Accuracy of thin section magnetic resonance using phased-array pelvic coil in predicting the T-staging of rectal cancer

Magnetic resonance (MR) imaging may contribute to staging rectal cancer and inform the decision regarding administration of pre-operative radiotherapy. The accuracy of MR has been debated. The aim of the present study was to determine the accuracy of thin section T2-weighted MR images in rectal cancer patients. MR results were compared with histological assessment of resection specimens. Over a 2-year period, 42 patients were studied. Histological staging was pT2 n = 13, pT3 n = 25 and pT4 n = 4. MR diagnostic accuracy was 74%. MR sensitivity and specificity was 62% and 79% for pT2 lesions, 84% and 59% for pT3 lesions and 50% and 76% for pT4 lesions. Estimation of tumour penetration by thin section MR imaging of rectal cancers using pelvic phased-array coil has moderate diagnostic accuracy. The limitations of MR should be acknowledged when selecting rectal cancer patients for pre-operative radiotherapy.

Estimation of diffuse and point source microbial pollution in the ribble catchment discharging to bathing waters in the north west of England

Achieving compliance with the mandatory standards of the 1976 Bathing Water Directive (76/160/EEC) is required at all U.K. identified bathing waters. In recent years, the Fylde coast has been an area of significant investments in 'point source' control, which have not proven, in isolation, to satisfactorily achieve compliance with the mandatory, let alone the guide, levels of water quality in the Directive. The potential impact of riverine sources of pollution was first confirmed after a study in 1997. The completion of sewerage system enhancements offered the potential for the study of faecal indicator delivery from upstream sources comprising both point sources and diffuse agricultural sources. A research project to define these elements commenced in 2001. Initially, a desk study reported here, estimated the principal infrastructure contributions within the Ribble catchment. A second phase of this investigation has involved acquisition of empirical water quality and hydrological data from the catchment during the 2002 bathing season. These data have been used further to calibrate the 'budgets' and 'delivery' modelling and these data are still being analysed. This paper reports the initial desk study approach to faecal indicator budget estimation using available data from the sewerage infrastructure and catchment sources of faecal indicators.

The 374 clinic: an outreach sexual health clinic for young men

OBJECTIVES

To describe the establishment of a community based walk-in outreach genitourinary medicine clinic, the "374 clinic," in south London to target young men under 25 in an area with high rates of sexually transmitted infections (STIs).

METHODS

The outreach clinic was set up within a Brook advisory centre, which already had gained the trust of local young people. Epidemiological, clinical, and laboratory data were obtained retrospectively for the first 24 weeks of the service.

RESULTS

134 attendances were recorded, including 94 new and 10 rebook events. The age range of the young men seen was 12-27 years (mean 18.2 years), the patients were mainly from black and ethnic minority groups, and all but one were heterosexual. Most men had heard about the clinic by "word of mouth," recommendation by Brook staff or through clinic promotional material. Condoms were used more frequently with non-regular sexual partners than with regular partners. The uptake of screening for gonococcal and chlamydial infections, mostly by urine based molecular techniques, was 98%. The uptake for HIV testing in men aged 16 or more was 72%. An overall STI prevalence rate of 26% was detected in the clinic population, which consisted almost equally of asymptomatic and symptomatic patients. The most prevalent STI was chlamydial infection (12%).

CONCLUSIONS

The young men who attended the outreach clinic were happy to undergo both non-invasive urine based testing for gonorrhoea and chlamydia as well as phlebotomy to test for HIV and syphilis. The 374 clinic approach may prove to be a useful model for further outreach services to combat poor sexual health of young men in inner city areas.

