The future of tobacco product regulation and labelling in Europe: implications for the forthcoming European Union directive

The European Commission has announced that it is considering legislation concerning further restrictions on cigarette tar and nicotine yields, as well as new provisions to regulate additives and the labelling of tobacco products. This report considers these issues and their relation to public health. In particular, we argue that further reductions in tar and nicotine yields as measured by the International Standards Organisation/Federal Trade Commission (ISO/FTC) method will be largely cosmetic and certainly misleading to consumers. If a new directive uses the ISO/FTC methodology as a basis for regulation, it risks lending further official support to the concept of "low tar" cigarettes, which may be used by smokers as an alternative to smoking cessation. Although new regulations based on the ISO/FTC methodology may appear to offer health gains, these will be illusory and there may even be negative health consequences, as has been the case with these tests up to the present. We therefore make the following recommendations for the way forward.

Sputum cytology: a limited role

AIMS

To determine the cost and sensitivity of sputum cytology in routine use and to determine when sputum cytology is most appropriate.

METHODS

A retrospective study, based on all sputum cytology requests received in five histopathology/cytopathology laboratories in Yorkshire from 1 January to 31 December 1993. Cytology findings were correlated with histological diagnosis or clinical outcome, and related to the speciality of the referring clinician.

RESULTS

Laboratory practice and performance was similar in all five centres. The average laboratory cost of sputum cytology was 26.93. The mean absolute sensitivity was 36% and the specificity was 99.6%. The majority of specimens was submitted by general physicians or geriatricians. The largest proportion of positive specimens were submitted by chest physicians.

CONCLUSIONS

Often sputum cytology is used inappropriately as a screening investigation on, or soon after, admission. In addition, it is used inappropriately before bronchoscopy. Sputum cytology should be limited to individuals in whom a histological diagnosis is desired, but in whom bronchoscopy is inappropriate or unsuccessful.

British urological surgery practice: 1. Prostate cancer

OBJECTIVE

To investigate the treatment of prostate cancer in the United Kingdom.

METHODS

A postal survey was conducted of consultant urologists and general surgeons with an interest in urology to assess the current patterns of management of patients with prostate cancer in the UK and to determine patterns of clinical practice.

RESULTS

Two-hundred and seventy-four replies were analysed. Radical radiotherapy (50%) and radical prostatectomy (29%) were the most favoured treatment options for patients < 70 years old with poorly differentiated T1 disease; for those aged > 70 years, active treatment was favoured by 183 (67%) consultants with radical radiotherapy (37%) and hormonal intervention (29%) the most frequent choices. In well-differentiated T1 disease, active treatment was favoured by 226 (83%) of consultants for patients < 70 years, with radical prostatectomy (44%) the most frequent choice. For patients > 70 years, observational management was preferred by 190 (69%) of consultants. In poorly differentiated T1 prostate cancer, active treatment was favoured by 252 (91%) for patients < 70, with radiotherapy (50%) the most frequent choice and for patients > 70 years, active treatment was favoured by 67% with radical radiotherapy the most common preference being chosen, by 102 (37%). For asymptomatic locally advanced disease, 55% of consultants favoured active treatment, whilst 63% favoured the active treatment of asymptomatic metastatic disease. For patients with symptomatic metastatic disease, GnRH agonist therapy was the treatment of choice of 66% of urologists and was given as monotherapy by 44% or as part of maximal androgen blockade by 22%. In clinical practice, 82% of urologists have close links with oncology, available through joint clinics or on-site referral. However, < 5% of urologists refer patients to an oncologist before the development of hormone refractory disease. At relapse, only 53% of urologists referred their patients to oncologists or palliative-care clinicians. A wide variety of hormonal treatments was offered at relapse; only 24% of urologists treated their patients by antiandrogen withdrawal or introduction, which is currently the most effective second-line hormonal treatment for recurrent prostate cancer.

