Imidazolidinyl Urea

The Expert Panel for Cosmetic Ingredient Safety reviewed updated information that has become available since their original assessment from 1980, along with updated information regarding product types, and frequency and concentrations of use, and reaffirmed their original conclusion that Imidazolidinyl Urea is safe as a cosmetic ingredient in the practices of use and concentration as described in this report.

BHT - Butylated Hydroxytoluene

The Expert Panel for Cosmetic Ingredient Safety reviewed updated information that has become available since their original assessment from 2002, along with updated information regarding product types, and frequency and concentrations of use, and reaffirmed their original conclusion that BHT is safe as a cosmetic ingredient in the practices of use and concentration as described in this report.

Sodium Naphthalenesulfonate and Sodium Polynaphthalenesulfonate

The Expert Panel for Cosmetic Ingredient Safety reviewed newly available studies since their original assessment in 2003, along with updated information regarding product types and concentrations of use, and confirmed that Sodium Naphthalenesulfonate and Sodium Polynaphthalenesulfonate are safe as cosmetic ingredients in the practices of use and concentration as described in this report in formulations intended to be applied to the skin.

A critical role for cortical amygdala circuitry in shaping social encounters

Aggression is an evolutionarily conserved behavior that controls social hierarchies and protects valuable resources like mates, food, and territory. In mice, aggressive behaviour can be broken down into an appetitive phase, which involves approach and investigation, and a consummatory phase, which involves biting, kicking, and wrestling. By performing an unsupervised weighted correlation network analysis on whole-brain c-Fos expression, we identified a cluster of brain regions including hypothalamic and amygdalar sub-regions and olfactory cortical regions highly co-activated in male, but not female aggressors (AGG). The posterolateral cortical amygdala (COApl), an extended olfactory structure, was found to be a hub region based on the number and strength of correlations with other regions in the cluster. Our data further show that estrogen receptor 1 (ESR1)-expressing cells in the COApl exhibit increased activity during attack behaviour, and during bouts of investigation which precede an attack, in male mice only. Chemogenetic or optogenetic inhibition of COApl ESR1 cells in AGG males reduces aggression and increases pro-social investigation without affecting social reward/reinforcement behavior. We further confirmed that COApl ESR1 projections to the ventrolateral portion of the ventromedial hypothalamus and central amygdala are necessary for these behaviours. Collectively, these data suggest that in aggressive males, COApl ESR1 cells respond specifically to social stimuli, thereby enhancing their salience and promoting attack behaviour.

Integrating the patients' voice in designing and delivering a research study: The Yorkshire Cancer Research funded PREHABS study's experience

INTRODUCTION

Engaging with patients when designing a clinical or research project is beneficial; feedback from the intended audience provides invaluable insight form the patients' perspective. Working with patients can result in developing successful research grants and interventions. The benefit of including the voice of the patient in the Yorkshire Cancer Research funded PREHABS study is described in this article.

METHODS

Patients were included in the PREHABS study from inception to completion. The Theory of Change methodology was used to provide a framework to implement patient feedback to refine the study intervention.

RESULTS

In total, 69 patients engaged with the PREHABS project. Two patients were recruited as co-applicants on the grant and were members on the Trial Management Group. Six patients attended the pre application workshop and provided feedback on their lived experiences of being a lung cancer patient. Commentary from the patients influenced the interventions selected and the design of the prehabs study. Following ethical approval (21/EE/0048) and informed written consent, 61 patients were recruited into the PREHABS study between October 2021 and November 2022. The breakdown of recruited patients was 19 males: mean age 69.1 years (SD 8.91) and 41 females; mean age 74.9 years (SD 8.9).

CONCLUSION

It is practicable and beneficial to include patients at all stages of designing and delivering a research study. Patient feedback can help refine the study interventions to allow for maximum acceptance, recruitment and retention.

IMPLICATIONS FOR PRACTICE

Including patients in the design of radiotherapy research studies can provide invaluable insight that can support the selection and delivery of interventions that are acceptable to the patient cohort.

Safety Assessment of Cocos nucifera (Coconut)-Derived Ingredients as Used in Cosmetics

The Expert Panel for Cosmetic Ingredient Safety (Panel) assessed the safety of 11 Cocos nucifera (coconut)-derived ingredients, most of which are reported to function as skin-conditioning agents in cosmetic products. The Panel reviewed the available data to determine the safety of these ingredients. The Panel concluded that 10 ingredients, derived from coconut flower, fruit, and liquid endosperm, are safe in cosmetics in the present practices of use and concentration described in this safety assessment, and that the available data are insufficient to make a determination of safety for Cocos Nucifera (Coconut) Shell Powder under the intended conditions of use in cosmetic formulations.

