Comparison of Sales From Vending Machines With 4 Different Food and Beverage Messages: A Randomized Trial

Importance

Point-of-sale food messaging can encourage healthier purchases, but no studies have directly compared multiple interventions in the field.

Objective

To examine which of 4 food and beverage messages would increase healthier vending machine purchases.

Design, Setting, and Participants

This randomized trial assessed 13 months (February 1, 2019, to February 29, 2020) of vending sales data from 267 machines and 1065 customer purchase assessments from vending machines on government property in Philadelphia, Pennsylvania. Data analysis was performed from March 5, 2020, to November 8, 2022.

Interventions

Study interventions were 4 food and beverage messaging systems: (1) beverage tax posters encouraging healthy choices because of the Philadelphia tax on sweetened drinks; (2) green labels for healthy products; (3) traffic light labels: green (healthy), yellow (moderately healthy), or red (unhealthy); or (4) physical activity equivalent labels (minutes of activity to metabolize product calories).

Main Outcomes and Measures

Sales data were analyzed separately for beverages and snacks. The main outcomes analyzed at the transaction level were calories sold and the health status (using traffic light criteria) of each item sold. Additional outcomes were analyzed at the monthly machine level: total units sold, calories sold, and units of each health status sold. The customer purchase assessment outcome was calories purchased per vending trip.

Results

Monthly sales data came from 150 beverage and 117 snack vending machines, whereas 1065 customers (558 [52%] male) contributed purchase assessment data. Traffic light labels led to a 30% decrease in the mean monthly number of unhealthy beverages sold (mean ratio [MR], 0.70; 95% CI, 0.55-0.88) compared with beverage tax posters. Physical activity labels led to a 34% (MR, 0.66; 95% CI, 0.51-0.87) reduction in the number of unhealthy beverages sold at the machine level and 35% (MR, 0.65; 95% CI, 0.50-0.86) reduction in mean calories sold. Traffic light labels also led to a 30-calorie reduction (b = -30.46; 95% CI, -49.36 to -11.56) per customer trip in the customer purchase analyses compared to physical activity labels. There were very few significant differences for snack machines.

Conclusions and Relevance

In this 13-month randomized trial of 267 vending machines, the traffic light and physical activity labels encouraged healthier beverage purchases, but no change in snack sales, compared with a beverage tax poster. Corporations and governments should consider such labeling approaches to promote healthier beverage choices.

Trial Registration

ClinicalTrials.gov Identifier: NCT06260176.

Effects of Sugary Beverage Text and Pictorial Warnings: A Randomized Trial

INTRODUCTION

Multiple U.S. localities have introduced legislation requiring sugar-sweetened beverage (SSB) warnings. This study effects of different warning designs on beverage selections and perceptions.

STUDY DESIGN

The study was an RCT.

SETTING/PARTICIPANTS

An online virtual convenience store and survey were used with a nationally representative sample of primary caregivers of 6-11-year-olds (n=961). Data were collected in January 2020 and analyzed in May-July 2020.

INTERVENTION

Participants were randomized to view SSBs with 1 of 4 front-of-package label designs: (1) no-warning control, (2) health-related text warning, (3) sugar pictorial warning (image of beverage sugar content in cubes/teaspoons/packets with health-related warning text), or (4) health pictorial warning (image of possible health consequences of overconsuming SSBs with health-related warning text).

MAIN OUTCOME MEASURES

Outcomes included participants' beverage choice for their child and perceptions of beverages, their assigned labels, and warning policies.

RESULTS

Proportionally fewer participants chose a SSB in the sugar pictorial warning condition (-13.4 percentage points; 95% CI= -21.6 to -0.1 percentage points; p=0.007) and in the health pictorial warning condition (-14.7 percentage points; 95% CI= -22.8 to -0.1 percentage points; p=0.004) compared to the control. Sugar pictorial warnings led to more accurate added-sugar content estimates than all conditions and greater label trust and support for sugar-sweetened beverage warning policies than health pictorial warnings.

CONCLUSIONS

SSB warning policies may be most effective if they mandate images of beverages' added sugar content accompanied by warning text.

TRIAL REGISTRATION

This study is registered at www.

CLINICALTRIALS

gov NCT03648138.

Social-contextual factors interact with masculinity to influence college men's HPV vaccination intentions: The role of descriptive norms, prototypes, and physician gender

Men’s low HPV vaccination uptake and HPV-related disease incidence are public health issues; gendered social–contextual factors likely play a role. In Study 1, college men (N = 130; M_age = 19.55; white = 58.1%) reported their social cognitions (male-referent descriptive norms and prototypes), self-reliance masculinity ideology, and vaccination intentions. In Study 2, college men (N = 106; M_age = 19.32; white = 61.3%) were randomly assigned to receive HPV vaccination information from a man or woman physician-avatar. Descriptive norms and favorable prototypes (bs ≥ .337; ps ≤ .016) were associated with higher HPV vaccination intentions. Men with higher self-reliance masculinity had higher HPV vaccination intentions with a man physician and when they perceived greater vaccination among men (ps ≤ .035). Men with higher self-reliance masculinity are more sensitive to gendered social–contextual effects in HPV vaccination decision-making. Gendered social–contextual factors should be integrated into public health interventions to increase college men’s HPV vaccination uptake.

Measurement of functional residual capacity by modified multiple breath nitrogen washout for spontaneously breathing and mechanically ventilated patients

BACKGROUND

There is a need for a bedside functional residual capacity (FRC) measurement method that performs well in intensive care patients during many modes of ventilation including controlled, assisted, spontaneous, and mixed. We developed a modified multiple breath nitrogen washout method for FRC measurement that relies on end-tidal gas fractions and alveolar tidal volume measurements as inputs but does not require the traditional measurements of volume of nitrogen or oxygen. Using end-tidal measurements, not volume, reduces errors from signal synchronization. This study was designed to assess the accuracy, precision, and repeatability of the proposed FRC system in subjects with variable ventilation patterns including some spontaneous effort.

METHODS

The accuracy and precision of measurements were assessed by comparing the novel N₂ washout FRC values to the gold standard, body plethysmography, in 20 spontaneously breathing volunteers. Repeatability was assessed by comparing subsequent measurements in 20 intensive care patients whose lungs were under controlled and assisted mechanical ventilation.

RESULTS

Compared with body plethysmography, the accuracy (mean bias) of the novel method was -0.004 litre and precision [1 standard deviation (sd)] was 0.209 litre [mean (sd)] [-0.1 (5.9)% of body plethysmography]. The difference between repeated measurements was 0.009 (0.15) litre [mean (sd)] [0.4 (6.4)%]. The coefficient of repeatability was 0.31 litre (12.7%).

CONCLUSIONS

The modified multiple breath nitrogen washout method for FRC measurement provides improved precision and equivalent accuracy and repeatability compared with existing methods during ventilation with variable ventilation patterns. Further study of the novel N₂ washout method is needed.