Increasing dose intensity of anthracycline antibiotics improves outcome in patients with acute myelogenous leukemia

To understand the effect of dose concentration in the overall survival of AML, we conducted a study on the efficacy and toxicity of a drug combination where the dose of daunorubicin was intensified. For this analysis, the outcome of patients entered into two consecutive prospective trials was compared. Inclusion criteria in both arms were identical and consisted of primary AML in adults. Treatment protocol for Cape Town Regimen 4 (CTR-IV) comprised of cytarabine infusion (100 mg/m(2)) and etoposide (100 mg/m(2)), injection daily for 7 days in combination with daunorubicin (45 mg/m(2)) on days 1, 2, and 3. Patients achieving remission were given two further courses of the same chemotherapy and received allogeneic or autologous transplantation. CTR-V was a similar treatment program, except that daunorubicin was escalated on days 1, 2, and 3 to 75 mg/m(2) during induction and to 60 mg/m(2) during a single consolidation. Patients were also offered stem cell transplantation. Between 1990 and 1997, 78 patients (median age 33; range 13-67 years) fulfilled entry criteria and received CTR-IV. From 1998 onwards, 35 patients (median age 36; range 15-66 years) were prospectively enlisted into the CTR-V trial. The patient population in CTR-V had fewer Caucasian individuals (P = 0.02) and had significantly lower presentation hemoglobin (P = 0.0002). Following initiation of induction chemotherapy, 40 patients failed to respond. Among these, 10 patients demised before day 28. Another 30 (25/69 CTR-IV and 5/32 in CTR-V groups; P = 0.01) had leukemia that was resistant to chemotherapy, and all died. Remission was achieved in 59% of patients treated with CTR-IV and 77% of those receiving CTR-V (P = 0.03). CR occurred with a single course in 64% versus 88% (P = 0.02), respectively. There were no differences in the toxicity profile between these two combinations. Disease recurred in 50% and 28% (P = 0.07) of patients. For the 113 individuals, median follow up is 254 (range 19-4,451) and 304 (12-1,702; P = 0.03) days. Survival is 23% and 40%, respectively, favoring patients treated with CTR-V (log rank; P = 0.03). Cox regression analysis showed that treatment group (P < 0.001), FAB type, hemoglobin level, and platelet count were independent factors for response to chemotherapy. Older age and not undergoing myeloablative therapy were the only adverse factors for survival. We conclude that increase in the treatment dose of daunorubicin in patients with AML led to a higher remission rate, particularly with a single course of chemotherapy and had an equivalent toxicity profile. This therapeutic modification is also likely to result in substantial reduction in patient stay in hospital and in the overall expenditure.

Extrarenal retroperitoneal angiomyolipoma: management of a rare benign tumour

BACKGROUND

Extrarenal retroperitoneal angiomyolipomas are benign tumours of mesenchymal tissue origin. The diagnosis of these tumours is usually based on the perioperative findings and confirmed by the resultant specimen's histology. The main differential diagnosis is liposarcoma, and accurate preoperative imaging combined with fine-needle aspiration cytology may permit a non-operative approach to these tumours.

CASE PRESENTATION

We describe a single case of extrarenal retroperitoneal pelvic angiomyolipoma and provide the first case of magnetic resonance imaging of these extremely rare tumours.

CONCLUSION

This article discusses the presentation, management, and outcome associated with these tumours.

Modified de Gramont with oxaliplatin in the first-line treatment of advanced colorectal cancer

We previously reported high activity for oxaliplatin and a modified de Gramont regimen (OxMdG) in a single centre study of patients with metastatic colorectal cancer. We now report results with a further 56 patients treated at 14 centres. Low rates of grade 3 and 4 toxicity were seen, with no toxic deaths. Objective response rates were CR/PR=53%; NC=34.7%; PD=12.2%. Median time to progression was 8.3 months and overall survival was 14.5 months. This regimen is more convenient than those based around the conventional de Gramont regimen but is highly active and well tolerated; it forms part of a current UK MRC phase 3 trial.

Potential role for advanced trauma life support programme in improving trauma care in Jamaica

Data from the Road Safety Unit in the Ministry of Transport and Works, Jamaica, show an increase in road traffic accidents from 7861 in 1991 to 11,010 in 1999. The average number of deaths annually was 380 +/- 48 (SD) while injuries averaged 3320 +/- 262 per year. This represents an injury to death ratio of 8.7 compared with 24.9 for Trinidad and Tobago and 40 for Canada. During the period 1991 to 2000, an average of 796 +/- 159 (SD) murders were committed annually. The number of murders increased by over 280 per cent between the decade of the seventies and the nineties. Data from the trauma registry of the University Hospital of the West Indies showed that 29.6 per cent of all admissions to the surgical ward between January 1998 and December 31, 2000, were due to injuries. There were 97 deaths (3%) during this period and 33 occurred in the Accident and Emergency Department with 70 per cent occurring within 120 minutes of their arrival. The Advanced Trauma Life Support (ATLS) Programme emphasizes the resuscitation and stabilization of injured patients in the first few hours after injury. Most Emergency Departments in Jamaica are staffed by relatively junior medical officers and the low injury to death ratio among victims of motor vehicle accidents may be due to suboptimal care. Introduction of an ATLS programme in Jamaica may reduce the number of preventable deaths and also stimulate interest in trauma care thus increasing preventative measures to decrease the high incidence of trauma in Jamaica.

