Slipping through the cracks-detection of sex trafficking in the adult emergency department: An integrative review

INTRODUCTION

Current research estimates that over 24 million individuals experience human trafficking worldwide. There is a growing prevalence of sex trafficking in the United States. An estimated 87% of trafficked persons visit the emergency department during their captivity. Emergency departments across the United States use differing screening methods for sex trafficking. Current screening tools return a high rate of false negatives, and the appropriate use of tools or standardised lists remains unclear.

AIMS

To explore best practices for identifying sex trafficking among adults who visit emergency departments. We sought to answer the practice question: How does the implementation of a multifaceted screening model for sex trafficking, versus the use of a list of standardised screening questions, improve the detection of trafficked persons?

METHODS

We conducted an integrative review of articles published after 2016 in PubMed, CINAHL, Embase, SCOPUS, and Web of Science databases. PRISMA checklist and guidelines were used. Whittemore and Knafl's method was used to review the literature.

RESULTS

A final selection of 11 articles were reviewed and appraised using the Johns Hopkins nursing evidence-based practice model. The synthesis of evidence yielded four themes: (1) Provider and personnel education; (2) Protocol establishment; (3) Legal consultation; and (4) Multidisciplinary teamwork.

CONCLUSION

Through this process, we learned the importance of using multifaceted screening tools for identifying persons who are experiencing sex trafficking. In addition to using multifaceted screening tools, detection is improved when all emergency department personnel receive training on sex trafficking. There is a recognised lack of education on sex trafficking recognition nationwide.

RELEVANCE TO CLINICAL PRACTICE

Notably, emergency department nurses play an essential role in sex trafficking identification due to their maximised interaction with patients and the increased perception of trust that patients have with nurses. Steps include the development of an education program to improve recognition.

NO PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public involvement in the design or drafting of this integrative review.

COVID-19: Implications for Nursing and Health Care in the United States

PURPOSE

COVID-19 and other recent infectious disease outbreaks have highlighted the urgency of robust, resilient health systems. We may now have the opportunity to reform the flawed health care system that made COVID-19 far more damaging in the United States (U.S.) than necessary.

DESIGN AND METHODS

Guided by the World Health Organization (WHO) Health System Building Blocks framework (WHO, 2007) and the socio-ecological model (e.g., McLeroy et al., 1988), we identified challenges in and strengths of the U.S.' handling of the pandemic, lessons learned, and policy implications for more resilient future health care delivery in the U.S. Using the aforementioned frameworks, we identified crucial, intertwined domains that have influenced and been influenced by health care delivery in the U.S. during the COVID-19 pandemic through a review and analysis of the COVID-19 literature and the collective expertise of a panel of research and clinical experts. An iterative process using a modified Delphi technique was used to reach consensus.

FINDINGS

Four critically important, inter-related domains needing improvement individually, interpersonally, within communities, and for critical public policy reform were identified: Social determinants of health, mental health, communication, and the nursing workforce.

CONCLUSIONS

The four domains identified in this analysis demonstrate the challenges generated or intensified by the COVID-19 pandemic, their dynamic interconnectedness, and the critical importance of health equity to resilient health systems, an effective pandemic response, and better health for all.

CLINICAL RELEVANCE

The novel coronavirus is unlikely to be the last pandemic in the U.S. and globally. To control COVID-19 and prevent unnecessary suffering and social and economic damage from future pandemics, the U.S. will need to improve its capacity to protect the public's health. Complex problems require multi-level solutions across critical domains. The COVID-19 pandemic has underscored four interrelated domains that reveal and compound deep underlying problems in the socioeconomic structure and health care system of the U.S. In so doing, however, the pandemic illuminates the way toward reforms that could improve our ability not only to cope with likely future epidemics but also to better serve the health care needs of the entire population. This article highlights the pressing need for multi-level individual, interpersonal, community, and public policy reforms to improve clinical care and public health outcomes in the current COVID-19 pandemic and future pandemics, and offers recommendations to achieve these aims.

Insights into diurnal variations of advanced hemodynamic parameters in ambulatory individuals enabled by a photoplethysmography-based wearable monitor

Background

Recent technological developments enable non-invasive monitoring of advanced hemodynamic parameters, allowing big data-driven insights on diurnal changes for the first time. This study aimed to describe the trends of multiple advanced cardiovascular parameters among ambulatory individuals using a medical grade wearable monitor.

