Implications of microscopic satellites of the primary and extracapsular lymph node spread in patients with high-risk melanoma: pathologic corollary of Eastern Cooperative Oncology Group Trial E1690

PURPOSE

To correlate the presence of extracapsular spread (ECS) of regional nodal metastases, and micrometastasis near the primary tumor, with disease outcome in the intergroup study E1690 in relation to the impact of recombinant interferon-alfa (rIFN alpha)-2b.

PATIENTS AND METHODS

E1690 included 642 patients with American Joint Committee on Cancer stage IIB or III cutaneous melanoma. Patients were randomized into high- and low-dose rIFN alpha-2b treatment arms and an observation arm. Pathologic slides were reviewed for selected parameters from at least half of the subjects in all three arms. Evaluation of the primary tumor included notations regarding ulceration, mitotic activity, thickness, microscopic satellites (MS), and nodal ECS on a standardized pathology form. These data were collated in relation to relapse-free survival (RFS) and overall survival (OS) at 50 months' follow-up and studied using Cox regression analysis.

RESULTS

Ulceration, mitotic activity, thickness, and size of tumor-bearing lymph nodes did not show a statistically significant correlation with either OS or RFS across all treatment arms. The presence of MS was correlated with RFS (P =.0008) and OS (P =.05). ECS correlated with RFS (hazard ratio = 1.44, P =.032) but not OS (P =.11).

CONCLUSION

The presence of MS (in 6% [18 of 308 patients]) had a significant adverse impact on both RFS (P =.0008) and OS (P =.053). Ulceration, mitotic activity, thickness, and number of positive lymph nodes had no significant effect on OS in this subset study (univariate or multivariate Cox analysis). The presence of ECS in lymph nodes had a significant adverse effect on RFS (P =.032) but not on OS.

Knee moment profiles during walking: errors due to soft tissue movement of the shank and the influence of the reference coordinate system

The effect soft tissue movement of the shank had on knee joint moments during natural cadence walking was investigated in this study. This was examined by comparing knee moments determined from bone-anchored and surface mounted tracking targets. Six healthy adult subjects participated in this study. The largest difference (3 N m) occurred about the AP axis, with smaller differences of approximately 2 and 1 N m about the flexion/extension (F/E) and longitudinal (Long) axes, respectively. The magnitude of these differences would not likely affect the clinical interpretation of the data. The effect of reporting knee moments in two different orthogonal reference systems was also examined. The peak extension moment was significantly greater when expressed about an anatomical axis following the line of the malleoli than when the moment was reported about an axis parallel to the frontal plane of the shank. In contrast, the first peak abduction moment was significantly greater when expressed about an axis perpendicular to the frontal plane of the shank. Care should therefore be exercised whenever comparisons between studies are made in which the reference axes are not aligned.

Deposition and pharmacokinetics of flunisolide delivered from pressurized inhalers containing non-CFC and CFC propellants

Our objective was to assess the deposition and pharmacokinetics of a novel formulation of flunisolide (Aerobid, Forest Laboratories) in hydrofluoroalkane (HFA) 134a delivered by pressurized metered dose inhaler (pMDI). The design was a two-way crossover investigation in 12 healthy male subjects comparing HFA-134a flunisolide by pMDI versus pMDI plus 50 mL spacer device. Four of these subjects also took part in a two-way crossover investigation comparing chlorofluorocarbon (CFC) flunisolide pMDI versus pMDI plus Aerochamber holding chamber. The imaging technique of gamma scintigraphy was used to quantify total and regional lung deposition of flunisolide. Plasma levels of flunisolide and its major metabolite (6beta-OH flunisolide) were also determined. The spacer and Aerochamber reduced oropharyngeal deposition dramatically for both the HFA and CFC products (mean 59.8 to 14.9% (p < 0.01) of ex-valve (metered) dose for HFA product; 66.3 to 12.3% (p < 0.01) of ex-valve dose for CFC product) owing to deposition of part of the dose on the walls of the add-on devices themselves. Lung deposition averaged 22.6 and 40.4% (p < 0.01) of the ex-valve dose for the HFA formulation used with pMDI alone and with pMDI plus spacer. Mean lung deposition of the CFC formulation delivered via the Aerochamber (mean 23.4%) was higher than that for the CFC pMDI alone (mean 17.0%), but this difference was not statistically significant. Lung deposition expressed as percentage ex-device (delivered) dose averaged 68.3% for HFA pMDI plus spacer and 19.7% for CFC pMDI. Plasma levels of flunisolide were higher for the pMDI plus spacer than for pMDI alone, reflecting higher lung deposition via the spacer, but plasma levels of the 6beta-OH flunisolide metabolite were higher for the pMDI alone as a consequence of higher oropharyngeal deposition. When delivered via the spacer, pulmonary targeting of the flunisolide HFA formulation was improved compared with the CFC formulation, which should benefit patients by providing satisfactory asthma therapy from a much-reduced delivered dose of flunisolide.