Inhibition of thromboxane A2-induced arrhythmias and intracellular calcium changes in cardiac myocytes by blockade of the inositol trisphosphate pathway

We have recently reported that left atrial injections of the thromboxane A(2) (TXA(2)) mimetic, (5Z)-7-[(1R,4S,5S,6R)-6-[(1E,3S)-3-hydroxy-1-octenyl]-2 -oxabicyclo[2.2.1]hept-5-yl]-5-heptenoic acid (U46619), induced ventricular arrhythmias in the anesthetized rabbit. Data from this study led us to hypothesize that TXA(2) may be inducing direct actions on the myocardium to induce these arrhythmias. The aim of this study was to further elucidate the mechanism responsible for these arrhythmias. We report that TXA(2)R is expressed at both the gene and protein levels in atrial and ventricular samples of adult rabbits. In addition, TXA(2)R mRNA was identified in single, isolated ventricular cardiac myocytes. Furthermore, treatment of isolated cardiac myocytes with U46619 increased intracellular calcium in a dose-dependent manner and these increases were blocked by the specific TXA(2)R antagonist, 7-(3-((2-((phenylamino)carbonyl)hydrazino)methyl)-7-oxabicyclo(2.2.1)hept-2-yl)-5-heptenoic acid (SQ29548). Pretreatment of myocytes with an inhibitor of inositol trisphosphate (IP(3)) formation, gentamicin, or with an inhibitor of IP(3) receptors, 2-aminoethoxydiphenylborate (2-APB), blocked the increase in intracellular calcium. In vivo pretreatment of anesthetized rabbits with either gentamicin or 2-APB subsequently inhibited the formation of ventricular arrhythmias elicited by U46619. These data support the hypothesis that TXA(2) can induce arrhythmias via a direct action on cardiac myocytes. Furthermore, these arrhythmogenic actions were blocked by inhibitors of the IP(3) pathway. In summary, this study provides novel evidence for direct TXA(2)-induced cardiac arrhythmias and provides a rationale for IP(3) as a potential target for the treatment of TXA(2)-mediated arrhythmias.

Role of serotonin in thromboxane A2-induced coronary chemoreflex

We reported previously that the thromboxane A(2) (TxA(2)) mimetic U-46619 stimulates cardiac vagal afferent nerves, eliciting a reflex decrease in heart rate (HR) and arterial blood pressure (ABP). The present experiments were designed to test the hypothesis that TxA(2) evokes these changes via the release of serotonin [5-hydroxytryptamine (5-HT)] and activation of the 5-HT(3) receptor. Injections of the 5-HT(3) antagonist tropisetron (1 mg of 3-tropanyl-indole-3-carboxylate or ICS-205-930) attenuated the decreases in HR and ABP induced by left atrial injections of U-46619 (20 microg). Tropisetron administration also eliminated the U-46619-induced increase in impulse frequency in a majority of cardiac, vagal afferent units tested. Measurement of serum 5-HT levels revealed an elevation in serum 5-HT levels after U-46619 injection in those rabbits that displayed a significant HR change following injection of U-46619. These results indicate that although other factors may also contribute to these reflex responses, the release of 5-HT and stimulation of the 5-HT(3) receptor plays a significant role in coronary reflexes induced by TxA(2).

Partial CO2 rebreathing indirect Fick technique for non-invasive measurement of cardiac output

OBJECTIVE

Evaluation in animals of a non-invasive and continuous cardiac output monitoring system based on partial carbon-dioxide (CO2) rebreathing indirect Fick technique.

METHODS

We have developed a non-invasive cardiac output (NICO) monitoring system, based on the partial rebreathing method. The partial rebreathing technique employs a differential form of the Fick equation for calculating cardiac output (QT) using non-invasive measurements. Changes in CO2 elimination (deltaVCO2) and partial pressure of end-tidal CO2 (deltaPETCO2) in response to a brief period of partial rebreathing are used to measure pulmonary capillary blood flow (Q(PCBF)). A non-invasive estimate of anatomic and intrapulmonary shunt fraction (Q(S)/Q(T)), based on oxygen saturation from pulse oximetry (SpO2) and inspired oxygen concentration (FIO2), is added to compute total cardiac output [Q(T) = Q(PCBF)/(1 - Q(S)/Q(T))]. The performance of the NICO was compared with iced 5% dextrose bolus thermodilution cardiac output (TDco) measurements in 6 dogs. Cardiac output was varied using dobutamine, and halothane, and by clamping of the inferior vena cava. Two hundred and forty-six (n = 246) paired measurements of TDco and NICO over a range of cardiac outputs (TDco range = 0.60-8.87 l/min) were compared using Bland-Altman analysis and weighted correlation coefficient.

RESULTS

The Bland-Altman technique yielded a NICO precision of +/- 0.70 l/min (13.8%) with a mean bias of -0.07 l/min (-1.4%) compared to TDco. The weighted correlation coefficient between TDco and NICO values was: r = 0.93 (n = 246).

CONCLUSION

The partial CO2 rebreathing technique for measurement of cardiac output is non-invasive, automated, and based on the well accepted Fick principle. The limits of agreement between NICO and TDco is within the recommended value for NICO to be a clinically acceptable method for cardiac output measurement. The results of this canine study show that NICO performed as well, and in some cases better, than other currently available non-invasive cardiac output techniques over a wide range of cardiac outputs.

Effects of intrathecal morphine on the ventilatory response to hypoxia

BACKGROUND

Intrathecal administration of morphine produces intense analgesia, but it depresses respiration, an effect that can be life-threatening. Whether intrathecal morphine affects the ventilatory response to hypoxia, however, is not known.

METHODS

We randomly assigned 30 men to receive one of three study treatments in a double-blind fashion: intravenous morphine (0.14 mg per kilogram of body weight) with intrathecal placebo; intrathecal morphine (0.3 mg) with intravenous placebo; or intravenous and intrathecal placebo. The selected doses of intravenous and intrathecal morphine produce similar degrees of analgesia. The ventilatory response to hypercapnia, the subsequent response to acute hypoxia during hypercapnic breathing (targeted end-tidal partial pressures of expired oxygen and carbon dioxide, 45 mm Hg), and the plasma levels of morphine and morphine metabolites were measured at base line (before drug administration) and 1, 2, 4, 6, 8, 10, and 12 hours after drug administration.

RESULTS

At base line, the mean (+/-SD) values for the ventilatory response to hypoxia (calculated as the difference between the minute ventilation during the second full minute of hypoxia and the fifth minute of hypercapnic ventilation) were similar in the three groups: 38.3+/-23.2 liters per minute in the placebo group, 33.5+/-16.4 liters per minute in the intravenous-morphine group, and 30.2+/-11.6 liters per minute in the intrathecal-morphine group (P=0.61). The overall ventilatory response to hypoxia (the area under the curve) was significantly lower after either intravenous morphine (20.2+/-10.8 liters per minute) or intrathecal morphine (14.5+/-6.4 liters per minute) than after placebo (36.8+/-19.2 liters per minute) (P=O.003). Twelve hours after treatment, the ventilatory response to hypoxia in the intrathecal-morphine group (19.9+/-8.9 liters per minute), but not in the intravenous-morphine group (30+/-15.8 liters per minute), remained significantly depressed as compared with the response in the placebo group (40.9+/-19.0 liters per minute) (P= 0.02 for intrathecal morphine vs. placebo). Plasma concentrations of morphine and morphine metabolites either were not detectable after intrathecal morphine or were much lower after intrathecal morphine than after intravenous morphine.

CONCLUSIONS

Depression of the ventilatory response to hypoxia after the administration of intrathecal morphine is similar in magnitude to, but longer-lasting than, that after the administration of an equianalgesic dose of intravenous morphine.