Methods

Common and advanced cardio-respiratory parameters were monitored for 24 hours in ambulatory volunteers using a photoplethysmography-based wearable monitor. The multi vital ambulatory monitoring (MVAM) included stroke volume (SV), cardiac index (CI), systemic vascular resistance (SVR), blood oxygen saturation (SpO2), respiratory rate (RR), systolic (SBP) and diastolic blood pressure (DBP), mean arterial pressure (MAP), pulse pressure (PP), and heart rate (HR). Diurnal variations were evaluated among all participants, and analyses were stratified based on sex, age, and body-mass index (BMI).

Results

A total of 256 participants were included in the analysis. All measured parameters showed significant (p<0.001) diurnal changes. Nighttime values were lower excluding RR and SVR, reaching the nadir at 5 am, and then increasing to a maximum at 10 am, plateauing, and then gradually declining from 7 to 8 pm. CI demonstrated a reduction of 0.6 L/min/m2 (20%), while SVR demonstrated the opposite trend and was higher during the night increasing by up to 212 dynes/sec/cm5 (16%). Females demonstrated higher HR and CI with lower SVR during daytime and nighttime. Obese participants (BMI >30 kg/m2) had a higher SBP and DBP, and lower SV and CI. SVR was higher among the elderly.

Conclusions

Diurnal changes using MVAM corresponding with awake-sleep hours were noticed in the monitored parameters and differed between sex, age, and BMI groups. This suggests that wearable monitoring platforms could shed more light on hemodynamic changes in subgroups, and might help with future efforts to provide tailored personalized medicine and pre-symptomatic diagnosis and prevention.

Funding Acknowledgement

Type of funding sources: None.

24-hour ambulatory blood pressure measurement using a novel non-invasive, cuff-less, wireless device

Background

Ambulatory blood pressure monitoring (ABPM) using cuff-based devices is used for diagnosis and treatment of hypertension. Technical limitations, low compliance and complex procedures limit their use.

Purpose

The aim of the present study was to test the accuracy of a new technique of 24H ABPM using a photoplethysmography (PPG)-based, wearable device (Wrist-monitor) as compared to the standard cuff-based ABPM device.

Methods

In this prospective observational study, 24H ABPM was performed in parallel for both devices on volunteers aged 18–65 years, while documenting their daily activities. Level of comfort and activity disturbance of both devices were recorded. Linear regression and Bland-Altman were used to evaluate the agreement between devices. Receiver Operating Characteristic (ROC) curve analysis was used to assess the capability of the Wrist-monitor to identify abnormal BP values.

Results

The study included 28 subjects (18 men) mean age 41.5±16.2 years. Bland-Altman analysis resulted in 24H bias of −1.1 mmHg for both diastolic blood pressure (DBP) and systolic blood pressure (SBP). Mean daytime bias was −1.9 mmHg for DBP and SBP, while nighttime bias was smaller (0.7 and 0.4 mmHg for DBP and SBP respectively). ROC curve analysis on all BP readings (n=2381) yielded a mean area under the curve (AUC) for 24H of 0.965 for both SBP and DBP. 24H ABPM with the Wrist-monitor caused significantly less inconvenience compared to the cuff-based device (p<0.001).

Conclusions

The cuff-less device provides comparable measurements to those obtained with the currently used cuff-based ABPM device, with significantly less inconvenience to the subject.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The ABPM devices were given for free by BioBeat LTD. Petach-Tikva, Israel. No other support was given.

Abstract S5-01: DCIS biological risk profile predicts risk of recurrence after breast conserving surgery in a Kaiser Permanente NW population

Background: Patients with DCIS and their physicians need tools that provide better information about the individual patient's biological risk profile to help make treatment decisions. Prelude and the Kaiser Permanente Northwest Center for Health Research (KPCHR) validated a biological risk signature based test to assess ipsilateral breast event (IBE) risk after breast conserving surgery (BCS) with radiation (+RT) or without radiation therapy (-RT).

