Secondary angiosarcoma following catheter-based brachytherapy

Secondary angiosarcoma of the breast following catheter-based brachytherapy after lumpectomy is rare. We describe a case of a patient with breast cancer treated with partial mastectomy and sentinel node biopsy followed by accelerated partial breast irradiation (APBI), who developed skin changes 6 years after completion of therapy. Punch biopsy confirmed the diagnosis of secondary angiosarcoma. This case is even more unique in that the location of the skin changes was remote to the lumpectomy site. There is a critical need to recognize secondary angiosarcoma presentation after APBI and determine the rate of occurrence compared with traditional external beam irradiation.

Outcomes in patients with gunshot wounds to the brain

Introduction

Gunshot wounds to the brain (GSWB) confer high lethality and uncertain recovery. It is unclear which patients benefit from aggressive resuscitation, and furthermore whether patients with GSWB undergoing cardiopulmonary resuscitation (CPR) have potential for survival or organ donation. Therefore, we sought to determine the rates of survival and organ donation, as well as identify factors associated with both outcomes in patients with GSWB undergoing CPR.

Methods

We performed a retrospective, multicenter study at 25 US trauma centers including dates between June 1, 2011 and December 31, 2017. Patients were included if they suffered isolated GSWB and required CPR at a referring hospital, in the field, or in the trauma resuscitation room. Patients were excluded for significant torso or extremity injuries, or if pregnant. Binomial regression models were used to determine predictors of survival/organ donation.

Results

825 patients met study criteria; the majority were male (87.6%) with a mean age of 36.5 years. Most (67%) underwent CPR in the field and 2.1% (n=17) survived to discharge. Of the non-survivors, 17.5% (n=141) were considered eligible donors, with a donation rate of 58.9% (n=83) in this group. Regression models found several predictors of survival. Hormone replacement was predictive of both survival and organ donation.

Conclusion

We found that GSWB requiring CPR during trauma resuscitation was associated with a 2.1% survival rate and overall organ donation rate of 10.3%. Several factors appear to be favorably associated with survival, although predictions are uncertain due to the low number of survivors in this patient population. Hormone replacement was predictive of both survival and organ donation. These results are a starting point for determining appropriate treatment algorithms for this devastating clinical condition.

Level of evidence

Level II.

The use of gamification in the teaching of disease epidemics and pandemics

With the launch of the teaching excellence framework, teaching in higher education (HE) is under greater scrutiny than ever before. Didactic lecture delivery is still a core element of many HE programmes but there is now a greater expectation for academics to incorporate alternative approaches into their practice to increase student engagement. These approaches may include a large array of techniques from group activities, problem-based learning, practical experience and mock scenarios to newly emerging approaches such as flipped learning practices and the use of gamification. These participatory forms of learning encourage students to become more absorbed within a topic that may otherwise be seen as rather ‘dry’ and reduce students engagement with, and therefore retention of, material. Here we use participatory-based teaching approaches in microbiology as an example to illustrate to University undergraduate students the potentially devastating effects that a disease can have on a population. The ‘threat’ that diseases may pose and the manner in which they may spread and/or evolve can be challenging to communicate, especially in relation to the timescales associated with these factors in the case of an epidemic or pandemic.

Introducing the H2020 AQUACROSS project: Knowledge, Assessment, and Management for AQUAtic Biodiversity and Ecosystem Services aCROSS EU policies

The AQUACROSS project was an unprecedented effort to unify policy concepts, knowledge, and management of freshwater, coastal, and marine ecosystems to support the cost-effective achievement of the targets set by the EU Biodiversity Strategy to 2020. AQUACROSS aimed to support EU efforts to enhance the resilience and stop the loss of biodiversity of aquatic ecosystems as well as to ensure the ongoing and future provision of aquatic ecosystem services. The project focused on advancing the knowledge base and application of Ecosystem-Based Management. Through elaboration of eight diverse case studies in freshwater and marine and estuarine aquatic ecosystem across Europe covering a range of environmental management problems including, eutrophication, sustainable fisheries as well as invasive alien species AQUACROSS demonstrated the application of a common framework to establish cost-effective measures and integrated Ecosystem-Based Management practices. AQUACROSS analysed the EU policy framework (i.e. goals, concepts, time frames) for aquatic ecosystems and built on knowledge stemming from different sources (i.e. WISE, BISE, Member State reporting within different policy processes, modelling) to develop innovative management tools, concepts, and business models (i.e. indicators, maps, ecosystem assessments, participatory approaches, mechanisms for promoting the delivery of ecosystem services) for aquatic ecosystems at various scales of space and time and relevant to different ecosystem types.

Identifying barriers, conflict and opportunity in managing aquatic ecosystems

Inland aquatic ecosystems play an important part in the delivery and support of ecosystem services. However, these ecosystems are subject to stressors associated with human activities such as invasive species introduction and landscape alteration. There is a delicate balance between maintaining good status of the ecosystem whilst meeting the needs of those stakeholders dependent on the ecosystem services it supplies, and where there are many different stakeholders, each with different aspirations and dependencies on the ecosystem, it can be difficult to strike a balance on suitable management measures to put in place. A better understanding of the interactions between the human and ecological functions of the ecosystem (a socio-ecological systems (SES) approach) can enable an effective dialogue to be opened to secure management solutions of best fit. In this study we took a SES approach to explore the dependencies and interactions in the Lough Erne catchment with a range of stakeholders representing the use of the Lough. In particular, we explored how individual stakeholder goals were perceived to be affected by both the biodiversity and activities found in the catchment. Results suggest there are distinct components deemed integral to the success of stakeholder goals in this system, including 'key habitat components' and 'policy relevant species', as well as activities associated with 'conservation and recreation' and 'scientific research'. Those components which were seen to limit the potential achievement of most goals included invasive species, and in particular, more recently introduced invasives, as well as extractive industries. Consideration of the similarity in goals based on their perceived interactions with the activities and biodiversity of the system indicated that there were shared dependencies between some stakeholders, but also differences that highlight the potential for conflict. Future management scenarios should take consideration of the key limiting and enabling factors identified here.

