0782 Duration Of Sun Exposure In Medical Students Impactschronotype

Introduction

Timing of the human sleep-wake cycle is determined by social constraints, biological processes (sleep homeostasis and circadian rhythmicity) and environmental factors, particularly natural and electrical light exposure. However the effect of environmental factors, especially duration of sun exposure, on circadian rhythmicity remains unknown. We aimed to study the relationship between duration of sun exposure and chronotype among medical students.

Methods

Eighty-six GW medical students (62 F [71%], 24 M [29%]; ages 21-33 y [mean 24.4 y]) completed the Munich Chronotype Questionnaire (MCTQ). Mid points, the middle of the participants reported bedtime and wake time on workdays, were used to determine chronotype. Two independent groups based on the mean split (mean = 45) of the distribution of minutes of sun exposure were created: 45 minutes or more (n=31) vs less than 45 minutes (n = 55) of sun exposure. Independent samples t-test was performed to compare the measured midpoint with the following pairs of groups of reported work day sunlight exposure (in minutes): less than 45 min (n = 55) versus 45 min or more (n = 31).

Results

In the total sample (n = 86), no significant association between duration of sun exposure and midpoints was found using Pearson correlation. However, medical students with reported sun exposure of greater than or equal to 45 minutes a day had a significantly earlier chronotype compared to students reporting a sun exposure of less than 45 minutes a day [mid point 2.196 (SD 0.085) versus a mid point 3.386 (SD 1.084); t(69) = 2.021; p = .047].

Conclusion

We found that, in GW medical students, greater amounts of sun exposure during the day was advancing the circadian rhythm. This may have implications on sleep duration and quality.

Support

NA

Gambling and the Role of Resilience in an International Online Sample of Current and Ex-serving Military Personnel as Compared to the General Population

Compared to the general population, military personnel are particularly vulnerable to developing gambling problems. The present study examined the presentation of gambling-including gambling frequency, personal thoughts on reducing gambling and recommendations from others to reduce gambling-across these populations. Additionally, the study measured the association between gambling and various psychosocial risk and protective factors-including psychological distress, suicidal ideation, external encouragement to reduce substance use, days out of role, personal wellbeing, resilience, social support and intimate bonds. Data was extracted from the Global Health & Wellbeing Survey, an online self-report survey conducted in Australia, Canada, New Zealand, the United Kingdom and the United States. Of the 10,765 eligible respondents, 394 were military veterans and 337 were active military personnel. Consistent with previous research, a higher proportion of gambling behaviours were observed in both current and ex-serving military samples, compared to the general population. To varying degrees, significant associations were found between the different gambling items and all psychosocial risk and protective factors in the general population sample. However, the military sample yielded only one significant association between gambling frequency and the protective factor 'resilience'. A post hoc stepwise linear regression analysis demonstrated the possible mediating role resilience plays between gambling frequency and other psychosocial risk (psychological distress, and suicidal thoughts and behaviour) and protective factors (personal wellbeing) for the military sample. Given the findings, it is recommended that routine screening tools identifying problem gambling are used within the military, and subsequent resilience focused interventions are offered to at risk personnel.

282 A Time to Wean: An Audit on Benzodiazepine and Z-drug Use Amongst Patients Attending a Geriatric Ambulatory Care Day Hospital

Background

Benzodiazepine prescription is common among the Irish patient cohort. 23% of medical card holders have been prescribed a benzodiazepine or Z-drug, with a third of these being for a period longer than three months. This is despite these drugs being associated with addiction, falls, cognitive and psychomotor impairment, mood disorder, sleep automatism and drug interactions. We performed an audit looking at the repeat prescriptions of patients attending a geriatric day hospital.

Methods

The repeat prescriptions of all patients currently enrolled at a day hospital were analysed for benzodiazepines or Z-drugs. Medical records were then analysed to look for indication and whether these patients were currently attending psychiatric services. Subsequent to this, notices were placed in the patient consult room in direct line of sight of the registrar reminding them to consider weaning these drugs and detailing the negative side effects and guidelines for weaning from the Canadian National Pain Centre.

Results

59 patients were enrolled at the day hospital when the audit was performed. 11 (19%) had either a benzodiazepine or Z-drug as part of their repeat prescription (benzodiazepine-5, Z-drug-5, both-1). The most common benzodiazepines prescribed were diazepam and clonazepam (2 patients on each). Of those prescribed a benzodiazepine, none were currently being weaned. Of those on benzodiazepines, 4 of 6 had a documented psychiatric diagnosis, and 1 of 6 had documented that they were currently attending psychiatric services. A re-audit three months later showed no change in those prescribed benzodiazepines (5/59), and a non-significant increase in those on Z-drugs (9/59, p=0.26).

