Developing primary care services for young people

The Cornwall and Isles of Scilly Health Promotion Service and Cornwall Youth Service have been working in partnership to facilitate the planning and promotion of high quality attractive and relevant designated health services for young people. This partnership arose from a joint project in North Cornwall looking at unwanted teenage pregnancies. It involved research with young people about their perspective of health services in their area, and a theatre in education project with the Barbican Theatre working with primary health care teams to raise awareness about the issues relating to health care for young people. The team have presented their work at several conferences, it has won a NHS 50 National Award sponsored by Glaxo-Wellcome, and has attracted much interest locally and nationally from policy makers and practitioners. This paper describes how the team came together, the various stages in the development and execution of the project, the outcomes and recommendations

Human plasma and tissue alpha-tocopherol concentrations in response to supplementation with deuterated natural and synthetic vitamin E

We report a comparison of natural and synthetic vitamin E in humans using deuterium labeling to permit the two forms of vitamin E to be measured independently in plasma and tissues of each subject. Differences in natural and synthetic vitamin E concentrations were measured directly under equal dosage conditions using an equimolar mixture of deuterated RRR-alpha-tocopheryl acetate and all-rac-alpha-tocopheryl acetate. Two groups of five adults took 30 mg of the mixture as a single dose and as eight consecutive daily doses, respectively. After a 1-mo interval the schedule was repeated but with a 10-fold higher dose (ie, 300 mg). In each case, the ratio of plasma d3-RRR-alpha-tocopherol to d6-all-rac-alpha-tocopherol (RRR:rac) increased from approximately 1.5-1.8 to approximately 2 after dosing ended. In an elective surgery study in which 22 patients were given 150 mg/d for up to 41 d before surgery, the RRR:rac in tissues was lower than in plasma and the percentage of deuterated alpha-tocopherol was lower in all tissues except gallbladder and liver. In a terminally ill patient given 30 mg/d for 361 d, plasma and tissue (x+/-SD) RRR-rac ratios (and % deuterated alpha-tocopherol) at autopsy were 2.06 (6.3%) and 1.71+/-0.24 (5.9+/-2.2%), respectively. In a second terminally ill patient given 300 mg/d for 615 d, the corresponding values were 2.11 (68%) and 2.01+/-0.17 (65+/-10%), respectively. The results indicated that natural vitamin E has roughly twice the availability of synthetic vitamin E. This 2:1 ratio is significantly higher than the currently accepted RRR:rac of 1.36:1.00. Gamma-Tocopherol, expressed as a fraction of total unlabeled tocopherols in 15 elective surgery patients, was 1.4-4.6 (mean: 2.6) times greater in adipose tissue, muscle, skin, and vein than in plasma, which is a substantially larger fraction than had been recognized previously.

The relationship of cervical lymph node metastases to primary sites of carcinoma of the upper aerodigestive tract: a pathological study

BACKGROUND

Therapeutic and elective dissection of the neck is accepted management in the treatment of squamous cell carcinoma (SCC) of the upper aerodigestive tract (UADT). Accurate histological assessment of the levels of involvement of cervical metastatic spread from different sites within the UADT has allowed the increasing use of less than radical procedures, with associated reduced morbidity.

METHODS

A total of 168 necks in 126 patients were examined pathologically. All levels were identified at surgery, marked and oriented by pinning the specimen to a cork board, and examined histologically. A total of 114 necks had a comprehensive neck dissection (CND) in which all levels were dissected. The number and level of involvement and the occult rate (114 necks) for each primary site was assessed. Of the total of 168 necks, 80 had pathologically involved nodes, and the number with greater than one node involved (N2b) was compared for each primary site. The number with extracapsular spread for each nodal staging was also examined.

RESULTS

The sites of primary SCC were the oral cavity, oropharynx, hypopharynx, supraglottic and glottic larynx. In those patients with a primary in the oral cavity, no patient had level 5 involvement, but in two patients (7%) level 4 was involved. In the oropharynx, level 1 and 5 were involved in two patients (11%) each. In the hypopharynx, level 1 was not involved in any patient, however, level 5 contained metastasis in 7 (23%). In the supraglottic larynx, level 1 was involved in one (4%) patient and level 5 was involved in three (11%). In the glottis only one patient had bilateral multiple nodes which included level 5. In no case was level 5 involved without positive nodes in other levels. The occult rate for each primary site was 45%, 22%, 77%, 54% and 29%, respectively. The multiple node rate in the 80 necks with positive nodes was, respectively, 31%, 54%, 66%, 45% and 40%. All patients with a node larger than 3 cm had extracapsular spread of tumour.