Prehabilitation and Rehabilitation for Patients with Lung Cancer: A Review of Where we are Today

Lung cancer is the third most common type of cancer in the UK, with nearly 50 000 new cases diagnosed a year. Treatments for lung cancer have improved in recent years with the advent of new surgical and radiotherapy techniques and the increased use of immunotherapies. These advances have resulted in increasing numbers of patients surviving beyond the completion of their treatment. Lung cancer patients are now not dying from their cancer diagnosis, but from other co-existing pathologies. Lung cancer patients commonly present with multiple comorbidities. Mitigating the effects of poor lifestyles and changing behaviours may improve the efficacy of treatments, reduce side-effects and improve the quality of life for lung cancer patients. Published evidence supports the use of interventions to manage behavioural habits, to optimise the health of patients. There is no consensus as to what, when or how to embed these into the patient pathway. Supporting patients before, during and after their cancer treatments to increase activity, eat well and stop smoking have been seen to decrease side-effects and improve patient outcomes and wellbeing. The challenge is to provide a package of interventions that is acceptable to patients and fits within the patient pathway so as not to conflict with diagnostic and therapeutic activities. This article reviews where we are today with providing behavioural support to optimise the health of lung cancer patients undergoing treatment.

IPV nurse education: Scoping things out to see who's doing what?

Introducing best practice approaches to help nursing students identify and respond to patients who are/have been exposed to intimate partner violence (IPV) is instrumental to their professional development. The objectives of this study are to gather preliminary data from the American Association for the Colleges of Nursing (AACN) affiliated schools of nursing to determine 1) if they offer any training of students at the undergraduate or graduate level in identifying and responding to IPV; 2) if so, what are the components of that training, outcomes, and satisfaction with the existing approach; 3) if not, what are the individual and institutional level barriers to offering this training; and 4) if schools are interested in incorporating best practice, IPV training content into their curriculum.

DESIGN AND METHODS

A total of 836 AACN affiliated nursing schools across the US were surveyed using a 64-item electronic survey.

RESULTS

Of the 95 (11%) schools that completed at least 40% of the survey, approximately 60% offer IPV training once at the undergraduate level and only 30% offered such preparation at the graduate level. We found that most IPV education took place as embedded material within an existing course. Those nursing schools not providing any IPV education identified that they would like to at both levels and the 50% of nursing schools already providing this education said they wanted to provide more. The greatest barriers to offering IPV education were lack of faculty expertise and time constraints, yet about 70% of the participants stated that IPV education should be an essential part of undergraduate and graduate nursing school.

CONCLUSION

This study provides useful insights to inform IPV curriculum development by identifying common gaps in IPV education experienced by participating schools and strategies for addressing them.

Clinical academic radiographers - A challenging but rewarding career

OBJECTIVES

To explain what a clinical academic career can be, what it can lead to for the individual, profession and most importantly the patient, and why these roles are so important to radiography.

KEY FINDINGS

Multiple challenges to the adoption of clinical academic careers exist, including achievable measurable outcomes, visibility & senior support, and balancing different time demands. Equally the rewards are wide ranging and can advance both the individual and profession through role extension opportunities, increased career progression, patient benefits, and academic and research skills.

CONCLUSION

Clinical academic careers can provide advantages for the individual, department, profession and most importantly the patient with advanced clinical practice through evidenced based research.

IMPLICATIONS FOR PRACTICE

Improving clinical academic careers within Radiography will promote research participation and increase radiographic roles in patient-centred research delivery and development. Combining evidenced based research with academic skills will lead to improved patient care and better clinical outcomes.

Safety Assessment of Hydrolyzed Wheat Protein and Hydrolyzed Wheat Gluten as Used in Cosmetics

The Cosmetic Ingredient Review (CIR) Expert Panel (Panel) reviewed the product use, formulation, and safety data on hydrolyzed wheat protein and hydrolyzed wheat gluten, which function as skin- and hair-conditioning agents. The Panel determined that data from clinical and laboratory studies were sufficient to demonstrate that these ingredients will not elicit type 1 immediate hypersensitivity reactions in sensitized individuals and will not induce sensitization when the polypeptide lengths of the hydrolysates do not exceed 30 amino acids. The Panel concluded that hydrolyzed wheat gluten and hydrolyzed wheat protein are safe for use in cosmetics when formulated to restrict peptides to an average molecular weight of 3,500 Da or less.

The Economic Impact of Space Weather: Where Do We Stand?

Space weather describes the way in which the Sun, and conditions in space more generally, impact human activity and technology both in space and on the ground. It is now well understood that space weather represents a significant threat to infrastructure resilience, and is a source of risk that is wide-ranging in its impact and the pathways by which this impact may occur. Although space weather is growing rapidly as a field, work rigorously assessing the overall economic cost of space weather appears to be in its infancy. Here, we provide an initial literature review to gather and assess the quality of any published assessments of space weather impacts and socioeconomic studies. Generally speaking, there is a good volume of scientific peer-reviewed literature detailing the likelihood and statistics of different types of space weather phenomena. These phenomena all typically exhibit "power-law" behavior in their severity. The literature on documented impacts is not as extensive, with many case studies, but few statistical studies. The literature on the economic impacts of space weather is rather sparse and not as well developed when compared to the other sections, most probably due to the somewhat limited data that are available from end-users. The major risk is attached to power distribution systems and there is disagreement as to the severity of the technological footprint. This strongly controls the economic impact. Consequently, urgent work is required to better quantify the risk of future space weather events.

