Tattoo allergy in patients receiving adjuvant radiotherapy for breast cancer

Tattooing is routinely employed prior to radiotherapy treatment but allergies to tattoos are rare. New information on the incidence of tattoo allergy at St George Hospital is presented with details of two clinical cases. The literature on tattoo allergy has been unable to estimate the incidence of allergic reaction to tattoos because the total number of patients treated is unknown and not all patients were followed up. Our radiation oncology population for the first time has provided a known denominator, but wide confidence intervals prevent an accurate estimate of the incidence. Salient issues about tattoo allergy are highlighted based on a review of the published literature from 1966 to 1998.

Health expectancy in New Zealand, 1981-1991: social variations and trends in a period of rapid social and economic change

STUDY OBJECTIVE

To assess social variations and trends in health expectancy over a period of rapid social and economic change.

DESIGN

Cross sectional survey data on the association between social status--gender, socioeconomic class and ethnic group--and measures of health status at two points in time approximately a decade apart. The Sullivan method of calculating health expectancy was used.

SETTING

The adult population of New Zealand in the periods 1980-81 and 1992-93.

PARTICIPANTS

Representative samples of the adult civilian non-institutionalised population of 6,891 (1980-81) and 5,873 (1992-93) respectively.

MAIN RESULTS

In comparison with life expectancy, adjusting for health status narrowed the gender gap but widened socioeconomic and ethnic differentials. These results were replicated for three measures--self reported health, mobility, and handicap--suggesting a robustness of outcome to specific indicators. Comparable data over the period of study were only available for the mobility measure. Increases in longevity appeared to be fully absorbed by minor disability. Ethnic and socioeconomic disadvantages remained static or widened for the 15-64 age group, suggesting a potential social polarisation in the disability transition.

CONCLUSIONS

The operationalization of health expectancy appears to be rather robust to specific indicators. Health expectancy may provide a sensitive health impact assessment of social and economic policy. Existing theories of the disability transition may need to be modified to take account of social variation, at least in the special case of disability free health expectancy over the 15-64 age range.

A simple method of evaluating patients' perceptions of their treatment and care

Surveys of patient satisfaction have become commonplace in mental health services. However, questions about the appropriateness of "satisfaction" as a concept and its use as an approach to evaluating the quality of service provision remain as pertinent as ever. Although surveys of patients of mental health services routinely generate high levels of apparent satisfaction, noncompliance with treatment and medication continues to be a major difficulty in psychiatric care. To evaluate services properly, there is a need to access patients' dissatisfaction to determine whether it is a more valid indicator of quality of services and a better predictor of noncompliance. However, a method that is not time consuming and costly is also required. The authors introduce a new patient evaluation tool, "Your Treatment and Care," which requires patients to report on their direct experience of care according to a set of principles of good practice. The tool forms part of a broader package for obtaining patients' views of their own problems, need for care, quality of care received, and health and social outcomes. The authors also report the results of a survey using this tool. Responses of 75 patients of a psychiatric hospital in the United States are presented and compared with results from a similar survey in the United Kingdom. The comparisons show striking differences in patients' perceptions of quality of treatment and care, both within each population and across clinical contexts.

Implementation of an outcomes management model of treatment

The author provides an overview of the new approach to clinical documentation and outcomes assessment and management that is being implemented at The Menninger Clinic as part of a larger effort to systematically study and refine the treatment provided by the Clinic. The scientific, clinical, economic, and regulatory context within which these changes are being made is discussed. Key aspects of the flow of clinical documentation, treatment planning, care recording, and the multifaceted assessment of outcomes and treatment satisfaction are summarized. This article explicates a model for the integration of the processes of clinical information recording with clinical measurement as a means for scientifically evaluating whole clinical systems and their treatment protocols and outcomes.

The How Are You? scale: a quality-of-life outcomes measure for routine practice

The How Are You? scale, a quality-of-life outcomes self-report measure to be completed by patients, was developed to address the concerns of the mental health consumer movement. Specific concerns included using less technical language in assessing mental health problems and developing a collaborative dialogue between clinician and patient. The How Are You? scale is a user-friendly instrument that allows patients to be actively involved in their assessment and treatment process. To implement the How Are You? scale into a recording and measurement system, its psychometric properties were assessed using two samples: (1) An employee group from The Menninger Clinic was used to assess internal consistency and stability, and (2) a patient group from The Menninger Clinic was used to assess known-group and discriminant validity, as well as sensitivity to change. The How Are You? scale was found to have good internal consistency and stability and good known-group and discriminant validity. It was also found to be sensitive to change. Although data continue to be collected at The Menninger Clinic, initial indications are that the How Are You? scale is a psychometrically sound outcomes measurement tool.