Oxidative interactions of synthetic lung epithelial lining fluid with metal-containing particulate matter

Epidemiology studies show association of morbidity and mortality with exposure to ambient air particulate matter (PM). Metals present in PM may catalyze oxidation of important lipids and proteins present in the lining of the respiratory tract. The present study investigated the PM-induced oxidation of human bronchoalveolar lavage (BAL) fluid (BALF) and synthetic lung epithelial lining fluid (sELF) through the measurement of oxygen incorporation and antioxidant depletion assays. Residual oil fly ash (ROFA), an emission source PM that contains approximately 10% by weight of soluble transition metals, was added (0-200 microg/ml) to BALF or sELF and exposed to 20% (18)O(2) (24 degrees C, 4 h). Oxygen incorporation was quantified as excess (18)O in the dried samples after incubation. BALF and diluted sELF yielded similar results. Oxygen incorporation was increased by ROFA addition and was enhanced by ascorbic acid (AA) and mixtures of AA and glutathione (GSH). AA depletion, but not depletion of GSH or uric acid, occurred in parallel with oxygen incorporation. AA became inhibitory to oxygen incorporation when it was present in high enough concentrations that it was not depleted by ROFA. Physiological and higher concentrations of catalase, superoxide dismutase, and glutathione peroxidase had no effect on oxygen incorporation. Both protein and lipid were found to be targets for oxygen incorporation; however, lipid appeared to be necessary for protein oxygen incorporation to occur. Based on these findings, we predict that ROFA would initiate significant oxidation of lung lining fluids after in vivo exposure and that AA, GSH, and lipid concentrations of these fluids are important determinants of this oxidation.

Feline vaccination guidelines

The 1998 Report of the American Association of Feline Practitioners and Academy of Feline Medicine Advisory Panel on Feline Vaccines was developed to help veterinary practitioners formulate vaccination protocols for cats. The current panel report updates information, addresses questions, and speaks to concerns raised by the 1998 report. In addition it reviews vaccine licensing, labeling, and liability issues and suggests ways to successfully incorporate vaccination protocol changes into a private practice setting.

Frequent overcrowding in U.S. emergency departments

OBJECTIVE

To describe the definition, extent, and factors associated with overcrowding in emergency departments (EDs) in the United States as perceived by ED directors.

METHODS

Surveys were mailed to a random sample of EDs in all 50 states. Questions included ED census, frequency, impact, and determination of overcrowding. Respondents were asked to rank perceived causes using a five-point Likert scale.

RESULTS

Of 836 directors surveyed, 575 (69%) responded, and 525 (91%) reported overcrowding as a problem. Common definitions of overcrowding (>70%) included: patients in hallways, all ED beds occupied, full waiting rooms >6 hours/day, and acutely ill patients who wait >60 minutes to see a physician. Overcrowding situations were similar in academic EDs (94%) and private hospital EDs (91%). Emergency departments serving populations < or =250,000 had less severe overcrowding (87%) than EDs serving larger areas (96%). Overcrowding occurred most often several times per week (53%), but 39% of EDs reported daily overcrowding. On a 1-5 scale (+/-SD), causes of overcrowding included high patient acuity (4.3 +/- 0.9), hospital bed shortage (4.2 +/- 1.1), high ED patient volume (3.8 +/- 1.2), radiology and lab delays (3.3 +/- 1.2), and insufficient ED space (3.3 +/- 1.3). Thirty-three percent reported that a few patients had actual poor outcomes as a result of overcrowding.

CONCLUSIONS

Episodic, but frequent, overcrowding is a significant problem in academic, county, and private hospital EDs in urban and rural settings. Its causes are complex and multifactorial.

The feasibility of a kinematic measure of lip closure during meaningful speech

PURPOSE

Assessment of dysarthria has traditionally been based on perceptual methods. The purpose of this study was to examine the feasibility of using 2D kinematic analysis to measure lip closure during normal speech.

METHOD

Retroflective markers (4 mm diameter) were placed on the midline of each lip of three healthy male, caucasian volunteers aged 69 years who repeated the sentence 'My mother made me an apple and blackberry pie' six times. Videorecordings were analysed using the Ariel Performance Analysis System to calculate the distance between the lips before, during and after the sentence.