Safety Assessment of Nylon as Used in Cosmetics

The Cosmetic Ingredient Review Expert Panel (Panel) reviewed the safety of nylon polymers, which function in cosmetics primarily as bulking and opacifying agents. The Panel reviewed relevant animal and human data related to these large polymers and determined that they are not likely to penetrate the skin. Whatever residual monomers may be present were not present at a sufficient level to cause any reactions in test subjects at the maximum ingredient use concentration. Accordingly, the Panel concluded that these ingredients are safe in the present practices of use and concentration.

Safety Assessment of Animal- and Plant-Derived Amino Acids as Used in Cosmetics

The Cosmetic Ingredient Review Expert Panel (Panel) reviewed the safety of animal- and plant-derived amino acid mixtures, which function as skin and hair conditioning agents. The safety of α-amino acids as direct food additives has been well established, based on extensive research through acute and chronic dietary exposures and the Panel previously has reviewed the safety of individual α-amino acids in cosmetics. The Panel focused its review on dermal irritation and sensitization data relevant to the use of these ingredients in topical cosmetics. The Panel concluded that these 21 ingredients are safe in the present practices of use and concentration as used in cosmetics.

Time-resolved imaging of contrast kinetics three-dimensional (3D) magnetic resonance venography in patients with pelvic congestion syndrome

The purpose of this study was to assess the role of magnetic resonance venography (MRV) with time-resolved imaging of contrast kinetics (TRICKS) in dynamically evaluating ovarian vein dilation, reflux and direction of flow in patients with suspected pelvic congestion syndrome (PCS). The hypotheses tested were: (i) That conspicuity scores of the ovarian veins across three raters was greater using TRICKS MRV compared with T2W or T(2)* imaging; (ii) That three key MR variables (ovarian vein diameter, timing and grade of reflux) correlated across all raters. We carried out a retrospective study of 13 patients undergoing T2W and TRICKS MRI and pelvic sonography (n = 4) or catheter venography (n = 5). Three observers rated conspicuity, vessel diameter, timing and grade of ovarian vein reflux for T(2)/T2*W and TRICKS MRI. The mean left ovarian diameter for all patients with reflux was 7.9 mm (range 2.2-12 mm). There was high inter-observer agreement for ovarian vein diameter for both sequences. TRICKS showed significantly greater conspicuity than T(2)/T2*W imaging (TRICKS: T(2)/T2* mean (SD) = 7.80 (3.20):5.50 (1.97), F (1,12) = 5.80, p < 0.05). TRICKS MRV demonstrated high inter-observer correlation for timing and grade of reflux (r (36) = 0.77,0.71,0.79, p < 0.01). TRICKS MRA/V was significantly degraded by breathing artefact in two patients. We conclude that TRICKS MRV accurately and dynamically demonstrates ovarian vein reflux in patients with PCS but requires quiet respiration. TRICKS MRV has better image conspicuity than T(2)/T2*W imaging and sufficient temporal resolution to distinguish between Grade I, II and III reflux.

Open access to MRI for general practitioners: 12 years' experience at one institution -- a retrospective analysis

The aim of this study was to evaluate 12 years of general practitioner (GP) use of open access MRI services at a single London teaching hospital. A retrospective analysis of reports from all GP requests for MRI scans between 1994 and 2005 was performed. The date, scanned body part, and requester details from 1798 scans requested by 209 individual GPs over a continuous 12-year period were recorded. All scans were then graded into four categories based on the severity of reported findings from normal to gross abnormality. Over the study period, GP requests as a percentage of the total (MRI) department workload remained low at approximately 2.6%. Spine, knee and brain requests constituted 86% (n = 1546) of requested scans. 48% (n = 868) of scans were reported as normal or minor degenerative changes only. 26% (n = 466) of scans demonstrated serious pathology that was likely to warrant hospital consultant referral. There was a wide range of scans requested per requester, from 1 to 240 over the period, with an average of 8.5 scans per GP. In conclusion, any department wishing to set up open access to MRI services for GPs could cover the majority of requests by offering spine, knee and brain imaging. The percentage of normal report rates for GP requests is comparable with previous studies of outpatient referrals. A large variation in requesting patterns between GPs suggests the need for increased communication between GPs and imaging departments to optimise use of the service.

Serial STIR magnetic resonance imaging correlates with clinical score of activity in thyroid disease

PURPOSE

To assess the correlation between inflammatory activity in extraocular muscles measured with serial short tau inversion recovery (STIR) sequence magnetic resonance imaging (MRI) scans and clinical disease activity in thyroid eye disease.

METHODS

In this retrospective study, 22 patients with thyroid eye disease who had undergone serial MRI scans using the STIR sequence were assessed. The signal intensity ratio (SIR) of the most inflamed extraocular muscle was compared with the Mourits score (a clinical measure of thyroid eye disease activity).

RESULTS

The SIR value has previously been shown to correlate with clinical activity of thyroid eye disease. In a particular patient the SIR value increases in proportion with the clinical features of the disease as assessed by the Mourits rating system. When the change in STIR sequence MRI is compared with the change in Mourits score rating for a given patient the correlation is highly significant (p < 0.001).

CONCLUSIONS

This study confirms that serial STIR sequence MRI scans correlate with clinical disease activity. Inflammatory activity in the most inflamed muscle (as measured by SIR) reflects overall disease activity. SIR values obtained from MRI scans provide a useful measure of disease activity and may help in the monitoring and treatment of this condition.