Which treatments help? The patient's perspective

In an effort to determine which specific aspects of treatment might account for patient satisfaction, the authors developed the Components of Treatment Questionnaire. This measure, which was administered to 500 adult inpatients along with the Client Satisfaction Questionnaire (CSQ-8; Larsen, Attkisson, Hargreaves, and Nguyen, 1979), asked patients to assess the helpfulness of their treatment. Convinced that patient input is pertinent to program design, the authors later surveyed 46 patients on treatments that they perceived as helpful and would like to receive. Respondents identified individual relationships and problem-focused therapies as the most helpful aspects of treatment.

Preventing bacterial adhesion onto surfaces: the low-surface-energy approach

Good-quality coatings prepared from poly(methylpropenoxyfluoroalkylsiloxane)s or poly(perfluoroacrylate)s are capable of inhibiting the bacterial colonisation of surfaces.

A rapid quantitative assay of intact paracetamol tablets by reflectance near-infrared spectroscopy

Near-infrared (NIR) reflectance spectroscopy was used to determine rapidly and non-destructively the content of paracetamol in bulk batches of intact Sterwin 500 mg tablets by collecting NIR spectra in the range 1100-2500 nm and using a multiple linear regression calibration method. The developed NIR method gave results comparable to the British Pharmacopoeia 1993 UV assay procedure, the standard errors of calibration and prediction being 0.48% and 0.71% m/m, respectively. The method showed good repeatability, the standard deviation and coefficient of variation for six NIR assays on the same batch on the same day being 0.14 and 0.16% m/m, respectively, while measurements over six consecutive days gave 0.31 and 0.36% m/m, respectively. Applying the calibration to a parallel test set gave a mean bias of -0.22% and a mean accuracy of 0.45%. The developed method illustrates how the full potential of NIR can be utilised and how the ICH guidelines which recommend the validation of linearity, range, accuracy and precision for pharmaceutical registration purposes can be applied. Duplicate determinations on bulk batches could be performed in under 2 min, allowing the potential use of the method on-line for real time monitoring of a running production process.

Pion conformal radiation of prostate cancer: results of a randomized study

PURPOSE

To compare the efficacy of pion radiation therapy with conventional external beam photon therapy, for the treatment of locally advanced stage T3/4, N0, M0 adenocarcinoma of the prostate.

METHODS AND MATERIALS

Two hundred seventeen eligible patients were randomly allocated to either photon or pion therapy. No adjuvant hormone therapy was used.

RESULTS

Median follow-up was 42 months (range 2-90). Acute bladder toxicity was worse in the pion arm, p = 0.2, but other acute toxicity did not differ. Late grade 2 toxicity was significantly less in the pion arm (29% at 5 years versus 48%, p = 0.002), but late grade 3 or 4 toxicity did not differ. Clinical local control was not significantly different between treatment arms (64% after 5 years with photons, 56% with pions, p = 0.6). Cause-specific and overall survival also did not differ (p = 0.7). There was a significant delay in time to first failure in the photon arm, largely as a result of decreased biochemical relapse, p = 0.01. A multivariate analysis is presented.

CONCLUSION

Pion therapy was well tolerated, with increased acute toxicity and significantly decreased late tissue injury. This contrasts with the late toxicity observed with higher LET particle therapy such as neutron therapy. No improvement in local control with pion therapy was observed.

Survival of brown kiwi exposed to 1080 poison used for control of brushtail possums in Northland, New Zealand

All 35 radio-tagged adult brown kiwi (Apteryx mantell i) survived at least three months after being exposed to 1080 poison (sodium monofluoroacetate) during a brushtail possum (Trichosurus vulpecul a) control operation; 22 birds were exposed to 1080 in pollard baits at a loading of 0.15% w/w, and 13 birds were exposed to 1080 presented in jam baits, at a loading of 0.08% w/w. A radio-tagged juvenile was killed by a predator 2.5 months after being exposed to jam baits. In the three months after the 1080 operation, the weights of adult kiwi in the poisoned area were no different from those in neighbouring bush patches. No traces of 1080 were found in six eggs collected from the poisoned area. From subsequent captures of birds, all 35 birds are known to have survived at least six months after the operation, and 33 (94%) survived one year after exposure to 1080 baits. These results are consistent with other similar, but smaller, studies of the survival of radio-tagged kiwi exposed to 1080 poison in pollard or carrot baits. We conclude that possum-control operations using green-dyed and cinnamon-lured pollard or jam baits laced with 1080 poison pose a very low risk to brown kiwi through accidental primary or secondary poisoning, or by starvation due to a diminished supply of large invertebrates.

