A single ultrasonographic scan at age 65 years excludes 95 per cent of men from future aneurysm risk

Background

In 1988, 236 men, then aged 65 or 66 years, underwent an abdominal ultrasonographic scan as part of a pilot study for an aneurysm screening programme; 223 (95 per cent) had an aortic diameter of 25 mm or less, and form the main study group.

Methods

This group was followed with repeat ultrasonography in 1993 and 2000. Eight men (4 per cent) were lost to follow-up or refused further scanning, but all are known to be still alive. Eighty-six men (39 per cent) died during the 12-year follow-up. Causes of death were investigated. None was related to abdominal aortic aneurysm (AAA). Some 129 men (58 per cent) had all three ultrasonographic scans, including some arranged in other hospitals or performed with a portable scanner at a home visit. Mean(s.e.m.) aortic diameter for this group was 18·9(2·3) mm in 1988, 19·0(2·6) mm in 1993 and 20·2(3·8) mm in 2000.

Results

At the scan in 2000, four men had an aortic diameter greater than 30 mm (32, 34, 34 and 36 mm respectively). In contrast, of the 13 men with an aortic diameter greater than 25 mm in 1988, three have undergone elective aneurysm repair, eight have died from causes unrelated to AAA and two remain under ultrasonographic surveillance.

Conclusion

Using an aortic diameter threshold of 25 mm, a single ultrasonographic scan at the age of 65 years is able to exclude 95 per cent of men who appear extremely unlikely ever to develop a clinically significant aortic aneurysm and to identify the 5 per cent who require further follow-up.

Population screening reduces the total community mortality rate from aortic aneurysms

Background

Screening of the male population for unsuspected abdominal aortic aneurysm (AAA) has been taking place in a single UK county (population 520 000) since 1990.

Methods

The general practitioner surgery-based programme involves ultrasonographic examination of each year's new batch of 65-year-old men, excluding those who were older than this when the programme started. This method of screening has resulted in a gradually enlarging cohort of screened men, so that by the end of 1998 all men between the ages of 65 and 73 years had been offered an ultrasound scan, with 85 per cent accepting and over 21 000 men examined. Total aneurysm-related deaths in the community have been quantified by examining inpatient records and post-mortem results for the county's hospitals, together with computerized death certificate records held by the health authority (available for 1994 onwards). This figure thus includes deaths at home from ruptured AAA, in-hospital deaths from ruptured AAA with or without emergency surgery and all deaths following elective AAA surgery.

Results

The 65–73-year-old age group has been progressively influenced by AAA screening as new 65 year olds are examined each year. Total aneurysm-related deaths in this age range have shown a progressive, year by year fall between 1994 and 1998, with an overall reduction in deaths by two-thirds during this 5-year period. In contrast, aneurysm-related deaths in men aged below 65 and over 73 years have tended to show a slight increase in the same period.

Conclusion

These figures clearly demonstrate that population screening reduces overall deaths from aortic aneurysms.

Prospective randomized trial of low- versus high-dose radiation therapy in adults with supratentorial low-grade glioma: initial report of a North Central Cancer Treatment Group/Radiation Therapy Oncology Group/Eastern Cooperative Oncology Group study

PURPOSE

To compare survival and toxicity in adult patients treated with low-dose (50.4 Gy/28 fractions) versus high-dose (64.8 Gy/36 fractions) localized radiation therapy (RT) for supratentorial low-grade astrocytoma, oligodendroglioma, and mixed oligoastrocytoma.

PATIENTS AND METHODS

From 1986 to 1994, 203 eligible/analyzable patients were randomized: 101 to low-dose RT, 102 to high-dose RT. Almost half were younger than 40 years, and 95% had grade 2 tumors. Histologic subtype was astrocytoma (or mixed oligo-astrocytoma with astrocytoma dominant) in 32% of patients and oligodendroglioma (or oligoastrocytoma with oligodendroglioma dominant) in 68%. Tumor diameter was less than 5 cm in 35% of patients, and 41% of tumors showed some degree of contrast enhancement. Extent of resection was gross total in 14% of patients, subtotal in 35%, and biopsy only in 51%.

RESULTS

At the time of the present analysis, 83 patients (41%) are dead, and median follow-up is 6.43 years in the 120 who are still alive. Survival at 2 and 5 years is nonsignificantly better with low-dose RT; survival at 2 and 5 years was 94% and 72%, respectively, with low-dose RT and 85% and 64%, respectively, with high-dose RT (log rank P =.48). Multivariate analysis identified histologic subtype, tumor size, and age as the most significant prognostic factors. Survival is significantly better in patients who are younger than 40 years and in patients who have oligodendroglioma or oligo-dominant histology. Grade 3 to 5 radiation neurotoxicity (necrosis) was observed in seven patients, with one fatality in each treatment arm. The 2-year actuarial incidence of grade 3 to 5 radiation necrosis was 2.5% with low-dose RT and 5% with high-dose RT.