Expanded analysis of injury mortality among unionized construction workers

BACKGROUND

To evaluate the utility of expanding the number and precision of injury categories used in previous occupational mortality studies, this study reanalyzed data from four previous studies of unionized construction workers (construction laborers, ironworkers, sheet metal workers, and operating engineers), by expanding the number of injury categories from 6 to 33.

METHODS

Proportionate mortality ratios (PMRs) were computed using the distribution of deaths from the National Occupational Mortality Surveillance System, a mortality surveillance system from 28 states, as a comparison. A blue collar comparison group was also used in additional analyses to adjust for socioeconomic and other factors.

RESULTS

This reanalysis identified significantly elevated PMRs in at least one of the four worker groups for falls, motor vehicle crashes, machinery incidents, electrocutions, being struck by falling objects, being struck by flying objects, explosions, suffocation, and water transport incidents. Limiting the comparison population to deaths among blue collar workers did not change the results substantially.

CONCLUSIONS

This study demonstrates that increasing the precision of categories of death from injury routinely used in mortality studies will provide improved information to guide prevention. Am. J. Ind. Med. 37:364-373, 2000. Published 2000 Wiley-Liss, Inc.

The immune response of the desert locust Schistocerca gregaria during mycosis of the entomopathogenic fungus, Metarhizium anisopliae var acridum

Topical application of Metarhizium anisopliae var acridum to the desert locust Schistocerca gregaria resulted in changes in the biochemistry and antimicrobial defenses of the haemolymph. M. anisopliae var acridum colonized the host haemolymph from day two post application. The haemocytes did not attach to, phagocytose or nodulate elements of the fungus. However, the presence of the fungus appeared to stimulate hemocyte aggregation over the first few days of mycosis though the number of aggregates declined subsequently. The total hemocyte count increased two days after application, indicating an overall stimulation of the immune system, but declined to a value below that for uninoculated controls by day four. The differential haemocyte count showed that the initial increase in total haemocyte count was primarily due to a larger number of coagulocytes. After day two consistent declines in cell number were observed for all haemocyte classes in mycosed insects. The activity of the enzyme, phenoloxidase, decreased during the course of infection. However, the converse was true for prophenoloxidase. Lysozyme levels were significantly smaller in infected than control locusts. There was a significant correlation between lysozyme and PO activities when data from mycosed and control insects were combined. The total protein content of the haemolymph decreased during the course of infection.

Cancer mortality in health and science technicians

BACKGROUND

Nearly one million U.S. women are employed as health or science technicians with various chemical and biological exposures, but few studies have looked at their health outcomes.

METHODS

Using 1984-1995 mortality data with coded occupation information, we calculated race- and age-adjusted proportionate cancer mortality ratios (PCMRs) and 95% confidence intervals for two age groups for black and white women with occupations of clinical laboratory (CLT), radiologic, and science technician.

RESULTS

For CLTs, the PCMRs for breast cancer were borderline significantly elevated. The PCMRs for leukemia were significantly elevated, particularly for myeloid leukemia. Radiologic technicians had no significantly elevated PCMRs. Science technicians had significantly elevated PCMRs for non-Hodgkin's lymphoma and multiple myeloma in the younger age group.

DISCUSSION

The elevated risks for lymphatic and hematopoietic neoplasms in CLTs and science technicians may be associated with occupational exposures.

School violence in an impoverished South African community

OBJECTIVE

The aim of this anthropological study was to create an understanding of school-related violence experienced by adolescents in the context of chronic poverty in a South African community.

METHOD

Qualitative methods of data collection such as participant observation, interviews, and group discussions were utilized for data collection. Sixteen children and three adults in turn kept diaries and wrote reports during the research period of three and one-half years (June 1992-December 1995). All the Standard seven pupils (N = 76) of the local school completed a self-concept questionnaire and wrote two essays about themselves and their lives, respectively.

RESULTS

The ideology and structures of apartheid created a context of impoverishment and structural violence to which children were exposed. The school was one of the social institutions where children were subjected to structural, psychological, and physical violence on a daily basis. Violent behavior or discipline was justified as being just and an effective teaching practice by authoritarian parents and teachers. The manifestations of poverty included emotional erosion, a negative self-concept, and reactive violence.

CONCLUSIONS

School-related violence was structurally interwoven with the very fabric of the social hierarchy of the school set-up and was sanctioned as an effective strategy to gain social control and discipline children. Poverty in itself provided the breeding-ground for violence at home and in the school. Children were caught up in a vicious circle of pro- and reactive violence and socialized to accept violence as an instrument of empowerment. Recommendations for possible intervention and further research are offered.

Tame the paper tiger

Computerizing an organization's policies and guidelines is difficult but rewarding. The assessment, planning, implementation, and evaluation of converting all paper policies and procedures into a computerized system are outlined, with particular focus on organizing guidelines according to the Joint Commission on Accreditation of Healthcare Organization's (JCAHO) functional standards.