Improving medical undergraduate trauma education through the Trauma Evaluation and Management programme at Mona

This study examines the potential role of the Trauma Evaluation and Management (TEAM) programme in the undergraduate curriculum for medical students in Jamaica. Thirty-two final year medical students were randomly assigned to two groups of 16. One group (No TEAM) completed two 20-item multiple choice question (MCQ) examinations on trauma resuscitation topics. The second group (TEAM group) completed the first 20-item MCQ. The TEAM manual was then distributed to both groups. After the TEAM programme for both groups, the TEAM group had the second MCQ examination. Unpaired "t" tests were used for in-between group and paired "t" tests for between group comparisons with p < 0.05 being considered statistically significant. Both groups completed a post-course questionnaire rating five items on a scale of one to five. The No TEAM group showed no difference in mean scores between the 1st and 2nd tests (55.3% in the 1st test to 52.2% in the 2nd test, p = 0.32). The TEAM Group improved their MCQ scores from 53.1% pre-module to 69.4% post-module (p < 0.001). A score of four of five was assigned by 28 students for the statement that the objectives were met, that trauma knowledge was improved and that there was overall satisfaction; by 17 students that clinical trauma skills were improved and 29 students that TEAM should be mandatory in the undergraduate curriculum. The TEAM programme improved trauma knowledge skills among senior medical students in Jamaica. The questionnaire results suggested enthusiasm for the programme and that it be made mandatory in the senior undergraduate medical curriculum.

Spreading depression-induced preconditioning in the mouse cortex: differential changes in the protein expression of ionotropic nicotinic acetylcholine and glutamate receptors

Preconditioning of the cerebral cortex was induced in mice by repeated cortical spreading depression (CSD), and the major ionotropic glutamate (GluRs) and nicotinic acetylcholine receptor (nAChRs) subunits were compared by quantitative immunoblotting between sham- and preconditioned cortex, 24 h after treatment. A 30% reduction in alpha-amino-3-hydroxy-5-methyl-4-iso- xazolepropionate (AMPA) GluR1 and 2 subunit immunoreactivities was observed in the preconditioned cortex (p < 0.03), but there was no significant change in the NMDA receptor subunits, NR1, NR2A and NR2B. A 12-15-fold increase in alpha7 nAChR subunit expression following in vivo CSD (p < 0.001) was by far the most remarkable change associated with preconditioning. In contrast, the alpha4 nAChR subunit was not altered. These data point to the alpha7 nAChR as a potential new target for neuroprotection because preconditioning increases consistently the tolerance of the brain to acute insults such as ischaemia. These data complement recent studies implicating alpha7 nAChR overexpression in the amelioration of chronic neuropathologies, notably Alzheimer's disease (AD).

A physiologically based pharmacokinetic model for trichloroethylene in the male long-evans rat

A physiologically based pharmacokinetic (PBPK) model for trichloroethylene (TCE) in the male Long-Evans (LE) rat was needed to aid in evaluation of neurotoxicity data collected in this rodent stock. The purpose of this study was to develop such a model with the greatest possible specificity for the LE rat. The PBPK model consisted of 5 compartments: brain, fat, slowly perfused tissue, rapidly perfused viscera, and liver. Partition coefficients (blood, fat, muscle, brain, liver) were determined for LE rats. The volumes of the brain, liver, and fat compartments were estimated for each rat, with tissue-specific regression equations developed from measurements made in LE rats. Vapor uptake data from LE rats were used for estimation of Vmaxc. As blood flow values for LE rats were not available, values from Sprague-Dawley (SD) and Fischer-344 (F344) rats were used in separate simulations. The resulting values of Vmaxc were used to simulate tissue (blood, liver, brain, fat) TCE concentrations, which were measured during (5, 20, 60 min) and after (60 min of TCE followed by 60 min of air) flow-through inhalation exposures of LE rats to 200, 2000, or 4000 ppm TCE. Simulation of the experimental data was improved by use of F-344 blood-flow values and the corresponding Vmaxc (8.68 mg/h/kg) compared to use of SD flows and the associated Vmaxc (7.34 mg/h/kg). Sensitivity analysis was used to determine those input parameters with the greatest influence on TCE tissue concentrations. Alveolar ventilation consistently (across exposure concentration, exposure duration, and target tissue) had the greatest impact on TCE tissue concentration. The PBPK model described here is being used to explore the relationship between measures of internal dose of TCE and neurotoxic outcome.

