Simplified PADUA Renal (SPARE) Nephrometry Scoring System: External Validation, Interobserver Variability, and Comparison with RENAL and PADUA in a Single-center Robotic Partial Nephrectomy Series

BACKGROUND

The RENAL (radius [R], exophytic/endophytic [E], nearness to collecting system/sinus [N], anterior/posterior [A], and location relative to polar lines [L]) and the PADUA (preoperative aspects and dimensions used for an anatomical classification) scores help in quantifying tumor complexity. However, nephrometry scoring systems have low interobserver variability. To simplify and improve score reproducibility, a new Simplified PADUA Renal (SPARE) scoring system was introduced.

OBJECTIVE

To externally validate the SPARE nephrometry scoring system and to determine its interobserver variability.

DESIGN, SETTING, AND PARTICIPANTS

A total of 202 patients were included in the analysis. We performed a retrospective analysis of robot-assisted partial nephrectomy (RAPN) cases for a single renal mass performed at a single academic institution during the period 2008-2018. For each renal mass, PADUA, RENAL, and SPARE nephrometry scores were calculated.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Three urology residents (URs), two urology attendings (UAs), two radiology residents (RRs), and one radiology attending (RA) retrospectively reviewed computed tomography scans blinded to clinical outcomes. The accuracy of the SPARE nephrometry score in the prediction of any complication (Clavien grade ≥1) was compared with other scoring systems in a univariable and a multivariate fashion. The area under the curve (AUC) and kappa statistics were used to assess interobserver variability of the SPARE score.

RESULTS AND LIMITATIONS

The SPARE score was not inferior to the PADUA and RENAL scores (AUC 0.61, 0.59, and 0.57, respectively, p = 0.43). Patients with intermediate to high SPARE scores had longer operative time (158 vs 135 min, p = 0.10) and a higher rate of complications (28% vs 14%, p = 0.012). Univariable analysis predicting overall complications showed that RRs performed slightly better than URs and UAs using the SPARE score. Interobserver agreement was 84% between an RA and an RR (kappa 0.42), 85% between an RA and a UA (kappa 0.39), and 85% between an RA and a UR (kappa 0.45).

CONCLUSIONS

These findings confirm that the SPARE nephrometry scoring system is a reproducible and easy tool offering overall fair interobserver agreement regardless of years of training or type of practice, while maintaining the predictive capabilities of more established nephrometry scores.

PATIENT SUMMARY

In this study, a novel and simple classification system was assessed using a sample of cases from our institution to define surgical complexity renal masses detected on radiological imaging. Our findings suggest that this tool can be useful in clinical practice to facilitate the characterization of renal masses and predict the complications of surgical treatment.

Uptake of risk-reducing salpingo-oophorectomy in women carrying a BRCA1 or BRCA2 mutation: evidence for lower uptake in women affected by breast cancer and older women

BACKGROUND

Bilateral risk-reducing salpingo-oophorectomy (BRRSO) is the only effective way of reducing mortality from ovarian cancer. This study investigates uptake of BRRSO in 700 BRCA1/2 mutation carriers from Greater Manchester.

METHODS

Dates of last follow-up and BRRSO were obtained, and the following variables were investigated: ovarian cancer risk/gene, age and breast cancer history. The date of the genetic mutation report was the initiation for Kaplan-Meier analysis.

RESULTS

The uptake of BRRSO in BRCA1 mutation carriers was 54.5% (standard error 3.6%) at 5 years post testing compared with 45.5% (standard error 3.2%) in BRCA2 mutation carriers (P=0.045). The 40-59 years category showed the greatest uptake for BRRSO and uptake was significantly lower in the over 60 s (P<0.0001). Of the unaffected BRCA1 mutation carriers, 65% (standard error 5.1%) opted for surgery at 5 years post-testing compared with 41.1% (standard error 5.1%) in affected BRCA1 mutation carriers (P=0.045).