Conclusion

This audit showed a significant number of patients attending our day hospital are being prescribed long term benzodiazepines or Z-drugs, and highlights that this setting is an opportune time and place to establish a supported program to wean people off these medications.

318 Does a Teleconference-Delivered Educational Programme (ECHO) Provided to Nursing Homes Reduce Emergency Hospital Transfers?

Background

Nursing home staff manage increasingly complex patients yet struggle to access education programmes due to geographical logistical barriers. The aim of this study is to measure the impact on emergency hospital transfers a novel teleconference-delivered palliative care education programme (ECHO) has on patient transfers from nursing homes to emergency departments.

Methods

Ten interactive sessions were provided to staff from 20 nursing homes, using teleconferencing technology through the “Project ECHO” model. “Transfer forms” were completed by participating staff 6 months before echo, and 6 months from commencement of echo outlining details of emergency hospital transfers. Participating sites must attend 4 or more of 10 sessions for study inclusion.

Results

Of 20 nursing homes, 15 attended sufficient sessions, and they submitted data regarding 260 emergency transfers over a 12-month period. There was no significant difference in the number of transfers pre vs post ECHO (137 of 260 vs 123 of 260, p=0.62). There was no significant difference in likelihood of hospital admission, length of stay, or number of weekend transfers to hospital (p=0.26, 0.68 and 0.6 respectively). Post-echo, patients were less likely to have pain documented as the primary symptom (11 of 137 vs 1 of 123, p=0.006), and it was more likely that transfer wishes were documented in advance (62 of 137 (45%) vs 82 of 123 (67%), p<0.001). Increase in transfer wishes documentation was explained primarily by an increase in a “for transfer” decision (27 of 62 vs 67 of 82) p=<0.001).

Conclusion

This teleconference, ECHO-delivered palliative education programme did not affect overall rates of emergency hospital transfers from nursing homes. However, it did significantly lower rates of transfers reporting pain as the primary symptom, tentatively suggesting a possible impact on “reversible” hospital transfers. ECHO significantly increased likelihood of transfer status discussion, while most “extra” discussions resulted in a “for transfer” decision.

Dialectical behaviour therapy (DBT) in the treatment of borderline personality disorder

Borderline personality disorder (BPD) is a complex disorder that is difficult to treat. However, dialectical behaviour therapy (DBT), developed by Dr. Marsha Linehan in the early 1990s, has emerged as a promising treatment option for those diagnosed with BPD. DBT is a multi-pronged treatment approach delivered normally in outpatient settings over 12 months and requires highly skilled and trained therapists. Many trials have provided evidence to support the use of DBT in the treatment of BPD. However, outcome measures vary and are mostly limited to measurable behavioural outcomes such as incidences of deliberate self-harm or suicidal thoughts. Two recent Cochrane reviews conclude that DBT does benefit those with BPD, but more robust evidence is needed. DBT training for health care professionals also has the potential to shift health care professionals' attitudes from one of therapeutic pessimism to one of optimism.

Experiences of involuntary admission in an approved mental health centre

The aim of this qualitative study was to gain an understanding of what it means to have an involuntary hospital admission. A sample of six people who were detained at an approved Irish mental health centre consented to recount their experiences were interviewed. The interview transcripts were analysed using Interpretative Phenomenological Analysis. Three superordinate themes were identified: 'The early days', 'Experiences of treatment' and 'Moving on?'. 'The early days' represented participants' initial feelings and opinions of the experience of coming into the approved centre. 'Experiences of treatment' refers to participants' experiences of medication and relationships with staff. Finally, the theme 'Moving on?' represented participants' views on how they adjusted to involuntary admission. 'Learning the way' was central to the participants' notion of moving on. The findings suggest that the meaning of detention is a varied one that evokes an array of emotional responses for participants and highlights the need for a renewed way of thinking and doing concerning those subject to involuntary.