Occupation and cervical cancer: an opportunity for prevention

Cervical cancer remains an important health problem for women. Few published studies have examined cervical cancer with respect to a woman's occupation. This study examines the association of cervical cancer mortality and occupation in a large national database. The purpose of the study is to recommend which occupations may most require health promotion activities. Mortality data from the National Occupational Mortality Surveillance System were used to calculate the proportion of deaths from cervical cancer according to occupation. This study is based on standardized death certificate data for almost 2 million deaths among women in 27 states, covering the period 1985-1990. Our results are consistent with those in previous studies, with service and apparel manufacturing workers showing elevated risk. Data presented show a difference in cervical cancer mortality by occupational group. Identification of these occupations suggests which women could be targeted for preventive services. Women in occupations with low socioeconomic status are less likely to have access to health promotion programs. Resources should be directed to these women.

Women: work and health

OBJECTIVES

This report describes the sociodemographics, household characteristics, and health of women according to workforce status and job conditions. The report also presents data on men for comparison.

METHODS

This report combines data from numerous data systems, including: The National Health Interview Survey, National Health and Nutrition Examination Survey, National Maternal and Infant Health Survey, National Hospital Ambulatory Medical Care Survey, National Traumatic Occupational Fatalities Surveillance System, and the National Occupational Mortality Surveillance System, which are conducted by the U.S. Department of Health and Human Services; the Census of Fatal Occupational Injuries and Annual Survey of Occupational injuries and illnesses conducted by the U.S. Department of Labor; and the Current Population Survey conducted by the U.S. Department of Commerce. The report also presents selected tables from publications of the Women's Bureau and the Bureau of Labor Statistics, U.S. Department of Labor.

RESULTS

The report presents summary data on physical conditions and exposures, health conditions attributed to work, other health conditions that impact on work, health promotion in the workplace, and health-related benefits provided by employers. Most estimates are shown according to sex, age, race, ethnicity, educational attainment, and major occupational group.

Mortality patterns among female nurses: a 27-state study, 1984 through 1990

OBJECTIVES

This study examined the mortality experience of 50,000 nurses using the National Occupational Mortality Surveillance database of death certificates.

METHODS

Proportionate mortality ratios adjusted by race (White, Black, or other) and 5-year age groups were calculated for selected causes of death among female nurses vs all workers and white-collar workers.

RESULTS

Excess deaths among nurses less than 65 years of age were seen in both comparison groups for viral hepatitis, cancer of the nasal cavities, accidental falls, suicide, and drug-related deaths. Among nurses 65 years old or older, deaths due to chronic myeloid leukemia were in excess. Proportionate mortality ratios for breast and colon cancers, diabetes, and heart disease varied by occupational comparison group.

CONCLUSIONS

These findings confirm results of previous studies and identify new associations. Redoubled efforts are called for in overcoming obstacles to reducing workplace hazards.

High frequency of apolipoprotein E epsilon 2 allele in hemorrhage due to cerebral amyloid angiopathy

From the somewhat conflicting published data on apolipoprotein E (apoE) genotype in hemorrhage due to cerebral amyloid angiopathy (CAA), it is unclear whether apoE genotype influences the risk of CAA-related hemorrhage independently of its association with concomitant Alzheimer's disease (AD). We determined the apoE genotypes of 36 patients presenting with cerebral hemorrhage associated with histologically confirmed CAA. The frequency of apoE epsilon 2 was 0.25 and the frequency of apoE epsilon 4 was 0.18. Patients with CAA-related hemorrhage and concomitant AD pathology (CERAD criteria, n = 17) had a high apoE epsilon 4 frequency, close to that in AD cases without hemorrhage. Patients in whom CAA-related hemorrhage occurred in the absence of significant AD pathology (n = 13) had an apoE epsilon 4 frequency somewhat lower than non-AD controls without hemorrhage. However, in CAA-related hemorrhage, the apoE epsilon 2 frequency was high regardless of whether significant AD pathology was present. We conclude that whereas possession of apoE epsilon 2 may be a risk factor for cerebral hemorrhage due to CAA, apoE epsilon 4 is a risk factor for concomitant AD but not an independent risk factor for CAA-related hemorrhage.

Accuracy of birth certificate data regarding the amount, timing, and adequacy of prenatal care using prenatal clinic medical records as referents

This study compared birth certificate data on the amount, timing, and adequacy of prenatal care with the same data abstracted from the prenatal clinic records of 2,032 women who attended a health department prenatal clinic in northeast Georgia from 1980 to 1988. Overall accuracy was poor. Only 14.3% (n = 291) of the records completely agreed on the total number of visits, while approximately 36% (n = 738) and 53% (n = 1,081) agreed within one visit and two visits, respectively. Complete agreement for month and trimester prenatal care began was 31.1% (n = 632) and 50.6% (n = 1,202), respectively. Because of the small geographic region included in the current study, the generalizability of these findings to other populations may be limited.

Randomized comparison of coronary thrombolysis achieved with double-bolus reteplase (recombinant plasminogen activator) and front-loaded, accelerated alteplase (recombinant tissue plasminogen activator) in patients with acute myocardial infarction. The RAPID II Investigators

BACKGROUND

The therapeutic benefit of thrombolytic therapy has been shown to correlate directly with completeness (TIMI grade 3 flow) and speed of reperfusion of the infarct-related coronary artery. The purpose of the RAPID II study was to determine whether a double-bolus regimen of reteplase, a recently developed deletion mutant of wild-type tissue plasminogen activator, could improve 90-minute coronary artery patency rates achieved with the most successful standard regimen, an "accelerated" front-loaded infusion of alteplase.