The role of protein kinase C in thromboxane A2-induced pulmonary artery vasoconstriction

In order to determine if protein kinase C (PKC) plays a significant role in the stimulant action of thromboxane A2 (TxA2) on pulmonary vascular smooth muscle, TxA(2)-induced contractile responses were measured following inhibition of PKC. Rabbits were sacrificed and segments of the main trunk of the pulmonary artery were removed and placed within a temperature-controlled (37 degrees C) organ bath. Contractile responses that were evoked by a TxA2 mimetic (U46,619, 0.5 microM) decreased by 27 and 35% following treatment with the PKC inhibitors, calphostin C (2 microM) and staurosporine (200 nM), respectively. These results account for the effect of the vehicle, DMSO, which was also found to have a concentration-dependent inhibitory effect on the U46,619-induced contractions. The effects of DMSO alone was subsequently subtracted from the previously measured responses to PKC inhibitors that were dissolved in DMSO to obtain effects attributable to the PKC inhibitor alone. It can therefore be concluded that inhibition of PKC results in partial attenuation of U46,619-induced responses supporting the hypothesis that activation of PKC plays a partial role in TxA2-induced contraction of pulmonary arterial smooth muscle.

Evaluation in volunteers of the VIA V-ABG automated bedside blood gas, chemistry, and hematocrit monitor

OBJECTIVE

To evaluate the VIA V-ABG (VIA Medical Corp.) point-of-care blood gas and chemistry monitor in healthy human volunteers, with particular emphasis on the measurement of blood gases.

METHODS

Experimental conditions were varied by intermittently subjecting volunteers to either isocapnic hypercapnia (end-tidal (ET), PETCO2 = 50+/-2 mmHg, ETPO2 = 130+/-5 mmHg) or isocapnic hypoxia (PETCO2 = 42+/-2, PETO2 + 45+/-2 mmHg) in addition to room air breathing. Measurements by the VIA V-ABG device were compared with paired samples and measurements performed by two ABL Radiometers (505 and 500). Analysis of results includes bias and precision plots and comparison of results with minimal performance criteria as established by CLIA.

RESULTS

Nineteen volunteers yielded 222 matched samples. The range of values were 7.32-7.61 for pH, 20.9-51.6 mmHg for PCO2, 27.9-184.5 mmHg for PO2, 134-141 mmol/l for Na, 3.1-4.1 mmol/l for K, and 30.0-50.4% for hematocrit. Bias and precision (+/-2 sd) for pH was 0.01 and 0.04, for PCO2 was 0.4 and 4.8, for PO2 was 1.0 and 17.0, for Na was -0.3 and 5.2, for K was 0.1 and 0.2, and for Hct was 2.0 and 5.4.

CONCLUSIONS

Over the range of blood gas values assessed, blood gas measurements by the VIA V-ABG device were clinically acceptable and met minimal performance criteria utilizing current Medicare CLIA proficiency standards. Performance criteria were also met by the VIA V-ABG device for Na, K, and Hct measurements but the range of values was too narrow to allow characterization of clinical acceptability. The VIA V-ABG device appears to perform well compared with the results which have been published for other point-of-care devices. Comparison between different studies investigating point-of-care devices is difficult due to several factors (range of values measured, comparison device, population studied, etc.). Some of these instruments, including the VIA V-ABG device, may serve quite well as point-of-care devices to perform certain tests at the bedside. Whether or not any of these devices can substitute for traditional laboratory blood gas and chemistry measurements remains an issue that is not adequately studied.

A preliminary laboratory investigation of air embolus detection and grading using an artificial neural network

SUMMARY STATEMENT

Processed digitized Doppler signals abstracted from recordings during continuous air infusion in dogs were used to train a neural network to estimate air embolism infusion rates.

BACKGROUND

Precordial Doppler is a sensitive technique for detecting venous air embolism during anesthesia, but it requires constant attentive listening. Since neural networks are particularly well suited to the task of pattern recognition, we sought to investigate this technology for detection and grading of air embolism.

METHODS

Air was infused into peripheral veins of four anesthetized dogs at rates of 0.025, 0.05, 0.10, 0.25, 0.50 and 1.0 ml-1.kg-1.min-1 while digital recordings of the precordial Doppler ultrasound signal were collected. The frequency content of the recordings was determined by Fourier analysis. The output of the Fourier transform was the input to a neural network. The network was then trained to estimate the air infusion rate.

RESULTS

The correlation coefficient between the size of the air embolism and the air infusion rate was greater than r2 = 0.93 for each of the four animals in the study when the network was trained using the data for all four dogs. When the data from a dog was withheld from the training set and used only for testing the correlation coefficients ranged from r2 = 0.75 to r2 = 0.27. For frequencies below 250 Hz, the acoustic energy tended to fall as the air infusion rate increased. The opposite occurred at frequencies above 325 Hz.

CONCLUSIONS

Neural network processing of the precordial Doppler signal provides a quantitative estimate of the size of an air embolism.

TxA2-induced pulmonary artery contraction requires extracellular calcium

In order to examine the role of extracellular calcium in the pulmonary arterial vasoconstriction that is elicited by thromboxane A2 (TxA2), rabbits were sacrificed and the main trunk of the pulmonary artery removed. Contractile responses of the isolated vessel to the TxA2 mimetic, U46 619, were measured in a temperature controlled (37 degrees C) organ bath. Compared with control responses, U46 619 microM) contractions were nearly eliminated when 1 mM EGTA was added to the buffer. In the presence of normal extracellular calcium concentrations, antagonists of voltage sensitive calcium channels (e.g. verapamil and nifedipine) attenuated the U46 619-induced contractions. These voltage sensitive calcium channel blockers were more effective in eliminating contractile responses to high KCl concentrations (6) or 120 mM KCl). The inability of these calcium channel antagonists to completely eliminate U46 619 responses was confirmed in the anesthetized rabbit where both nifedipine and verapamil failed to block the increase in pulmonary arterial blood pressure resulting from intravenous U46 619 infusion. These results indicate that extracellular calcium is essential for U46 619-induced pulmonary vascular contraction, and that mechanisms in addition to voltage operated calcium channels participate in the movement of extracellular calcium through the plasma membrane.

Clinical analysis of the flexor hallucis brevis as an alternative site for monitoring neuromuscular block from mivacurium

STUDY OBJECTIVES

To compare the flexor hallucis brevis, which is responsible for flexion of the great toe, to the adductor pollicis as a site for monitoring the onset and recovery from neuromuscular block after an intubating dose of mivacurium chloride.

DESIGN

Prospective patient-controlled study.

SETTING

University teaching hospital.

PATIENTS

10 ASA physical status I and II adults (age 18 to 55 years, 6 women, 4 men) scheduled for elective procedures requiring muscle relaxation for tracheal intubation.

MEASUREMENTS AND MAIN RESULTS

Patients were monitored at the adductor pollicis and the flexor hallucis brevis during the onset and recovery of neuromuscular block, which was administered to facilitate tracheal intubation. All subjects were given mivacurium 0.2 mg/kg over 30 seconds. Their train-of-four (TOF) response was continually monitored at both sites until the patient recovered from the intubating dose to a TOF ratio of 0.75. The time to onset of neuromuscular block, recovery of the first TOF response, and recovery to a TOF ratio of 0.75 were compared between the two monitoring sites using the Wilcoxon signed rank test. Following administration of the intubating dose of mivacurium, the loss of all twitch response occurred 1.2 minutes sooner at the adductor pollicis than at the flexor hallucis brevis (p < 0.02). Reappearance of the first twitch occurred 0.49 minutes slower at the adductor pollicis, although this difference was not statistically significant. The time to recovery to a TOF ratio of 0.75 at the adductor pollicis was slower by 2.83 minutes (p = 0.046).