Monitoring and documentation of side effects from depot antipsychotic medication: an interdisciplinary audit of practice in a regional mental health service

This audit reviewed current practice within a rural mental health service area on the monitoring and documentation of side effects of antipsychotic depot medication. A sample of 60 case files, care plans and prescriptions were audited, which is 31% of the total number of service users receiving depot injections in the mental health service region (n= 181). The sample audited had a range of diagnoses, including: schizophrenia, schizoaffective disorder, bipolar affective disorder, depression, alcoholic hallucinosis and autism. The audit results revealed that most service users had an annual documented medical review and a documented prescription. However, only five (8%) case notes examined had documentation recorded describing the condition of the injection site, and alternation of the injection site was recorded in only 28 (47%) case notes. No case notes examined had written consent to commence treatment recorded. In 57 (95%) of case notes, no documentation of recorded information on the depot and on side effects was given. The failure to monitor and record some blood tests was partly attributed to a lack of clarity regarding whose responsibility it was. A standardized checklist has been developed as a result of the audit and this will be introduced by all teams across the service.

Patient centric identification and association

Increased technological complexity of medical devices and systems coupled with increased workloads and reduced staffing, have created difficulties and discontinuities in the management of patient information. These issues have directly impacted and contributed to a rise in equipment-related errors, patient dissatisfaction, a potential for patient injury and resulting overall increased concern for patient safety. In response these concerns a variety of new devices, systems and applications have been developed to share information, provide cross checks along with verified delivery of critical information to the point of care. These applications include biomedical information systems, medication administration, sample collection, and electronic medical records. The deployment of these new integrated and networked devices, systems and applications are dependent on an accurate and consistent patient identification and association methodology which dynamically manages the relationship between patients, staff and equipment. Since the association information is common to many applications and utilizes a variety of technologies, (i.e. active and passive radio frequency identification (RFID), barcodes, etc.) an institutional approach is necessary to mange these processes in a consistent manor utilizing a common set of identification hardware. Implementation of a "Patient Centric Identification and Association Platform" represents a significant advance in the management of clinical patient information. The implementation of a Biomedical Device Information Network at Memorial Sloan-Kettering Cancer Center (MSKCC) integrates the identification and association of patients with devices and care providers and provides the methodologies to manage alarms, providing the ability to filter low priority or nuisance alarms. This implementation enables critical information to be distributed directly to care providers utilizing dedicated communications devices. Patient Centric Identification and Association is the enabling technology providing precise identification and association establishing an enhanced environment of care, increased patient safety, and a clear proactive response to the regulatory requirements of the Joint Commission (JCAHO) national patient safety initiatives.

Knowledge and attitudes of mental health professionals in Ireland to the concept of recovery in mental health: a questionnaire survey

Recovery is the model of care presently advocated for mental health services internationally. The aim of this study was to examine the knowledge and attitudes of mental health professionals to the concept of recovery in mental health. A descriptive survey approach was adopted, and 153 health care professionals (nurses, doctors, social workers, occupational therapists and psychologists) completed an adapted version of the Recovery Knowledge Inventory. The respondents indicated their positive approach to the adoption of recovery as an approach to care in the delivery of mental health services. However, respondents were less comfortable in encouraging healthy risk taking with service users. This finding is important because therapeutic risk taking and hope are essential aspects in the creation of a care environment that promotes recovery. Respondents were also less familiar with the non-linearity of the recovery process and placed greater emphasis on symptom management and compliance with treatment. Multidisciplinary mental health care teams need to examine their attitudes and approach to a recovery model of care. The challenge for the present and into the future is to strive to equip professionals with the necessary skills in the form of information and training.

Neuodevelopmental Outcomes for Children Transplanted Under the Age of 3 Years

Our previous investigations on neurodevelopmental outcomes for intestinal transplanted infants revealed that while some children were able to achieve a normal developmental outcomes, most children suffered from significant motor delays and several experienced severe cognitive delays. In our current investigation, we were especially interested in children who are transplanted before the age of 3 years because the impact of the chronic illness and nutrition impairment on the infant's developing brain may be more severe than those children who receive a liver transplant.

METHODS

We evaluated 34 infants using the Bayley Scales of Infant Development. Twenty-seven children received a liver/intestine or multivisceral transplant and seven received a liver transplant.

RESULTS

Comparison of the two groups revealed that children receiving an intestine/multivisceral transplant have much poorer outcomes. Seventy-four percent of these children were significantly delayed mentally compared to only 57.14% of the liver transplant infants. Furthermore, 42.86% of the liver-transplanted infants were actually functioning in the normal range posttransplant. The intestinal/multivisceral transplant infants' motor development shows the most striking difference, with 96.3% being severely delayed as compared to liver transplant infants in whom only 71% experienced serious delays. The neurodevelopmental impact of organ failure and transplant before the age of 3 years may depending on the type of organ transplant. Our study found that it may be more likely to expect a good outcome for liver transplant patients than for intestinal and multivisceral transplanted infants. This difference maybe due to the overall severity of the disease and the possible impact of nutritional deficits early in infancy.