CONCLUSION

This phase III prospective randomized trial of low- versus high-dose radiation therapy for adults with supratentorial low-grade astrocytoma, oligodendroglioma, and oligoastrocytoma found somewhat lower survival and slightly higher incidence of radiation necrosis in the high-dose RT arm. The most important prognostic factors for survival are histologic subtype, tumor size, and age. The study design of the ongoing intergroup trial in this population will be discussed.

Sleep in the laboratory and sleep at home II: comparisons of middle-aged insomnia sufferers and normal sleepers

STUDY OBJECTIVES

The study compared adaptation responses and sleep pattern differences shown by normal sleepers and insomnia sufferers during lab (LPSG) and home (HPSG) polysomnography.

DESIGN

A counter-balanced, matched-group design was used. Participants underwent 3 consecutive nocturnal LPSG's and 3 consecutive nocturnal PSG's in their homes (HPSG's).

SETTING

The sleep disorders laboratories at affiliated VA and university medical centers.

PARTICIPANTS

Thirty-five (18 women) middle-aged (40 to 59 years) noncomplaining normal sleepers and an age-matched sample of 33 (17 women) individuals who met structured interview criteria for persistent primary insomnia were the study participants.

MEASUREMENTS AND RESULTS

A series of multivariate and univariate analyses were conducted with 9 common sleep parameters to address study objectives. Bed partner influences were controlled by conducting separate sets of analyses for those with and without routine home bed partners. The interaction of participant type (normal vs. insomnia), sleep setting, and PSG sequence (HPSG 1st vs. LPSG 1st) affected first night values of sleep efficiency and stage 2 sleep among those without routine bed partners, and REM latency and sleep efficiency among those with routine bed partners. Analyses which controlled for first night and sequencing effects showed a significant participant type x sleep setting interaction among those with bed partners. These latter analyses suggested that LPSG's may underestimate the home sleep time of insomnia sufferers and overestimate the sleep continuity of normal sleepers, at least among those who routinely sleep with a bed partner.

CONCLUSIONS

The nocturnal recording site may influence adaptation effects and sleep pattern differences noted between insomnia sufferers and normal sleepers.

Self management for chronic disease. An introduction

BACKGROUND

Improving the quality of health care for those with chronic diseases, largely consequent to an increasingly ageing population, is the emerging challenge for health care. One approach to enhancing management of chronic disease is the expansion of patient self management.

OBJECTIVE

This article discusses the importance of self care as a means of improving health outcomes for patients with chronic disease.

DISCUSSION

The optimum management of persons with chronic disease is facilitated by an effective primary health care system. The Enhanced Primary Care (EPC) package initiated by the Federal Government and designed to assist people with chronic illnesses and complex care needs, recognises the importance of appropriate self management interventions. 'Sharing health care' is part of the EPC package that encompasses self management initiatives and is central to the program as an acknowledgment that the patient is responsible for managing some aspect of their illness.

A single normal ultrasonographic scan at age 65 years rules out significant aneurysm disease for life in men

BACKGROUND

Screening for abdominal aortic aneurysm (AAA) has been carried out in Gloucestershire since 1990. All men in the county are offered aortic ultrasonography in their 65th year. Men with an aortic diameter of less than 26 mm are considered 'normal' and no follow-up is arranged. The aim of this study was to ascertain if men with 'normal' aortic diameters at age 65 years ever develop a clinically significant aneurysm.

METHODS

A cohort study was performed on 223 65-year-old men who had an aorta of less than 26 mm in diameter in 1988. These men had repeat ultrasonography in 1993 and 2000. The causes of death in men who died during this interval were investigated.

RESULTS

Eight men were lost to follow-up. As far as it was possible to ascertain, none of the 86 men who died over the 12-year interval did so from ruptured AAA. There was no clinically significant increase in mean aortic diameter in the remaining 129 men who had three serial ultrasonographic scans over the 12-year interval.

CONCLUSION

A single, 'normal' ultrasound scan at age 65 years effectively rules out the risk of clinically significant aneurysm disease for life in men.