METHODS AND RESULTS

Three hundred twenty-four patients with acute myocardial infarction were randomized to receive (along with intravenous heparin and aspirin) either a 10 plus 10 megaunits double bolus of reteplase or front-loaded alteplase. The primary end point of "patency at 90 minutes, graded according to the TIMI classification" was centrally assessed in a blinded fashion. Infarctrelated coronary artery patency (TIMI grade 2 or 3) and complete patency (TIMI grade 3) at 90 minutes after the start of thrombolytic therapy were significantly higher in the reteplase-treated patients (TIMI grade 2 or 3: 83.4% versus 73.3% for front-loaded alteplase-treated patients, P = .03; TIMI grade 3: 59.9% versus 45.2%, P = .01). At 60 minutes, the incidence of both, patency and complete patency, was also significantly higher in reteplase-treated patients (reteplase versus alteplase, TIMI grade 2 or 3: 81.8% versus 66.1%, P = .01; TIMI grade 3: 51.2% versus 37.4%, P < .03). Reteplase-treated patients required fewer acute additional coronary interventions (13.6% versus 26.5%, P < .01), and 35-day mortality was 4.1% for reteplase and 8.4% for alteplase (P = NS). There were no significant differences between reteplase and alteplase in bleedings requiring a transfusion (12.4% versus 9.7%) or hemorrhagic stroke (1.2% versus 1.9%).

CONCLUSIONS

Reteplase, when given as a double bolus of 10 plus 10 megaunits to patients with acute myocardial infarction, achieves significantly higher rates of early reperfusion of the infarct-related coronary artery and requires significantly fewer acute coronary interventions than front-loaded alteplase without an apparent increased risk of complications.

Assessment of mortality in the construction industry in the United States, 1984-1986

Construction, one of the larger industries in the United States, employs 7.6 million workers, many in skilled trades occupations. Previously published data about potential worksite exposures and mortality of construction site workers are limited. We analyzed occupation and industry codes on death certificates from 19 U.S. states to evaluate mortality risks among men and women usually employed in construction occupations. Proportionate mortality ratios (PMRs) for cancer and several other chronic diseases were significantly elevated among 61,682 white male construction workers who died between 1984 and 1986. Men younger than age 65, who were probably still employed immediately prior to death, had significantly elevated PMRs for cancer, asbestos-related diseases, mental disorders, alcohol-related disease, digestive diseases, falls, poisonings, traumatic fatalities that are usually work-related, and homicides. Elevated PMRs for many of the same causes were observed to a lesser degree for black men and white women whose usual industry was construction. In addition, women experienced excess cancer of the connective tissue and suicide mortality. Various skilled construction trades had elevated PMRs for specific sites, such as bone cancer and melanoma in brickmasons, stomach cancer in roofers and brickmasons, kidney and bone cancer in concrete/terrazzo finishers, nasal cancer in plumbers, pulmonary tuberculosis in laborers, scrotal cancer and aplastic anemia in electricians, acute myeloid leukemia in boilermakers, rectal cancer and multiple sclerosis in electrical power installers, and lung cancer in structural metal workers. Using a standard population of blue collar workers did not result in fewer elevated PMRs for construction workers. Despite lifestyle differences and other limitations of the study, the large numbers of excess deaths observed in this study indicate the need for preventive action for construction workers.

Suicide and occupation: a review of the literature

Suicide is the eighth leading cause of death in the United States. Suicide rates have been reported to be particularly high in professional, managerial, and executive groups. We reviewed English language epidemiological studies on suicide and occupation published since 1982. Some studies suggest that workers in a number of occupations, including chemistry, farming, and law enforcement, may have elevated suicide rates. The weight of current evidence supports the conclusion that both male and female physicians have elevated rates of suicide, with females at particularly high risk. Elevated rates of suicide in a particular occupational group may result from a complex interaction between job factors such as work stress and access to means and other risk factors such as age and presence of a mental disorder.

Subtotal submucosal cricoid resection: an experimental study

It has generally been considered that the cricoid cartilage is essential for maintaining airway continuity. The purpose of this experimental study was to test this concept by evaluating the effects of subtotal excision of the canine cricoid cartilage. Eight adult mongrel dogs were studied. They received general anesthesia and were intubated. By using a vertical midline incision, the cricoid cartilage was exposed. Subtotal cricoid resection was performed by submucosal dissection; the mucosal continuity was not violated. The resultant defect in the cricoid cartilage was reconstructed with a polytetrafluoroethylene (PTFE) graft which was sutured in place with prolene sutures. All the dogs were extubated immediately after surgery. None required tracheostomy or ventilatory support and none had any respiratory problems during the follow-up period. They were all able to eat soon after surgery. The animals were followed for up to 4 to 6 months and then sacrificed to permit evaluation of the condition of the airway and subglottic space. There was fibrous scarring outside the graft but no evidence of airway narrowing. Despite submucosal fibrosis, the mucosa appeared normal. The data documented that dogs tolerate subtotal cricoid resection very well and develop no subglottic stenosis. The resultant defect in the cricoid cartilage can readily be reconstructed with a PTFE graft.