Neurodevelopmental Outcomes of Infant Multivisceral Transplant Recipients: A Longitudinal Study

This longitudinal investigation compares cognitive and physical capabilities of transplant recipients, both before and after receiving an intestinal transplant.

METHODS

Using the Bayley Scales of Infant Development, we conducted pretransplant and posttransplant assessments on nine children (4 males, 5 females) who received either an isolated intestine, combined intestine and liver, or multivisceral transplants, with a mean age at transplant of 18 months (range 8-29) and a mean time posttransplant of 2 months (range 1-4 months).

RESULTS

Scores on the Mental Developmental Index reflected that a majority (55.6%) of patients who scored in the significantly delayed range prior to transplant remained in the significantly delayed classification after receiving a transplant. In addition, 33.3% showed a decrease in their mental classification; either from "mildly delayed" to "significantly delayed" or from "within normal limits" to "mildly delayed". Results on the Motor Developmental Index demonstrated that 78% of recipients had significant delays both before and after receiving a transplant, while 11.1% fell one standard deviation after transplantation. We found that the majority of children who experience developmental delays prior to transplant are still experiencing delays when they are discharged from inpatient care. In addition, those children receiving multivisceral transplantations, as opposed to an isolated bowel, may be at a much greater risk of developing and retaining both cognitive and physical delays. Early neurodevelopmental evaluations of these patients is essential for early parental education and compliance with early intervention services to maximize potential recovery and ability to obtain normal development.

The sociology of intimacy in the nurse-patient relationship

This article examines intimacy from a sociological perspective. It reveals that 'over-involved' or 'intimate' nurse-patient relationships do not tend to be welcomed by nurses. The work of certain theorists is explored to provide a sociological explanation of intimate nurse-patient relationships and to highlight the complexities of nurses developing intimate relationships with patients in the workplace.

The trials, tribulations, and relative success of the ongoing clinical merger of two large academic hospital systems

The North Shore Health System and the Long Island Jewish Medical Center merged in 1997 and now form the third largest not-for-profit academic health care system in the United States. The authors analyze the specific factors responsible for the relative success of the clinical merger, review their merger's initial failures and how they crafted a more pragmatic and appropriate set of guiding principles to continue the merger, and discuss the future of their institution's clinical integration strategy. In 2000, clinical integration of the 19 clinical departments at the two merged institutions was surveyed across five broad areas: conferences, residency programs, common faculty and support staff, finances, and research. Extents of clinical integration ranged from 20% to 72%. Six departments had more than 50% clinical integration, and overall clinical integration was 42%. Not surprisingly, clinical integration had occurred most frequently with conferences (50%) and least with finances (25%). The single-chairperson model for department leadership has been most successful in achieving significant clinical integration of the formerly separate departments. The relative success of the clinical merger has been guided by the principle that no clinical service should be integrated simply for the sake of merging, but rather that integration should be encouraged where and when it makes sense to achieve specific program goals. In addition, the merger would not have proceeded without constant communication among the leadership and staff, flexibility in building leadership models, patience in having events progress over a time course that developed trust among the senior leaders, and the presence of a senior executive structure whose authority to make decisions is accepted. The most important factor for achieving a reasonable level of clinical integration is the ability of the clinical leaders to collaborate and lead the change process.

Changing NHS structures: implications for nursing careers

This article explores what implications the flatter NHS structures (after the restructuring of April 1999) might have for nursing careers. It examines issues of recognition, reward systems and career pathways and the problems these may pose for the retention of qualified staff within nursing. It is seen that flatter structures will offer little in the way of traditional vertical promotion opportunities and readers are invited to explore the possibility of lateral promotion, continuous development, career grids and the rise of the generic nurse. Speculation about the introduction of competency-based pay systems is introduced. The article attempts to progress the debate in the area of the links between structure and supporting human resource infrastructures within the public sector set against background context of severe cash constraints. It seeks to raise the issues and open debate among practitioners.

Idiopathic ischemic cerebral infarction in childhood: depiction of arterial abnormalities by MR angiography and catheter angiography

BACKGROUND AND PURPOSE

We report our experience with MR imaging, MR angiography, and catheter angiography in children with acute idiopathic cerebral infarction and suggest that catheter angiography may still play an important role in this setting.

METHODS

During the past 8 years, 18 children with idiopathic cerebral infarction underwent MR imaging and catheter angiography; 17 were also studied with MR angiography. MR imaging was done within 34 hours after onset of hemiplegia or seizures or both. Sixteen patients underwent catheter angiography within 36 hours of MR imaging; 12 studies were performed within 22 hours. Two patients underwent catheter angiography, in both cases within 72 hours. Infarcts were compared with arterial abnormalities seen at catheter angiography, and the results of MR angiography were compared with those seen at catheter angiography.