CONCLUSION

There is a wide variation in the clinical management of prostate cancer and we recommend the establishment of standards of practice.

An epidemic of optic neuropathy and painful sensory neuropathy in Cuba: clinical aspects

An epidemic of bilateral optic neuropathy and painful sensory neuropathy occurred in Cuba in 1991-1993. Over 45,000 individuals were stated to have been affected. We report a clinical study on 25 patients seen in Cuba in 1993-1994. Affected patients showed either bilateral optic neuropathy with caecocentral scotomata or a distal predominantly sensory neuropathy sometimes associated with deafness, or a combination of both optic and peripheral sensory neuropathy. The nature of the epidemic is discussed. The clinical features in patients with confirmed neurological deficits were consistent with a diagnosis of Strachan's syndrome, probably related to nutritional deficiency. Other patients with similar symptoms showed no evidence either of optic or peripheral neuropathy and were considered to represent disease mimicry on a psychoneurotic basis.

Validation of weighed records and other methods of dietary assessment using the 24 h urine nitrogen technique and other biological markers

Results from analysis of 24 h urine collections, verified for completeness with para-amino benzoic acid, and blood samples collected over 1 year were compared with 16 d weighed records of all food consumed collected over the year, and with results from 24 h recalls, food-frequency questionnaires and estimated food records in 160 women. Using the weighed records, individuals were sorted into quintiles of the distribution of the urine N excretion:dietary N intake ratio (UN:DN). UN exceeded DN in the top quintile of this ratio; mean ratio UN:DN = 1.13. Individuals in this top quintile were heavier, had significantly greater body mass indices, were reportedly more restrained eaters, had significantly lower energy intake:basal metabolic rate ratios (EI:BMR), and had correlated ratios of UN:DN and EI:BMR (r -0.62). Those in the top quintile reported lower intakes of energy and energy-yielding nutrients, Ca, fats, cakes, breakfast cereals, milk and sugars than individuals in the other quintiles but not lower intakes of non-starch polysaccharides, vitamin C, vegetables, potatoes or meat. Correlations between dietary intake from weighed records and 24 h urine K were 0.74 and 0.82, and between dietary vitamin C and beta-carotene and plasma vitamin C and beta-carotene 0.86 and 0.48. Correlations between dietary N intake from weighed records and 24 h urine excretion were high (0.78-0.87). Those between N from estimated food records and urine N were r 0.60-0.70. Correlations between urine N and 24 h recalls and food-frequency questionnaires were in the order of 0.01 to 0.5. Despite problems of underreporting in overweight individuals in 20% of this sample, weighed records remained the most accurate method of dietary assessment, and only an estimated 7 d diary was able to approach this accuracy.

Age specific antibody prevalence to parvovirus B19: how many women are infected in pregnancy?

Infection with parvovirus B19 is an important cause of late fetal mortality in the second trimester, and many infections in pregnancy remain undiagnosed. A serological survey stratified by age has been used to estimate the incidence of maternal infection with parvovirus B19 in pregnancy. Serum remaining from specimens submitted for diagnosis from 6864 people of all ages to seven public health laboratories in England was tested for antibody to parvovirus B19. The antibody prevalence rose with age to 45% at 10 years and 60% to 70% in adults. The age specific force of infection was highest in children aged less than 10 years and lowest in adults. Maternal infection with parvovirus B19 is estimated to occur in approximately one pregnancy in 400. It has been estimated that fetal death occurs in 9% of these cases, which suggests that parvovirus B19 may cause more than 150 fetal deaths in England and Wales each year. Testing for evidence of recent infection with parvovirus B19 should be considered for unexplained cases of fetal hydrops in the second trimester, especially in years of parvovirus B19 epidemics.