Methods: The Prelude DCIS test was independently validated in a retrospective cohort from the Kaiser Permanente Northwest (KPNW) integrated healthcare system in patients diagnosed with DCIS from 1990- 2007 and treated with BCS±RT(n=608). KPCHR performed central pathology review to identify patients meeting study eligibility criteria with formalin fixed paraffin embedded (FFPE) tissue samples (n=475); KPCHR also reviewed medical records to collect patient, treatment, and outcome data. FFPE patient samples were provided to Prelude for testing. REMARK guidelines were followed.

A panel of biomarkers (HER2, PR, Ki-67, COX2, p16/INK4A, FOXA1 and SIAH2) were assayed by the Prelude CLIA lab and scored by board-certified pathologists (n=455). Prelude's DCIS test was executed independently using biomarker and clinicopathologic data while blinded to patient outcome data. The risk results were provided to KPCHR under a Data Transfer Authority. KPCHR biostatisticians executed a predefined and co-developed statistical analysis plan. IBE rates were assessed using Kaplan-Meier survival analysis. Hazard ratios (HR) were determined using Cox proportional hazards analysis, with RT as a covariate.

Results: The Prelude DCIS test score was statistically associated with total IBE as a continuous linear variable (0-10 unit scale) on a per unit basis, HR of 1.12, 95% CI [1.03,1.23], p=0.01. The DCIS test score (0-10) corresponded to recurrence risks ranging from 10% to 42% (≤2, >7) for patients treated with BCS-RT and ranging from 4% to 11% (≤2, >7) for patients treated with BCS+RT. Patients treated with BCS ±RT with an elevated test score (≤3 vs >3) had a higher recurrence risk, n=455, HR=1.87 [1.03 - 3.38], p=0.04. In patients treated with BCS-RT in this sample, patients with a higher DCIS signature had an elevated recurrence risk, n=78, HR=2.37, 95% CI [0.82, 6.85], p=0.11. The 10-year contralateral breast event rate was 4%, 95% CI [2%, 6%]. Median follow-up time was 10.4 years.

Discussion: Patients diagnosed with DCIS and treated with BCS ±RT, were stratified into clinically relevant low and elevated risk groups (≤3 vs >3) in an independent validation of the Prelude DCIS test. Patients in the elevated risk group had substantially higher likelihood of 10-year total IBE. The number of patients treated with BCS -RT was limited and while the stratification by risk group for BCS -RT was in the expected direction, it did not reach statistical significance. Two additional validation studies are scheduled to be completed in 2016.

10-YEAR IBE RISKBCS –RTBCS +RTRisk, [95% CI]PrevalenceNRisk, [95% CI]PrevalenceNBaseline Total Risk20%, [12%, 32%]100%788%, [5%, 11%]100%377Low Risk Group (≤3)10% [3%, 29%]53%415%, [2%, 10%]40%149Elevated Risk Group (>3)30%, [17%, 51%]47%3710%, [6%, 15%]60%228

Citation Format: Bremer T, Whitworth P, Leo M, Barry T, Goldstein N, Ganders C, Francisco M, Leesman G, Linke S, Patel R, Pellicane J, Weinmann S. DCIS biological risk profile predicts risk of recurrence after breast conserving surgery in a Kaiser Permanente NW population [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr S5-01.

Associations of ofatumumab exposure and treatment outcomes in patients with untreated CLL receiving chemoimmunotherapy

Relationships between patient characteristics, ofatumumab pharmacokinetics, and treatment outcomes were investigated in this phase 2 trial of ofatumumab plus fludarabine and cyclophosphamide (FC) in untreated chronic lymphocytic leukemia. Patients were randomized 1:1 to receive 500 or 1000 mg ofatumumab (Cycle 1; 300 mg) plus FC every 4 weeks for six cycles. Median C_max and C_trough values were similar at Cycle 1 regardless of the ultimate clinical outcome. At later doses, these values were higher for patients with complete response (CR) than for other patients. Higher C_max and C_trough values at Cycles 3 and 6 were significantly associated with an increased likelihood of CR, whereas ofatumumab pharmacokinetics were not associated with an objective response (OR) on the basis of univariate analyses. Multivariate analyses indicated that baseline patient/disease factors were predominantly associated with CR (17p status) or OR (bulky lymphadenopathy, gender, and serum thymidine kinase), rather than ofatumumab pharmacokinetics.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT00410163).