Post-feeding activity of Lucilia sericata (Diptera: Calliphoridae) on common domestic indoor surfaces and its effect on development

Developmental data of forensically important blowflies used by entomologists to estimate minimum post mortem interval (mPMI) are established under controlled laboratory conditions for various temperature ranges throughout the stages of egg, 1st-3rd instar, puparia, and adult fly emergence. However, environmental conditions may influence the patterns of development and behaviour of blowflies, potentially impacting on these established development rates. Previous studies investigating indoor colonisation have focused on the delay to oviposition, with behaviour during the post-feeding phase in this setting often overlooked. The environment in which third instar larvae disperse when searching for a pupariation site may vary drastically at both outdoor and indoor scenarios, influencing the activity and distance travelled during this phase and possibly affecting developmental rates. This study investigated the effect of eight common domestic indoor surfaces on dispersal time, distance travelled, and behaviour of post-feeding Lucilia sericata as well as any resulting variation in development. It was found that pupariation and puparia length within a pupariation medium of sawdust (often used in laboratory settings) produced comparable results with that of carpeted environments (those deemed to be 'enclosed'). Non-carpeted environments (those which were 'exposed') produced a delay to pupariation likely due to increased activity and energy expenditure in searching for pupariation sites which enabled burial. In addition, the observed speed of travel during dispersal was seen via time lapse photography to be greater within 'exposed' conditions. Larvae which dispersed upon burnt laminate flooring were observed to travel faster than in all other conditions and showed the only significant variation (P=0.04) in the day of emergence in comparison to the control condition of sawdust. This study has demonstrated that wandering phase activity is affected by the environmental surface which has potential implications for estimating both the distance travelled by dispersing larvae in indoor conditions and with further research, may be a consideration in mPMI calculations.

Normothermic Ex Vivo Kidney Perfusion Following Static Cold Storage-Brief, Intermediate, or Prolonged Perfusion for Optimal Renal Graft Reconditioning?

Normothermic ex vivo kidney perfusion (NEVKP) demonstrated superior results compared to hypothermic storage in donation after circulatory death (DCD) kidney transplantation. It is unknown whether an optimal perfusion time exists following hypothermic storage to allow for the recovery of renal grafts from cold ischemic injury. In a porcine model of DCD kidney autotransplantation, the impact of initial static cold storage (SCS) (8 h) followed by various periods of NEVKP recovery was investigated: group A, 8 hSCS only (control); group B, 8 hSCS + 1 hNEVKP (brief NEVKP); group C, 8 hSCS + 8 hNEVKP (intermediate NEVKP); and group D, 8 hSCS + 16 hNEVKP (prolonged NEVKP). All grafts were preserved and transplanted successfully. One animal in group D was sacrificed and excluded by postoperative day 3 due to hind limb paralysis, but demonstrated good renal function. Postoperative graft assessment during 8 days' follow-up demonstrated lowest levels of peak serum creatinine for intermediate (C) and prolonged (D) NEVKP (p = 0.027). Histological assessment on day 8 demonstrated a significant difference in tubular injury (p = 0.001), with highest values for group B. These results suggest that longer periods of NEVKP following SCS are feasible and safe for postponing surgical transplant procedure and superior to brief NEVKP, reducing the damage caused during cold ischemic storage of renal grafts.

Continuous Normothermic Ex Vivo Kidney Perfusion Is Superior to Brief Normothermic Perfusion Following Static Cold Storage in Donation After Circulatory Death Pig Kidney Transplantation

Hypothermic preservation is known to cause renal graft injury, especially in donation after circulatory death (DCD) kidney transplantation. We investigated the impact of cold storage (SCS) versus short periods of normothermic ex vivo kidney perfusion (NEVKP) after SCS versus prolonged, continuous NEVKP with near avoidance of SCS on kidney function after transplantation. Following 30 min of warm ischemia, kidneys were removed from 30-kg Yorkshire pigs and preserved for 16 h with (A) 16 h SCS, (B) 15 h SCS + 1 h NEVKP, (C) 8 h SCS + 8 h NEVKP, and (D) 16 h NEVKP. After contralateral kidney resection, grafts were autotransplanted and pigs followed up for 8 days. Perfusate injury markers such as aspartate aminotransferase and lactate dehydrogenase remained low; lactate decreased significantly until end of perfusion in groups C and D (p < 0.001 and p = 0.002). Grafts in group D demonstrated significantly lower serum creatinine peak when compared to all other groups (p < 0.001) and 24-h creatinine clearance at day 3 after surgery was significantly higher (63.4 ± 19.0 mL/min) versus all other groups (p < 0.001). Histological assessment on day 8 demonstrated fewer apoptotic cells in group D (p = 0.008). In conclusion, prolonged, continuous NEVKP provides superior short-term outcomes following DCD kidney transplantation versus SCS or short additional NEVKP following SCS.

Community variability and ecological functioning: 40 years of change in the North Sea benthos

Using established associations between species traits (life history, morphological and behavioural characteristics) and key ecological functions, we applied biological traits analysis (BTA) to investigate the consequences of 40 years of change in two North Sea benthic communities. Ecological functioning (trait composition) was found to be statistically indistinguishable across periods that differed significantly in taxonomic composition. A temporary alteration to functioning was, however, inferred at both sampling stations; coinciding with the North Sea regime shift of the 1980s. Trait composition recovered after 1 year at the station located inside the grounds of a trawl fishery, whereas the station located outside the main area of fishing activity underwent a six-year period of significantly altered, and temporally unstable, trait composition. A further alteration to functioning was inferred at the fished station, when the population of a newly established species rapidly increased in numbers. The results suggest that density compensation by characteristically similar (redundant) taxa acts to buffer changes to ecological functioning over time, but that functional stability is subject to aperiodic disruption due to substitutions of dissimilar taxa or uncompensated population fluctuations. The rate at which ecological functioning stabilises and recovers appears to be dependent on environmental context; e.g. disturbance regime.