An experimental model for the surgical correction of tracheomalacia

Tracheomalacia may result from large intrathoracic goiters. Due to the chronic compression, particularly within the confines of the thoracic inlet, the tracheal wall weakens, with disintegration of some of the cartilaginous rings. Tracheomalacia can cause acute airway distress, particularly during the post-operative period, and may occasionally result in death. The other major cause of tracheomalacia is related to either prolonged endotracheal intubation or over-inflation of the tracheostomy cuff. While various techniques such as internal stenting, external support devices, tracheostomy, and tracheal resection have been used based on individual circumstances, no one method appears to be perfect. To further study this difficult problem, an experimental model of tracheomalacia was created in eight dogs. Six to seven rings of the tracheal cartilages were dissected submucosally. More than half of the circumference of the tracheal rings was resected. The tracheal walls were reconstructed with polytetrafluoroethylene (PTFE) grafts. The grafts strengthened the tracheal wall without causing luminal constriction. Tracheostomy was not performed on any of the dogs. All dogs tolerated the procedure well and were extubated at the conclusion of the experiment. The dogs were followed for 4 to 6 months and then sacrificed so that the tracheal wall could be examined histologically. There was considerable fibrosis leading to stiff neotrachea. The results of this experimental technique for prosthetic reconstruction to counteract problems simulating tracheomalacia are very encouraging.

Parathyroid autotransplantation during thyroid surgery

Permanent hypoparathyroidism is one of the most distressing complications of thyroid surgery. The incidence of this iatrogenic complication varies between 3 and 25 percent among patients undergoing total thyroidectomy. Parathyroid injury may be caused by inadvertent removal of the parathyroids, ligation of the blood supply, or destruction secondary to capsular hematoma. Attention to such technical details as identification of the parathyroids, dissection close to the thyroid gland, preservation of the blood supply to the parathyroids, and avoiding manipulation of parathyroids reduces the incidence of temporary and permanent hypoparathyrodism. However, if the parathyroids are injured, the best method of preserving their function is by autotransplantation. Over the past 7 years we have performed 250 thyroidectomies. An attempt was made to identify and preserve parathyroid gland in each case. Even during lobectomy procedures, the ipsilateral parathyroids were identified and preserved. Whenever any of the parathyroids was devascularized or separated from the surrounding structures, it was autotransplanted into the sternomastoid muscle. The sternomastoid was chosen for autotransplantation rather than forearm muscles to avoid an added incision and because selective measurement of parathormone is not essential in this group of patients. Prior to autotransplantation, confirmation of the nature of the tissue was made by frozen section of a small portion of the parathyroid gland. Parathyroid autotransplantation was performed in 15 instances, even when only one parathyroid was injured. Only one member of this group of 15 patients developed temporary hypoparathyroidism, which disappeared after 4 weeks of calcium supplementation. The remaining patients had an uncomplicated recovery. Autotransplantation of the parathyroid glands should be performed whenever the parathyroid is devascularized or damaged by retraction or hematoma. It is essential for every thyroid surgeon to be familiar with the technique of parathyroid autotransplantation.

Goiters and airway problems

Even though thyroid enlargement occurs commonly, the incidence of goiter has decreased in the United States due to the routine use of iodized salt. We continue to see a large number of patients with neglected goiters that cause airway compression. The progressive nature of this disease occasionally results in severe tracheal compression and acute airway distress. We treated 120 patients with airway compression secondary to goiters during a 7-year period. Thirty patients presented initially with acute airway distress requiring either intubation or semiemergent surgery. The decision to operate was based primarily on clinical evaluation and airway films. Ninety patients had substernal goiters. Only one patient required sternal splitting. If one lobe was enlarged causing tracheal deviation, lobectomy was performed; if both lobes were enlarged, subtotal thyroidectomy was performed. Two patients required tracheostomy. There were no operative deaths, and morbidity was limited to minor wound problems. It is important to consider early surgical decompression whenever tracheal compression is caused by goiters, especially if the patients are symptomatic or there is mediastinal extension.

A case-control study of bladder cancer using city directories as a source of occupational data

Commercial city directories, currently produced in 1,250 United States cities, potentially provide yearly information on occupation and employer for all city residents over age 18 years. To investigate the usefulness of these occupational data, the authors have conducted a case-control study of male bladder cancer mortality in Hamilton County, Ohio (which includes Cincinnati). A total of 731 bladder cancer cases who died during 1960-1982 were matched on age, sex, race, date-of-death, and residence at death to two controls per case. Risks of bladder cancer death were calculated by occupation, industry, and specific employer, using both city directories (multiple statements) and death certificates (single statement). Four companies showed a significant excess bladder cancer risk when using city directories. Only one would have been identified using death certificates, which ask for usual lifetime type of industry rather than a specific company name. Using city directories, significant positive associations were found between bladder cancer and occupation as an engineer, tailor, carpenter, furnace operator, blending machine operator, chemist, pressing machine operator, house cleaner, or salesman. For industry, the authors found significant positive associations for the textile, chemical, grain mill, foundry, petroleum, building service, entertainment, and advertising industries. A significant increase in risk for those with 20 or more years of employment was seen for those employed as truck drivers and furnace operators, or those employed in the railroad industry. A check of the validity of city directory data indicated that 77 per cent of the listings agreed with Social Security earnings reports for employer in any given year. One limitation of Hamilton County city directory data was the fairly large number of yearly listings without any occupational data (15 per cent for occupation, 36 per cent for employer). While city directory data do provide work history over time, unlike death certificates, such data are available only for years of residence in the city in question.