Helicobacter pylori infection in patients with selective immunoglobulin a deficiency

Selective immunoglobulin A (IgA) deficiency (IgAD) is the most common primary immunodeficiency in the western world. The aim of the study was to investigate the prevalence and clinical characteristics of Helicobacter pylori-infected dyspeptic patients with IgAD. Case samples were drawn from all subjects ≥ 12 years of age (n = 104729) who had undergone serum total IgA measurements during 2004-14 for any reason at Leumit Healthcare Services (Israel) and had serum total IgA < 0·07 g/l. The control group was comprised of a random sample of remaining patients with a case-control ratio of 10 controls for each case. The dyspeptic diseases were identified and retrieved from Leumit Health Care Services electronic database using specific ICD-9-CM diagnostic codes. The case group included 347 subjects and the control group 3470 subjects. There were no significant differences in the prevalence of patients with dyspepsia [84 (24·2%) versus 821 (23·6%) for cases and controls, respectively]. Additionally, there was no difference in a proportion of dyspeptic H. pylori-positive subjects [59 (17·1%) versus 524 (15·1%)] between the case and control groups. Only 59 (17%) among the 347 IgAD patients underwent gastroscopy. A significantly larger proportion of case subjects experienced several forms of gastritis [13 (61·9%) versus 38 (21·6%), P < 0·001), duodenal ulcers [seven (33·3%) versus 19 (10·8%); P = 0·01] and nodular lymphoid hyperplasia (NLH) [two (9·5%) versus none; P = 0·011]. IgAD is not associated with increased prevalence of H. pylori-associated dyspepsia; nevertheless, H. pylori-infected dyspeptic IgAD subjects experience more EGD-proved gastritis, duodenal ulcers and NLH.

The relationships among coping strategies, religious coping, and spirituality in African American women with breast cancer receiving chemotherapy

PURPOSE/OBJECTIVES

To (a) examine coping capacity, psychological distress, spiritual well-being, positive and negative religious coping, and coping strategies among African American (AA) women with breast cancer, and (b) explore relationships among these variables to enhance an already tested comprehensive coping strategy program (CCSP) intervention for AA women with breast cancer (CCSP-AA).

DESIGN

Descriptive-correlational.

SETTING

Comprehensive cancer center in Maryland.

SAMPLE

17 AA women with breast cancer.

METHODS

Women completed the Hospital Anxiety and Depression Scale, Sense of Coherence scale, Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being, Brief Religious Coping Inventory, and Coping Strategies Questionnaire.

MAIN RESEARCH VARIABLES

Psychological distress, coping capacity, coping strategies, religious coping, and spiritual well-being.

FINDINGS

A higher coping capacity was beneficial, as it was related to less psychological distress, negative religious coping, and catastrophizing. Women using less negative religious coping had greater spiritual well-being and less distress. Using more coping self-statements was associated with higher spiritual well-being and less negative religious coping. Catastrophizing had a negative effect on psychological distress and spiritual well-being.

CONCLUSIONS

The development of a CCSP-AA that incorporates aspects of spirituality and components in a coping intervention needs to be tested in a clinical trial. The intervention will teach patients to recognize and restructure their thinking to avoid catastrophizing and negative religious coping.

IMPLICATIONS FOR NURSING

Nurses need to work collaboratively with AA women to reinforce beneficial coping patterns and approaches. A tailored CCSP-AA for women with breast cancer administered by a nurse can be taught to assist AA patients in coping more effectively.

KNOWLEDGE TRANSLATION

AA women with breast cancer use more positive religious coping and experience less distress and greater spiritual well-being, but catastrophizing has a negative effect on spiritual well-being. Nurses need to reinforce positive coping patterns for AA women with cancer.