CONCLUSION

The uptake of BRRSO is lower in women previously affected by breast cancer and in older women. As there is no efficient method for early detection of ovarian cancer, uptake should ideally be greater. Counselling should be offered to ensure BRCA1/2 mutation carriers make an informed decision about managing their ovarian cancer risk.

Menopausal symptoms and bone health in women undertaking risk reducing bilateral salpingo-oophorectomy: significant bone health issues in those not taking HRT

BACKGROUND

Women at high ovarian cancer risk, especially those with mutations in BRCA1/BRCA2, are encouraged to undergo bilateral risk-reducing salpingo-oophorectomy (BRRSPO) prior to the natural menopause. The decision to use HRT to cover the period of oestrogen deprivation up to 50 years of age is difficult because of balancing the considerations of breast cancer risk, bone and cardiovascular health.

METHODS

We reviewed by questionnaire 289 women after BRRSPO aged ≤48 years because of high ovarian cancer risk; 212 (73%) of women responded.

RESULTS

Previous HRT users (n=67) had significantly worse endocrine symptom scores than 67 current users (P=0.006). A total of 123 (58%) of women had ≥24 months of oestrogen deprivation <50 years with 78 (37%) never taking HRT. Bone density (DXA) evaluations were available on 119 (56%) women: bone loss with a T score of ≤-1.0 was present in 5 out of 31 (16%) women with no period of oestrogen deprivation <50 years compared with 37 out of 78 (47%) of those with ≥24 months of oestrogen deprivation (P=0.03).

INTERPRETATION

Women undergoing BRRSPO <50 years should be counselled concerning the risks/benefits of HRT, taking into consideration the benefits on symptoms, bone health and cardiovascular health, and that the risks of breast cancer from oestrogen-only HRT appear to be relatively small.

Effect of prefeeding on foraging patterns of brushtail possums (Trichosurus vulpecula) about prefeed transects

Context. Brushtail possums (Trichosurus vulpecula) are a major pest of native biodiversity and agricultural production in New Zealand. To maximise the effectiveness of control operations, prefeeding (free-feeding) of non-toxic bait before poison is often used, but the mechanisms by which it does so, remain unclear. One possibility is that prefeeding changes foraging patterns and space use in ways that increase the likelihood of possums finding and eating a lethal dose of poison bait. Aim. To determine whether prefeeding along transects increases possum activity on the transect, and if so, how long the effect lasts. Methods. We monitored the time that radio-collared possums spent within a few metres of 350 m of aerial wire laid along a transect. Key results. Initially, possums spent only 2.6 min per night in the vicinity of the wire, but after 20 kg of bait per kilometre were placed along the wire, that time increased 20-fold on the first night and remained high for the next four nights (by which time all of the bait had been consumed). After that there was a gradual decline in time spent near the wire over a further 18 days. The increased amount of time spent near the wire was the product of both an increase in the number of visits and the duration of those visits. Conclusions. We conclude that sowing prefeed in concentrated strips is likely to greatly increase the probability of possums rapidly encountering toxic bait sown along the same strips, especially where the toxin can be sown immediately after all of the prefeed has been eaten. Implications. Possum control operations can now be designed to apply much smaller quantities of toxic bait that will potentially reduce concerns about 1080 poisoning because of a move away from broadcast sowing operations that are intuitively disliked by many, to much more localised baiting regimes.

The neoadjuvant approach in the treatment of patients with advanced epithelial ovarian carcinoma

AIMS

Ovarian cancer has a very poor prognosis, with 5-year survival rates of 5-20% for advanced-stage disease. This work was designed to verify whether the neoadjuvant approach had an effect on survival in patients with advanced-stage ovarian cancer.

MATERIALS AND METHODS

Patients with stage III or IV disease who received neoadjuvant platinum-based chemotherapy (group 1) were compared with a group of conventionally treated patients (group 2).

RESULTS

Most of the patients in group 1 (76%) had partial tumoral responses after chemotherapy. Patients from group 1 (n = 42) had a median survival that was not different from that in patients from group 2 (n = 348). Patients who received platinum-based chemotherapy with taxanes had the same survival of patients who received no taxanes.