The onset of coulomb explosions in polyatomic molecules

With the development of high intensity femtosecond lasers, the ionisation and dissociation dynamics of molecules has become an area of considerable interest. Using the technique of femtosecond laser mass spectrometry (FLMS), the molecules carbon disulphide, pyrimidine, toluene, cyclohexanone and benzaldehyde are studied with pulse widths of 50 fs in the near infrared (IR) wavelength region (790 nm). Results are presented and contrasted for laser beam intensities around 10(15) and 10(16) W cm(-2). For the lower intensities, the mass spectra yield dominant singly charged parent ions. Additionally, the appearance of doubly charged parent ions is evident for carbon disulphide, toluene and benzaldehyde with envelopes of doubly charged satellite species existing in these local regions. Carbon disulphide also reveals a small triply charged component. Such atomic-like features are thought to be a strong fingerprint of FLMS at these intensities. However, upon increasing the laser intensity to approximately 10(16) W cm(-2), parent ion dominance decreases and the appearance of multiply charged atomic species occurs, particularly carbon. This phenomenon has been attributed to Coulomb explosions in which the fast absorption of many photons may produce transient highly ionised parent species which can subsequently blow apart. Copyright 1999 John Wiley & Sons, Ltd.

Uniform molecular analysis using femtosecond laser mass spectrometry

The potential of femtosecond laser time-of-flight mass spectrometry (FLMS) for uniform quantitative analysis of molecules has been investigated. Various samples of molecular gases and vapours have been studied, using ultra-fast ( approximately 50 fs) laser pulses with very high intensity (up to 1.6 x 10(16) Wcm(-2)) for non-resonant multiphoton ionisation/tunnel ionisation. Some of these molecules have high ionisation potentials, requiring up to ten photons for non-resonant ionisation. The relative sensitivity factors (RSF) have been determined as a function of the laser intensity and it has been demonstrated that for molecules with very different masses and ionisation potentials, uniform ionisation has been achieved at the highest laser intensities. Quantitative laser mass spectrometry of molecules is therefore a distinct possibility. Copyright 1999 John Wiley & Sons, Ltd.

Quantification of paracetamol in intact tablets using near-infrared transmittance spectroscopy

Production batch samples of paracetamol tablets and specially prepared out-of-specification batches covering the range 90-110% of the stated amount (500 mg) were analysed by the BP official UV assay and by NIR transmittance spectroscopy. NIR measurements were made on 20 intact tablets from each batch, scanned five times each (10 min measurement time per batch) over the spectral range 6000-11,520 cm-1. An average spectrum was calculated for each batch. Partial least squares (PLS) regression models were set up using a calibration set (20 batches) between the NIR response and the reference tablet paracetamol content (UV). Various pre-treatments of the spectra were examined; the smallest relative standard error of prediction (0.73%) was obtained using the first derivative of the absorbance over the full spectrum. Only two principal components were required for the PLS model to give a good relationship between the spectral information and paracetamol content. Applying this model to the validation set (15 batches) gave a mean bias of -0.08% and a mean accuracy of 0.59% with relative standard deviations of 0.75 and 0.44%, respectively. The proposed method is non-destructive and therefore lends itself to on-line/at-line production control purposes. The method is easy to use and does not require a knowledge of the mass of the tablets.

Extreme hypoventilation reduces ventilator-induced lung injury during ventilation with low positive end-expiratory pressure in saline-lavaged rabbits

OBJECTIVE

To compare the degrees of ventilator-induced lung injury caused by two ventilation protocols.

DESIGN

Randomized trial.

SETTING

University animal laboratory.

SUBJECTS

Sixteen New Zealand white rabbits.

INTERVENTIONS

After five sequential saline lung lavages, eight pairs of anesthetized rabbits were allocated randomly to receive either of two ventilation protocols for 4 hrs during neuromuscular blockade. Both groups received 3 cm H2O of positive end-expiratory pressure and 100% oxygen. Control group animals received an estimated tidal volume of 12 mL/kg, an inspiratory time of 0.7 sec, and a ventilatory rate adjusted for a PaCO2 of 35 to 45 torr (4.7 to 6 kPa). Study group animals were ventilated through an intratracheal catheter, with inspiratory time of 1.5 secs, ventilatory rate of 20 breaths/min, and peak inspiratory pressure of 4 to 8 cm H2O, adjusted to maintain PaCO2 at 150 to 250 torr (20 to 33 kPa).