Blood-brain barrier unlocked

The brain is protected by a physiological blood-brain barrier (BBB) against toxins and some metabolites circulating in the blood. At the same time, the BBB limits penetration into the brain of many neuroactive drugs. Efficient ways to increase BBB permeability for delivery of drugs of different chemical nature into the brain are unknown. This work deals with delivery into the brain of 10(-2) M dopamine, a substance that does not penetrate the BBB under normal circumstances. It was studied in two independent experiments: (i) penetration of (3)H-labeled dopamine from its mixture with 10(-5) M H2O2 into hypothalamus and striatum structures of intact rat brain, and (ii) effect of unlabeled dopamine from a mixture with H(2)O(2) on the rat motor activity in a haloperidol catalepsy model. It was shown that (i) at the third minute after nasal application of the dopamine + H(2)O(2) mixture, the dopamine level increases 45-fold in the hypothalamus and almost 30-fold in the striatum and (ii) motility of animals in the catalepsy haloperidol model is recovered 90 sec after intranasal introduction of dopamine. No such effects were observed after replacement of H(2)O(2) by 0.9% NaCl solution. Thus, it was shown on the example of dopamine that its introduction into the nasal cavity simultaneously with H(2)O(2) provides for rapid delivery of the drug into the brain. These results expand our knowledge concerning the biological role of exoROS in modulating BBB permeability and may contribute to the development of a new therapeutic strategy for neurological diseases.

Anti-tumor and cell cycle responses in KB cells treated with a chimeric anti-EGFR monoclonal antibody in combination with cisplatin

Overexpression of the epidermal growth factor receptor (EGFR) has been found to correlate with a poor prognosis for many cancers. The EGFR appears to play an important role in regulating cell growth during tumorigenesis and blockade of the EGFR/ligand interaction may be a means of inducing cell cytotoxicity, terminal differentiation, or apoptosis. In this report, we show that the growth of well-established xenografts of the human epidermoid carcinoma cell line KB could be significantly inhibited by the combination of cisplatin plus C225, a chimeric anti-EGFR monoclonal antibody, whereas the individual treatments had no effect on tumor growth. Substantive changes in the protein expression levels of the EGFR as well as several important cell cycle regulatory proteins were found in cells treated with the combination. In addition, cisplatin plus C225 inhibited the overall phosphorylation patterns including EGFR activation. These in vitro data suggest a mechanism of action for the in vivo therapeutic effects of C225 plus cisplatin.

Long-term effect of the self-management comprehensive coping strategy program on quality of life in patients with breast cancer treated with high-dose chemotherapy

BACKGROUND

This study aims to examine the effectiveness of a self-management multimodal comprehensive coping strategy program (CCSP) on quality of life (QOL) among breast cancer patients 1 year after treatment.

METHODS

Patients (n = 110) with stage II, III, or IV breast cancer scheduled to receive high dose chemotherapy and autologous hematopoietic stem cell transplantation were randomized to either CCSP treatment or control group. The CCSP intervention was taught 2 week before hospital admission with reinforcement at specified times during treatment and 3 months after discharge. The CCSP components included educational information, cognitive restructuring, coping skills enhancement, and relaxation with guided imagery. Instruments administered at baseline included the following: Quality of Life Index-Cancer Version (QOLI-CV), State-Trait Anxiety Inventory, Beck Depression Inventory, and Coping Strategies Questionnaire. At 1-year follow-up, patients (n = 73) completed and returned the follow-up QOLI-CV.

RESULTS

Patients were mainly ≥ 40 years of age, married, Caucasian, and diagnosed with advanced breast cancer. A model measuring effectiveness of CCSP on QOL (total and subscale) at 1-year follow-up showed that the CCSP group (n = 38) had significant improvement in overall QOL (p < 0.01), health and functioning (p < 0.05), and socioeconomic (p < 0.05) and psychological/spiritual well-being (p < 0.01) compared with the control group (n = 35). The CCSP patients frequently used the CCSP to manage psychological (51%) and sleep problems (60%).

CONCLUSIONS

The CCSP improved QOL for patients at 1-year follow-up. Patients overwhelmingly reported that CCSP was beneficial. The CCSP as an effective coping intervention has potential as a self-management program for breast cancer survivors.

Electronic health records and adverse drug events after patient transfer

BACKGROUND

Our objective was to examine the frequencies of medication error and adverse drug events (ADEs) at the time of patient transfer in a system with an electronic health record (EHR) as compared with a system without an EHR. It was hypothesised that the frequencies of these events would be lower in the EHR system because of better information exchange across sites of care.

METHODS

469 patients transferred between seven nursing homes and three hospitals in New York and Connecticut between 1999 and 2005 were followed retrospectively. Two groups of patients were compared: US Veterans Affairs (VA) patients, with an EHR, and non-VA patients, without an EHR, on the following measures: (1) medication prescribing discrepancies at nursing home/hospital transfer, (2) high-risk medication discrepancies and (3) ADEs caused by medication discrepancies according to structured medical record review by pairs of physician and pharmacist raters.