RESULTS

Comparing MR angiography with catheter angiography, we found the positive predictive value of MR angiography for arteriopathy was 100%, with a negative predictive value of 88%. MR angiography was equivalent to catheter angiography in the detection and depiction of proximal middle cerebral artery disease; however, depiction of disease in the internal carotid artery (ICA) and detection of peripheral embolic disease were better with catheter angiography than MR angiography.

CONCLUSION

Basal ganglia lesions associated with ICA disease by MR angiography should probably be studied with digital subtraction angiography, as MR angiography did not depict the length and severity of ICA disease as well as catheter angiography did. Hemispheric infarcts should be studied with catheter angiography, as emboli may occur in the absence of heart disease; the circle of Willis may be uninvolved with embolic disease, and MR angiography is not sensitive to emboli in small peripheral intracranial arteries.

Liquid chromatographic determination of hippuric acid for the evaluation of ethacrynic acid as angiotensin converting enzyme inhibitor

A rapid, simple and interference-free method is described to evaluate the inhibitory effects of organic compounds on the activity of angiotensin converting enzyme irrespective of their acid-base properties. The assay is based on the high performance liquid chromatographic separation of the synthetic substrate hippuryl-L-histidyl-L-leucine, the hydrolysis product hippuric acid and the test compound. Using the new method, the diuretic drug ethacrynic acid was found to act as an inhibitor for the enzyme in a non competitive mode.

Multiple myeloma

This blood disorder, involving the abnormal proliferation of plasma cells in bone marrow, can cause many complications. This article discusses the therapies available and the prevention and management of the various symptoms of this condition.

Prospective evaluation of a composite scoring system for mammographically detected cytologically assessed impalpable breast abnormalities

The aim of all breast screening programmes is a reduction in deaths from the disease. It is hoped that this can be achieved with minimal intervention in the patient cohort who do not have cancer. In this study we have assessed the efficacy of a combination of mammographic and cytological scoring systems in the evaluation of 208 women with screen-detected non-palpable breast lesions. All mammograms were scored 1-5 and those with a score of 3 or more required needle localization. A cytology score of 1 to 5 was generated for each patient according to a similar system and an aggregate score for each patient was achieved by the addition of the mammographic and cytology score. Ninety-three of the 208 patients had malignancy--the positive predictive value for mammography alone in this series was 45%. All 58 patients who had an aggregate score of 8 or greater had cancer. The 60 patients who had an aggregate score of 4 had benign disease on excision biopsy. We suggest that a 'wait and repeat mammogram' approach is appropriate in patients with grade 3 mammography and benign (grade 1) cytology. Patients with an intermediate aggregate score of 5-7 should have an excision biopsy and those with an aggregate score of 8 could have definitive surgery rather than excision biopsy. Application of this aggregate scoring technique would enhance the delivery of more appropriate surgery to a majority of patients with screen-detected breast abnormalities.

Stereotactic cytology in a regional breast-screening programme

Stereotactic localization and fine-needle aspiration are new procedures for the management of non-palpable mammographic abnormalities. In this prospective study, stereotactically guided cytology with immediate reporting was performed before biopsy in a consecutive series of 166 patients with screen-detected non-palpable abnormalities. All specimens were obtained by multiple stereotactically guided passes with a 22-G Franzén needle and graded as: 1, acellular or inadequate; 2, benign; 3, atypical, probably benign; 4, probably malignant; or 5, malignant. After definitive surgery all tumours were staged according to the Union Internacional Contra la Cancrum classification. Of 71 patients with malignancy, 56 were correctly diagnosed by cytology before operation. Twelve patients with malignancy had grade 1 cytology and 50 of the 52 with grade 2 cytology had benign disease. This study confirms that stereotactic cytology is a valuable diagnostic test in a breast-screening programme.