CONCLUSIONS

Due to its lag behind the adductor pollicis, the flexor hallucis brevis is not a good indicator of when to intubate the trachea during the onset of neuromuscular block; however, its faster recovery may make it useful for monitoring deep neuromuscular block intraoperatively or during recovery when the adductor pollicis TOF response still shows complete blockade.

Stimulation of group III and IV afferent nerves from the hindlimb by thromboxane A2

These experiments were designed to test the hypothesis that the TxA2 mimetic, U46,619, would stimulate group III and IV afferent nerve endings from the hindlimb of the anesthetized cat. Nerve impulses were recorded from the dorsal rootlets of the L7-S1 segments of the spinal cord, and afferent units identified by measurement of conduction velocities, mechanical probing of hindlimb muscles, and local injection of chemical stimulants (capsaicin and bradykinin). Five of the 15 group III fibers were stimulated by U46,619 (2-10 micrograms injected into the abdominal aorta; mean baseline impulse frequency increasing from 7.3 (+/- 3.2) impulses/s to 16.0 (+/- 3.1)), while 7 of the 12 group IV fibers responded to U46,619 (impulse frequency increasing from 4.3 (+/- 3.2) to 8.8 (+/- 3.6)). The average latency for the response (20-30 s) did not differ between the two groups of afferent fibers. We conclude that group III and IV afferent fibers originating from the skeletal muscle of the hindlimb are stimulated by TxA2 and that the release of TxA2 in skeletal muscle could evoke cardiorespiratory reflexes known to be activated by stimulation of these afferent nerves.

The time commitment of the community nursing services to Project 2000

As part of an English National Board funded research study, the authors sent questionnaires to 2500 individuals with community nursing qualifications. The survey was complemented by a series of interviews with community nurse managers. Data indicated that community nurses were spending very considerable amounts of time with students. The number of placements provided per year varied considerably from one respondent to another, as did the average duration of a placement. Community nurses were providing community experience for a variety of types of nursing students, as well as students of other professions, and the time commitment involved placed them under considerable strain. The authors conclude that there is a need to recognise the time given by community nurses to work with students, and the resource implications of this commitment.

A comparison of dynamic and isometric force sensors for train-of-four measurement using submaximal stimulation current

OBJECTIVE

We studied the accuracy and repeatability of train-of-four (TOF) ratio measurements made from a dynamic piezoelectric sensor that records movement of the thumb in response to ulnar nerve stimulation compared with an isometric mechanomyogram that measures force of contraction of the adductor pollicis.

METHODS

The study involved 10 patients whose level of neuromuscular block was held constant with an intravenous (IV) infusion of vecuronium bromide (0.4 to 1.0 micrograms/kg/min) (Organon, West Orange, NJ). The sensors were attached to opposite arms of each patient and simultaneous measurements of TOF ratio were taken at stimulation current levels of 50, 30, and 20 mA.

RESULTS

In comparison to the TOF ratio measured at the maximal stimulation current (50 mA), the TOF ratio from the piezo sensor showed a bias and standard deviation of -0.13 +/- 0.24 when the stimulation current was reduced to 30 mA. At 20 mA, the bias and standard deviation was -0.24 +/- 0.28. The TOF ratio from the mechanomyogram showed a bias and standard deviation of 0.01 +/- 0.07 at 30 mA and 0.0 +/- 0.20 at 20 mA when compared with measurements made when the stimulation current was 50 mA.

CONCLUSIONS

Both sensors showed diminished repeatability in TOF measurement with decreasing stimulation current. The data indicate that neither sensor is reliable for general monitoring of neuromuscular block at submaximal current levels. However, the individual patient results showed that some patients could be monitored accurately with both sensors, even at the lowest stimulation current levels.

Prostaglandin B2-induced pulmonary hypertension is mediated by TxA2/PGH2 receptor stimulation

We investigated whether the physiological effects of prostaglandin B2 (PGB2) in the pulmonary circulation might be due to stimulation of thromboxane A2-prostaglandin H2 (TxA2/PGH2) receptors. In seven anesthetized rabbits, intravenous infusion of PGB2 (5.0 micrograms/kg) caused pulmonary hypertension as evidenced by increases in right ventricular systolic blood pressure. The magnitude of the pulmonary hypertension was comparable to that observed after infusion of the TxA2 mimetic U-46619 at a significantly lower dose (0.5 micrograms/kg), indicating that the effects of PGB2 in the intact animal are similar to TxA2 but less potent. Additionally, the TxA2/PGH2-receptor antagonist SQ-29548 blocked the pulmonary blood pressure responses elicited by PGB2. Receptor-binding studies using the TxA2 receptor ligand [3H]SQ-29548 indicated that PGB2 was a potent competitor for TxA2/PGH2 receptor binding. In agreement with the results from the intact animal, however, the efficacy of inhibition with PGB2 was significantly less than that measured for the TxA2 agonist U-46619. All of these results are consistent with the hypothesis that the physiological effects of PGB2 are mediated by stimulation of TxA2/PGH2 receptors.

Thromboxane A2 mimetic U-46619 induces systemic and pulmonary hypertension and delayed tachypnea in the goat

Cardiorespiratory variables were measured continuously in five conscious goats before and after the infusion of U-46619 at a dose of either 2, 4, or 6 micrograms.kg-1.5 min-1. Infusion of U-46619 led to immediate increases in pulmonary arterial blood pressure (ABP) that were sustained for up to 15 min after the end of the infusion. Systemic ABP also increased, but the relative increase from control was less than the pulmonary pressor response. At the highest dose, U-46619 elicited a delayed tachypneic response that was greatest several minutes after the infusion was stopped. U-46619 was also infused simultaneously with sodium nitroprusside to clamp ABP pressure at baseline levels to determine whether stimulation of baroreceptors might contribute to the latency of the tachypneic response. Although sodium nitroprusside infusion prevented the increase in ABP, the increase in breathing frequency was still delayed 3-4 min from the start of the infusion. We conclude that U-46619 elicits pulmonary and systemic arterial hypertension in the conscious goat. At the higher dose U-46619 also elicits a delayed tachypnea that remains delayed even if ABP is normal.

An effectiveness study of a new piezoelectric sensor for train-of-four measurement

We have developed an easy-to-use, noninvasive piezoelectric sensor for quantitative monitoring of neuromuscular block. In a clinical evaluation with 23 patients, the piezo sensor was objectively compared to a mechanomyogram (MMG) for its ability to measure train-of-four (TOF) ratio from the adductor pollicis. After administration of succinylcholine (120-200 mg intravenously [i.v.]) to facilitate intubation, neuromuscular block was maintained with vecuronium by either boluses (1-2 mg i.v.) or an infusion (0.4-1.0 micrograms.kg-1.min-1 i.v.). Paired measurements were made of the TOF ratio from both sensors over a complete range of block levels (8%-100%). The difference in the TOF ratio measurement between the sensors showed a bias of 0.018. The SD of the difference between the sensors was +/- 0.129. The limits of agreement, which define the range in which 95% of the differences between the sensor measurements lie, were from -0.24 to 0.275. The sensitivity of the piezo sensor for detecting recovery based on a TOF ratio greater than 0.70 was shown to be 0.74 with specificity of 0.91. Under the conditions tested, the piezo sensor was not as accurate as the MMG. However, it was able to predict recovery of neuromuscular block with better accuracy than shown previously by manual evaluation of the TOF ratio, making it a reasonable, convenient alternative for quantitative monitoring of recovery from neuromuscular block.

