Home respiratory strategies in COPD patients with chronic hypercapnic respiratory failure: a systematic review and network meta-analysis

Background: Home non-invasive positive pressure ventilation (NPPV) may improve chronic hypercarbia in COPD and patient important outcomes. The efficacy of home high flow nasal cannula (HFNC) as an alternative is unclear.Methods: We searched MEDLINE, EMBASE, Cochrane CENTRAL, SCOPUS, and Clinicaltrials.gov for randomized trials of patients from inception to March 31st and updated the search on July 14, 2023. We performed a frequentist network meta-analysis and assessed the certainty of the evidence using the GRADE approach. We analyzed randomized trials (RCTs) comparing NPPV, HFNC, or standard care in adult COPD patients with chronic hypercapnic respiratory failure. Outcomes included mortality, COPD exacerbations, hospitalizations, and quality of life (SGRQ).Results: We analyzed twenty-four RCTs (1850 patients). We found that NPPV may reduce death risk compared to standard care (relative risk [RR] 0.82 [95% CI 0.66 to 1.00]) and probably reduces acute exacerbations (RR 0.71 [95% CI 0.58 to 0.87]). HFNC probably reduces acute exacerbations compared to standard care (RR 0.77 [0.68 to 0.88]) but its effect on mortality is uncertain (RR 1.20 [95% CI 0.63 to 2.28]). HFNC probably improves SGRQ scores (mean difference [MD] -7.01 [95% CI -12.27 to -1.77]) and may reduce hospitalizations (RR 0.87 [0.69 to 1.09]) compared to standard care. No significant difference was observed between HFNC and NPPV in reducing exacerbations.Conclusion: Both NPPV and HFNC reduce exacerbation risks in COPD patients compared to standard care. HFNC may offer advantages in improving quality of life.

One-week radiology boot camp for pre-clerkship medical students: A novel format improving image interpretation and confidence

RATIONALE AND OBJECTIVES

To measure change in radiology knowledge, confidence in radiology skills, and perceptions pertaining to radiology following a one-week boot camp elective for undergraduate medical students.

MATERIALS AND METHODS

A five-day comprehensive radiology boot camp was developed including sessions on image interpretation, procedural skills, and appropriate image ordering. A multiple-choice quiz was administered before and after the elective, utilizing radiology questions from the validated AMSER STARS database. Additionally, a pre- and post-elective survey was administered assessing radiology career interest, confidence in radiology-based skills, and the potential ability of radiology-based skills to increase confidence in specialties other than radiology. Responses from the assessments were analysed using paired t-tests.

RESULTS

15 students enrolled in the course and 14 completed all assessments. The average score on the quiz increased from 50.1% to 66.0% (p<0.001). On the post-elective survey, the average student confidence score increased by more than one point on a six-point Likert scale in each of radiographic interpretation (p=0.004), ultrasound interpretation (p=0.0002), CT/MRI interpretation (p=0.02), general radiology knowledge including procedural skills (p=0.0001), and appropriate image ordering (p=0.004). Average student satisfaction with the elective was 8.1 out of 10.

CONCLUSION

A one-week radiology boot camp for pre-clerkship medical students improved radiology knowledge and confidence in radiology skills, showing potential for this format to meet the demand for increased radiology content in undergraduate training. Students indicated that confidence in radiology knowledge would increase confidence on non-radiology clerkship rotations, highlighting the importance of how a one-week radiology bootcamp can impact both future radiology and non-radiology clerkship experiences.

A229 THE BACTERIAL VIRULENCE FACTOR NLEA UNDERGOES HOST-MEDIATED O-LINKED GLYCOSYLATION

NOT PUBLISHED AT AUTHOR’S REQUEST

Drivers and barriers of international migration of doctors to and from the United Kingdom: a scoping review

BACKGROUND

Many high-income countries are heavily dependent on internationally trained doctors to staff their healthcare workforce. Over one-third of doctors practising in the UK received their primary medical qualification abroad. Simultaneously, an average of around 2.1% of doctors leave the UK medical workforce annually to go overseas. The aim of this study was to identify the drivers and barriers of international migration of doctors to and from the UK.