Antibody capture haemadherence tests for parvovirus B19-specific IgM and IgG

In the absence of serum inhibitor human parvovirus B19 agglutinates primate red cells. Agglutination of baboon erythrocytes by inhibitor free baculovirus expressed VP1/VP2 proteins of B19 virus was enhanced by low pH. To avoid interference from inhibitor(s) present in serum specimens microtitre tests with an antibody capture configuration were designed and optimised. Antigen binding was demonstrated by the adherence of baboon erythrocytes. These tests (MACHAT, GACHAT) detected IgM or IgG anti-B19 in 1032 serum specimens with an overall sensitivity of 99%, specificity of 98.2% and positive predictive value of 96.8% with reference to the radioimmunoassays currently in diagnostic use. MACHAT and GACHAT are straightforward, and well suited to large scale research and seroepidemiological investigations. They are without the risks from infectious antigen and radiation associated with existing radioimmunoassays and allow the phenomenon of B19 virus haemagglutination to be put to practical advantage.

The perception of identity by 6 1/2-month-old infants

In Study 1, sixteen 6 1/2-month-olds were habituated to a Reversible stimulus (an upright face that could be perceived as an entirely different upright face when it was rotated 180 degrees) and to a Nonreversible stimulus (a face that could be perceived as upright in only one orientation). Following habituation for each type of stimulus, test trials paired the habituated face with a novel stimulus (an inversion of the same face). For both Reversible and Nonreversible stimuli, the physical difference between the old and new test stimuli was the same (a 180 degrees rotation); however, infants devoted more visual attention to the 180 degrees rotation only when it was a Reversible face, suggesting that the identity change was detected. Experiment 2 ruled out the explanation that infants might have failed to dishabituate to the inversion of the Nonreversible stimulus because they could not remember it. Results are interpreted as evidence that 6 1/2-month-old infants are not limited to face recognition based on similarity in pattern arrangement alone, but are capable of processing faces at a representational level.

Fatty acids in plasma phospholipids and cholesterol esters from identical twins concordant and discordant for schizophrenia

The fatty acid compositions of plasma phospholipids and cholesterol esters were measured in 18 pairs of twins discordant for schizophrenia and 20 pairs concordant for schizophrenia. In the twins discordant for schizophrenia the only significant abnormalities were elevations of adrenic (22:4n-6) and docosapentaenoic (22:5n-6) acids in the schizophrenic twins. These fatty acids have also recently been reported to be elevated in brains from schizophrenics. The twins concordant for schizophrenia showed many differences from the normal discordant twins. 22:4n-6 and 22:5n-6 were even more abnormal than in the schizophrenic discordant twins. In addition, linoleic acid was significantly reduced, an abnormality which has been found consistently in other schizophrenic populations. These observations are consistent with the concept that unsaturated fat metabolism may be abnormal in schizophrenia.

Minimal deviation adenocarcinoma (adenoma malignum) of the endocervix: a histochemical and immunohistochemical study of two cases

The histopathological diagnosis of minimal deviation adenocarcinoma (adenoma malignum) of the endocervix may be difficult. Two cases of minimal deviation adenocarcinoma (MDA) were examined using mucin histochemistry and immunocytochemistry with antibodies to epithelial membrane antigens (HMFG1, Ep1), low-molecular-weight cytokeratins (CAM 5.2), carcinoembryonic antigen (CEA), and alpha-amylase. The results were compared with those for normal endocervical glands. Reactivity for CEA in MDA was focal and would be unreliable for biopsy diagnosis. Both cases of MDA contained abundant neutral mucins and sialomucins, whereas sulfomucins were rarely detected; this pattern contrasted with that of normal endocervix. Neoplastic glandular epithelial cells in MDA consistently showed both luminal and cytoplasmic reactivity with Ep1 and HMFG1, whereas normal cervix showed luminal labeling only. Thus, mucin histochemistry and immunohistochemical detection of epithelial membrane antigens may distinguish between extremely well differentiated neoplastic glands in MDA and normal endocervical glands, and hence may aid diagnosis in biopsy specimens.