CONCLUSIONS

The level of nodal involvement and therefore the type of neck dissection should be determined by the site of the primary within the UADT and the presence or absence of nodes at surgery. There is a high number (39-66%) of pathologically involved necks which have multiple nodes and also nodes with extracapsular spread of tumour, which may influence the decision for postoperative radiotherapy.

New nursing graduates: a key factor in nursing supply

The Canadian nursing education system is the most significant contributor to the country's supply of registered nurses. This article provides current data on the numbers of nursing graduates produced in each province in 1994. The authors highlight some of the differences in the numbers produced and use the national average of new graduates as the percentage of the population of Canada as one method to arrive at the numbers of new graduates per year which each province could attempt to produce. This article provides a national perspective on current and future nursing human resources and will assist nursing administrators in their staffing plans related to registered nurses.

D-methionine provides excellent protection from cisplatin ototoxicity in the rat

Cisplatin (CDDP) is a widely used chemotherapeutic agent. Unfortunately, CDDP is highly ototoxic. We tested D-methionine (D-Met), a sulfur containing compound, as an otoprotectant in male Wistar rats. Complete data sets were obtained for five groups of five animals each, including a treated control group (16 mg/kg CDDP), an untreated control group (administered an equivalent volume of saline) and three groups that received either 75, 150, or 300 mg/kg D-Met 30 min prior to the 16 mg/kg CDDP dosing. Auditory brainstem response (ABR) thresholds were obtained in response to clicks, and 1 kHz, 4 kHz, 8 kHz, and 14 kHz toneburst stimuli, before and 3 days after drug administration. Scanning electron microscopy (SEM) was used to examine the outer hair cells of the apical, middle and basal turns of the cochlea. Animal weight was measured on the first and final day. D-Met provided excellent otoprotection even at the lowest level with complete otoprotection obtained for the 300 mg/kg dosing as measured by both ABR and SEM. D-Met also markedly reduced weight loss and mortality. All animals receiving D-Met (15/15) survived to the end of the study period as opposed to only 5/10 of the treated controls.

Use of an occupational therapy motor performance checklist by a school health service: a pilot study

OBJECTIVE

The aim of this pilot study was to assess whether the School Health Service could play a role in identifying the children in most need of community occupational therapy services.

METHODOLOGY

A two-tiered referral system, which incorporated a Motor Performance Checklist (MPC) devised by the authors, was used. This checklist consisted of 12 gross and fine motor items and was administered to 123 children in their first year of school. Comparison was made between parent/teacher referrals alone and the two-tiered referral system as measured against a 'gold standard' test (the Bruininks-Oseretsky Test of Motor Proficiency) in a smaller subgroup.

RESULTS

Results indicated that the two-tiered referral system incorporating the MPC had a sensitivity of 75% and specificity of 95% while the teacher/parent referrals had a sensitivity of 88% but a low specificity of only 41%. There was no significant difference in sensitivity (z = 0, P > 0.05) but a highly significant difference in specificity (z = 3.56, P < 0.005) between these two systems.

CONCLUSIONS

This two-tiered referral system has the potential to impact significantly on paediatric occupational therapy utilization, service delivery and waiting times in the community health setting.

Gait initiation by patients with lower-half parkinsonism

Patients with multiple deep cerebral infarcts and white matter degeneration commonly exhibit a hesitant, shuffling gait, with preserved arm swing. This pattern of walking is called lower-half or lower-body parkinsonism. Gait initiation and turning consist of one or more short, hesitant steps in which the feet shuffle across the floor. This abnormality of gait initiation was studied with quantitative motion analysis in five patients, ages 74-87 years. Five men and five women with normal mobility and comparable ages exhibited three key events of gait initiation: (i) activation of tibialis anterior and inactivation of triceps surae produced bilateral ankle dorsiflexion and a sagittal moment of force that propelled the body anteriorly; (ii) abduction of the swing hip occurred simultaneously with event (i); and (iii) abrupt 3-10 degrees flexion of the support hip and knee occurred nearly simultaneously with events (i) and (ii) and produced a transient reduction in vertical force beneath the support foot. Events (ii) and (iii) produced a coronal moment of force about the ankles that propelled the body toward the support foot. Thus, in normal gait initiation, a smooth sequence of postural shifts propels the body anterolaterally toward the support limb, culminating in a forward step. The patients, by comparison, exhibited errant deviations in their postural shifts of gait initiation, and one or more aborted steps frequently preceded the first complete step. Nevertheless, all patients employed the usual three key events in their initial attempt at stepping, consistent with a normal motor strategy of gait initiation. These results and previous clinical observations suggest that the principal locomotor deficit is an impaired generation of postural shifts that mediate changes from one steady-state posture or movement to another.