MEASUREMENTS AND MAIN RESULTS

Arterial blood gases were measured every 30 mins. After 4 hrs, a final lung lavage was performed. Physiologic parameters, cell counts and protein concentration in the final lavage, and lung histology were compared between groups. The alveolar-arterial oxygen tension gradient was higher in the study group over the first 1.5 hrs, but the time profile showed significantly (p = .001) greater improvement in the study group. After 4 hrs, the mean alveolar-arterial oxygen tension gradient was lower in the study group (94 torr [12.5 kPa] vs. 201 torr [26.8 kPa]). The increase in neutrophil count from the initial to the final lung lavage was lower in the study group (0.27 x 10(7) cells/L vs. 2.01 x 10(7) cells/L, p = .037), as was the absolute value of the neutrophil count in the final lavage (1.33 x 10(7) cells/L vs. 3.02 x 10(7) cells/L, p = .04). The median hyaline membrane score was lower in the study group (0.5 vs. 3.0) but the difference was not statistically significant.

CONCLUSION

These findings suggest that a very low tidal volume reduces ventilator-induced lung injury in saline-lavaged rabbits during ventilation at low lung volume.

Approximate standard errors and confidence intervals for indices of positive and negative agreement

Indices of positive and negative agreement for observer reliability studies, in which neither observer can be regarded as the standard, have been proposed. In this article, it is demonstrated by means of an example and a small simulation study that a recently published method for constructing confidence intervals for these indices leads to intervals that are too wide. Appropriate asymptotic (i.e., large sample) variance estimates and confidence intervals for the positive and negative agreement indices are presented and compared with bootstrap confidence intervals. We also discuss an alternative method of interval estimation motivated from a Bayesian viewpoint. The asymptotic intervals performed adequately for sample sizes of 200 or more. For smaller samples, alternative confidence intervals such as bootstrap intervals or Bayesian intervals should be considered.

Child rearing and child outcomes in Japan and the UK

Japan and the UK are compared in relation to various child health outcomes. It is noted that in the rates of child abuse and criminal activity, Japan is in a more favorable position. Rates of behavior problems and suicide rates are very similar in the two countries. Consideration is given to the reasons for the differences. The rates of single parents and divorce are much lower in Japan. The rates of working mothers are about the same, but Japanese women work longer hours. However, it is suggested that more important differences may lie in the greater respect for authority and emphasis on discipline and conformity in Japan. The effects of industrialization on family life and on child development are summarized. It is suggested that the separation of the adolescent age group from the rest of the population has had especially negative results in Western industrialized countries. Various suggestions are made concerning the positive role that pediatricians can play in promoting child development. In particular, pediatricians are encouraged to support and not undermine parents, to involve fathers in management of illness and disability, to press for full implementation of the United Nations Convention on the Rights of the Child, and for ready availability of good substitute child care facilities.

Use of the urine cortisol-to-creatinine ratio for monitoring dogs with pituitary-dependent hyperadrenocorticism during induction treatment with mitotane (o,p'-DDD)

OBJECTIVE

To determine whether the urine cortisol-to-creatinine ratio (UCCR) could replace the ACTH stimulation test in monitoring effectiveness of mitotane induction treatment in dogs with pituitary-dependent hyperadrenocorticism (PDH).

ANIMALS

15 dogs with PDH.

PROCEDURE

All 15 dogs were given an induction dose of mitotane (o,p'-DDD: 35 to 50 mg/kg of body weight/d) for 3 to 14 days. During the induction period, free-catch morning urine samples were collected for determination of UCCR, followed by ACTH stimulation testing, every other day. Treatment response was divided into 3 categories: well-controlled PDH (post-ACTH serum cortisol concentration > or = 28 nmol/L but < or = 138 nmol/L), deficient cortisol secretion (post-ACTH serum cortisol concentration < 28 nmol/L), and excess cortisol secretion (post-ACTH serum cortisol concentration > 138 nmol/L).

RESULTS

The linear relation between UCCR and post-ACTH serum cortisol concentration was significant (P < 0.001); however, the prediction intervals surrounding the line were too broad to be clinically useful. The UCCR overlapped among the 3 categories of treatment response. Nevertheless, dogs with PDH receiving mitotane induction treatment and with UCCR > 79 x 10(-6) were always classified as having excess cortisol secretion.

CONCLUSION AND CLINICAL RELEVANCE

The UCCR failed to predict post-ACTH cortisol concentration during mitotane induction treatment sufficiently close to be a clinically reliable indicator of treatment control. Seemingly, however, UCCR > 79 x 10(-6) obtained from a dog with PDH during mitotane induction would indicate inadequate adrenal cortex destruction and the need for continued mitotane induction; UCCR < or = 79 x 10(-6) would be inconclusive.