A breathing circuit alarm system based on neural networks

OBJECTIVE

The objectives of our study were (1) to implement intelligent respiratory alarms with a neural network; and (2) to increase alarm specificity and decrease false-alarm rates compared with current alarms.

METHODS

We trained a neural network to recognize 13 faults in an anesthesia breathing circuit. The system extracted 30 breath-to-breath features from the airway CO2, flow, and pressure signals. We created training data for the network by introducing 13 faults repeatedly in 5 dogs (616 total faults). We used the data to train the neural network using the backward error propagation algorithm.

RESULTS

In animals, the trained network reported the alarms correctly for 95.0% of the faults when tested during controlled ventilation, and for 86.9% of the faults during spontaneous breathing. When tested in the operating room, the system found and correctly reported 54 of 57 faults that occurred during 43.6 hr of use. The alarm system produced a total of 74 false alarms during 43.6 hr of monitoring.

CONCLUSION

Neural networks may be useful in creating intelligent anesthesia alarm systems.

Mechanisms for the tachypneic response to the thromboxane A2 mimetic U-46,619 in rabbits

These experiments were designed to determine if intravenous infusion of the thromboxane A2 mimetic, U-46,619, would elicit tachypnea in the rabbit, and if so whether the afferent signal was generated by receptors innervated by myelinated or unmyelinated vagal nerve fibers. Intravenous infusion of U-46,619 (0.5 microgram/kg delivered over 10 s) increased breathing frequency (26%) and right ventricular blood pressure (59%) in the anesthetized rabbit (n = 10). Systemic arterial blood pressure, heart rate, and tidal volume were unaffected by the infusion of U-46,619. When myelinated fiber conduction in the vagus nerve was eliminated by bilaterally cooling the nerve to 6 degrees C, the increase in breathing frequency was only 5% above baseline levels. The tachypneic response to U-46,619 was totally eliminated when both myelinated and unmyelinated fiber conduction was abolished by cooling the vagi to 0 degree C. The increase in right ventricular blood pressure after U-46,619 infusion was unaffected by vagal cooling. Because most (> 80%) of the tachypneic response to U-46,619 was eliminated by blockade of myelinated vagal fiber conduction, we conclude that the tachypneic response to U-46,619 is mediated mostly by receptors innervated by myelinated vagal afferent fibers in the anesthetized rabbit.

Transient ventilatory responses to endotoxin infusion in the cat are mediated by thromboxane A2

We tested the hypothesis that ventilatory responses to endotoxin infusion in the anesthetized cat are mediated by thromboxane A2 (TxA2). Intravenous infusion of endotoxin (1.6 mg/kg of E. coli, strain 05:B55, delivered over 1 min) in six cats elicited increases in right ventricular blood pressure (Prv) and a transient systemic hypotension. These hemodynamic changes were accompanied by an abrupt apnea, followed by a transient period of rapid, shallow breathing, Cardiorespiratory changes coincided with large increases (> 10-fold) in the plasma concentration of TxB2, the stable metabolite of TxA2. These effects and the release of TxA2 did not occur if endotoxin was infused a second time into the same animal. In addition, animals that were pretreated with either indomethacin (n = 3; 3.0 mg/kg) or the TxA2 receptor antagonist, daltroban, (n = 4; 7.5 mg/kg) exhibited no change in Prv, arterial blood pressure, or respiration when given equivalent doses of endotoxin. We conclude that the release of TxA2 is responsible for the early pulmonary hypertension and rapid, shallow breathing observed during endotoxin infusion in the anesthetized cat. These TxA2-mediated responses are severe but transient in nature.

Integration of monitoring for intelligent alarms in anesthesia: neural networks--can they help?

Although there has been a decrease in the number of anesthesia-related critical incidents, there are still opportunities for further improvement. We discuss the potential of integrated monitoring and artificial neural networks as a means of vigilantly watching for patterns in multiple variables to detect incidents and reduce false alarms. We estimate that half the anesthesia-related events could be detected with integrated monitoring using only 5 variables. A review of research using artificial intelligence/expert systems indicates limited potential for success using these tools alone for integrated monitoring in the operating room. We present artificial neural networks as an approach that is more suited to the type of multivariable monitoring and pattern recognition required. Along with rule-based artificial intelligence, these now have the potential to help develop innovative monitoring in the operating room.

A parallel implementation of the backward error propagation neural network training algorithm: experiments in event identification

An artificial neural-network-based (ANN) event detection and alarm generation system has been developed to aid clinicians in the identification of critical events commonly occurring in the anesthesia breathing circuit. To detect breathing circuit problems, the system monitored CO2 gas concentration, gas flow, and airway pressure. Various parameters were extracted from each of these input waveforms and fed into an artificial neural network. To develop truly robust ANNs, investigators are required to train their networks on large training data sets, requiring enormous computing power. We implemented a parallel version of the backward error propagation neural network training algorithm in the widely portable parallel programming language C-Linda. A maximum speedup of 4.06 was obtained with six processors. This speedup represents a reduction in total run-time from 6.4 to 1.5 h. By reducing the total run time of the computation through parallelism, we were able to optimize many of the neural network's initial parameters. We conclude that use of the master-worker model of parallel computation is an excellent method for speeding up the backward error propagation neural network training algorithm.

Intelligent alarms reduce anesthesiologist's response time to critical faults

The proliferation of monitors and alarms in the operating room may lead to increased confusion and misdiagnosis unless the information provided is better organized. Intelligent alarm systems are being developed to organize these alarms, on the assumption that they will shorten the time anesthesiologists need to detect and correct faults. This study compared the human response time (the time between the sounding of an alarm and the resolution of a fault) when anesthesiologists used a conventional alarm system and when they used an intelligent alarm system. In a simulated operating room environment, we asked 20 anesthesiologists to resolve seven breathing circuit faults as quickly as possible. Human response time was 62% faster, decreasing from 45 to 17 s, when the intelligent alarm system was used. The standard deviations in response time were only half as large for the intelligent alarm system. It appears that the computer-based neural network in the intelligent alarm system diagnosed faults more rapidly and consistently than did the anesthesiologists. This study indicates that breathing circuit faults may be more rapidly corrected when the anesthesiologist is guided by intelligent alarms.