RESULTS

The graphs produced from the data objectively measured the distance between the lips and identified the eight bilabial sounds. However, in spite of stringent study criteria to minimize differences linked to age, gender and race, differences were found between participants.

CONCLUSION

Kinematic 2D analysis may have potential for the objective measurement of lip closure in dysarthria in the context of meaningful speech. These results justify further pilot work to explore: the possible variability within defined populations; and the usefulness of 2D kinematic analysis in the measurement of disordered lip closure in dysarthria.

Guidelines for the microbiological quality of some ready-to-eat foods sampled at the point of sale. PHLS Advisory Committee for Food and Dairy Products

These guidelines for the microbiological quality of ready-to-eat foods represent a revision and expansion of guidelines first published by the PHLS in September 1992 and revised in March 1996. The latest guidelines incorporate many of the constructive comments received from food examiners and other microbiologists within and outside the PHLS and from environmental health officers throughout the United Kingdom. This document reviews the changes and the reasons they were made and sets out the new guidelines. It also clarifies the role of food examiners in interpreting the microbiological results of formal samples.

Concepts of health: implications for public health work

This article explores the health concepts of community health care (CHC) nurses in relation to their potential roles as public health workers. On examining Ewen's (1998) study of CHC nurses' role perceptions, it is evident that an individualized, person-centred, holistic approach to care continues to dominate practice. The public health role within CHC nursing remains underdeveloped and is equated with primary prevention with the well population. A 'community-as-foreground' model is proposed as a useful way of redefining CHC nursing practice to incorporate public health. The discussion revolves around the need for a broader view of health to include a political and social dimension, and considers the role of education and practice in achieving this.

Disease and gill lesions in yellow perch (Perca flavescens) exposed to oil sands mining-associated waters

Adult yellow perch were stocked into experimental ponds designed to test the biological effects of aquatic reclamation alternatives currently being pursued by the oil sands mining industry. Water-quality characteristics of oil sands-influenced water in the experimental ponds included increased salinity and elevated trace organics associated with raw oil sands (bitumen). After 3 and 10 months of exposure to affected waters, perch gross pathologies including severe fin erosion and virally induced tumors were observed in exposed individuals. Gill histopathology revealed large aneurysms accompanied by a proliferation of chloride and epithelial cells in the interlamellar spaces. Gill pathologies were not paralleled by a decrease in plasma sodium, calcium, or chloride. The frequencies of gross pathologies and gill changes were correlated to the concentrations of the oil sands-related compounds. As inorganic and organic compounds associated with oil sands activities are highly intercorrelated, and the observed lesions and changes are not diagnostic of particular toxicants, it was not possible to isolate the causative chemical factor(s) responsible. The incidence of observed lesions and gill pathologies could not be conclusively linked to increased mortality rates observed in the exposed populations. Evidence of recovery in the pathologies was observed between 3 and 10 months of exposure, coincident with a stabilization in population numbers.

Induction of pulmonary matrilysin expression by combustion and ambient air particles

The molecular mechanism(s) by which chemically complex air pollution particles mediate their adverse health effects is not known. We have examined the ability of combustion and ambient air particles to induce pulmonary matrilysin expression due to the well-documented role of matrix metalloproteinases in tissue injury and repair responses. Rats were exposed to saline, residual oil fly ash (2.5 mg/rat), or ambient air particles (2.5 mg/rat) via intratracheal instillation and examined 3-72 h after exposure. Saline-exposed animals had low levels of matrilysin mRNA, whereas the animals exposed to either complex particle showed an early induction of pulmonary matrilysin gene expression as well as of the 19-kDa activated form of matrilysin. Immunocytochemistry and in situ hybridization analyses identified the alveolar macrophages and monocytes as primary sources of air pollution particle-induced matrilysin expression. Matrilysin gene induction and protein activation by combustion and ambient air particles correlated with the early histopathological changes produced by these particles. These results demonstrate the ability of combustion and ambient air particles to induce pulmonary matrilysin expression and suggest a role for this matrix metalloproteinase in the initiation of lung injury produced by these particles.

High- and low-dose interferon alfa-2b in high-risk melanoma: first analysis of intergroup trial E1690/S9111/C9190

PURPOSE

Pivotal trial E1684 of adjuvant high-dose interferon alfa-2b (IFNalpha2b) therapy in high-risk melanoma patients demonstrated a significant relapse-free and overall survival (RFS and OS) benefit compared with observation (Obs).

PATIENTS AND METHODS

A prospective, randomized, three-arm, intergroup trial evaluated the efficacy of high-dose IFNalpha2b (HDI) for 1 year and low-dose IFNalpha2b (LDI) for 2 years versus Obs in high-risk (stage IIB and III) melanoma with RFS and OS end points.