METHODS

A scoping review was conducted. We searched EMBASE, MEDLINE, CINAHL, ERIC and BEI in January 2020 (updated October 2021). Grey literature and citation searching were also carried out. Empirical studies reporting on the drivers and barriers to the international migration of doctors to and from the UK published in the English language from 2009 to present were included. The drivers and barriers were coded in NVivo 12 building on an existing framework.

RESULTS

40 studies were included. 62% were quantitative, 18% were qualitative, 15% were mixed-methods and 5% were literature reviews. Migration into and out of the UK is determined by a variety of macro- (global and national factors), meso- (profession led factors) and micro-level (personal factors). Interestingly, many of the key drivers of migration to the UK were also factors driving migration from the UK, including: poor working conditions, employment opportunities, better training and development opportunities, better quality of life, desire for a life change and financial reasons. The barriers included stricter immigration policies, the registration process and short-term job contracts.

CONCLUSIONS

Our research contributes to the literature by providing a comprehensive up-to-date review of the drivers and barriers of migration to and from the UK. The decision for a doctor to migrate is multi-layered and is a complex balance between push/pull at macro-/meso-/micro-levels. To sustain the UK's supply of overseas doctors, it is vital that migration policies take account of the drivers of migration particularly working conditions and active recruitment while addressing any potential barriers. Immigration policies to address the impact of Brexit and the COVID-19 pandemic on the migration of doctors to and from the UK will be particularly important in the immediate future. Trial registration PROSPERO CRD42020165748.

Examining the Threat of ChatGPT to the Validity of Short Answer Assessments in an Undergraduate Medical Program

OBJECTIVES

ChatGPT is an artificial intelligence model that can interpret free-text prompts and return detailed, human-like responses across a wide domain of subjects. This study evaluated the extent of the threat posed by ChatGPT to the validity of short-answer assessment problems used to examine pre-clerkship medical students in our undergraduate medical education program.

METHODS

Forty problems used in prior student assessments were retrieved and stratified by levels of Bloom's Taxonomy. Thirty of these problems were submitted to ChatGPT-3.5. For the remaining 10 problems, we retrieved past minimally passing student responses. Six tutors graded each of the 40 responses. Comparison of performance between student-generated and ChatGPT-generated answers aggregated as a whole and grouped by Bloom's levels of cognitive reasoning, was done using t-tests, ANOVA, Cronbach's alpha, and Cohen's d. Scores for ChatGPT-generated responses were also compared to historical class average performance.

RESULTS

ChatGPT-generated responses received a mean score of 3.29 out of 5 (n = 30, 95% CI 2.93-3.65) compared to 2.38 for a group of students meeting minimum passing marks (n = 10, 95% CI 1.94-2.82), representing higher performance (P = .008, η2 = 0.169), but was outperformed by historical class average scores on the same 30 problems (mean 3.67, P = .018) when including all past responses regardless of student performance level. There was no statistically significant trend in performance across domains of Bloom's Taxonomy.

CONCLUSION

While ChatGPT was able to pass short answer assessment problems spanning the pre-clerkship curriculum, it outperformed only underperforming students. We remark that tutors in several cases were convinced that ChatGPT-produced responses were produced by students. Risks to assessment validity include uncertainty in identifying struggling students and inability to intervene in a timely manner. The performance of ChatGPT on problems requiring increasing demands of cognitive reasoning warrants further research.

A scoping review of natural language processing of radiology reports in breast cancer

Various natural language processing (NLP) algorithms have been applied in the literature to analyze radiology reports pertaining to the diagnosis and subsequent care of cancer patients. Applications of this technology include cohort selection for clinical trials, population of large-scale data registries, and quality improvement in radiology workflows including mammography screening. This scoping review is the first to examine such applications in the specific context of breast cancer. Out of 210 identified articles initially, 44 met our inclusion criteria for this review. Extracted data elements included both clinical and technical details of studies that developed or evaluated NLP algorithms applied to free-text radiology reports of breast cancer. Our review illustrates an emphasis on applications in diagnostic and screening processes over treatment or therapeutic applications and describes growth in deep learning and transfer learning approaches in recent years, although rule-based approaches continue to be useful. Furthermore, we observe increased efforts in code and software sharing but not with data sharing.