Failure of pulmonary acidosis to increase respiratory drive

Experiments were performed to determine whether increases in acidity isolated to the pulmonary circulation would stimulate hypothesized pulmonary chemoreceptors and increase respiratory drive in the anesthetized paralyzed mechanically ventilated cat (n = 9). Respiratory drive was assessed by measuring the frequency and amplitude of the integrated phrenic neurogram. To create an isolated pulmonary acidosis, blood returning to the lung was acidified by infusion of 0.3 M lactic acid (1.91 ml/min) into the inferior vena cava, while systemic arterial pH was restored to near normal levels by simultaneous infusion of base (0.3 M NaOH) into the left atrium. Six minutes after the start of this dual infusion of acid and base, right ventricular (pulmonary) pH decreased from 7.286 to 7.179 and PCO2 increased 7 Torr. Systemic arterial pH and PCO2 were unchanged from measurements immediately before the infusion. This level of pulmonary acidosis failed to increase respiratory drive as assessed by phrenic activity. To test the sensitivity of the preparation to known systemic arterial chemical stimuli, a combined pulmonary and systemic acidosis was elicited by infusion of 0.3 M lactic acid into the inferior vena cava and 0.3 M NaCl into the left atrium. This infusion significantly lowered both systemic arterial and pulmonary arterial pH (7.343 to 7.155 for systemic arterial pH and 7.286 to 7.067 for pulmonary pH) and increased phrenic efferent activity 45%. We conclude that phrenic efferent activity is unaffected by moderate reductions in the pH of the pulmonary circulation in the absence of a significant systemic arterial acidosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Thromboxane A2 mimetic, U46,619, and slowly adapting stretch receptor activity in the rabbit

The effect of infusing the thromboxane A2 mimetic U46,619 on afferent activity from slowly adapting airway stretch receptors (SARs) in the anesthetized rabbit was examined in these experiments. SAR vagal afferent fibers (n = 29) were identified by their slow adaptation to a sustained (10-15 s duration) lung inflation in the closed-chest, mechanically ventilated animal (n = 16). Intravenous infusion of U46,619 increased the discharge frequency of the SAR, measured at the end of inspiration, in a dose-dependent manner: by 6.6% and 8.0% at doses of 0.1 and 0.5 microgram of U46,619/kg, respectively. This increase in SAR activity was correlated with increases in end-inspiratory tracheal airway pressure (6.4% at 0.1 micrograms/kg and 9.1% at 0.5 micrograms/kg). Higher doses of U46,619 could not be administered due to decreases in systemic arterial blood pressure. The increase in SAR activity and tracheal airway pressure was qualitatively comparable to the response to histamine (25 micrograms/kg), a known bronchoconstrictor. We conclude that intravenous infusion of U46,619 in the anesthetized rabbit at doses that elicit significant hemodynamic effects causes modest bronchoconstriction and comparable increases (less than 10%) in SAR afferent nerve activity. From these data, it appears that U46,619 has no direct effect on SARs, but rather increases SAR activity due to bronchoconstriction.

Effects of the thromboxane A2 mimetic, U46,619, on pulmonary vagal afferents in the cat

Release of thromboxane A2 (TxA2) or infusion of the TxA2 mimetic U46,619 in the cat elicits pulmonary hypertension and rapid shallow breathing (Shams et al., Respir. Physiol. 71: 169-183, 1988). The vagus nerve mediates the observed respiratory, but not the circulatory, effects (Shams and Scheid, J. Appl. Physiol. 68: 2042-2046, 1990). To identify the type of lung vagal afferent fibers involved in this respiratory response to TxA2, we have recorded the functional single-unit activity and its response to infusion of U46,619 in fine strands of the vagus nerve in the artificially ventilated cat and rabbit. The fibers were classified as originating from slowly adapting (SAR) or rapidly adapting (RAR) stretch receptors by their response to sustained pulmonary inflation (intrapulmonary pressure of 20-25 cmH2O) or as C-fibers, by their response to a bolus injection of phenylbiguanide. C-fibers responded variably to lung inflation. U46,619 infusion caused only a small increase in SAR or RAR activity along with increases in end-inspiratory tracheal airway pressure (Paw), but evoked a marked increase in the firing rate of C-fibers, independent of their response to lung inflation. This increase in C-fiber activity was unrelated to the increase in Paw, which accompanied the infusion of U46,619. Since these responses remained the same after indomethacin they appear to be due to a direct action of U46,619, and not to be mediated by prostanoids that might be released by U46,619. These data suggest that C-fibers are indeed involved in the respiratory effects of TxA2. Since the effects exerted on C-fibers by U46,619 were unrelated to increased Paw, TxA2 is likely to stimulate the nerve endings directly, rather than via smooth muscle contraction. On the other hand, the small stimulating effect of U46,619 on SAR and RAR may be mediated by bronchoconstriction.

Evaluation of a parallel implementation of the learning portion of the backward error propagation neural network: experiments in artifact identification

Various methods have been proposed in an attempt to solve problems in artifact and/or alarm identification including expert systems, statistical signal processing techniques, and artificial neural networks (ANN). ANNs consist of a large number of simple processing units connected by weighted links. To develop truly robust ANNs, investigators are required to train their networks on huge training data sets, requiring enormous computing power. We implemented a parallel version of the backward error propagation neural network training algorithm in the widely portable parallel programming language C-Linda. A maximum speedup of 4.06 was obtained with six processors. This speedup represents a reduction in total run-time from approximately 6.4 hours to 1.5 hours. We conclude that use of the master-worker model of parallel computation is an excellent method for obtaining speedups in the backward error propagation neural network training algorithm.

Fast neutron treatment for squamous cell carcinoma of the head and neck: final report of Edinburgh randomised trial

OBJECTIVE

To compare neutron treatment and megavoltage (photon) radiotherapy in locally advanced squamous cell carcinoma of the head and neck.

DESIGN

Randomised trial of patients stratified by site of primary tumour and presence or absence of lymph node metastases. Follow up of patients after treatment.

SETTING

Department of clinical oncology, Western General Hospital, Edinburgh.

PATIENTS

165 Patients with untreated, histologically proved squamous cell carcinoma of the oral cavity, oropharynx, larynx, or hypopharynx. All patients completed treatment, and no patient was lost to follow up.

INTERVENTION

Treatment with either neutrons or photons.

MAIN OUTCOME MEASURES

Disease state and morbidity (scored with the system of the European Organisation for Research on Treatment of Cancer) at each visit during follow up.

RESULTS

Of the 165 patients, 85 were randomised to receive neutron treatment and 80 to receive photon treatment. Minimum follow up was five years. Local control of cancer remained similar in the two groups, being achieved in 37 (44%) patients after neutron treatment and 36 (45%) after photon treatment. Five year and actuarial 10 year survival rates were 24% (20/85) and 14% respectively in the group treated with neutrons and 34% (27/80) and 30% respectively in the group treated with photons. Five year survival rates without local disease were 19% (16/85) and 30% (24/80) respectively. Necrosis was more common after neutron treatment than after photon treatment. Seven patients in the neutron group who developed necrosis died whereas no deaths were associated with photon treatment.

CONCLUSION

Rates of long term local control were similar in the two groups. Necrosis related to radiation was more common in patients treated with neutrons, and the mortality related to treatment was significantly higher in these patients.