Screening for breast cancer in Ireland: the Eccles Breast Screening Programme

The Eccles Breast Screening Programme is a population-based screening programme for breast cancer, based at the Mater Misericordiae Hospital, Dublin. It began in 1989 simultaneously with similar programmes in Belgium, France, Greece, Portugal and Spain. The objectives of the Eccles Programme are: (i) to evaluate the impact of mammographic screening on morbidity and mortality from breast cancer in Irish women; and (ii) to address the feasibility and potential value of a national breast cancer screening programme. The specific group targeted for screening is women born in 1925 to 1940 inclusive, in a defined geographical area comprising north Dublin City and County, and Counties Cavan and Monaghan. The areas combined comprise 16% of the country's population; just over 29,000 women were invited for screening. An analysis of the demographic and socioeconomic features of the target population reveals that it represents the total population remarkably well. Participants were invited from a population register to attend one of two screening units. Follow-up treatment for those with abnormalities takes place predominantly at the Mater Hospital where the facilities of the Departments of Pathology, Surgery and Oncology have been made available to the programme. Almost 18,000 women had a mammogram in the first round of screening, an overall response rate of 62%. A total of 129 cancers were detected, a prevalence of breast cancer of 7.2 per 1,000. Of those, 15 (11.6%) were entirely intraduct, and an additional 7 (5.4%) had minimal invasion. This is considerably higher than the proportion of intraduct cancers seen in referral practice populations.

Fine needle aspiration cytology of thyroid nodules: review of 36 months experience

Studies suggest that fine needle aspiration of thyroid nodules is a sensitive and specific tool for the detection of thyroid cancers thus preventing unnecessary operations. This technique was introduced in our institution in 1987 and performed where indicated under strictly defined criteria. We reviewed the aspirates performed over a 36 month period to critically evaluate the role of this procedure. Review was limited to F.N.A.s of nodules considered to be potentially malignant by conventional criteria and hence all the following criteria needed to be fulfilled: (1) solitary or dominant nodules in a multinodular goitre, (2) cold on isotope scanning, (3) solid or complex cystic nodule on ultrasonography. During the period May 1987 to May 1990 88 aspiration procedures were performed on 77 patients. 93% of the 77 patients had adequate aspirates and of these approximately 30% were considered suspicious or malignant. The overall resection rate was 23.4% which is approximately one third of the rate expected should suspicion have been based solely on conventional imaging criteria. The yield of neoplasia (adenoma and carcinoma) at resection was 89%. We found FNA to be a very useful adjunct in the management of nodular thyroid disease when used in conjunction with clinical laboratory and radiological evaluation. It is safe, inexpensive and provides useful additional information towards making appropriate decisions in an area beset with uncertainty.

Case-mix classification of Medicare residents in skilled nursing facilities: resource utilization groups (RUG-T18)

Medicare residents in Skilled Nursing Facilities (SNFs) represent a small but unique population about which little is known. Data collected in a national sample of 2,564 Medicare residents in 38 SNFs were used to derive a resident classification system appropriate for use in a payment system. The classification system, Resource Utilization Groups-Medicare (RUG-T18) explains 55.5% of the per-diem resource cost differences of Medicare SNF residents. No classification system could be derived to provide significant explanation of per-episode costs. Although Medicare residents are admitted to SNFs immediately following an acute stay that is paid according to their diagnosis-related groups, the DRGs were ineffective in explaining SNF resource costs.

ChlVPP--an effective and well-tolerated alternative to MOPP therapy for Hodgkin's disease

The substitution of chlorambucil for nitrogen mustard and vinblastine for vincristine has been suggested to be an equally effective and well-tolerated variation of the MOPP regimen (mechlorethamine, vincristine, procarbazine, and prednisone). We treated 76 patients with advanced (i.e., Stage III, IV, or II with bulky mediastinal mass) or recurrent Hodgkin's disease with chlorambucil 6 mg/m2, procarbazine 100 mg/m2, and prednisone 40 mg p.o. daily, all on days 1-14; plus vinblastine 6 mg/m2 i.v. on day 1 and 8 of each 28-day cycle (ChlVPP). There was no maximum dose of the myelosuppressive agents. Patients who had not previously been irradiated received from 2,300 to 4,100 cGY to sites of previously bulky diseases after completing 6 cycles of ChlVPP. ChlVPP was easy to administer (i.e., 87% of patients without previous chemotherapy received greater than or equal to 80% of the planned doses of myelosuppressive drugs) and was generally well tolerated, with only occasional vomiting from procarbazine and phlebitis from vinblastine. In patients without previous chemotherapy, 49 (76%) achieved a complete remission (CR) and 7 (11%) a stable partial remission (i.e., residual, stable radiographic abnormality). With a maximum follow-up of 4 years, only one CR has relapsed for an actuarial CR durability of 97%. ChlVPP with consolidative radiation therapy to sites of bulky disease is effective in advanced Hodgkin's disease and, compared with most other available regimens, is extremely well tolerated.