A novel carbon-fibre adjustable reusable accessory (CARA) for supine breast positioning to reduce toxicity in breast adjuvant radiotherapy: a study protocol for a multicentre phase III randomized controlled trial

Background

A novel device for supine positioning in breast radiotherapy for patients with large or pendulous breasts has been developed and tested in phase II studies. This trial is designed to assess the efficacy of the device to reduce skin toxicity and unwanted normal tissue dose in comparison to the current clinical standard for supine breast support during breast radiotherapy.

Methods

Patients at high risk for moist desquamation, having infra-mammary fold or lateral ptosis, will be randomized into two arms. Patients in the control arm will receive breast radiotherapy with supine positioning using current standard of care. Patients in the experimental arm will be positioned supine with the novel device. The primary endpoint is the incidence of moist desquamation in the infra-mammary fold. We hypothesize a 20% reduction (from 50 to 30%) in the rate of moist desquamation in the study arm versus the control arm. For 80% power, two-tailed α = 0.05 and 10% loss to follow up, 110 patients will be assigned to each arm. The proportion of patients experiencing moist desquamation in the two arms will be compared using logistic regression adjusting for brassiere cup size, skin fold size, body mass index, smoking status, and dose fractionation schedule. An unadjusted comparison will also be made using the chi-square test, or Fisher’s exact test, if appropriate. Secondary endpoints include dose-volume statistics for the lung and heart, skin dose and clinical parameters including setup time, reproducibility, and staff experience with setup procedures. Patient-reported pain, skin condition interference with sleep and daily activities, and comfort during treatment are also secondary endpoints.

Discussion

Based on results from earlier phase II studies, it is expected that the device-enabled elimination of infra-mammary fold should reduce toxicity and improve quality of life for this patient population. Earlier studies showed reduction in dose to organs at risk including lung and heart, indicating potential for other long-term benefits for patients using the device. This study is limited to acute skin toxicity, patient-reported outcomes, and clinical factors to inform integration of the device into standard breast radiotherapy procedures.

Trial registration

Clinicaltrials.gov identifier: NCT04257396. Registered February 6 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09759-y.

Effect of treating carious teeth on children's and adolescents' anthropometric outcomes: A systematic review of randomised controlled trials

OBJECTIVE

To examine the impact of treating carious teeth on children's and adolescents' anthropometric outcomes.

BASIC RESEARCH DESIGN

Four electronic databases and four electronic clinical trials registries were searched. Two reviewers independently conducted the screening, data extraction and critical appraisal. The Cochrane Risk of Bias Tool for Randomised Controlled Trials was used to assess the risk of bias in the included studies.

RESULTS

The searches yielded 399 potential studies. Following deduplication and screening of the papers, four were considered eligible for inclusion of which two referred to the same study. None of the included studies was found to have a high risk of bias in any of the domains. However, performance bias was deemed of unclear risk in all studies. One of the studies found that following extraction of pulpally involved teeth, underweight children exhibited a statistically significant improvement in their weight-for-age (change in mean=0.26; p⟨0.001) and BMI-for-age z scores (change in mean=0.52, p⟨0.001) and had a significant weight gain (change in mean=1.2; p⟨0.001). Two studies showed that dental intervention did not have a significant effect on anthropometric outcomes. Treatment of caries significantly improved children's oral health-related quality of life in two studies.

CONCLUSIONS

The evidence into the impact of treating carious teeth on children's growth is mixed and inconclusive. However, there is consistent evidence that treatment of severely carious teeth can significantly improve children's oral health-related quality of life. Oral health promotion and strategies to screen for oral health problems and widen dental access should be considered as part of integrated public health programs targeting children.

Health care engagement behaviors of men who use performance- and image-enhancing drugs in Australia

Background: Although people who inject performance- and image-enhancing drugs (PIEDs) report fewer unsafe injecting practices, stigma and discrimination may negatively impact their access to help and information. Engagement with health care services, compared with social networks (friends, relatives, and gym associates) and the Internet and media (steroid user forums, information sites, and magazines), may be important for harm minimization. Methods: A cross-sectional Internet or in-person survey of men who use PIEDs in Australia in 2014-2015 examined differences in sources for PIEDs, injecting equipment, and anabolic-androgenic steroids (AAS) information and factors associated with having periodical medical checks related to PIEDs issues using multivariate logistic regression. Results: In total, 267 men (mean age: 25 years, SD: 8.7 years; 246 of 267 [92%] reported recent AAS injection) were recruited. Most participants sourced injecting equipment from health professionals, PIEDs from their social networks, and AAS information from the Internet and media. Self-reported AAS knowledge was high and frequent. Higher income (adjusted odds ratio [AOR]: 2.04, 95% confidence interval [CI]: 1.03, 4.00), ≥2 different PIEDs used in addition to AAS (AOR: 1.94, 95% CI: 1.08, 3.49), and sourcing AAS information from health care professionals (AOR: 3.14, 95% CI: 1.81, 5.46) were independently associated with periodical medical checks. Participants nominated preference for improved health services through needle-syringe programs, primary care services, and peer educator support groups. Conclusion: Men who use PIEDs in Australia consider themselves well informed but tend to use Internet and media sources, providing potentially misleading or inaccurate information. Increasing trust between men who use PIEDs and health care providers may enable delivery of PIEDs-specific information to those at greatest need.