RESULTS

A total of 642 patients were enrolled (608 patients eligible), of whom a majority (75%) had nodal metastasis (50% had nodal recurrence). Unlike E1684, E1690 allowed entry of patients with T4 (> 4 mm) deep primary tumors, regardless of nodal dissection, and 25% of the patients entered onto this trial had deep primary tumors (compared with 11% in E1684). At 52 months' median follow-up, HDI demonstrated an RFS benefit exceeding that of LDI compared with Obs. The 5-year estimated RFS rates for the HDI, LDI, and Obs arms were 44%, 40%, and 35%, respectively. The hazards ratio for the intent-to-treat analysis of HDI versus Obs was 1.28 (P(2) =.05); for LDI versus Obs, it was 1.19 (P(2) =.17). By Cox analysis, the impact of HDI on RFS achieved significance (P(2) =.03). The RFS benefit was equivalent for node-negative and node-positive patients. Neither HDI nor LDI has demonstrated an OS benefit compared with Obs at this time. A major improvement in the median OS of patients in the E1690 Obs arm was noted in comparison with E1684 (6 years v 2.8 years). An analysis of salvage therapy for patients who relapsed on E1690 demonstrated that a significantly larger proportion of patients in the Obs arm received IFNalpha-containing salvage therapy compared with the HDI arm; this therapy was unavailable to patients during E1684, and patients with undissected regional nodes were not included in E1684. This study did not specify therapy at recurrence. Analysis of treatments received at recurrence demonstrated significantly more frequent use of IFNalpha2b at relapse from Obs than from HDI, which may have confounded interpretation of the survival benefit of assigned treatments in E1690.

CONCLUSION

The results of the intergroup E1690 trial demonstrate an RFS benefit of IFNalpha2b that is dose-dependent and significant for HDI by Cox multivariable analysis.

"Wet Voice" as a predictor of penetration and aspiration in oropharyngeal dysphagia

This article describes the results of a study that investigated how well wet phonation can predict penetration and/or aspiration of ingested material in dysphagic patients. Voice samples of 23 subjects with neurologic oropharyngeal dysphagia were collected immediately after each subject had swallowed nine different boluses on videofluoroscopy. The boluses were graded according to three different consistencies and three different sizes. The presence of wetness in the voice was analyzed in relation to any ingested material that remained in the larynx or trachea after each bolus was swallowed. Results showed that there was no association between the presence of a wet voice and penetration or aspiration of prandial material after a swallow. The importance of detecting wet phonation by itself was therefore not considered diagnostic in detecting prandial penetration/aspiration by the bedside, but a wet voice may still be useful in identifying those with dysphagia who may have laryngeal dysfunction and therefore may be at risk of penetrating/aspirating any type of material, not just prandial material.

Pandora's box: physician order entry and nursing work redesign

The Canadian health care industry is undergoing unprecedented restructuring in response to the quest for quality management and cost reduction. Physician order entry and on-line results viewing within a fully integrated hospital clinical information system is often thought to be essential to maximum quality management, cost control, and clinical decision support. Using Hackman and Oldham's Job Characteristics model (1989) as a grounding for discussion, this author examines the impact of computerized physician order entry and on-line results viewing on the intrinsic meaning of nursing work and its subsequent redesign. This paper explores the historical meaning of nursing work related to the manual transcription of physician's orders, and contemplates the implications for future nursing work and research. Until now there has been little discussion in the current informatics literature on this topic.

Prediction of bone strength of distal forearm using radius bone mineral density and phalangeal speed of sound

This investigation compares quantitative ultrasound (QUS) measurement of the phalanges with peripheral quantitative computed tomography (pQCT) and dual X-ray absorptiometry (DXA) measurement of the forearm, to estimate the strength of the distal radius in 13 cadaveric forearms. The cadavers were scanned at the distal radius by pQCT and DXA for bone mineral density (BMD) and at the approximate phalanges by QUS for speed of sound (SOS). The distal radii were subjected to a simulated Colles fracture produced with a materials testing machine. The load at which the distal radius was fractured was considered as a representation of bone strength. The bone strength correlated significantly with SOS at different phalanges (r = 0.63-0.72), BMD at different regions of interest by DXA (r = 0.67-0.75), and cortical BMD at different sites by pQCT (r = 0.61-0.67). Standard stepwise regression analysis showed that adding phalangeal SOS into forearm densitometric variables significantly enhanced the statistical power for prediction of the strength of the distal radius. Our results suggest that, for assessment of site-specific distal forearm strength, QUS measurement of the phalanges is comparable to forearm densitometry. Phalangeal QUS may add clinical value if distal forearm strength has a high priority.