The effect of Nd:YAG radiation at nanosecond pulse duration on dentine crater depth

The effect of laser parameters on laser-dentine interaction is little known. The aim of this in vitro study was to determine the effect on dentine crater depth of Nd:YAG laser radiation in relation to pulse repetition rate, total delivered energy, dentine site and the presence or absence of a dye. One hundred and forty-four sound third molars were extracted and sectioned transversely to provide 288 upper and lower cut surfaces. The upper surfaces were painted with a layer of dye (IR5) suitable for absorption at 1064 nm. The specimens were divided into 12 sub-groups each containing 12 upper and 12 lower specimens. These were exposed to a Nd:YAG laser with a 30 nanosecond (ns) pulse duration. This laser operated in a non-contact mode (spot diameter 165 microm) with pulse repetition rates of 2.5, 5.4 and 10.5 Hz. Four total energies were delivered at each repetition rate; 2.3, 3.63, 3.96, 4.29 joule (J) at 2.5 Hz repetition rate; 2.3, 2.64, 3.63, 4.29 J at 5.4 and 10.5 Hz repetition rates. Five outer and three inner sites were irradiated on each specimen. Each dentine crater depth was measured five times using a Reflex Microscope and a three-dimensional centre of gravity derived. An upper and lower specimen were taken from each sub-group and viewed under a scanning electron microscope (SEM). ANOVA was applied: total delivered energy and dyed/undyed were found to have a statistically significant effect on crater depth (p<0.0001). In general increasing energy and the presence of dye produced deeper craters. Inner/outer dentine location and repetition rate were not found to be statistically significant. All craters were carbonised.

The portrayal of ECT in American movies

OBJECTIVE

To describe the portrayal of electroconvulsive therapy (ECT) in American films. This has not been systematically studied previously, despite some notorious ECT scenes in the history of American cinema and the impact of films on audiences.

METHOD

All movies depicting or making reference to ECT were identified from a number of sources. Available movies were viewed on at least two occasions.

RESULTS

22 films, beginning with The Snake Pit and ending with Requiem for a Dream, portraying or making reference to ECT were made between 1948 and 2000. 20 (91%) of these movies were obtained and viewed.

CONCLUSION

Having commenced its movie career as a severe but helpful remedy for personal distress, ECT on film has become a progressively more negative and cruel treatment, leaving the impression of a brutal, harmful, and abusive maneuver with no therapeutic benefit.

Merging nitrogen management and renewable energy needs

The ARBRE (ARable Biomass Renewable Energy) project, the first large-scale wood-fueled electricity generating plant in the U.K., represents a significant development in realising British and European policy objectives on renewable energy. The plant is fueled by a mix of wood from short rotation coppice (SRC) and forest residues. Where feasible, composted/conditioned sewage sludge is applied to coppice sites to increase yields and improve soil structure. In the Yorkshire Water region, typical total N:P:K composition of composted/conditioned sludge is 2.9:3.8:0.3, respectively. Sludge application is calculated on the basis of total nitrogen (N) content to achieve 750 kg N ha(-1), for 3 years" requirement. Willow coppice forms a dense, widely spaced, root network, which, with its long growing season, makes it an effective user of nutrients. This, in combination with willow"s use as a nonfood, nonfodder crop, makes it an attractive route for the recycling of sewage sludge in the absence of sea disposal, banned under the EC Urban Waste Water Treatment Directive (UWWTD). Further work is required on the nutritional requirements of SRC in order to understand better the quantities of sludge that can be applied to SRC without having a detrimental impact on the environment. This paper suggests the source of N rerouting under the UWWTD and suggests the likely expansion of SRC as an alternative recycling pathway.