Chemotherapy for diffuse large-cell lymphoma--rapidly responding patients have more durable remissions

Fifty-one patients with diffuse large-cell lymphoma (DLCL) were treated with a six-drug combination chemotherapy regimen including cyclophosphamide, doxorubicin, procarbazine, bleomycin, vincristine, and prednisone. The patients were restaged after three cycles of therapy, and restaging was repeated at 2-month intervals in patients who had persistent disease. Responding patients received two cycles of therapy after documentation of complete remission (CR). With all patients considered evaluable, 73% of the patients achieved a CR. Twenty-six of the 37 CRs (70%) achieved remission in the first three treatment cycles. The durability of remission in the rapidly responding patients was significantly better than for patients who required five cycles to achieve CR (80% v 40% at 2 years, P = .02) despite the latter patients having received two more cycles of therapy. Rapidly responding patients with DLCL do not require prolonged therapy and have a better prognosis than patients achieving a CR more slowly.

Treatment of acute lymphoblastic leukemia in adults: results of the L-10 and L-10M protocols

Two successive protocols (L-10 and L-10M) employing multidrug induction therapy with vincristine, prednisone, and doxorubicin (Adriamycin) plus an intensive consolidation phase and maintenance program have led to a significant improvement in the prognosis of adult acute lymphoblastic leukemia (ALL). The complete remission (CR) rates for the 34 patients entered on the L-10 protocol and the 38 patients entered on the L-10M protocol were 85% and 84%, respectively. The median duration of remission has not yet been reached for either the L-10 (median follow-up, 5.5 years; range, 3.5-7.5 years) or the L-10M protocol (median follow-up, 2.5 years; range, 1-3.5 years). The median survival time has not yet been reached for the L-10M protocol. Central nervous system prophylaxis with intrathecal methotrexate alone was effective in preventing central nervous system relapse. An analysis of possible prognostic factors indicated that patients less than 25 years of age had a higher CR rate than older patients (p = 0.02). Patients with an initial leukocyte count below 15,000/microL experienced longer remissions than patients with a leukocyte count above 15,000/microL (p = 0.008), and patients who achieved CR within the first month of therapy were in remission longer than those requiring a longer time to achieve CR (p = 0.04). Patients with T cell ALL did not have a poorer prognosis than other patients treated on these protocols. The L-10 and L-10M protocols were well tolerated with minimal morbidity.

Combination chemotherapy of advanced chronic lymphocytic leukemia: the M-2 protocol (vincristine, BCNU, cyclophosphamide, melphalan, and prednisone)

The M-2 protocol (vincristine, cyclophosphamide, BCNU, melphalan, and prednisone) was administered monthly to 63 evaluable patients with advanced chronic lymphocytic leukemia. Complete remission (absence of all clinical and bone marrow evidence of leukemia) and partial response (greater than 50% decrease in organ enlargement and reduction of WBC count to below 15,000 x 10(6)/liter) were achieved in 17% and 44%, respectively, for a total response rate of 61%. The median survivals from therapy of patients achieving a CR, RR, or no response were 73+, 40, and 14 mo respectively. The median survival time from onset of treatment for stages II, III, and IV disease were 47, 20 and 19 mo, respectively, which was not statistically different from historical controls. However, when untreated patients are compared to this latter group, a significant survival advantage from diagnosis was found (p = 0.01), stressing the importance of prior therapy as the only unfavorable prognostic factor. Although complete remissions in CLL, as reflected in apparently normal bone marrow B-lymphocyte markers, can be induced wih acceptable morbidity, the majority of patients relapse after cessation of therapy. An alternative approach to the M-2 protocol will be needed to eradicate the disease.

Cyanide formation from glyoxylate and hydroxylamine catalysed by extracts of higher-plant leaves

Extracts of spinach, maize and barley contain an enzyme which catalyses the formation of hydrogen cyanide from glyoxylate and hydroxylamine. The enzyme is dependent upon ADP and a divalent cation such as manganese. Glyoxylicacid oxime is a poor substrate for the enzyme. Carbon dioxide is another product of the reaction and is probably produced in 1:1 stoichiometry with hydrogen cyanide. The possible relationship of this enzyme to the regulation of nitrate reduction is discussed.