Variable pulmonary responses from exposure to concentrated ambient air particles in a rat model of bronchitis

Chronic bronchitis may be considered a risk factor in particulate matter (PM)-induced morbidity. We hypothesized that a rat model of human bronchitis would be more susceptible to the pulmonary effects of concentrated ambient particles (CAPs) from Research Triangle Park, NC. Bronchitis was induced in male Sprague-Dawley rats (90-100 days of age) by exposure to 200 ppm sulfur dioxide (SO2), 6 h/day x 5 days/week x 6 weeks. One day following the last SO2 exposure, both healthy (air-exposed) and bronchitic (SO2-exposed) rats were exposed to filtered air (three healthy; four bronchitic) or CAPs (five healthy; four bronchitic) by whole-body inhalation, 6 h/day x 2 or 3 days. Pulmonary injury was determined either immediately (0h) or 18 h following final CAPs exposure. The study protocol involving 0 h time point was repeated four times (study #A, November, 1997; #B, February, 1998; #C and #D, May, 1998), whereas the study protocol involving 18 h time point was done only once (#F). In an additional study (#E), rats were exposed to residual oil fly ash (ROFA), approximately 1 mg/ m(3)x6 h/day x 3 days to mimic the CAPs protocol (February, 1998). The rats allowed 18 h recovery following CAPs exposure (#F) did not depict any CAPs-related differences in bronchoalveolar lavage fluid (BALF) injury markers. Of the four CAPs studies conducted (0 h time point), the first (#A) study (approximately 650 microg/m3 CAPs) revealed significant changes in the lungs of CAPs-exposed bronchitic rats compared to the clean air controls. These rats had increased BALF protein, albumin, N-acetyl glutaminidase (NAG) activity and neutrophils. The second (#B) study (approximately 475 microg/m3 CAPs) did not reveal any significant effects of CAPs on BALF parameters. Study protocols #C (approximately 869 microg/m3 CAPs) and #D (approximately 907 microg/m3 CAPs) revealed only moderate increases in the above mentioned BALF parameters in bronchitic rats exposed to CAPs. Pulmonary histologic evaluation of studies #A, #C, #D, and #F revealed marginally higher congestion and perivascular cellularity in CAPs-exposed bronchitic rats. Healthy and bronchitic rats exposed to ROFA (approximately 1 mg/m3) did not show significant pulmonary injury (#E). Analysis of leachable elemental components of CAPs revealed the presence of sulfur, zinc, manganese, and iron. There was an apparent lack of association between pulmonary injury and CAPs concentration, or its leachable sulfate or elemental content. In summary, real-time atmospheric PM may result in pulmonary injury, particularly in susceptible models. However, the variability observed in pulmonary responses to CAPs emphasizes the need to conduct repeated studies, perhaps in relation to the season, as composition of CAPs may vary. Additionally, potential variability in pathology of induced bronchitis or other lung disease may decrease the ability to distinguish toxic injury due to PM.

The efficacy of tone-reducing features in orthotics on the gait of children with spastic diplegic cerebral palsy

This study analyzed the effects of tone-reducing features in ankle-foot orthotics (AFOs) on the gait of eight children (ages 4-11 years) with spastic diplegic cerebral palsy. A standard gait analysis was performed on each subject in each of three trial orthotics and in a baseline shoes-only condition. A 4-week accommodation period was allotted for each of the three devices: a standard hinged AFO, an AFO with tone-reducing features, and a supramalleolar orthotic with tone-reducing features. Most significant differences were at the ankle, between free-ankle and plantar flexion-limiting conditions. No significant functional changes in gait were evident with the addition of tone-reducing properties to a standard articulating AFO.

Implications of Working Time Regulations for theatre nurses working in the NHS

The European Working Times Regulations have implications for staff throughout the NHS. In particular, theatre staff and others working on call and shifts need to be aware of the implications of these regulations. In this article, Jon Richards, National Officer for Unison, explains the background to and implications of these regulations for theatre staff.

Validity and reliability of a kinematic protocol for determining foot contact events

Timing of foot contact events provides important information for gait studies. The aim of the study is to validate the use of kinematic data, collected at 50 Hz to define foot contact events during gait initiation. Simultaneous kinetic and kinematic data recordings of four discrete foot contact events were made for normal adults. Raters were asked to estimate the timing of the events from kinematic data curves and these timings were compared with those derived from the kinetic data. For the four events, between 88 and 98% of all ratings were accurate to within 0.03 s. Inter-rater reliability was extremely high, reflecting the precision of the definitions used.