Assessing the sensitivity of habitats to fishing: from seabed maps to sensitivity maps

In the Welsh part of the Irish Sea, a method was developed for assessing the sensitivity of different seabed habitats to existing fishing activities, across a range of potential fishing intensities. The resistance of 31 habitats and their associated biological assemblage to damage by 14 categories of fishing activity were assessed along with the rate at which each habitat would recover following impact (resilience). Sensitivity was scored based on a combination of the resistance of a habitat to damage and its subsequent rate of recovery. The assessments were based, wherever possible, on scientific literature, with expert judgement used to extrapolate results to habitat and gear combinations not directly examined in the published literature. The resulting sensitivity matrices were then subject to further peer review at a series of workshops. Following consensus on the habitat sensitivity, these data were combined with the most resolved sea-floor habitat maps. These habitat sensitivity maps can help inform the development of site-specific management plans, as well as having a place in spatial planning and aiding managers in developing dialogue with other stakeholders. A case study of their application is provided.

The mobilisation of sediment and benthic infauna by scallop dredges

We present the results of experiments to assess the immediate impact of scallop dredging on the seabed sediment and on the inhabiting infauna. The passage of the scallop dredge is shown to homogenise the seabed, flattening sand ripples. The turbulent wake entrains up to the equivalent of a 1 mm layer of sediment per unit of swept width, although an analysis of the finer particles material implies that the suspended silt material must originate from depths of at least 10 mm. The species most abundant in the sediment plume either swim actively in the water column or are found in, or on, the upper layers of the substrate, whereas those most abundant in core samples taken from the sediment, but not present in the net samples, are almost all tube-building or deep burrowing. The vertical stratification of sediment concentration and of animal numbers in the water column suggests that even if some of these species respond actively to the presence of the dredge, once entrained, they are transported more or less passively in the same way as the larger sediment particles. There was no difference between the core samples taken before or after towing suggesting that animals mobilised by the dredge resettle in the tow path. Our analysis does not provide any information regarding the fate of these animals.

"Start to stop": results of a randomised controlled trial of a smoking cessation programme for teens

OBJECTIVE

To examine the feasibility, acceptability, and effectiveness of a school based smoking cessation programme among students caught smoking at school.

DESIGN

A randomised controlled trial comparing cessation rates among students in a behavioural cessation programme and those receiving self help materials only.

SETTING

Eighteen schools in the Memphis, Tennessee area.

SUBJECTS

Two hundred and sixty one adolescent cigarette smokers (166 male, 95 female) averaging 15.8 years of age.

INTERVENTION

Students assigned to the intervention received a four session behavioural treatment programme administered individually by a health educator. In addition, these students received stage matched intervention in brief phone calls monthly until the one year follow up.

MAIN OUTCOME MEASURE

Self reported and biochemically verified smoking cessation at post-test and 12 month follow up.

RESULTS

Recruiting students who were caught smoking at school proved to be highly successful. Participants rated the programme favourably, and retention rates were high. Although treated participants improved more in tobacco related knowledge relative to controls (p = 0.002), there were no group differences in changes in attitudes toward smoking. In addition, treated and control participants demonstrated no significant differences in cessation rates both at post-test and follow up. Comparisons between self reported cessation rates and those obtained under bogus pipeline conditions or with biochemical verification suggested significant falsification of cessation among participants.

CONCLUSIONS

Our results failed to demonstrate any significant effect of the cessation programme on smoking rates for treated adolescents compared with controls. Our findings also highlight the importance of utilising strong methodology in research on adolescent smoking cessation, including control groups and biochemical verification of smoking status.

Suspended multiwalled carbon nanotubes as self-aligned evaporation masks

We describe the nanofabrication study of self-aligned electrodes on suspended multiwalled carbon nanotube structures. When metal is deposited on a suspended multiwalled carbon nanotube structure, the nanotube acts as an evaporation mask, resulting in the formation of discontinuous electrodes. The metal deposits on the nanotubes are removed with lift-off. Using Al sacrificial layers, it was possible to fabricate self-aligned contact electrodes and control electrodes nanometers from the suspended carbon nanotubes with a single lithography step. It was also shown that the fabrication technique may also be used to form nano-gapped contact electrodes. The technique should prove useful for the fabrication of nano-electromechanical systems.

Novel inhibitors of procollagen C-proteinase. Part 2: glutamic acid hydroxamates

Glutamic acid derived hydroxamates were identified as potent and selective inhibitors of procollagen C-proteinase, an essential enzyme for the processing of procollagens to fibrillar collagens. Such compounds have potential therapeutic application in the treatment of fibrosis.

Novel inhibitors of procollagen C-terminal proteinase. Part 1: diamino Acid hydroxamates

The parallel synthesis of novel inhibitors of procollagen C-terminal proteinase is described. The synthetic strategy allowed for the facile synthesis of a large number of side-chain diversified diamino acid hydroxamates, of which the D-diaminopropionic acid derivatives were shown to be single digit nanomolar PCP inhibitors.

Amino acid derived sulfonamide hydroxamates as inhibitors of procollagen C-proteinase: solid-phase synthesis of ornithine analogues

A discussion of the solid-phase synthesis of ornithine derived sulfonamide hydroxamic acids is illustrated. These analogues are shown to be potent, non-peptide inhibitors of procollagen C-proteinase (PCP).