Improving the use of epidemiologic data in health risk assessment

Epidemiologic data with quantitative exposure measures is infrequently available for specific environmental agents. This lack of exposure measures creates confusion in interpreting epidemiologic data and therefore has impeded its efficient use in health risk analysis. This paper discusses screening and evaluating epidemiologic studies for use in assessing health risk. It also describes the larger role of epidemiology in reducing uncertainties in risk analysis. The approach recognizes that the various designs used to increase statistical power and to control for covariables have different functions in contemporary risk assessment as practiced by regulatory agencies. Each of these study designs is categorized for its role in risk analysis as useful for hazard identification or for dose-response assessment. Studies presenting geographic correlations are construed to be not directly useful in health risk assessment. The numerical level of the exposure data is a deciding factor in using valid epidemiologic studies. However, data measured on an ordinal scale can be used in qualitative assessments and can demonstrate the strength of the relationship. The application of this procedure is illustrated using epidemiologic studies on the carcinogenicity of chemicals contaminated with dioxins.

The effect of dimethylsulfoxide on the mutagenicity of the hair dye p-phenylenediamine

Published data on the mutagenicity of the oxidative hair dye intermediate p-phenylenediamine in the Ames test are conflicting. The work reported here resolves the discrepancies, showing that the activity of p-phenylenediamine in the Ames Salmonella/microsome test is markedly influenced by the use of dimethylsulfoxide as solvent, and by the age of the solution prior to plating. Thus, aqueous solutions of p-phenylenediamine are non-mutagenic; fresh solutions in DMSO are equally non-mutagenic, but become highly active on standing at room temperature for 4 hr. These results suggest the need for caution in the choice of solvents and tight controls in the execution of the test.

Heritable translocation study on two hair dye formulations

Sexually mature Charles River Sprague Dawley CD outbred male rats received topical applications of hair dyes twice weekly for 10 weeks. They were then mated to one sexually mature female of the same strain each week for three weeks. One hundred F1 males from these matings, maintained under standard conditions for 12 weeks, were paired with one mature female per week for three weeks. The pregnancies were interrupted after approximately 16 days and the numbers of live and dead fetuses and implantations and resorptions were recorded. Fertility rates were high for both generations. Average litter sizes for the two hair dye groups and the control in the F1 generation were nearly identical and were in excess of 11 live pups per litter. There is no evidence from these results that frequent topical applications of hair dyes cause stable chromosomal rearrangements, such as translocations, which may result in reduced fertility of the offspring of the treated subject.

Evaluation of the toxicity and carcinogenicity of hair dyes

The chronic toxicological and carcinogenic potential following skin painting in mice was evaluated for nine oxidative and three nonoxidative hair dyes. Groups of male and female Swiss mice were treated one time weekly for at least 20 mo with one dose level of each dye. The oxidative dyes were mixed 1:1 with 6% hydrogen peroxide before treatment and the three semipermanent formulations were applied without dilution. Control groups were shaved only and received no applications. Body weights and survival rates did not differ between appropriate male and female treatment and control groups. Absolute and relative liver and kidney weights were equivalent for treatment and control groups. After 7 and 9 mo of treatment, 10 males and 10 females randomly selected from each group were necropsied and tissues taken for histopathologic evaluation. Animals found dead or sacrificed in moribund condition or at termination of the study were necropsied and evaluated histopathologically. Comparison of incidence of tumors and of nontumor pathology among the various treatment and control groups revealed no biologically significant differences. Toxicological and carcinogenic effects were not induced by the hair dye formulations.

Reproductive tract peroxidases as endproducts of estrogen-specific gene expression

Estrogen is an essential requirement for the postpubertal trophic development and maintenance of the differentiated state of the oviduct, uterus, cervix, vagina and mammary glands of mammals. Estrogen, apparently functioning through its specific cytoplasmic receptor protein via a multistep interaction pathway induces gene expression of specific biochemical events leading to growth and differentiation of target tissues (Jensen et al., Proc Natl Acad Sci, 59:632, 1968; Gorski et al., Recent Prog Horm Res 24:45, 1968). One biochemical expression of the estrogen gene is the synthesis of specific mRNA transcripts for certain specific marker proteins, including ovalbumin, lysozyme and ovomucoid in the chick oviduct (O'Malley and McGuire, Proc Natl Acad Sci 60:1527, 1968; Palmiter and Schimke, J Biol Chem 248:1502, 1973), tubulin in the mammalian oviduct (Brenner and Anderson, Handbook of Physiology 7(2):123, 1973; Brenner et al., Endocrinology 95:1094, 1974) and peroxidase (EC 1,11.1.7) in the rodent uterus (Brockelmann and Fawcett, Biol Reprod 1:59, 1969; Churg and Anderson, J Cell Biol 62:449, 1974; Anderson et al., J Cell Biol 64:668, 1975).