RESULTS

The overall incidence of ADE caused by medication discrepancies was 0.20 per hospitalisation episode. After controlling for demographic and clinical covariates, there were no significant differences between VA and non-VA groups in medication discrepancies (mean difference 0.02; 95% CI -0.81 to 0.85), high-risk medication discrepancies (-0.18; 95%CI -0.22 to 0.58) or occurrence of an ADE caused by a medication discrepancy (OR 0.96; 95% CI 0.18 to 5.01).

CONCLUSIONS

There was no difference, with and without an EHR, in the occurrence of medication discrepancies or ADEs caused by medication discrepancies at the time of transfer between sites of care. Reducing such problems may require specialised computer tools to facilitate medication review.

Prescribing discrepancies likely to cause adverse drug events after patient transfer

BACKGROUND

Medication-prescribing discrepancies are used as a quality measure for patients transferred between sites of care. The objective of this study was to quantify the rate of adverse drug events (ADEs) caused by prescribing discrepancies and the discrimination of an index of high-risk transition drug prescribing.

METHODS

We examined medical records of patients transferred between seven nursing homes and three hospitals between 1999 and 2005 in New York and Connecticut for transfer-associated prescribing discrepancies. ADEs caused by discrepancies were determined by two clinician raters. We calculated the fraction of medication discrepancies that caused ADEs in each of 22 drug classes by calculating positive predictive values (PPVs). We calculated the discrimination of a count of high-risk drug discrepancies, selected from published lists of high-risk medications and using observed PPVs.

RESULTS

208 patients were hospitalised 304 times. Overall, 65 of 1350 prescribing discrepancies caused ADEs, for a PPV of 0.048 (95% CI 0.037 to 0.061). PPVs by drug class ranged from 0 to 0.28. Drug classes with the highest PPVs were opioid analgesics, metronidazole, and non-opioid analgesics. Patients with 0, 1-2 and >/=3 high-risk discrepancies had a 13%, 23% and 47% chance of experiencing a discrepancy-related ADE, respectively.

CONCLUSIONS

Discrepancies in certain drug classes more often caused ADEs than other types of discrepancies in hospitalised nursing-home patients. Information about ADEs caused by medication discrepancies can be used to enhance measurement of care quality, identify high-risk patients and inform the development of decision-support tools at the time of patient transfer.

Meaning-making of a group of South Africans in their experience of living with HIV: a phenomenological study

With the primary focus of disease specific studies on the medical and biological transmission and progression of HIV/AIDS, the lived experience and meaning-making of individuals who live with this disease, is a literary scarcity. Opsomming Met die primêre fokus van siektespesifieke studies op die mediese en ook biologiese oordrag en progressie van MIV/VIGS, is daar ‘n literêre skaarste oor die geleefde ondervinding en betekenisgewing van individue wat met hierdie siekte leef. *Please note: This is a reduced version of the abstract. Please refer to PDF for full text.

Allergic rhinitis due to house dust mites: evaluation of the efficacy of specific sublingual immunotherapy

BACKGROUND

The efficacy and safety of sublingual immunotherapy (SLIT) in patients with chronic rhinitis related to sensitization to house dust mites are still controversial.

METHODS

After application of an anti-mite mattress cover, patients were only included in the study when the cumulative symptom score over a fortnight was greater than 70 out of a possible total of 168. Thirty-two of the 120 patients selected were randomized to receive SLIT for 2 years: 17 received placebo and 15 received the Dermatophagoides pteronyssinus and D. farinae 50/50 allergen extract.

RESULTS

Significant between-group differences were observed after 1 year and persisted at the end of the second year for the rhinitis total score (P < 0.02), blocked nose score (P < 0.01) and nasal itching score (P < 0.01). Skin reactivity to house dust mites was significantly reduced in the group receiving house dust mite extract (P < 0.03). No statistical difference was observed between the two groups for medication scores, but a low medication consumption was observed in all patients. No serious and no systemic adverse reactions were reported.