Radio-guided surgical biopsy for the diagnosis of suspected osseous metastases

Radioisotope bone scanning is frequently employed in staging malignancies. However, false positive results are common, and biopsy is usually required. In the absence of plain radiographic abnormalities or local symptoms, localization of the area of abnormal tracer activity at the time of open rib or sternum biopsy may be difficult. It often requires resection of a large portion of one or more ribs or other bones to assure that the target area was biopsied, and still the area in question is commonly missed. In this setting, the newly-developed, small gamma probe is now used as a tool to allow precise intraoperative localization of increased tracer activity in the target bone. The use of gamma counting is an easy, highly accurate aid (100% sensitivity) to localize areas of abnormal radioisotope uptake in suspected asymptomatic osseous metastases, usually for open biopsy of a rib. The use of this technique obviates the need to obtain intraoperative localizing radiographs to confirm accurate rib identification, thereby substantially decreasing operative time.

Adult grief reactions following a sibling's death from AIDS

The AIDS epidemic has resulted in an unprecedented death toll among young adults, many of whom are survived by siblings. Whereas the circumstances surrounding deaths from AIDS place survivors at risk for intense bereavement, no reported studies have examined the pattern or intensity of grief among adult siblings. One hundred and two adults who had experienced the death of a sibling from AIDS were recruited into this study in which grief reactions were measured using the Grief Experience Inventory. Time since the sibling's death ranged from 3 months to 11 years. Grief reactions were found to exceed those previously reported. A positive relationship was found between the level of closeness of the survivor to the deceased and the intensity of grief reactions. No relationship was found between time since the sibling's death and intensity of grief.

Evaluation and management of patients with stage IIIA (N2) non-small-cell lung cancer

Management of the stage IIIA (N2) patient remains one of the most controversial areas in thoracic oncology. The potential curability of at least some of these patients has encouraged the development of more complex, aggressive, and toxic multimodality treatment regimens.

A role for fractalkine and its receptor (CX3CR1) in cardiac allograft rejection

The hallmark of acute allograft rejection is infiltration of the inflamed graft by circulating leukocytes. We studied the role of fractalkine (FKN) and its receptor, CX(3)CR1, in allograft rejection. FKN expression was negligible in nonrejecting cardiac isografts but was significantly enhanced in rejecting allografts. At early time points, FKN expression was particularly prominent on vascular tissues and endothelium. As rejection progressed, FKN expression was further increased, with prominent anti-FKN staining seen around vessels and on cardiac myocytes. To determine the capacity of FKN on endothelial cells to promote leukocyte adhesion, we performed adhesion assays with PBMC and monolayers of TNF-alpha-activated murine endothelial cells under low-shear conditions. Treatment with either anti-FKN or anti-CX(3)CR1-blocking Ab significantly inhibited PBMC binding, indicating that a large proportion of leukocyte binding to murine endothelium occurs via the FKN and CX(3)CR1 adhesion receptors. To determine the functional significance of FKN in rejection, we treated cardiac allograft recipients with daily injections of anti-CX(3)CR1 Ab. Treatment with the anti-CX(3)CR1 Ab significantly prolonged allograft survival from 7 +/- 1 to 49 +/- 30 days (p < 0.0008). These studies identify a critical role for FKN in the pathogenesis of acute rejection and suggest that FKN may be a useful therapeutic target in rejection.

Ethnic differences in patterns and correlates of age of initiation in a population of Air Force recruits

Early age of initiation is a significant risk factor for long-term dependent smoking and may also relate to other unhealthy behaviors. The current study assessed age of initiation in relationship to smoking dependence and motivation to quit, physical activity, dietary intake, body mass index (BMI), attitude toward illegal drug use, binge drinking, seat belt use, and smoking status at follow-up. Subjects were 7995 Air Force recruits who reported smoking regularly up to Basic Military Training. Euro-Americans initiated smoking more than a year earlier on average (15.5 years) than did African-Americans (16.8 years), with Hispanic-Americans (16.0 years) between these two groups. No gender differences were found for age of initiation for any ethnic group. Early age of initiation in Euro-Americans was associated with greater dependence on tobacco, reduced motivation to quit, less likelihood of quitting in the next 12 months, and a number of other health risk factors including lower self-reported physical activity, greater intake of high-fat foods, more favorable attitudes toward illegal drugs, increased likelihood of binge drinking, and less reported use of seat belts. Relationships between early age of initiation and other unhealthy behaviors were less consistent for African-Americans and for neither African-Americans nor Hispanics did age of initiation predict smoking status at 1-year follow-up.

A survey of managed care strategies for pregnant smokers

OBJECTIVE

The purpose of this study was to measure the content and comprehensiveness of pregnancy specific smoking cessation strategies within managed care organisations (MCOs) responding affirmatively to the national 1997-98 Addressing Tobacco in Managed Care (ATMC) survey.

DESIGN

This cross sectional follow up study consisted of a fax survey sent to medical directors and a 37 question telephone survey of program overseers about the smoking cessation strategy.

SUBJECTS

147 MCOs identifying a pregnancy specific smoking cessation strategy on the 1997-98 ATMC survey served as the initial sample; 88 MCOs of 128 eligible plans completed both components, with a response rate of 69%.

RESULTS

Pregnancy specific smoking cessation strategies varied. 40% of respondents used the Agency for Health Care Policy and Research guidelines for clinical smoking cessation to design their strategy. Strategies included self help materials, quit classes, telephone support and brief counselling by providers, linkages to quality improvement efforts, and use of patient databases for outreach. Only 42% offered a postpartum relapse prevention element. Lack of patient interest, competing clinic priorities, and the lack of a smoker identification system were the most problematic barriers to implementing strategies, common to at least a quarter of respondents. A majority ranked best practice manuals and web site linkages as the most useful form of technical assistance, followed by peer-to-peer counselling, regional workshops, newsletters, on-site assistance, and national conferences.