Degradation of substituted phenylurea herbicides by Arthrobacter globiformis strain D47 and characterization of a plasmid-associated hydrolase gene, puhA

Arthrobacter globiformis D47 was shown to degrade a range of substituted phenylurea herbicides in soil. This strain contained two plasmids of approximately 47 kb (pHRIM620) and 34 kb (pHRIM621). Plasmid-curing experiments produced plasmid-free strains as well as strains containing either the 47- or the 34-kb plasmid. The strains were tested for their ability to degrade diuron, which demonstrated that the degradative genes were located on the 47-kb plasmid. Studies on the growth of these strains indicated that the ability to degrade diuron did not offer a selective advantage to A. globiformis D47 on minimal medium designed to contain the herbicide as a sole carbon source. The location of the genes on a plasmid and a lack of selection would explain why the degradative phenotype, as with many other pesticide-degrading bacteria, can be lost on subculture. A 22-kb EcoRI fragment of plasmid pHRIM620 was expressed in Escherichia coli and enabled cells to degrade diuron. Transposon mutagenesis of this fragment identified one open reading frame that was essential for enzyme activity. A smaller subclone of this gene (2.5 kb) expressed in E. coli coded for the protein that degraded diuron. This gene and its predicted protein sequence showed only a low level of protein identity (25% over ca. 440 amino acids) to other database sequences and was named after the enzyme it encoded, phenylurea hydrolase (puhA gene).

Red palm oil in the maternal diet increases provitamin A carotenoids in breastmilk and serum of the mother-infant dyad

BACKGROUND

Despite vitamin A supplementation programs, vitamin A deficiency in children remains a public health concern in Honduras.

AIM OF THE STUDY

We investigated the effectiveness of short-term dietary supplementation of mothers with red palm oil as a strategy for improving the vitamin A status of the mother-infant dyad.

METHODS

Lactating mothers in Colonia Los Pinos, a barrio of Tegucigalpa, Honduras, consumed a total of 90-mg beta-carotene as red palm oil (n = 32) supplements (n = 36) or placebo (n = 18) in six equal doses over 10 days. Carotenoids and retinol in maternal and infant serum, and breastmilk carotenoids and retinol were measured before and after supplementation. Maternal diet was evaluated by 24-hour recall.

RESULTS

Maternal serum alpha-carotene and beta-carotene concentrations were increased 2 fold by palm oil compared with 1.2 fold by beta-carotene supplements. Changes were significantly different in infant serum alpha-carotene but not beta-carotene among the three experimental groups. Increases in breastmilk beta-carotene were greater for the palm oil group (2.5 fold) than for the beta-carotene supplement group (1.6 fold) and increases in milk alpha-carotene concentrations (3.2 fold) were slightly greater than those of beta-carotene. There were also small but significant changes among groups in breastmilk lutein and lycopene. Breastmilk retinol was not significantly different among the groups over the treatment period.

CONCLUSIONS

Red palm oil in the maternal diet increases provitamin A carotenoids in breastmilk and serum of the mother-infant dyad. The use of dietary red palm oil to improve the vitamin A status of this population should be further investigated.

A comparison of the mortality rate after elective repair of aortic aneurysms detected either by screening or incidentally

OBJECTIVE

to compare predicted and actual mortality rates, using POSSUM scoring, after elective repair of abdominal aortic aneurysms (AAAs) detected from the Gloucestershire Aneurysm Screening Programme and those discovered incidentally.

METHODS

a sample of 276 men undergoing elective AAA repair in Gloucestershire between 1991 and 1998 was studied. AAAs were either detected from the screening programme or were discovered incidentally and referred from other sources. Mortality data relating to these patients have been recorded prospectively. POSSUM scoring was performed retrospectively from patients>> notes in both groups and related to outcome (30 day and in-hospital mortality). POSSUM and P-POSSUM methodology were used to compare observed and predicted mortality rates.

RESULTS

in the 276 men who had elective AAA repair, the overall mortality rate was 7%. Mortality was lower in screen-detected AAAs (3/111, 3%) than AAAs discovered incidentally (16/175, 9%) (p=0.05). Preoperative physiology scores were significantly lower in men with a screen-detected AAA (median 19, range 13-29 versus 21, 12-41, p<0.001). POSSUM operative scores were similar between the groups. Actual versus predicted death ratios in the sample group were more accurate using POSSUM (ratio 0.93) than P-POSSUM (2.38) analysis.

CONCLUSIONS

men with a screen-detected AAA had a lower mortality rate after elective repair than in those detected incidentally; lower preoperative physiology scores suggested they were fitter (as well as younger). In this study POSSUM analysis more accurately predicted outcome than P-POSSUM.