Modeling Sustainable, National, Regional and Local Healthcare Systems Based on Childhood Cancer Shared-Care Networks in LMICS

Background: World Child Cancer (WCC) has been working in partnership with pediatric oncology programs in low-middle income countries (LMICs) to support improved services for children with cancer. Central to the success of services is the development of effective shared-care networks situated to match population centers. Literature on how to develop shared-care networks in LMICs does not currently exist. Aim: Modeling sustainable national, regional and local health systems based on childhood cancer shared-care networks in LMICs. Methods: The model was developed through learning from a 3 year UK Government (DFID) funded program in Ghana and Bangladesh and lessons shared from WCC-funded programs in Myanmar and the Philippines. A workshop was held focusing on lessons learned from practitioners representing shared-care networks in different stages of development to identify key elements and steps necessary to build a shared-care network. Results: The overarching themes of the model are; good communication, health partnerships (twinning) and funding. A successful shared-care network must have a strong hub hospital at its center which requires a doctor with training and some experience in pediatric oncology, a committed multidisciplinary team, dedicated bed space, provision for training, patient data accurately recorded, essential medicines available and research opportunities accessible. A health partnership with an external developed center is beneficial. A tangible plan, developed treatment guidelines and protocols, measurable outcomes and financial support are needed for development into a center of excellence. Support would ideally be available for patients and families, to include accommodation, treatment costs, food and transport. Each shared-care center needs an interested doctor, a basic multidisciplinary team, some ward space for oncology patients and the support of the hospital administration. Patient data needs to be stored and there must be a close relationship with the hub center. A development plan is outlined and services provided should replicate the hub as well as resources allow. Major challenges include obtaining support from the hospital administration, and even more importantly, government policies and financing for such developments. Collaborative working and good communication are emphasized by using the same treatment protocols, developing two-way referral systems and sharing challenges and successes. The overarching principle of sustainability requires availability of training within the system and funding. Conclusion: This model can be shared to enable others in LMICs to access the information and inform their systems development. While the model is not exhaustive and requires further research, it represents an important first step with lessons learned from practitioners with experience. The inclusion of such practitioners in the process of developing this model is essential for sustainability.

A realistic phantom for validating MRI-based synthetic CT images of the human skull

PURPOSE

To introduce a new realistic human skull phantom for the validation of synthetic CT images of cortical bone from ultra-short echo-time (UTE) sequences.

METHODS

A human skull of an adult female was utilized as a realistic representation of skull cortical bone. The skull was stabilized in a special acrylic container and was filled with contrast agents that have T₁ and T₂ relaxation times similar to human brain. The phantom was MR scanned at 3T with UTE and T₂ -weighted sequences, followed by CT. A clustering approach was developed to extract the cortical bone signal from MR images. T2∗ maps of the skull were calculated. Synthetic CT images of the bone were compared to cortical bone signal extracted from CT images and confounding factors, such as registration errors, were analyzed.

RESULTS

Dice similarity coefficient (DSC) of UTE-detected cortical bone was 0.84 and gradually decreased with decreasing number of spokes. DSC did not significantly depend on echo-time. Registration errors were found to be significant confounding factors, with 25% decrease in DSC for consistent 2 mm error at each axis.

CONCLUSION

This work introduced a new realistic human skull phantom, specifically for the evaluation and analysis of synthetic CT images of cortical bone.