CONCLUSIONS

The survey provides the first profile of prenatal tobacco treatment strategies in managed care. While design limitations prevent generalisation of these results to all MCOs, such information can help guide technical assistance to plans interested in reducing smoking among pregnant women.

Information needs of elderly postsurgical cancer patients during the transition from hospital to home

PURPOSE

To describe information needs of elderly postsurgical cancer patients. Few reports have described learning needs of postsurgical cancer patients during the initial weeks after hospitalization. Responding to information needs during the transition to home is important for helping patients and families to appropriately manage illness.

DESIGN

Descriptive, using records kept for patients assigned to the experimental group in a larger study completed in 1996. The sample was 148 American patients surgically treated for a new diagnosis of prostate, breast, gastrointestinal, lung, or head and neck cancer. Information needs were identified from topics addressed by advanced practice nurses during 4-week episodes of home care.

METHODS

Content analysis of 3,280 statements of teaching interventions.

FINDINGS

Teaching themes were instructing on postoperative self-care, advising on symptom management, clarifying the illness experience, discussing psychological responses, and preparing patients and families to coordinate follow-up care. Topics included describing the expected course of illness, informing about community resources, identifying events that require physician notification, and advising on pain management. Topic emphasis varied by site of cancer.

CONCLUSIONS

Information needs of elderly postsurgical cancer patients during transition from hospital to home are extensive. Teaching interventions ranged from giving concrete instructions about care of a surgical wound to interpreting complex information about options for cancer treatment. Elderly postsurgical cancer patients need informational support during the transition from hospital to home.

Rationale and design of the OPTIME CHF trial: outcomes of a prospective trial of intravenous milrinone for exacerbations of chronic heart failure

BACKGROUND

The optimal management of an acute exacerbation of chronic heart failure (CHF) is uncertain. There is little randomized evidence available to support the various treatment strategies for patients hospitalized with an exacerbation of CHF. Inotropic agents may produce beneficial hemodynamic effects, and although they are currently used in these patients, their effect on clinical response and impact on clinical outcome is unclear. We present a unique and simple study designed to determine whether a treatment strategy for CHF exacerbations that includes an intravenous agent with inotropic properties can reduce hospital length of stay and lead to improved patient outcome.

METHODS

The OPTIME CHF (Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure) trial is an ongoing multicenter, randomized, placebo-controlled trial of a treatment strategy for patients with acute exacerbations of CHF. The design of this study provides a novel approach to the evaluation of treatment strategies in the care of this population. The OPTIME CHF design uses early initiation of intravenous milrinone as both an adjunct to the best the medical therapy and to facilitate optimal dosing of standard oral therapy for heart failure. Patients with known systolic heart failure requiring hospital admission for a CHF exacerbation are randomly assigned within 48 hours of admission to receive a 48-hour infusion of either intravenous milrinone or placebo. The primary end point of this design is a reduction in the total hospital days for cardiovascular events within 60 days after therapy. Enrollment of 1000 patients began July 7, 1997, at 80 US centers and is projected to conclude in late 1999.

Age of initiation, smoking patterns, and risk in a population of working adults

BACKGROUND

Early age of initiation is a significant risk factor for long-term dependent smoking and may also relate to other unhealthy behaviors and increased likelihood of illness, independent of duration of smoking.

METHODS

The current study assessed age of initiation in relation to cigarette dependence, interest in quitting, social environment pertaining to smoking, behavioral risk factors, and current health problems. Subjects were 2120 current daily smokers in 24 worksites in the Minneapolis/St. Paul, Minnesota, metropolitan area.

RESULTS

Findings were surprisingly consistent with early age of initiation predicting more dependent smoking, less interest and confidence in ability to quit, poorer diet, less use of seat belts, more illness and hospitalization, and greater likelihood of smoking among partner/spouse, friends, and co-workers.

CONCLUSIONS

The overall strength of the findings was unexpected. Early initiation of regular smoking predicted a significant constellation of risk factors throughout adulthood. Interventions that significantly delay smoking onset, even in the absence of permanent prevention, could have important public health implications.

Bone localization

Accurate staging of malignancies is essential to guide the clinician in selecting the most appropriate therapy. Metastases to bone suggested by radionuclide bone scans must be proven histologically because of the high frequency of false-positive results. If the plain bone radiographs, however, are normal and there are no localizing symptoms, precise biopsy of the area of bone scan abnormality is usually difficult and time-consuming. The recently described intraoperative use of the hand-held gamma probe now allows for great accuracy and sensitivity in the radioisotope-guided open biopsy of clinically suspected bone metastases.

Gender and ethnic differences in young adolescents' sources of cigarettes

OBJECTIVE

To identify the sources used by young adolescents to obtain cigarettes.

DESIGN

In early 1994 a survey assessing usual sources of cigarettes and characteristics of the respondents was administered in homeroom classes.

SETTING

A large urban, predominantly African American school system.

SUBJECTS

A population-based sample of 6967 seventh graders averaging 13 years of age.

MAIN OUTCOME MEASURE

Reports of usual sources of cigarettes.

RESULTS

At this age level, young smokers were more likely to get cigarettes from friends (31.2%) than buy them in stores (14.3%). However, the odds of purchasing varied for different groups of children. Regular smokers were much more likely (48.3%) to have purchased cigarettes than experimental smokers (9.6%), p < 0.001. Girls were less likely to have bought their cigarettes than boys (p < 0.001), and black smokers were less likely to have purchased cigarettes than white children (p < 0.001). Results suggested that family members who smoke may constitute a more important source of tobacco products than previously recognised, particularly for young girls.

