection of either substance. The method of corticosteroid delivery may be as important as the actual drug effects on the biomechanical and histologic properties of tendons.

Discontinuous incremental threshold loading test: measure of respiratory muscle endurance in patients with COPD

STUDY OBJECTIVE

To assess the discontinuous incremental threshold loading (DC-ITL) test as a measure of respiratory muscle endurance for patients with COPD in terms of perceived breathing difficulty, reliability, and validity.

DESIGN

The DC-ITL test was repeated three times at weekly intervals under identical test conditions.

SETTING

Clinical research laboratory.

PATIENTS

Forty-eight patients with moderate to severe COPD.

MEASUREMENTS AND RESULTS

Rating of perceived breathing difficulty (RPBD) was measured at the end of each stage of the DC-ITL test with a Borg category-ratio scale. The maximal inspiratory pressure (PImax) was measured before and after the DC-ITL test. Breathing patterns were measured during the DC-ITL test. The mean (+/-SD) for RPBD at the maximal load was 6.3 (3.1), 6.6 (2.8), and 6.7 (2.7) for visits one, two, and three, respectively (not significant). The mean relative maximal load for the DC-ITL test (peak mouth pressure as a percent of PImax) at the last completed stage was 59+/-23%, 62+/-20%, and 63+/-19% for visits one, two, and three, respectively (not significant). Test-retest reliability was r1,2=0.82 and r2,3=0.69 for relative maximal load and r1,2=0.90 and r2,3=0.90 for absolute maximal load (peak mouth pressure). Tidal volume decreased (p < 0.01) and respiratory rate increased (p < 0.01) from the next-to-the-last to the last completed stage. PImax decreased after the DC-ITL test (p < 0.01).

CONCLUSIONS

Moderate breathing difficulty was experienced during the DC-ITL test. The test was reliable and the results of this study support its validity as a measure of respiratory muscle endurance.

Error estimates in novice and expert raters for the KT-1000 arthrometer

STUDY DESIGN

Single group repeated measures with multiple raters.

OBJECTIVES

To determine the inter-rater reliability of KT-1000 measurements of novice and experienced raters and to provide error estimates for these raters.

BACKGROUND

The KT-1000 arthrometer is often used clinically to quantify anterior tibial displacement. Few data have been documented, however, about the relative reliability of KT-1000 measurements obtained by novice compared with experienced users.

METHODS AND MEASURES

Two novice and two experienced KT-1000 users performed measurements on 29 knees of 25 patients after anterior cruciate ligament (ACL) reconstruction or with a diagnosis of ACL deficiency. Measurements were performed at 131 N. Interrater and intertrial reliability coefficients (interclass correlation coefficient; ICC) and the standard error of measurement were calculated for expert and novice raters.

RESULTS

The interrater ICC for novices was 0.65 and the interrate error was +/- 3.52 mm (90% confidence interval [CI]). The interrater ICC for experts was 0.79 and the interrater error was +/- 2.94 mm (90% CI).

CONCLUSIONS

These results suggest that experience in using the KT-1000 is related to the interrater error of measurements and that training is an important consideration when using the KT-1000 arthrometer.

A new technique for sizing of atrial septal defects

This article evaluates a new compliant balloon catheter for sizing of Atrial Septal Defects (ASDs) in vitro and in vivo using X-ray and echo measurements. A phantom consisting of a plastic plate with 17 circular holes varying from 8 to 30 mm was used to determine the accuracy of the measurements. The catheter has a 7 Fr shaft with a double lumen. The balloon is made from a 0.002" plastic membrane. Four platinum marker bands on the shaft of the catheter allow radiographic measurements. The balloon catheter was placed through various holes of the phantom and inflated with 38% contrast medium. X-ray measurement by video and cine recording were performed and compared with the true measurement of the model. The study was carried out in a double blind fashion. For echo measurements, the plastic model was immersed in a water bath. The balloon was inflated with water and measured in a long-axis view. The actual diameters were compared with the measurements obtained by video, cine, and echo recordings. One young pig with a surgically created ASD was used for in vivo measurement. The balloon catheter was passed through the ASD over an exchange wire, inflated with diluted contrast medium until a waist was observed, which was measured by video and cine techniques. The animal was euthanized, and the defect was measured by a tapered measuring probe. The difference between the actual size and measurements obtained by video recordings was 0.54 +/- 0.30 mm, by cine 0.62 +/- 0.20 mm, and by echo measurements 0.60 +/- 0.43 mm. All measurements were less than 1 mm in error except for four measurements (<1.5 mm). A strong correlation was present between each two groups (r = 0.99, P < 0.0001). In the in vivo study, the size of the video and cine recordings (14.2 and 13.9 mm, respectively) were very closer to the actual size (14 mm) as measured by a probe in the postmortem specimen. The new balloon catheter provides a more rapid and precise determination of the stretched diameter of atrial septal defects. It eliminates the error of pulling a catheter through the communication. This new technique should be of benefit to all investigators using septal occlusion devices and will facilitate the selection of the properly sized Amplatzer septal occluder.

Confirmation of FWT1 as a Wilms' tumour susceptibility gene and phenotypic characteristics of Wilms' tumour attributable to FWT1

A susceptibility gene for Wilms' tumour (WT), designated FWT1, was previously mapped to chromosome 17q12-q21 by linkage analysis of a single family. We now confirm the existence of this gene by analysis of additional cases in the original family (3-point LOD score=5.69), and by detecting strong evidence of linkage to this region in an unrelated pedigree with seven cases of WT (3-point LOD score=2.56). Analysis of 11 smaller WT families confirms that there is genetic heterogeneity in familial WT, as three families exhibit strong evidence against linkage to FWT1. One of these was subsequently found to have a predisposing WT1 mutation. However, the other two families show evidence against both FWT1 and WT1, suggesting that at least one further familial WT gene exists. Analysis of the phenotype of 16 WT cases from the families linked to FWT1 demonstrates that they present at a significantly older age and a significantly later stage than both sporadic WT and the six cases from two families unlinked to either FWT1 or WT1. The results confirm the role of FWT1 in susceptibility to WT, provide strong evidence for genetic heterogeneity in familial WT and suggest there are phenotypic differences between familial WT due to FWT1, familial WT due to other genes and non-familial WT.