Treatment planning for success: wise choices for maxillary single-tooth implants

The purpose of this article is to demonstrate to general practitioners who have no experience with dental implant treatment the esthetic limitations of such treatment. The criteria for wise case selection will be described so that esthetic excellence can be predictably achieved in general practice. A checklist of criteria will be provided as a treatment-planning tool to determine if a patient is likely to have an esthetically successful outcome.

Time trends in HIV incidence among homosexually active men seen at sexual health clinics in Australia, 1993-1999

BACKGROUND

Increases in sexual risk behaviour have recently been reported among homosexually active men in Australia and in other industrialised countries, potentially facilitating an increase in HIV incidence.

OBJECTIVE

To monitor HIV incidence among homosexually active men seen through a network of sexual health clinics in Australia.

STUDY DESIGN

Selected metropolitan public sexual health clinics provided counts of the number of people seen at the clinics during a calendar year, the number voluntarily tested for HIV antibody and the number newly diagnosed with HIV infection, broken down by sex, age group, HIV exposure category and HIV antibody testing history. HIV incidence was estimated among homosexually active men with a history of a negative test in the 12 months prior to last being seen in a calendar year.

RESULTS

Of 23924 men seen at the clinics in 1993-1999 with a reported history of male homosexual contact, 7440 (31.1%) had a negative test in the 12 months prior to last being seen in a calendar year. The percentage of men with a recent negative test declined significantly over time, from more than 33% in 1994-1996 to 29% in 1999 (P=0.003), and with increasing age, from 34.3% among men aged 25-29 years to 27.4% among men aged 40 years or older (P<0.0005). A total of 5346 (71.9%) men were retested for HIV antibody within 12 months of the last negative test. The percentage of men retested declined significantly over time, from 77.8% in 1994 to 67.2% in 1999 (P=0.021) but did not change by age group (P=0.132). Overall, 56 men were newly diagnosed with HIV infection. Estimated HIV incidence was 2.1% in 1993-1999; incidence did not change significantly by year (P=0.498) or age group (P=0.757).

CONCLUSION

HIV incidence has remained stable among homosexually active men seen through a network of sexual health clinics in Australia.

Management of hepatic cysts by percutaneous drainage and instillation of tetracycline hydrochloride

This paper reports two cases of benign hepatic cysts successfully treated by the instillation of tetracycline hydrochloride. The patients presented with solitary large symptomatic hepatic cysts and underwent ultrasound guided needle aspiration followed by the instillation of tetracycline hydrochloride. The cyst size diminished without complication and the patients have remained symptom free. We review the treatment of this uncommon entity and propose that injection of tetracycline hydrochloride is an effective nonoperative treatment of symptomatic solitary hepatic cysts.

Patterns of trauma injuries in rural versus urban Jamaica

Trauma admissions to St Ann's Bay Hospital in rural Jamaica and The University Hospital of the West Indies (UHWI) in the capital city of Kingston are compared. Trauma accounted for 19% and 22% of surgical admissions to UHWI and the St Ann's Bay Hospital, respectively. Sixty-three per cent of trauma cases admitted to the St Ann's Bay Hospital and 56% to the UHWI were due to unintentional injuries (95% CI, -0.05, 0.19). The main cause of unintentional injuries at both hospitals was motor vehicle accidents, accounting for 43% and 37% at UHWI and St Ann's Bay Hospital respectively (95% CI, -0.04, 0.17). The prevalence of falls was significantly higher in St Ann's Bay Hospital compared with UHWI, 41% and 26% respectively (95% CI, 0.10, 0.21). Intentional injuries accounted for 37% of cases in St Ann's Bay Hospital and 44% at UHWI (95% CI, -0.20, 0.04). The prevalence of firearm injuries was significantly higher at the UHWI than in St Ann's Bay Hospital, 55% and 18% respectively (95% CI, -0.15, -0.05). There was no significant difference in age and injury severity scores in the two hospitals but patients remained in hospital significantly longer at UHWI.