CONCLUSIONS

In this middle-school sample, peers provided the major point of cigarette distribution. However, even at this age, direct purchase was not uncommon. Sources of cigarettes varied significantly with gender, ethnicity, and smoking rate.

Aspergillus and other fungi

Opportunistic infections that arise in the immunocompromised host are a major cause of morbidity and mortality. Although bacterial infections are more frequent, invasive fungal infections occur commonly and carry higher risks in these immunocompromised patients. Newer antifungal agents, along with an occasional pulmonary resection, have improved the treatment options and the survival from invasive fungal infections in immunocompromised patients.

Low cardiac output complicating pericardiectomy for pericardial tamponade

Neoplastic involvement of the pericardium resulting in an effusion and subsequent tamponade is an emergency requiring prompt decompression, generally safely accomplished by subxiphoid pericardiectomy. However, the current case report describes a patient with florid pericardial tamponade who underwent surgical decompression with transient hemodynamic improvement, who then rapidly developed progressive, heart failure and death. This paradoxical response to pericardial decompression, similar to that seen occasionally with pericardiectomy in constrictive pericarditis, may be more frequent than currently appreciated. Its cause may relate to the sudden removal of the chronic external ventricular support from the effusion resulting in ventricular dilatation and failure.

The relationship between smoking and body weight in a population of young military personnel

Evidence indicates that middle-aged smokers weigh less than nonsmokers and that smoking cessation reliably produces weight gain, but recent studies have questioned the weight control "benefits" of smoking in younger populations (the time that people typically initiate smoking). The relationship between smoking and body weight was evaluated in all U.S. Air Force Basic Military Training recruits during a 1-year period (n = 32,144). Those who smoked prior to Basic Military Training (n = 10,440) were compared to never smokers or experimental smokers. Results indicated that regular-current smoking had no relationship to body weight in women (p > .05) and a very small effect in men (p < .05). Ethnicity, education, income, and duration and intensity of smoking did not affect the relationship between smoking and body weight. It was concluded that smoking has no effects on the body weights of young women and minimal effects in young men.

The role of adhesion molecules in human leukocyte attachment to porcine vascular endothelium: implications for xenotransplantation

Many obstacles still prevent successful xenotransplantation of porcine donor organs. When hyperacute rejection is averted, transplanted pig organs are subject to acute vascular and cellular rejection. In autologous systems, leukocyte recruitment into inflamed tissues involves selectins, integrins, and Ig family members. To determine whether these mechanisms allow human leukocytes to effectively enter porcine grafts, the pathways by which human leukocytes adhere to TNF-alpha-stimulated porcine aortic endothelium were examined under static and physiologic flow conditions. L-selectin and E-selectin had overlapping functions in neutrophil capture and rolling, whereas Ab blockade of E-selectin and the beta2 integrins inhibited firm arrest of rolling neutrophils. Combined blockade of selectins and beta2 integrins resulted in negligible human neutrophil attachment to pig endothelium. Lymphocyte attachment to porcine endothelium was primarily L-selectin mediated, whereas beta2 integrin and VCAM-1/very late Ag-4 (VLA-4) interactions promoted static adhesion. Concurrent beta2 integrin, VLA-4, VCAM-1, and L-selectin blockade completely inhibited lymphocyte attachment. Thus, interactions between leukocyte-endothelial cell adhesion receptor pairs remained remarkably intact across the human-porcine species barrier. Moreover, disrupting the adhesion cascade may impair the ability of human leukocytes to infiltrate a transplanted porcine organ during rejection.

Fractalkine and CX3CR1 mediate a novel mechanism of leukocyte capture, firm adhesion, and activation under physiologic flow

Leukocyte migration into sites of inflammation involves multiple molecular interactions between leukocytes and vascular endothelial cells, mediating sequential leukocyte capture, rolling, and firm adhesion. In this study, we tested the role of molecular interactions between fractalkine (FKN), a transmembrane mucin-chemokine hybrid molecule expressed on activated endothelium, and its receptor (CX3CR1) in leukocyte capture, firm adhesion, and activation under physiologic flow conditions. Immobilized FKN fusion proteins captured resting peripheral blood mononuclear cells at physiologic wall shear stresses and induced firm adhesion of resting monocytes, resting and interleukin (IL)-2-activated CD8(+) T lymphocytes and IL-2-activated NK cells. FKN also induced cell shape change in firmly adherent monocytes and IL-2-activated lymphocytes. CX3CR1-transfected K562 cells, but not control K562 cells, firmly adhered to FKN-expressing ECV-304 cells (ECV-FKN) and tumor necrosis factor alpha-activated human umbilical vein endothelial cells. This firm adhesion was not inhibited by pertussis toxin, EDTA/EGTA, or antiintegrin antibodies, indicating that the firm adhesion was integrin independent. In summary, FKN mediated the rapid capture, integrin-independent firm adhesion, and activation of circulating leukocytes under flow. Thus, FKN and CX3CR1 mediate a novel pathway for leukocyte trafficking.

The relationship between smoking and body weight in a population of young military personnel

Evidence indicates that middle-aged smokers weigh less than nonsmokers and that smoking cessation reliably produces weight gain, but recent studies have questioned the weight control "benefits" of smoking in younger populations (the time that people typically initiate smoking). The relationship between smoking and body weight was evaluated in all U.S. Air Force Basic Military Training recruits during a 1-year period (n = 32,144). Those who smoked prior to Basic Military Training (n = 10,440) were compared to never smokers or experimental smokers. Results indicated that regular-current smoking had no relationship to body weight in women (p > .05) and a very small effect in men (p < .05). Ethnicity, education, income, and duration and intensity of smoking did not affect the relationship between smoking and body weight. It was concluded that smoking has no effects on the body weights of young women and minimal effects in young men.