CONCLUSION

This study indicates the superiority of active treatment vs. placebo, evaluated on efficacy criteria (rhinitis score) or objective criteria (skin reactivity). The availability of a solid form (tablet) could represent a progress in terms of patient acceptability.

Workshop on Partial Breast Irradiation: State of the Art and the Science, Bethesda, MD, December 8-10, 2002

Breast conserving surgery followed by radiation therapy has been accepted as an alternative to mastectomy in the management of patients with early-stage breast cancer. Over the past decade there has been increasing interest in a variety of radiation techniques designed to treat only the portion of the breast deemed to be at high risk for local recurrence (partial-breast irradiation [PBI]) and to shorten the duration of treatment (accelerated partial-breast irradiation [APBI]). To consider issues regarding the equivalency of the various radiation therapy approaches and to address future needs for research, quality assurance, and training, the National Cancer Institute, Division of Cancer Treatment and Diagnosis, Radiation Research Program, hosted a Workshop on PBI in December 2002. Although 5- to 7-year outcome data on patients treated with PBI and APBI are now becoming available, many issues remain unresolved, including clinical and pathologic selection criteria, radiation dose and fractionation and how they relate to the standard fractionation for whole breast irradiation, appropriate target volume, local control within the untreated ipsilateral breast tissue, and overall survival. This Workshop report defines the issues in relation to PBI and APBI, recommends parameters for consideration in clinical trials and for reporting of results, serves to enhance dialogue among the advocates of the various radiation techniques, and emphasizes the importance of education and training in regard to results of PBI and APBI as they become emerging clinical treatments.

Reactive oxygen species as essential components of ambient air

In this review evidence for the presence of the anion radical O2(-*) in atmospheric air is considered, and the biological activity of superoxide and negative air ions is compared. Various aspects of the biological effect of superoxide and other reactive oxygen species contained in air at the cell, tissue, and organism levels are discussed. The results of the therapeutic use of exogenous gaseous superoxide and low doses of H2O2 for the treatment of bronchial asthma, pain, and Parkinson's disease are reported. A hypothesis on the mechanism of physiological action of exogenous reactive oxygen species is discussed.

[Overuse of antibiotics with upper respiratory tract infections in a primary care clinic]

In the majority of cases upper respiratory tract infections (URI's) are caused by viruses. Nonetheless, in many instances, patients with URI's are over-treated with antibiotics. In order to evaluate the use of antibiotic therapy in patients with URI's, we recorded medications prescribed for URI's in 394 young adults seeking care in a primary care clinic. The following parameters were assessed: rhinnorhea, cough, sore throat, dysphagia, tonsillar exudates, tonsillar enlargement and cervical lymphadenopathy. Throat cultures were taken from all the patients.

RESULTS

Antibiotic therapy was prescribed for 99 of the 370 patients (26.8%) with URI's and negative throat cultures. Among these patients, a high prevalence of the following findings was evident: tonsillar enlargement (66.7%), tonsillar exudates (48.5%), cervical lymphadenopathy (42.4%), lack of rhinorrhea (40.4%), lack of cough (32.0%) and fever (31.3%).

CONCLUSIONS

Excess antibiotic therapy was prescribed for patients with URI's. Possible explanations are: clinical findings that suggest a diagnosis of follicular tonsillitis, early antibiotic treatment that is not based on throat cultures or antigen detection tests, and multiple treating physicians.

RECOMMENDATIONS

We recommend that in cases of patients with URI's, antibiotics should not be prescribed unless diagnosis of a streptococcal infection is supported by results of throat cultures or antigen detection tests. Furthermore, in primary care clinics with a number of physicians, treatment should guarantee appropriate medical follow-up.

Auditory deprivation modifies biological rhythms in the golden hamster

To assess to what extent auditory sensory deprivation affects biological rhythmicity, sleep/wakefulness cycle and 24 h rhythm in locomotor activity were examined in golden hamsters after bilateral cochlear lesion. An increase in total sleep time as well as a decrease in wakefulness (W) were associated to an augmented number of W episodes, as well as of slow wave sleep (SWS) and paradoxical sleep (PS) episodes in deaf hamsters. The number of episodes of the three behavioural states and the percent duration of W and SWS increased significantly during the light phase of daily photoperiod only. Lower amplitudes of locomotor activity rhythm and a different phase angle as far as light off were found in deaf hamsters kept either under light-dark photoperiod or in constant darkness. Period of locomotor activity remained unchanged after cochlear lesions. The results indicate that auditory deprivation disturbs photic synchronization of rhythms with little effect on the clock timing mechanism itself.