Cardiopulmonary responses to HCl infusion are mediated by thromboxane A2 but not by serotonin

Intravenous infusion of HCl has been shown to elicit the release of thromboxane A2 (TxA2) which alters blood pressure and breathing independent of reductions in circulating blood pH. The present experiments were designed to determine if the release of serotonin (5-HT) in the anesthetized cat contributed to cardiorespiratory responses during acid infusion and, furthermore to define the source of TxA2, viz. blood or other tissues. To infuse HCl into the bloodstream without reducing circulating blood pH (= neutral acid-base infusion), an extracorporeal arteriovenous shunt (20 ml/min) between the femoral artery and femoral vein was installed. Into this loop, acid (0.25 M HCl), and approximately 10 cm downstream, base (0.25 M NaOH) could be infused whereby blood pH could be locally reduced in the blood within the loop. This procedure was performed in three groups of cats: one group which received no drugs, a second group that was pretreated with indomethacin (2.5 mg/kg) and a third group that received the 5-HT2 receptor antagonist, ketanserin (0.75 mg/kg), prior to the infusion. During neutral acid-base infusion in the nontreated animals, right ventricular blood pressure (PRV) increased and systemic arterial blood pressure (Pa) decreased. Respiratory frequency was increased, but total ventilation was not elevated because of a concomitant fall in tidal volume (VT). The response was transient and could not be evoked with repetitive infusions of HCl and NaOH. These responses were significantly attenuated in the indomethacin-treated animals, but persisted in the cats pretreated with ketanserin. In addition, TxB2, the stable degradation metabolite of TxA2, was elevated during the acid/base infusion, but there were no measurable changes in plasma 5-HT concentration. The source of TxA2 was likely to be the blood since TxB2 was increased in plasma when acid and base were added to blood in vitro. We conclude from these experiments that transient cardiorespiratory responses to HCl infusion are mediated by the release of TxA2 from the blood and do not involve serotonin.

Cardiopulmonary function in exercising bar-headed geese during normoxia and hypoxia

To investigate possible physiologic mechanisms that allow the bar-headed goose to perform strenuous physical activity when flying at high altitude (e.g., above 9,000 m), we measured cardiopulmonary variables during running exercise (treadmill; 0.6 m.sec-1; 2 degrees incline) while the bird breathed either normoxic (21% O2) or hypoxic (7% O2) gases via a face mask. 1. During normoxic exercise, O2 uptake rate doubled and both ventilation and cardiac output increased. Blood gases and pH in arterial, mixed venous and blood from the leg, however, remained virtually unaltered. 2. Hypoxia at rest stimulated ventilation to rise but not cardiac output. The birds reached a steady state with virtually unaltered O2 uptake. 3. Exercise during hypoxia further stimulated ventilation, resulting in elevated arterial PO2 and O2 content compared to hypoxia at rest. However, O2 uptake increased only slightly, and cardiac output did not rise over the resting hypoxic value. The hyperventilation resulted in respiratory alkalosis and increased CO2 output, with R values being as high as 2.0. 4. It is concluded that neither ventilation nor pulmonary gas transfer were the limiting step in supplying O2 to the working muscles during hypoxic exercise in our experiments. It is more likely that muscle blood flow or diffusion from muscle capillaries to mitochondria, or both, determined the aerobic capacity under these conditions.

A prototype gas exchange monitor for exercise stress testing aboard NASA Space Station

A monitor was developed to track weightlessness deconditioning aboard the National Aeronautics and Space Administration (NASA) Space Station by measuring the O2 uptake (VO2) and CO2 production (VCO2) and calculating maximum VO2 and anaerobic threshold during an exercise stress test. The system uses two flowmeters in series to achieve a completely automatic flow calibration, and it uses breath-by-breath compensation for sample line transport delay. The accuracy of the system was measured over the range of VO2 and VCO2 from 100 to 800 ml/min by means of simulation. Accuracy was 0.54% for VO2 and 2.9% for VCO2. The system was further evaluated using two laboratory methods, the first method being comparison with a breath-by-breath system. As volunteers performed a maximum effort on a cycle ergometer, the mean difference in readings between the two systems was 17 ml/min for VO2 and 8.0 ml/min for VCO2. The correlation coefficient squared was greater than 0.96 for both. The second laboratory test was to use the system for 2 mo in a Human Performance Laboratory. Readings of maximum VO2 (VO2max) and anaerobic threshold were repeatable and consistent with the individual's activity level. The accuracy and convenience of operation will make this a valuable instrument aboard the Space Station.

Cardiorespiratory responses to HCl vs. lactic acid infusion

Previous reports indicate that intravenous infusion of HCl can alter breathing and blood pressure even if reductions in systemic arterial pH are prevented. To extend these findings, as well as to determine whether other acids elicit comparable results, this report compares the cardiopulmonary response between right atrial infusion of lactic acid and HCl in awake ponies. Lactic acid, infused at a dose of 1.5 mmol/kg over 18 min, lowered systemic and pulmonary arterial pH 0.062 and 0.092 U, respectively, and increased pulmonary arterial pressure (delta Ppa, 4 mmHg), heart rate (HR, 4/min), and tidal volume (delta VT, 190 ml/m2). HCl, infused at a reduced dose of 0.5 mmol/kg over 18 min, lowered systemic and pulmonary arterial pH 0.024 and 0.047 U, respectively, but produced increases in Ppa (delta 23 mmHg), HR (delta 42/min), and VT (delta 321 ml/m2) that were significantly greater than from the larger dose of lactic acid. These results indicate that cardiopulmonary responses to infusion acidosis differ between the type of acid infused. It is suggested that, in the unanesthetized pony, HCl-induced infusion acidosis has a unique cardiopulmonary-stimulating action unrelated to the pH changes imparted to the circulating arterial blood and that this response is absent during the infusion of lactic acid.

Absence of CO2-sensitive venous chemoreceptors in the cat

We tested for the presence of CO2-sensitive venous chemoreceptors in anesthetized, paralyzed, artificially ventilated cats (N = 8). Systemic venous PCO2 was elevated (venous CO2 loading) by continuously passing blood withdrawn from the femoral artery (20 ml/min) through an extracorporeal gas exchanger, ventilated with 50% CO2 and 50% O2, and returning this hypercapnic blood to the femoral vein. Respiratory output was assessed by means of the amplitude of the integrated phrenic neurogram. Results of venous CO2 loading were compared to those of airway CO2 loading in which inspired CO2 levels were adjusted to give the same arterial PCO2 (PaCO2) as in venous loading. Despite large differences in mixed venous PCO2 (PvCO2) during venous CO2 loading (PvCO2 = 55 Torr, PaCO2 = 37 Torr) compared to airway CO2 loading (PvCO2 = 45 Torr, PaCO2 = 37 Torr), phrenic output was unchanged. However, phrenic output was elevated 33% when PaCO2 was increased 6-7 Torr by raising inspired CO2 and reduced 50% when PaCO2 was lowered 6-7 Torr by lowering inspired CO2, thereby substantiating the responsiveness of the respiratory control system to changes in PaCO2. The respiratory output response to changes in venous CO2 was also tested at a higher PaCO2 (40 Torr, created by adding 1% CO2 to the inspired air) and, as before, no change in phrenic output occurred when PvCO2 was elevated at a constant PaCO2. These experiments provide direct evidence for the absence of chemoreceptors in the central veins, right heart, and pulmonary arterial system of the cat that would respond to changes in PvCO2.

An evaluation of fast neutron irradiation in the treatment of squamous cell carcinoma in cervical lymph nodes

Analyses have been made of the response of metastatic cervical lymph nodes following neutron therapy, either as part of a randomized trial or in patients treated electively. In the trial patients, the overall regression and local control rates were similar after photons and neutrons. Mobile nodes, less than 3.0 cm, appeared to respond better to neutron therapy, and node masses greater than 3.0 cm had better control after photon therapy. The differences observed however were not statistically significant. There was a highly significant association between the control of the primary tumor and control of nodal disease. No survival advantage for neutrons was observed in association with apparently better control rates in cervical nodes.