Intraoperative gamma probe-directed biopsy of asymptomatic suspected bone metastases

BACKGROUND

Radioisotope bone scanning is frequently used in staging malignancies. However, false-positive results are common, and biopsy is usually required. In the absence of plain radiographic abnormalities or local symptoms, localization of the area of abnormal tracer activity at the time of open rib or sternum biopsy may be difficult. It often requires resection of a large portion of one or more ribs or the sternum to assure that biopsy of the target area was performed. In this setting, a small gamma probe underwent evaluation as an aid to precise intraoperative localization of increased tracer activity in the target bone.

METHODS

Ten patients with asymptomatic suspected osseous chest metastases by radioisotope bone scanning but with normal plain radiographs underwent open biopsy of 13 ribs and 1 sternum. Six to 12 hours before operation, each received an intravenous injection of 28 mCi of technetium-99m oxidronate. The hand-held, pencil-sized gamma probe in a sterile sleeve was used to localize the area of greatest activity in the target bone, once the bone was exposed through a small incision. Biopsy of a 3-cm length of rib or portion of sternum was performed. In the first two rib biopsies, an intraoperative radiograph with a radiopaque marker on the rib confirmed that the correct rib was selected for biopsy. Intraoperative radiographs were not done on later cases.

RESULTS

The mean ratio of hot spot activity on the targeted rib to background counts on adjacent ribs was 1.65 +/- 0.22 (range, 1.35 to 2.05), and the difference was easily discernible intraoperatively. The ratio of hot spot activity on the sternum was somewhat lower (1.22), but the target area was still easy to detect. An abnormal diagnosis to account for the increased tracer activity was found in each of the 13 ribs and 1 sternal biopsy in all 10 patients: metastatic squamous cell carcinoma (1 rib), metastatic prostatic adenocarcinoma (1 rib), lymphoma (2 ribs), localized hypercellular marrow (1 rib), medullary fibrosis/Paget's disease of the bone (2 ribs), localized fibrosis/granulation tissue (1 rib), enchondroma (3 ribs), and chondroma (2 ribs, 1 sternum). The difference in background counts to hot spot activity was best with injection of the tracer 6 hours before operation.

CONCLUSIONS

The intraoperative use of gamma counting is an easy, highly accurate aid (100% sensitivity) to localize areas of abnormal radioisotope uptake in suspected asymptomatic rib and sternal metastases. Use of this technique obviates the need to obtain intraoperative localizing radiographs to confirm accurate rib identification, thereby decreasing operative time.

Pleural tenting during upper lobectomy decreases chest tube time and total hospitalization days

OBJECTIVE

A prolonged air leak after an upper lobectomy is a major determinant of morbidity and hospital stay. Creation of a pleural tent after upper lobectomy was used to investigate whether obliterating the usual postoperative intrapleural apical space with the parietal pleura would help shorten chest tube time.

METHODS

From August, 1994, through January, 1997, 48 consecutive patients undergoing an isolated upper lobectomy for a neoplasm were reviewed. Twenty-eight patients had creation of a pleural tent and 20 patients did not. Demographic and clinical profiles of both groups were not significantly different. Chest tubes were removed when there was no air leak for 48 hours and chest tube drainage was less than 75 ml per 8 hours.

RESULTS

The tented patients had significantly shorter mean air leak (tented 1.6 +/- 0.3 days vs nontented 3.9 +/- 1.2 days, p = 0.04), mean chest tube total drainage (tented 1619.5 +/- 95.5 ml vs nontented 2476.3 +/- 346.4 ml, p = 0.009), mean chest tube duration (tented 4.0 +/- 0.2 days vs nontented 6.6 +/- 1.0 days, p = 0.004), mean total hospitalization time (tented 6.4 +/- 0.4 days vs nontented 8.6 +/- 1.0 days, p = 0.02). No operative deaths occurred. Morbidity was not significantly different between groups.

CONCLUSIONS

(1) Creation of a pleural tent at the time of upper lobectomy appears to significantly reduce chest tube time and shorten hospitalization. (2) No morbidity or mortality was associated with this simple, quick procedure. (3) Surgeons should consider creation of a pleural tent at the time of upper lobectomy.

Ethnic and gender differences in risk factors for smoking onset

The purpose of this investigation was to explore gender and ethnic differences in the prevalence of risk factors for smoking onset. As part of a larger study, 6,967 seventh graders completed a questionnaire measuring variables shown in previous research to predict cigarette smoking. The results indicated that at this age level, risk factors for smoking initiation are less prevalent among African Americans than European American youth and among girls relative to boys. These findings are consistent with the lower incidence of smoking among African Americans and girls at this young age. Future research should examine changes in risk factors over time to determine whether such changes accompany the rising smoking rate typically observed among girls and African Americans later in adolescence.

The Pleural Tent

This regular feature will enhance your knowledge of imaging technology in oncologic diagnosis, treatment, and evaluation.

Is smoking associated with lower body mass in adolescents? A large-scale biracial investigation

The present investigation evaluated the relationship between smoking and body weight (body mass index [BMI]) in a large, biracial sample of seventh-grade students. Participants were 6751 (5,607 African American, 1,144 White) seventh-grade students participating in an evaluation of smoking determinants in adolescence. In addition to providing, in this survey design, information about their smoking status, participants self-reported both their height and weight, which was converted into a BMI. Contrary to predictions, smoking was positively related to BMI. That is, with increasing levels of smoking exposure, BMI significantly increased. Thus, it appears that smoking is not related to lowered BMI in adolescent populations. Implications and possible reasons for these findings are discussed.