Diagnostic accuracy of faecal biomarkers in detecting colorectal cancer and adenoma in symptomatic patients

BACKGROUND

The diagnosis of colorectal cancer (CRC) can be difficult as symptoms are variable with poor specificity. Thus, there is a quest for simple, non-invasive testing that can help streamline those with significant colonic pathology.

AIM

To assess using faecal immunochemical test for haemoglobin (FIT) or faecal calprotectin (FCP) to detect CRC and adenoma in symptomatic patients referred from primary care.

METHODS

A total of 799 referred for urgent lower gastrointestinal investigations were prospectively recruited. Of these, 430 completed colonic investigations and returned stool samples, and were included in the final statistical analysis. Faecal immunochemical test for haemoglobin was performed on HM-JACKarc analyser (Kyowa Medex, Tokyo, Japan), and FCP by the EliA Calprotectin immunoassay (Thermo Fisher Scientific, Waltham, United States).

RESULTS

The negative predictive value (NPV) using FIT alone or both markers (FIT and FCP) in combination was similar at 99% for CRC, with a sensitivity and specificity of 84% and 93%, respectively. FIT measurements were significantly higher in left-sided colonic lesions compared with the right side; 713 vs. 94; P = 0.0203). For adenoma, the NPV using FIT alone, or both markers (FIT and FCP) in combination, was similar at 94% with a sensitivity and specificity of 69% and 56%, respectively.

CONCLUSIONS

Undetectable faecal immunochemical test for haemoglobin is sufficiently sensitive to exclude colorectal cancer, with higher values in left-sided lesions. FCP in combination does not appear to provide additional diagnostic information. Further studies to determine the health economic benefits of implementing faecal immunochemical test for haemoglobin in primary care are required.

Exposure to life events as a risk factor for psychological problems in adults with intellectual disabilities: a longitudinal design

BACKGROUND

Several cross-sectional studies have shown an association between exposure to life events and psychological problems in adults with intellectual disability (ID). To establish life events as a risk factor, prospective designs are needed.

METHODS

Support staff informants provided data on the psychological problems of 68 adults with ID and their recent exposure to life events. Using data collected on the same sample 3.5 to 4 years earlier, prospective analysis of the relationships between life events exposure and psychological problems over time was explored.

RESULTS

Hierarchical linear regression analyses demonstrated a contribution of life events to the prediction of later psychological problems after controlling for earlier psychological problems. Exploratory analyses showed that the relationship between life events and psychological problems might be unidirectional, and non-spurious; remaining present once the impact of other correlates of psychological problems was controlled.

CONCLUSIONS

These data offer support for the status of life events (with a negative valence) as a risk factor for psychological problems in adults with ID. To establish life events as a causal risk factor, research is needed to examine the mechanisms via which life events have their impact on psychological well-being.

The relationship between age and risky injecting behaviours among a sample of Australian people who inject drugs

BACKGROUND

Limited evidence suggests that younger people who inject drugs (PWID) engage in high-risk injecting behaviours. This study aims to better understand the relationships between age and risky injecting behaviours.

METHODS

Data were taken from 11 years of a repeat cross-sectional study of sentinel samples of regular PWID (The Australian Illicit Drug Reporting System, 2001-2011). Multivariable Poisson regression was used to explore the relationship between age and four outcomes of interest: last drug injection occurred in public, receptive needle sharing (past month), experiencing injecting-related problems (e.g. abscess, dirty hit; past month), and non-fatal heroin overdose (past six months).

RESULTS

Data from 6795 first-time study participants were analysed (median age: 33 years, interquartile range [IQR]: 27-40; median duration of injecting: 13 years [IQR: 7-20]). After adjusting for factors including duration of injecting, each five year increase in age was associated with significant reductions in public injecting (adjusted incidence rate ratio [AIRR]: 0.90, 95% confidence interval [CI]: 0.88-0.92), needle sharing (AIRR: 0.84, 95% CI: 0.79-0.89) and injecting-related problems (AIRR: 0.96, 95% CI: 0.95-0.97). Among those who had injected heroin in the six months preceding interview, each five year increase in age was associated with an average 10% reduction in the risk of heroin overdose (AIRR: 0.90, 95% CI: 0.85-0.96).

CONCLUSIONS

Older PWID report significantly lower levels of high-risk injecting practices than younger PWID. Although they make up a small proportion of the current PWID population, younger PWID remain an important group for prevention and harm reduction.

Policing pubs: what happens to crime?