Treatment of acute nonlymphocytic leukemia in adults: response to 2,2-anhydro-1-B-D-arabinofuranosyl-5-fluorocytosine and thioguanine on the L-12 protocol

Fifty-one adult patients with acute nonlymphocytic leukemia (excluding acute promyelocytic leukemia) were treated on the L-12 protocol. The L-12 differed from the preceding L-6 in that 2,2-anhydro-1-B-D-arabinofuranosyl-5-fluorocytosine (AAFC), replaced arabinosylcytosine (ara-C) together with 6-thioguanine (TG) for remission induction. Achievement of remission was followed by an extended 14-week multi-drug consolidation program. With this more intense regimen, an overall complete remission rate of 49% and a median remission duration of 23.7 months were achieved; these results were not significantly better than the 57% complete remission rate and 8.6 months median remission duration obtained with the L-6 regimen. Four year disease-free survival was 22% on the L-12 compared with 16% on the L-6 protocol. No relationship between prognosis and FAB classification was found on either the L-6 or the L-12 protocol.

Hypercapnic stimulation of respiratory activity in unanesthetized fetal sheep in utero

Respiratory responses to hypercapnia were studied in seven chronic in utero fetal lambs between 105 and 138 days' gestation (16 expts). Fetal arterial CO2 tension was raised (mean increase 9.9 Torr) by altering maternal inspired gas concentrations. Diaphragmatic electromyogram (EMG) was recorded as the index of respiratory activity. Electrocortical and electroocular activity (3 fetuses) were monitored in an attempt to define sleep state. Average respiratory rate increased (90%) and fetal apnea decreased (60%) during hypercapnia. Mean respiratory rate during "on" periods (greater than 6 EMG bursts/min) increased significantly during hypercapnia throughout the gestational epoch studied. Mean duration of the inspiratory time (TI) showed no significant change. Variability in both rate and TI decreased in response to CO2 at all gestations. Integrated EMG activity per burst divided by TI increased significantly at all gestations; however, no gestational increase in responsiveness to CO2 was seen. Sleep states were not able to be consistently identified, and a quantifiable electrocortical response to CO2 was not observed. These results indicate a relatively early functional maturation of fetal respiratory responses to CO2.

Development of patterns of respiratory activity in unanesthetized fetal sheep in utero

Respiratory activity (diaphragmatic electromyogram) was recorded in six unanesthetized in utero fetal lambs, between 0.7 of gestation and term. Respiratory patterns generated by the fetus showed developmental changes that included 1) an emergence of a periodic modulation of respiratory rate producing alternating active and quite phases (mean cycle length of 37 min between 130 and 140 days' gestation; 2) an increase in percentage apnea (expiratory time greater than 10 s) from 20% at 110 days to 60% at 140 days; and 3) a linear decrease in the 2-h average respiratory rate, while mean rate during active phases showed no consistent gestational decline. Electrocortical and electroocular activity was monitored in three of six fetuses; however, discrete sleep state patterns could not be consistently identified. The results demonstrate a gestational change in the respiratory patterns of the developing fetus and suggest an orderly maturation of the mechanisms controlling respiratory neuronal output.

Metabolism of hydroxylamine by spinach leaf discs and its relationship to nitrate reduction

Nitrate reduction in vivo by spinach leaf discs was shown to be inhibited by hydroxylamine when this was included in the nitrate reductase assay solutions or introduced to the tissue during a preincubation period. The sensitivity of nitrate reduction to hydroxylamine was not sufficient to suggest a natural process, considering the small endogenous concentrations of hydroxylamine in the leaves. Inhibition of nitrate reduction in vivo could be approximately related to rates of in vitro inhibition of nitrate reductase by this compound. There was no need to suppose conversion of hydroxylamine to cyanide to inhibit nitrate reduction. Some of the in vivo and in vitro characteristics of hydroxylamine inhibition of nitrate reductase are described. Hydroxylamine was metabolised by discs at rates comparable to nitrate reduction. Rates of metabolism of hydroxylamine, and its accumulation in the tissues from an external solution were both enhanced by light but little affected by anaerobiosis.

Evaluation of preschool meals programmes on the nutritional health of Aboriginal children

One hundred and sixteen three to five year old Aboriginal children were included in an evaluation of the effect of preschool meals programmes on their nutritional health. Sixty-one children attending preschools in five communities were examined at the beginning and end of the school year. Fifty-five control children in five matched communities had two examinations, 38 weeks apart. Height, weight and haemoglobin concentrations were determined on all children and serum levels of ascorbic acid, ferritin, iron, total protein, albumin, cholesterol and triglycerides were determined on a subsample. Aboriginal children in both groups had initial measurements and nutrient levels below acceptable levels. The 61 children who received preschool meals had consistently better growth than the control children. A negative correlation was found between gains in weight and height and serum levels of ferritin, haemoglobin and ascorbic acid, indicating that more rapidly growing children may have been rapidly utilizing nutrients for growth.