Appearance of immune complex glomerulonephritis following the onset of type I diabetes mellitus in a child

Renal disease is a frequent late complication of type I diabetes mellitus, occurring almost entirely in adult patients. Typical diabetic nephropathy is characterized by proteinuria, and by the histological lesions of mesangial expansion and basement membrane thickening. We report an interesting case of a 3-year-old boy who developed immune complex glomerulonephritis with nephrotic syndrome 2 months after the onset of insulin-dependent diabetes mellitus.

Ethnic and gender differences in risk factors for smoking onset

The purpose of this investigation was to explore gender and ethnic differences in the prevalence of risk factors for smoking onset. As part of a larger study, 6,967 seventh graders completed a questionnaire measuring variables shown in previous research to predict cigarette smoking. The results indicated that at this age level, risk factors for smoking initiation are less prevalent among African Americans than European American youth and among girls relative to boys. These findings are consistent with the lower incidence of smoking among African Americans and girls at this young age. Future research should examine changes in risk factors over time to determine whether such changes accompany the rising smoking rate typically observed among girls and African Americans later in adolescence.

Radioisotope-Guided Surgical Biopsy of Suspected Osseous Metastases

BACKGROUND: Radioisotope bone scanning is frequently used to stage patients with suspected or proven malignancies. Since false-positive results are common, especially in the ribs, open biopsy is often necessary. The conventional approach of visual inspection of the bone scan image to guide the surgeon usually requires excision of a large area of one or two ribs to assure that the biopsy was performed on the correct rib. A more precise method to guide the biopsy is desirable. METHODS: One technique to localize the suspicious area of bone intraoperatively for accurate biopsy involves percutaneous injection of the bone abnormality with a radioisotope followed by injection of methylene blue into the periosteum and subsequent open surgical biopsy. A more recent technique uses a hand-held gamma probe in a sterile sleeve in the operating room to locate the bone "hot spot" directly in the wound to guide the biopsy. RESULTS: Both techniques are effective in pinpointing the bone scan abnormality, but use of the gamma probe is less cumbersome and consumes less time and fewer resources. In one series of 10 patients undergoing gamma probe-guided biopsies of 13 rib and 1 sternal bone scan lesions, this technique showed a sensitivity of 100% in locating the area of abnormal radioisotope uptake. All biopsies yielded an abnormal diagnosis to account for the bone scan abnormality, but only 4 of 14 (29%) demonstrated metastatic tumor. CONCLUSIONS: Techniques described for radioisotope-guided localization of areas of increased tracer uptake in asymptomatic suspected bone metastases are accurate, sensitive guides to the open biopsy of these bony abnormalities. Due to the high false-positive rates in these asymptomatic but suspicious bone scan abnormalities, a diagnosis should be histologically confirmed.

The ability of children with specific language impairment to access and participate in an ongoing interaction

This study investigated the ability of 6 children with specific language impairment (SLI), ages 8;10 to 12;5 (years; months), to enter and participate in an ongoing dyadic interaction. Performance was compared to that of 6 chronological age-matched (CA) peers and 6 language-similar (LS) peers. All children in the LS and CA groups successfully accessed the interaction, and most did so quickly. Two children from the SLI group did not access, and the 4 remaining subjects required varying amounts of time to access. Following successful access, the triadic interactions of subjects were examined. The accessing children with SLI talked significantly less, were addressed significantly less, and collaborated less than either of the partners within their triads. Few significant differences were observed between LS or CA children and their partners.

Predictors of risk for different stages of adolescent smoking in a biracial sample

This investigation was designed to identify the risk factors associated with different stages of cigarette use in a large biracial adolescent sample. A questionnaire assessing smoking habits and variables thought to be related to smoking was administered to 6,967 7th graders. Analysis revealed that the best predictor of experimentation with cigarettes was the perception that they were easily available. Regular smoking appeared to be heavily influenced by cost. Social influences contributed to both experimental and regular smoking, but the impact of social models varied with ethnicity and gender. Analysis further revealed that weight-related variables were closely tied to regular smoking. Implications of the findings for smoking prevention programs are discussed.

Predictors of risk for different stages of adolescent smoking in a biracial sample

This investigation was designed to identify the risk factors associated with different stages of cigarette use in a large biracial adolescent sample. A questionnaire assessing smoking habits and variables thought to be related to smoking was administered to 6,967 7th graders. Analysis revealed that the best predictor of experimentation with cigarettes was the perception that they were easily available. Regular smoking appeared to be heavily influenced by cost. Social influences contributed to both experimental and regular smoking, but the impact of social models varied with ethnicity and gender. Analysis further revealed that weight-related variables were closely tied to regular smoking. Implications of the findings for smoking prevention programs are discussed.

Chronic dieting and the belief that smoking controls body weight in a biracial, population-based adolescent sample

OBJECTIVE

To evaluate the prevalence of weight concerns and smoking for body weight reasons as a function of race and gender.

DESIGN

A questionnaire measuring a number of factors thought to be predictive of smoking was administered.

SETTING

The Memphis (Tennessee) school system.

PARTICIPANTS

Participants were 6961 seventh-grade students (mean age 13 years). This population consisted of 80.8% black children, 16.5% white children, and 2.7% of other ethnic origins.

MAIN OUTCOME MEASURES

Weight concerns were assessed using items from a restraint scale. Students were questioned regarding their smoking status, beliefs that smoking controls body weight, and their own weight-control smoking behaviour.

RESULTS

Dietary restraint interacted with race in that, whereas white girls scored the highest on dietary restraint, black boys scored higher on dietary restraint than white boys. Almost 40% of subjects at this school level believed that smoking controls their body weight. Of the regular smokers, 12% indicated they have smoked to control their weight, with white girls endorsing this belief significantly more than other respondents.

CONCLUSIONS

The propensity to smoke for weight control reasons, previously described by other researchers among white females of college and high-school age, was also found among this sample of students of junior high school age.