The aim of this study was to test the effect of heightened police enforcement of the NSW Liquor and Registered Clubs Acts on overall criminal offences and, specifically, the number of assaults. Ten police patrols were included in the study. Five of these patrols were allocated to the experimental condition and five were allocated to the control condition. Beat police in the experimental controls conducted frequent but random visits to predesignated licensed premises over a 2-month period. Police in the control patrols maintained their normal duties. Numbers of offences in the experimental and control patrols were then compared for 2 months before the intervention, for the 2-month intervention phase and for 2 months post-intervention. Results of the study indicated a significant increase in the number of offences in the experimental patrols during the intervention phase. Reasons for this increase are discussed.

Pre-clinical evaluation and efficacy studies of a melanin-binding IgM antibody labeled with 188Re against experimental human metastatic melanoma in nude mice

PURPOSE

Currently there is no satisfactory treatment for metastatic melanoma. Radioimmunotherapy (RIT) uses the antigen-antibody interaction to deliver lethal radiation to target cells. Recently we established the feasibility of targeting melanin in tumors with 188-Rhenium ((188)Re)-labeled 6D2 mAb to melanin. Here we carried out pre-clinical development of (188)Re-6D2 to accrue information necessary for a Phase I trial in patients with metastatic melanoma.

RESULTS

TCEP proved to be effective in generating a sufficient number of -SH groups on 6D2 to ensure high radiolabeling yields with (188)Re and preserved its structural integrity. (188)Re-6D2 was quickly cleared from the blood with the half-life of approximately 5 hrs and from the body--with the half-life of 10 hr. The doses of 0.5, 1.0 and 1.5 mCi significantly (p < 0.05) slowed down A2058 tumor growth in nude mice, also causing release of melanin into the extracellular space which could provide additional target for repeated treatments. Transient effects of RIT on WBC and platelet counts resolved by Day 14 post-treatment.

EXPERIMENTAL DESIGN

Tris(2-Carboxyethyl) Phosphine Hydrochloride (TCEP) was evaluated as potential agent for generation of -SH groups on 6D2 mAb. TCEP-treated 6D2 mAb was radiolabeled with (188)Re and its radiochemical purity and stability was measured by ITLC and HPLC and its immunoreactivity--by melanin-binding ELISA. The pharmacokinetics, therapeutic efficacy and acute hematologic toxicity studies were performed in nude mice bearing lightly pigmented A2058 human metastatic melanoma tumors.

CONCLUSIONS

We have developed radiolabeling and quality control procedures for melanin-binding (188)Re-6D2 mAb which made possible currently an on-going Phase I clinical trial in patients with metastatic melanoma.

Predictors of hippocampal, cerebral, and cerebellar volume reduction in childhood epilepsy

PURPOSE

We examined the factors related to brain volume reduction in a pediatric sample of patients that included those with nonintractable epilepsy.

METHODS

Entry criteria were children less than 18 years old with epilepsy referred for MRI, including a whole brain volumetric sequence. The sample size was 231. Risk factors were ascertained from interviews and reviews of medical records. Factors included age of onset, seizure years, family history, status epilepticus, intellectual disability, and febrile convulsions. MRI data were obtained for 44 normal childhood control subjects.

RESULTS

Cerebral and cerebellar volumes were significantly associated with age, gender, moderate-to-severe intellectual disability (p < 0.001), seizure years, and status epilepticus (p < 0.03). Compared with controls, the brain volume of all patients was reduced by 10% (p < 0.001). Hippocampal volume was significantly associated with total brain volume, age (p < 0.001), focal cerebral ischemic injury, and complex febrile convulsions (p < 0.05).

CONCLUSIONS

Significant brain volume reduction is present in children with epilepsy. A component of this reduction is due to acquired insults. The reduction is seen even in children with infrequent seizures over a brief time, suggesting an innate structural abnormality. When evaluating possible etiologic factors in the development of hippocampal volume reduction, one must control for total brain volume. We have confirmed the association of complex febrile convulsions with unilateral hippocampal volume reduction.