Immediate breast reconstruction for stage III breast cancer using transverse rectus abdominis musculocutaneous (TRAM) flap

BACKGROUND

The management of state III breast cancer is challenging; it often includes multimodal treatment with systemic therapy and/or radiation therapy and surgery. Immediate breast reconstruction has not traditionally been performed in these patients. We review the results of immediate transverse rectus abdominis musculocutaneous (TRAM) flap in 21 patients treated for stage III breast cancer.

METHODS

Data have been collected retrospectively on 21 patients diagnosed with stage III breast cancer between 1987 and 1994. All patients had mastectomy and immediate TRAM reconstruction. Thirteen patients received primary systemic therapy, 10 patients received postoperative consolidation radiotherapy to the operative site, and 3 patients received preoperative radiation.

RESULTS

Mean follow-up for the group was 26 months. Two patients died with disseminated disease: neither of them developed local disease recurrence in the operative site; 82% of the patients followed for at least two years are free of disease. Sixty-two percent of the patients received preoperative chemotherapy, the remaining patients received postoperative multiagent chemotherapy and/or radiation therapy. Two of the patients received autologous bone marrow transplants after their adjuvant therapy. Ten patients had postoperative radiotherapy for consolidation; three patients received preoperative radiation.

CONCLUSIONS

Immediate TRAM reconstruction for stage III breast cancer is not associated with a delay in adjuvant therapy or an increased risk of local relapse. It facilitates wide resection of involved skin without skin grafting. Radiation therapy can be delivered to the reconstructed breast when indicated without difficulty. Breast reconstruction facilitates surgical resection of stage III breast cancer with primary closure and should be considered if the patient desires immediate breast reconstruction.

Use of a fibrillar polylactic acid homopolymer in sheep cranial defects

Guided tissue regeneration has been shown to permit osteoconduction in otherwise nonhealing cranial defects. The relative importance of preventing the prolapse of soft tissue versus the infiltration of individual connective tissue cells has not been determined. A fibrillar form of polylactic acid (PLA) was tested in 13-mm-diameter defects in the parietal bones of 12 sheep. The polymer was hypothesized to prevent the prolapse of dura and periosteum but allow entrance of individual cells. Control defects in the same sheep were either filled with autogenous bone shavings or left unfilled. The animals were killed at times ranging from 6 to 25 weeks and the defects examined grossly, radiologically, and histologically. The autogenous bone-filled defects were spanned by trabeculated bone by 6 weeks. The unfilled defects demonstrated prolapse of soft tissues into the defect; however, progressive centripetal bone growth was evident. The fibrillar PLA-filled defects were occupied by a full-thickness mixture of fibrous tissue interspersed with PLA. After 19 weeks, small "fingers" of bone were seen to minimally infiltrate the fibrous tissue. Although separation of the dura and periosteum was maintained by the fibrillar PLA, invasion of fibrous tissue restricted osteoconduction.

Improved staging of B-cell non-Hodgkin's lymphoma patients with 99mTc-labeled LL2 monoclonal antibody fragment

Radioimmunodetection (RAID) with the 99mTc-labeled Fab' fragment of monoclonal antibody (MoAb) LL2 has been reported to have a high lesion detection rate for malignant lymph nodes as well as for visceral and skeletal tumor masses (20). Our purpose in this study was to evaluate the safety and staging efficacy of the 99mTc-labeled Fab' fragment of MoAb LL2 in patients with various grades and stages of B-cell non-Hodgkin's lymphoma (NHL). Thirty adult patients, 13 male and 17 female, ranging in age from 20 to 80 years, with at least one biopsy-proved malignant node (> or = 0.5 cm) and a Karnofsky performance score of > or = 60% were enrolled in this study. Patients underwent selected planar and single photon emission computed tomographic imaging at 6 and 18 h after receiving an i.v. infusion of 0.25-1 mg of LL2 Fab' fragment labeled with 25-30 mCi of 99mTc. RAID findings were compared with physical examination, chest radiography, computed tomography, magnetic resonance imaging, and bone and 67Ga scan findings. The RAID scan was positive in all but three patients. The sensitivity for known lesions was 90% and for suspected lesions, 89%, with an overall positive predictive value of 96%. Twenty-nine of the 30 patients had either low- or intermediate-grade NHL. Fifteen of 16 (94%) low-grade patients were correctly staged by RAID; three of these patients were correctly upstaged. Twelve of the 13 (92%) intermediate-grade patients were correctly staged by RAID; two of these patients were correctly upstaged. The high-grade NHL patient was staged correctly by RAID. Infused doses of 99mTc-labeled LL2 Fab' of 0.5 and 1.0 mg did not affect lesion sensitivity. The RAID sensitivity decreased as the total tumor burden increased > or = 100 g. On the basis of these initial results, the 99mTc-labeled Fab' fragment of MoAb LL2 (LymphoScan) seems to yield useful clinical information, especially for the staging of B-cell NHL patients who do not have bulky disease (i.e., tumor burdens of < or = 100 g).