Insomnia and the eye of the beholder: are there clinical markers of objective sleep disturbances among adults with and without insomnia complaints?

Previous findings suggest that some who report insomnia sleep well, whereas some noncomplaining individuals sleep rather poorly. This study was conducted to determine if mood, anxiety, and sleep-related beliefs might relate to perceived sleep disturbance. Thirty-two women and 32 men (aged 40-79 years) with primary insomnia and an aged-matched sample of 61 normal sleepers (31 women, 30 men) completed 6 nocturnal sleep recordings, as well as the Beck Depression Inventory (BDI), the Trait portion of the State-Trait Anxiety Inventory (STAI-2), and the Dysfunctional Beliefs and Attitudes About Sleep Questionnaire. Sleep and interview data were used to subdivide the majority of the sample (n = 108) into objective normal sleepers and subjective insomnia sufferers who seemingly slept well and subjective normal sleepers and objective insomnia sufferers who slept poorly. The 2 subjective subgroups showed the most marked differences on most of the psychometric measures. The findings suggest that the psychological factors scrutinized in this study may mediate sleep satisfaction and/or predict objective sleep difficulties.

Population screening reduces mortality rate from aortic aneurysm in men

BACKGROUND

Rupture of an unsuspected abdominal aortic aneurysm is a major cause of death in men over the age of 65 years. A significant reduction in deaths is likely to result only from higher rates of detection and increased numbers of elective aneurysm repairs. Screening of men reaching the age of 65 years has been taking place in the county of Gloucestershire, UK since 1990 and the aim of this study was to investigate any change in the mortality rate from aortic aneurysm in the screened portion of the population.

METHODS

Total number of deaths from all aortic aneurysm-related causes in the county's population was calculated from hospital and post-mortem records, together with computerized death certificate records, for the years 1994-1998. The overall number of aneurysm-related deaths in men aged 65-73 years, who have been progressively influenced by the screening programme, was compared with that for men of all other ages.

RESULTS

The total number of aneurysm-related deaths in men aged 65-73 years decreased progressively year by year between 1994 and 1998; this reduction is highly statistically significant (P < 0. 001). No such change was observed in the unscreened part of the population.

CONCLUSION

Screening for asymptomatic abdominal aortic aneurysm results in a significant reduction in numbers of deaths from all aneurysm-related causes in the screened portion of the male population.

Single dose radiosurgical treatment of recurrent previously irradiated primary brain tumors and brain metastases: final report of RTOG protocol 90-05

PURPOSE

To determine the maximum tolerated dose of single fraction radiosurgery in patients with recurrent previously irradiated primary brain tumors and brain metastases.

METHODS AND MATERIALS

Adults with cerebral or cerebellar solitary non-brainstem tumors </= 40 mm in maximum diameter were eligible. Initial radiosurgical doses were 18 Gy for tumors </= 20 mm, 15 Gy for those 21-30 mm, and 12 Gy for those 31-40 mm in maximum diameter. Dose was prescribed to the 50-90% isodose line. Doses were escalated in 3 Gy increments providing the incidence of irreversible grade 3 (severe) or any grade 4 (life threatening) or grade 5 (fatal) Radiation Therapy Oncology Group (RTOG) central nervous system (CNS) toxicity (unacceptable CNS toxicity) was < 20% within 3 months of radiosurgery. Chronic CNS toxicity was also assessed.

RESULTS

Between 1990-1994, 156 analyzable patients were entered, 36% of whom had recurrent primary brain tumors (median prior dose 60 Gy) and 64% recurrent brain metastases (median prior dose 30 Gy). The maximum tolerated doses were 24 Gy, 18 Gy, and 15 Gy for tumors </= 20 mm, 21-30 mm, and 31-40 mm in maximum diameter, respectively. However, for tumors < 20 mm, investigators' reluctance to escalate to 27 Gy, rather than excessive toxicity, determined the maximum tolerated dose. In a multivariate analysis, maximum tumor diameter was one variable associated with a significantly increased risk of grade 3, 4, or 5 neurotoxicity. Tumors 21-40 mm were 7.3 to 16 times more likely to develop grade 3-5 neurotoxicity compared to tumors < 20 mm. Other variables significantly associated with grade 3-5 neurotoxicity were tumor dose and Karnofsky Performance Status. The actuarial incidence of radionecrosis was 5%, 8%, 9%, and 11% at 6, 12, 18, and 24 months following radiosurgery, respectively. Forty-eight percent of patients developed tumor progression within the radiosurgical target volume. A multivariate analysis revealed two variables that were significantly associated with an increased risk of local progression, i.e. progression in the radiosurgical target volume. Patients with primary brain tumors (versus brain metastases) had a 2.85 greater risk of local progression. Those treated on a linear accelerator (versus the Gamma Knife) had a 2.84 greater risk of local progression. Of note, 61 % of Gamma Knife treated patients had recurrent primary brain tumors compared to 30% of patients treated with a linear accelerator.