A prospective randomized trial of the anti-emetic efficacy of ondansetron and granisetron during bone marrow transplantation

To determine the comparative anti-emetic efficacy of ondansetron and granisetron in patients undergoing bone marrow transplantation, we performed a double-blind, randomized trial in pediatric and adult patients receiving transplants at the University of Minnesota. The results in 187 patients stratified by age (<18 years, n = 51; > or =18 years, n = 136) were analyzed. The average number of emetic episodes in the entire group from day -7 to 2 was 0.86/day for patients receiving ondansetron and 0.73/day for those receiving granisetron (p = 0.32). No differences were noted between the two drugs in total days of complete or major control of emesis or in the number of requests for additional drugs to alleviate symptoms of nausea. The use of total-body irradiation-containing conditioning regimens was associated with a decreased number of emetic episodes compared with regimens of chemotherapy alone. Perceived nausea was evaluated using a nausea scoring system, and no differences were apparent between the granisetron and ondansetron groups; however, reported nausea was significantly higher in females (p<0.01) and in the adult population (p = 0.05). We conclude that both ondansetron and granisetron provide good control of nausea and vomiting experienced with conditioning regimens for bone marrow transplantation. The relative cost of the drugs within an institution must be considered in developing standard anti-emetic regimens for bone marrow transplantation.

Don't volunteer for trouble

Volunteers have always played an important role in the continuum of care a hospital provides to its patients and the community, and the reliance on hospital volunteers appears to be on the rise. This may be one of many responses to widespread cost containment efforts due primarily to an increase in reimbursement pressures. The use of volunteers raises unique liability issues, which warrant periodic review within the overall risk management plan of a hospital. A recent Michigan case has brought renewed attention to the use of volunteers.

Plasma vitamin A and E in preterm babies fed on breast milk or formula milk with or without long-chain polyunsaturated fatty acids

Plasma vitamin A and E, the antioxidant nutrients copper and zinc, and magnesium were investigated in preterm babies. They were fed on their own mother's breast milk, or a formula with, or without, AA and DHA. Vitamin A (2.4 mg/d) and E (15 mg/d) supplements were also given. Vitamin A and E levels of most of the babies were sub-optimal at birth. The mean concentrations of vitamin E increased in all the groups by the expected date of delivery (EDD) (p < 0.001). Those fed on their mother's breast milk had the highest value compared with the other groups (p < 0.001). There was an increase in the mean level of vitamin A (p > 0.05) and copper (p < 0.05) and a decrease in zinc (p < 0.05) between birth and EDD. Concentrations of the two vitamins were not different (p > 0.05) between the babies fed on the formula with, and without, AA and DHA. It is concluded that the amount of AA and DHA incorporated in the formula milk did not adversely influence the plasma vitamin A and E of the babies.

Cytokine-primed bone marrow stem cells vs. peripheral blood stem cells for autologous transplantation: a randomized comparison of GM-CSF vs. G-CSF

Autologous transplantation for non-Hodgkins lymphoma and Hodgkin's disease is widely used as standard therapy for those with high-risk or relapsed tumor. Peripheral blood stem cell (PBSC) collections have nearly completely replaced bone marrow stem cell (BMSC) harvests because of the perceived advantages of more rapid engraftment, less tumor contamination in the inoculum, and better survival after therapy. The advantage of PBSC, however, may derive from the hematopoietic stimulating cytokines used for PBSC mobilization. Therefore, we tested a randomized comparison of GM-CSF vs. G-CSF used to prime either BMSC or PBSC before collection for use in autologous transplantation. Sixty-two patients receiving transplants (31 PBSC; 31 BMSC) for non-Hodgkin's lymphoma (n = 51) or Hodgkin's disease (n = 11) were treated. All patients received 6 days of randomly assigned cytokine. Those with cellular marrow in morphologic remission underwent BMSC harvest, while those with hypocellular marrow or microscopic marrow tumor involvement had PBSC collected. Neutrophil recovery was similarly rapid in all groups (median 14 days; range 10-23 days), though two patients had delayed neutrophil recovery using GM-CSF primed PBSC (p = 0.01). Red cell and platelet recovery were significantly quicker after BMSC mobilized with GM-CSF or PBSC mobilized with G-CSF. This speedier hematologic recovery resulted in earlier hospital discharge as well. However, in multivariate analysis, neither the stem cell source nor randomly assigned G-CSF vs. GM-CSF was independently associated with earlier multilineage hematologic recovery or shorter hospital stay. Relapse-free survival was not independently affected by either the assigned stem cell source or the randomly assigned priming cytokine, though malignant relapse was more frequent in those assigned to PBSC (RR of relapse 3.15, p = 0.03). These data document that BMSC, when collected following cytokine priming, can yield a similarly rapid hematologic recovery and short hospital stay compared with cytokine-primed PBSC. Using primed BMSC, no difference in malignant relapse or relapse-free survival was observed. These findings suggest that despite widespread use of PBSC for transplantation, BMSC, when collected following hematopoietically stimulating cytokines, may remain a satisfactory source of stem cells for autologous transplantation. G-CSF and GM-CSF are both effective in priming autologous PBSC or BMSC for collection.