Dominant lethal and heritable translocation tests with chlorambucil and melphalan in male mice

Chemicals used in the treatment of cancer include several that are potent mutagens in a range of in vitro and in vivo assays. For some, genetic effects have also been demonstrated in humans, detected as chromosomal aberrations in peripheral lymphocytes. Because (1) many of these agents are confirmed mutagens, (2) humans are exposed to them in relatively high doses, and (3) an increasing number of early cancer victims are surviving to reproductive age, it is important that information be available on the genetic and reproductive hazards associated with exposure to these agents. Chlorambucil and melphalan are structurally related chemicals that are included in our efforts to identify and assess such hazards among cancer chemotherapy agents. To date, both have been reported to induce specific locus mutations in germ cells of male mice (Russell et al., 1989; Russel et al., 1992b) and melphalan is one of very few chemicals shown to induce such mutations in spermatogonial stem cells. More recently, both chemicals were found to have strong reproductive effects in female mice (Bishop and Generoso, 1995, in preparation). In the present studies, these chemicals were tested for the induction of dominant lethal mutations and heritable translocations in male mice. Both chemicals were found to have reproductive effects attributable to cytotoxicity in specific male germ cell stages and to induce dominant lethal mutations and heritable translocations in postmeiotic germ cells, particularly in mid to early stage spermatids. Thus, relatively extensive data are now available for assessing the genetic and reproductive hazards that may result from therapeutic exposures to these chemicals.

Biokinetics in humans of RRR-alpha-tocopherol: the free phenol, acetate ester, and succinate ester forms of vitamin E

The bioavailability of RRR-alpha-tocopherol from the oral administration of RRR-alpha-tocopherol itself and its acetate and succinate esters was determined in healthy human subjects. Venous blood samples were withdrawn periodically over a 51-h period following oral administration of a gelatin capsule containing an equimolar mixture of RRR-alpha-tocopherol and RRR-alpha-tocopheryl acetate. In a second study, subjects received a capsule containing an equimolar mixture of RRR-alpha-tocopheryl acetate and RRR-alpha-tocopheryl succinate. In Study 1, RRR-alpha-tocopherol was absorbed at similar rates from both the free phenol, and the acetate ester and maximum plasma levels occurred at 12 h in most subjects. The extent of absorption of RRR-alpha-tocopherol varied considerably between subjects in absolute terms, but the relative absorption from the two forms was remarkably consistent, and a ratio of 1.0 was found for parameters of relative bioavailability in plasma. The concentration of RRR-alpha-tocopherol from each form was maximal at approximately 27 h in red blood cells and, as seen with the plasma data, there was a large interindividual variability. In Study 2, there was no significant difference in the extent of absorption of RRR-alpha-tocopherol from the acetate ester and the succinate ester, although there was an apparently higher initial rate of absorption from the acetate ester.

Recovery of DNA, RNA and protein from gels with microconcentrators

The use of a new product, Microcon/Micropure (a centrifugal ultrafiltration device combined with a microporus insert), for the purification of DNA, RNA, peptides and proteins from gels is described. Using this system, DNA can be recovered from agarose gel in concentrated, contamination-free form in only 15 min. Results of studies on the effects of fragment size and various pretreatment of the gel slice on DNA recovery are presented. The Microcan/Micropure combination can also be used for the recovery of macromolecules from polyacrylamide gels. Optimized protocols for the recovery of RNA, oligonucleotides and proteins from polyacrylamide gels using a crush and elute method, along with a study of critical parameters, are presented.