[Altered functional and biochemical parameters during treatment of patients with bronchial asthma with inhaled gaseous superoxide]

To investigate the impact of adaptive oxidative training with inhaled gaseous superoxide (GS) on endogenous oxidative stress (EOS) and lung function in asthmatics and healthy volunteers, short-term GS inhalation was repeated. The study involved 27 patients (median age 42 (34 to 44) years with atopic bronchial asthma and a median disease duration of 130 (120 to 180) months prior to the investigation and 8 healthy volunteers whose median age was 20.5 (18 to 25 years). The rates of GS generation at a distance of 1 cm from the source was 0.25 mumol/min. The examinees inhaled GS nasally over 15 minutes per session, on an average of 20 times over 2 periods of 4 weeks each. Spirometric studies, a mathacholine challenge test, salbutamol test and blood cell count were performed, and blood antioxidative components were measured. There is evidence that GS inhalations in asthmatics cause an adaptive oxidative training and promote reductions in EOS, as well as activation of antiinflammatory mechanisms and improved spirometric parameters.

[Audit and standardization of allergologic practices for urticaria]

In November 1997, by the initiative of allergists and ANAICE commissions of harmonization and allergy practice were created to improve the quality of care. The summary of the results is reported of one of the commissions, that on urticaria. The common attitudes and disagreements between the allergists from different faculties and who worked in different towns are presented. The work has also shown the importance of interactions between urticaria and mind in chronic urticaria in adults and has analysed invalidated indications. The work has obtained the support of the principal representative structures of liberal allergy: the SNAF, ANAFORCAL and ANAICE. It needs to be followed by scientific and rigorous methodology, like the audits of ambulatory medical practice. The harmonization commissions have done preliminary work which is indispensable for introduction of audits in the different sectors of activity in allergy.

Irradiation of the tumor bed alone after lumpectomy in selected patients with early-stage breast cancer treated with breast conserving therapy

BACKGROUNDS AND OBJECTIVES

We present the interim findings of our in-house protocol treating the tumor bed alone after lumpectomy with low-dose-rate (LDR) interstitial brachytherapy in selected patients with early-stage breast cancer treated with breast conserving therapy (BCT).

METHODS

From 1 March 1993 through 1 January 1995, 50 women with early-stage breast cancer were entered into a protocol of tumor bed irradiation alone using an interstitial LDR implant. Patients were eligible if their tumor was an infiltrating ductal carcinoma < or =3 cm in diameter, surgical margins were clear by at least 2 mm, the tumor did not contain an extensive intraductal component, the axilla was surgically staged with < or =3 nodes involved with cancer, and a postoperative mammogram was performed. Implants were positioned using a template guide delivering 50 Gy over 96 hr to the lumpectomy bed plus a 1-2-cm margin. Local control, cosmetic outcome, and complications were assessed.

RESULTS

Patients ranged in age from 40 to 84 years (median, 65). The median tumor size was 10 mm (range, 1-25). Seventeen of 50 patients (34%) had well-differentiated tumors, 22 (44%) had moderately differentiated tumors, and in 11 (22%) the tumor was poorly differentiated. Forty-five patients (90%) were node-negative while five (10%) had 1-3 positive nodes. A total of 23 (46%) patients were placed on tamoxifen and 3 (6%) received adjuvant systemic chemotherapy. No patient was lost to follow-up. The median follow-up for surviving patients is 47 months (range, 37-59). No patient has experienced a local, regional, or distant failure. Three patients have died at 19, 33, and 39 months after treatment. All were without clinical evidence of recurrent disease and all deaths were unrelated to treatment. Good-to-excellent cosmetic results have been observed in 49 of 50 patients (98%) (median cosmetic follow-up was 44 months with a range of 19-59). No patient has experienced significant sequelae related to their implant.

CONCLUSIONS

Interim results with treatment of the tumor bed alone with an LDR interstitial implant appear promising. Long-term follow-up of these patients and additional studies will be necessary to establish the equivalence of this treatment approach compared to standard BCT.