A transcript map for the 2.8-Mb region containing the multiple endocrine neoplasia type 1 locus

Multiple endocrine neoplasia type 1 (MEN 1) is an inherited cancer syndrome in which affected individuals develop multiple parathyroid, enteropancreatic, and pituitary tumors. The locus for MEN1 is tightly linked to the marker PYGM on chromosome 11q13, and linkage analysis places the MEN1 gene within a 2-Mb interval flanked by the markers D11S1883 and D11S449. Loss of heterozygosity studies in MEN 1 and sporadic tumors suggest that the MEN1 gene encodes a tumor suppressor and have helped to narrow the location of the gene to a 600-kb interval between PYGM and D11S449. Focusing on this smaller MEN1 interval, we have identified and mapped 12 transcripts to this 600-kb region. A precise ordered map of 33 transcripts, including 12 genes known to map to this region, was generated for the 2.8-Mb D11S480-D11S913 interval. Fifteen candidate genes (of which 10 were examined exhaustively) were evaluated by Southern blot and/or dideoxy fingerprinting analysis to identify the gene harboring disease-causing mutations.

Alcohol-history taking by nurses and doctors--how accurate are they really?

The aim of this study was to look at how nurses and doctors record alcohol histories on the patients under their care and the frequency and appropriateness of the way they use an alcohol withdrawal scale in the acute hospital setting. To achieve these aims patient records were audited and compared at two points in time, in 1992 and 1994. Results of the study showed that nurses and doctors took alcohol histories from patients on approximately three-quarters of occasions and that this level of recording has not changed over time. The adequacy of alcohol-history taking has, however, increased for both nurses and doctors since 1992. At that time, 71% of the alcohol histories taken by nurses and 74% of alcohol histories taken by doctors were judged to be adequate. By 1994, however, 79% of alcohol histories taken by nurses and 77% of histories by doctors were rated as adequate. The increase in the adequacy of history taking by nurses was significant (chi 2 = 5.05; d.f. = 1; P < 0.05) and the increase by doctors was not significant (chi 2 = 1.03; d.f. = 1; P > 0.05). These results are seen as being positively associated with the major governmental nursing initiative in New South Wales, Australia, the New South Wales Strategic Plan for the Nursing Management of Alcohol and Other Drugs.

General practice receptionists' attitudes and beliefs towards preventive medicine before and after training and support interventions

OBJECTIVES

Receptionists are an integral part of the primary care service. We aimed to discover their views on preventive medicine issues.

METHOD

One hundred and fifty receptionists from general practices in Sydney, Australia, completed a questionnaire on their attitudes and beliefs towards preventive medicine and brief intervention for alcohol. They were matched according to practice variables into a control, no, minimal, or maximal training and support condition. In all conditions except the control condition, receptionists received 5 minutes of initial training in implementing a brief intervention programme; the amount of ongoing support varied across conditions. Attitudes and beliefs were re-assessed 3 months later.

RESULTS AND CONCLUSIONS

The results indicated that when no training and support were given, receptionists developed negative views towards being involved in preventive medicine activities. When training and support were provided, these negative effects were abolished.

The BRMD thyroid-neck phantom: design and construction

The Human Monitoring Laboratory, which acts as the Canadian National Calibration Reference Center for In Vivo monitoring, has constructed a robust neck-thyroid phantom for use in the Canadian Thyroid Intercomparison Program. The phantom is rugged and capable of being distributed through the mail with no expectation of a leak of radioactive materials; it is anthropomorphic; the thyroid inserts simulate 125I and 131I; the phantom can be used to mimic different layers of adipose tissue over the thyroid insert; and it is cost effective. This paper describes the design criteria and the manufacturing process; the performance characteristics have been described in an earlier publication.