Rarefied white matter in patients with Alzheimer disease

Magnetic resonance head scans of 94 patients with probable Alzheimer disease (AD) and 45 patients with possible AD were examined prospectively to determine the prevalence and significance of rarefied cerebral white matter (leukoaraiosis) in patients with AD. Only 8.7% of patients with probable AD and 11.1% of patients with possible AD exhibited large confluent areas of subcortical leukoaraiosis. The remaining patients had variable degrees of leukoaraiosis surrounding the lateral ventricles. The magnitude of leukoaraiosis correlated with the patient's age but not with the Hachinski Ischemic and Mini Mental Status scores. Postmortem studies of two Alzheimer patients showed that their large confluent areas of subcortical leukoaraiosis consisted of rarefied white matter, gliosis, and arteriosclerotic small arteries. Eight additional Alzheimer patients who underwent autopsy had similar but less pronounced white matter changes limited to the periventricular regions of the cerebral hemispheres. Large confluent areas of rarefied subcortical white matter occur in a small minority of Alzheimer patients and are probably not caused by AD.

Factors influencing the amplitude and frequency of essential tremor

Quantitative electromyography (EMG) and triaxial accelerometry were used to measure hand tremor, finger tremor, and forearm motor unit activity in 36 men and 23 women with essential tremor. Hand tremor was studied with and without 300-g mass loading. Tremor and EMG were recorded twice, with a 3-min rest interval, to assess the spontaneous intertrial variability in tremor amplitude, frequency, and motor unit entrainment. In general, the minimum detectable differences in tremor amplitude, frequency, and motor unit entrainment were roughly 30%, 5%, and 10% of the initial sample means, respectively, assuming a sample size of 30 patients, a statistical power of 0.9, and a significance level of 0.05. Linear regression analyses were performed to test the hypotheses that (a) there is an age-associated decrease in tremor frequency that is independent of symptom duration and (b) tremor frequency and motor unit entrainment make independent contributions to tremor amplitude. Our data supported both hypotheses.

Pulse oximetry is accurate in acute anemia from hemorrhage

HYPOTHESIS

Pulse oximetry is an accurate, noninvasive assay of oxygen saturation percentage (SaO2) in acutely severe anemia (less than 5 g/dL).

DESIGN

A paired comparison of SaO2 by pulse oximetry (SpO2) and arterial blood gas analysis (SaO2) in patients with either acute gastrointestinal bleeding or blunt trauma with hematocrit of less than 20%.

SETTING

An academic emergency department in a tertiary referral hospital with a Level I trauma center.

PARTICIPANTS

Seventeen nonhypoxic patients were identified with initial hematocrit of less than 20% over a 9-month period.

MEASUREMENTS AND MAIN RESULTS

Determination of SaO2 by pulse oximetry and arterial blood analysis was not statistically significantly different (P < .05) over a range of hemoglobin levels from 2.3 to 8.7 g/dL. The observed mean difference between SpO2 and SaO2 was 0.53 +/- 0.23% (mean +/- SEM; n = 17). The 95% confidence interval associated with this difference score ranged from 0.044 to 1.014.

CONCLUSION

Despite reports that pulse oximetry is inaccurate below a hemoglobin concentration of 5 g/dL, our study suggested that this technology is accurate and reliable at 2.3 g/dL for nonhypoxic SaO2 values (SaO2 of more than 93%). The anemic endpoint where pulse oximetry either becomes inaccurate or simply fails to work has not been determined. Pulse oximetry overestimates SaO2 on average by 0.53% over a range of hemoglobin concentrations from 2.3 to 8.7 g/dL.

A district epilepsy service, with community-based specialist liaison nurses and guidelines for shared care

In order to improve epilepsy services, Doncaster Hospital doctors and general practitioners agreed upon a collaborative approach. A district epilepsy service was inaugurated around specialist services based in a hospital clinic. Guidelines were produced to clarify respective roles and to assist non-specialist hospital doctors and general practitioners in epilepsy management. A novel feature of the new service was the appointment of a community-based specialist liaison nurse. The new service is perceived to be effective, and the contribution of the specialist nurse to represent an important advance in epilepsy care. It has been possible to supervise complicated changes in medication successfully at home with a reduction in the need to attend clinic or GP. Counselling and support for patients and families, previously lacking, has been a major contribution. Evaluation to determine the extent to which the service meets the needs of those in the local population with epilepsy is planned. This document describes the first 5 years of the service and the scope and content of the specialist liaison nurse's role.