CONCLUSIONS

The maximum tolerated doses of single fraction radiosurgery were defined for this population of patients as 24 Gy, 18 Gy, and 15 Gy for tumors </= 20 mm, 21-30 mm, and 31-40 mm in maximum diameter. Unacceptable CNS toxicity was more likely in patients with larger tumors, whereas local tumor control was most dependent on the type of recurrent tumor and the treatment unit.

[Right ventricular outflow obstruction due to a giant pseudoaneurysm of the anterior descending coronary artery in a patient with Behçet's disease]

Giant pseudoaneurysms of coronary arteries in patients with Behçet's disease is a uncommon finding. It has been described exceptionally in the literature. We present a case of giant pseudoaneurysm of the left anterior descending coronary artery with obstruction of the right ventricular outflow in a patient with Behçet's disease. He improved after surgical resection and steroid treatment.

The effect of a peer counseling program on breastfeeding initiation and longevity in a low-income rural population

Breastfeeding rates among low-income women in the east-south-central United States are among the lowest in the country. This study examined the effect of a peer counseling program on breastfeeding initiation and duration in a low-income rural population in West Tennessee. A postpartum survey and chart review were conducted with WIC clients at nine health departments. Response rate was 99% (291/293). Breastfeeding initiation and duration at 6 weeks were increased in the peer counselor group (n = 156) compared with women in the no-peer counselor group (n = 135) (53% vs. 33%, p < 0.001, and 26% vs. 13%, p = 0.006, respectively). Multivariate analysis revealed that women in the peer counselor group were significantly more likely to initiate breastfeeding (OR = 2.43, 95% CI = 1.23-4.67) and to be breastfeeding at 6 weeks (OR = 2.78, 95% CI = 2.08-9.51), than those in the no-peer counselor group.

Novel, starch-like polysaccharides are synthesized by an unbound form of granule-bound starch synthase in glycogen-accumulating mutants of Chlamydomonas reinhardtii

In vascular plants, mutations leading to a defect in debranching enzyme lead to the simultaneous synthesis of glycogen-like material and normal starch. In Chlamydomonas reinhardtii comparable defects lead to the replacement of starch by phytoglycogen. Therefore, debranching was proposed to define a mandatory step for starch biosynthesis. We now report the characterization of small amounts of an insoluble, amylose-like material found in the mutant algae. This novel, starch-like material was shown to be entirely dependent on the presence of granule-bound starch synthase (GBSSI), the enzyme responsible for amylose synthesis in plants. However, enzyme activity assays, solubilization of proteins from the granule, and western blots all failed to detect GBSSI within the insoluble polysaccharide matrix. The glycogen-like polysaccharides produced in the absence of GBSSI were proved to be qualitatively and quantitatively identical to those produced in its presence. Therefore, we propose that GBSSI requires the presence of crystalline amylopectin for granule binding and that the synthesis of amylose-like material can proceed at low levels without the binding of GBSSI to the polysaccharide matrix. Our results confirm that amylopectin synthesis is completely blocked in debranching-enzyme-defective mutants of C. reinhardtii.

Adolescents' insight in heavy drinking

PURPOSE

Because so few adolescents with alcohol problems seek treatment, this study examined the factors associated with adolescents' recognition or insight into having a substance use problem.

METHOD

Data were extracted from a self-report questionnaire used in an epidemiological study of public middle school students on substance abuse in Arkansas. Those drinking heavily were divided into "admitters" and "deniers" based on their response to the question of having a substance use problem. Odds ratios were calculated to measure the association of several variables with admitting a problem.

RESULTS

Of 3395 adolescents, 13.4% (455) met or exceeded our threshold for heavy drinking. Only 15.9% (65) of these heavy drinkers acknowledged having a substance use problem. Reporting more types of negative social events related to alcohol use and scoring higher on a measure of positive alcohol expectancies were significantly related to admitting to a substance use problem. Recent health care contact and perceived environmental factors did not independently contribute to insight.

CONCLUSIONS

If these results are generalizable, treatment and educational interventions should emphasize linking alcohol use and negative social consequences.