Cardiorespiratory changes during HCl infusion unrelated to decreases in circulating blood pH

To test the hypothesis that infusion of HCl changes blood pressure and respiration independent of decreases in circulating blood pH, an extracorporeal arteriovenous shunt (20 ml/min) between the femoral artery and vein was installed in anesthetized cats. Into this loop, acid (0.25 M HCl) and, approximately 10 cm downstream, base (0.25 M NaOH) could be infused simultaneously. Likewise, either acid or base could be infused individually. Right ventricular (Prv) and arterial (Pa) blood pressure, tidal volume (VT), and respiratory frequency (fresp) were recorded as well as blood gases and pH in arterial, right ventricular, and shunt loop blood at the reentrance into the animal. When HCl and NaOH were infused simultaneously and at equimolar rates (0.2 mmol/min for 10 min), there was a large increase in Prv, with little change or decrease in Pa. Respiratory frequency was increased, but total ventilation was not elevated because of a concomitant fall in VT. The rise in Prv and increase in fresp were transient in that they could only be evoked during the first HCl-NaOH infusion in a given animal. Repetitive infusions of HCl-NaOH into the same animal failed to elicit the response. Similar transient acid effects were evoked when HCl was infused without NaOH but not when NaOH was infused without HCl. During the second and third infusion of HCl, ventilatory responses were elicited that were explainable by stimulation of known chemoreceptors. The transient rise in Prv and fresp evoked by acid infusion might be explained by release of an agent from blood elements at the tip of the HCl infusion catheter, which in turn would constrict pulmonary vessels and influence breathing.(ABSTRACT TRUNCATED AT 250 WORDS)

Neutron therapy for malignant tumours of the salivary glands. A report of the Edinburgh experience

A group of 28 patients with malignant tumours of the salivary glands have been treated by d(15) + Be neutron irradiation. Nineteen patients had inoperable cancers. Three had gross recurrent cancer and three had measurable residual cancer after surgery. Three patients were treated post-operatively for microscopic residual disease. Seven different histological types of tumour were included. Six out of 8 patients with adenoid cystic carcinomas have lasting local tumour control. 54.5% of the gross tumours were locally controlled. All three of those classified as microscopic residual disease have no evidence of local recurrence. 11/14 cancers given 16.0 Gy or more in 20 fractions in 4 weeks were controlled compared with only 1/8 given a lower dose. 12/19 cancers less than 10.0 cm maximum diameter were controlled. The radiation-related morbidity was similar to that observed after photon therapy.

Fast neutron therapy for squamous cell carcinoma in the head and neck region: results of a randomized trial

A randomized trial of fast neuron therapy compared with 4MV photons for patients with head and neck cancer is reported. One hundred and sixty-eight patients were recruited between 1977 and 1984. The minimum follow-up is 2 years. Three patients were withdrawn before treatment began. Eighty-five were allocated to neutron therapy and 80 to receive photon therapy. All patients had squamous cell cancers in one of four primary sites: oral cavity, oropharynx, larynx, and hypopharynx. Local tumor control was similar in both groups: 44.7% after neutrons and 45.0% after photons. Salvage surgery was performed on 18 patients in each treatment group for residual or recurrent cancer. Acute radiation reactions of the mucous membranes were significantly more severe after photons. The number of patients with serious late reactions was greater after neutron therapy but the difference was not statistically significant. There were six deaths related to late morbidity after neutron therapy but none after photon therapy. Survival was better after photon therapy but the difference compared with the neutron group failed to reach statistical significance. When intercurrent deaths are excluded, the difference is less marked. Photon therapy was clearly better in terms of disease-free survival giving a 2-year local disease-free rate of 41.3% (s.e. 5.5%) compared with 29.4% (s.e. 4.9%) after neutrons.

Intravenous acid infusion without lowering arterial pH stimulates breathing

The aim of this study was to determine whether increases in ventilation would occur during intravenous acid infusion even if systemic arterial pH was held constant. In six awake ponies, HCl (500 ml, approximately 0.312 M) was infused into the right atrium at a total dose of 1.0 meq/kg over 18 min while an equivalent dose of NaOH was infused into the left heart to restore systemic arterial pH to normal. Total ventilation increased at the onset of the infusion and remained elevated although systemic arterial pH was normal to slightly alkaline. The increase in ventilation during the initial 2 min of the infusion coincided with an increase in pulmonary arterial PCO2 and decrease in pulmonary arterial pH. As the infusion progressed, however, pulmonary arterial pH and PCO2 returned to near control values due to the recirculation of systemic arterial blood with an acid-base status that had been altered consequent to the hyperventilation. Pulmonary arterial blood pressure was increased significantly during the entire infusion. Infusion of equivalent doses of hypertonic saline led to only minor alterations in the variables that were measured. These experiments demonstrate that this dose of intravenous HCl can increase ventilation independent of reductions in systemic arterial pH. Because increases in ventilation and pulmonary arterial H+ were not well correlated throughout the entire infusion, and pulmonary arterial blood pressure was increased, it is not clear if the mechanism for this ventilatory response is due to stimulation of pulmonary chemoreceptors, pulmonary vascular mechanoreceptors, or some other mechanism unrelated to increases in systemic arterial H+ concentration.

Applications of tensor theory to object recognition and orientation determination

A method is developed by which images resulting from orthogonal projection of rigid planar-patch objects arbitrarily oriented in three-dimensional (3-D) space may be used to form systems of linear equations which are solved for the affine transform relating the images. The technique is applicable to complete images and to unlabeled feature sets derived from images, and with small modification may be used to transform images of unknown objects such that they represent images of those objects from a known orientation, for use in object identification. No knowledge of point correspondence between images is required. Theoretical development of the method and experimental results are presented. The method is shown to be computationally efficient, requiring O(N) multiplications and additions where, depending on the computation algorithm, N may equal the number of object or edge picture elements.

Long-term results of local excision and radiotherapy in pleomorphic adenoma of the parotid

Three hundred and eleven patients with primary pleomorphic salivary adenoma of the parotid gland seen between 1950 and 1971 are reviewed. All were managed by a combination of surgery, usually local excision, and irradiation. The minimum follow-up is 10 years. Recurrence rates at 0-5 years and 5-10 years were 1 and 1.5%, respectively, and all recurrences in this period were histologically or clinically benign. This recurrence rate is similar to those reported after superficial parotidectomy. After 10 years, however, the recurrence rate rose, becoming maximal at 15-20 years (4%) and yielding a cumulative risk of recurrence of 8.0% at 20 years. The late recurrences were predominantly malignant tumors. One tumor was probably radiation-induced; the remainder were compatible with spontaneous malignant transformation of benign pleomorphic adenoma, although radiation may have increased the incidence. In the absence of a comparable purely surgical series, this cannot be determined. The recommendation is made that the management of these tumors should be primarily surgical with irradiation reserved for patients presenting surgical difficulties. In addition, prolonged follow-up is necessary since there is a significant incidence of late recurrence and such recurrence may be more likely to be malignant regardless of the primary form of management.