CONCLUSIONS

Our results showed similar responses and survival rates for patients with stage III or IV ovarian cancer treated with neoadjuvant platinum-based chemotherapy, when compared with patients who underwent primary suboptimal cytoreductive surgery. Our data therefore support the ongoing trials to determine the optimum timing of surgery for ovarian cancer.

Defining the dermatological content of the undergraduate medical curriculum: a modified Delphi study

BACKGROUND

Dermatological problems are common, but in undergraduate medical courses time for learning dermatology and teaching dermatology is limited. The Delphi technique has been used in other specialties to define undergraduate and postgraduate curricula and to reach consensus on what is important.

OBJECTIVES

To identify the core dermatological content of the undergraduate medical curriculum.

METHODS

Modified Delphi technique. A questionnaire was designed after review of previous recommendations made by dermatologists. Items were written as explicit learning outcomes. A multidisciplinary panel of 66 individuals responded. Outcomes were rated using a Likert scale (1-5).

RESULTS

Fifty-three learning outcomes were rated 'very important'. We recommend that these are included in the content of U.K. undergraduate medical core curricula.

CONCLUSIONS

A multidisciplinary panel identified dermatological learning outcomes that should be achieved by all medical graduates. Undergraduate medical curricula must provide sufficient resources for learning, teaching and assessment of dermatology so that graduates achieve these outcomes.

The interval from surgery to chemotherapy in the treatment of advanced epithelial ovarian carcinoma

BACKGROUND

To study the effect of the interval between surgery and the start of chemotherapy in the treatment of patients with advanced ovarian cancer.

METHODS

We stratified patients according to the start of platinum-based chemotherapy in group 1 (within 4 weeks from surgery), group 2 (between 4 and 8 weeks) and group 3 (between 8 and 12 weeks).

RESULTS

Three hundred and ninty-four stage III ovarian cancer patients were analysed. In the multivariate analysis there were no differences in survival according to the interval between surgery and chemotherapy among the three groups. The independent prognostic variables were type of procedure (p = 0.014), performance status (p = 0.040) and post-chemotherapy CA-125 (p < 0.0001).

CONCLUSIONS

The interval between surgery and chemotherapy does not affect outcome.

Matrix metalloproteases and their inhibitors are produced by overlapping populations of activated astrocytes

Matrix metalloproteases (MMPs) and tissue inhibitors of metalloproteases (TIMPs) are involved in many cell migration phenomena and produced by many cell types, including neurons and glia. To assess their possible roles in brain injury and regeneration, we investigate their production by glial cells, after brain injury and in tissue culture, and we investigate whether they are capable of digesting known axon-inhibitory proteoglycans. To determine the action of MMPs, we incubated astrocyte conditioned medium with activated MMPs, then did western blots for several chondroitin sulphate proteoglycans. MMP-3 digested all five proteoglycans tested, whereas MMP-2 digested only two and MMP-9 none. To determine whether MMPs or TIMPs are produced by astrocytes in vitro, we tested both primary cultures and astrocyte cell lines by western blotting, and compared them with Schwann cells. All cultures produced at least some MMPs and TIMPs, with no obvious correlation with the ability of axons to grow on those cells. Both MMP-9 and TIMP-3 were regulated by various cytokines. To determine which cells produce MMPs and TIMPs after brain injury, we made lesions of adult rat cortex, and did immunohistochemistry. MMP-2 was seen to be induced in activated astrocytes through the whole thickness of the cortex but not deeper, but MMP-3 was not seen in the injured brain. TIMP-2 and TIMP-3 immunoreactivities were induced in activated astrocytes in deep cortex and the underlying white matter. In situ hybridisation confirmed induction of TIMP-2 in glia as well as neurons, but showed no expression of TIMP-4. These results show that both MMPs and TIMPs are produced by some astrocytes, but TIMP production is particularly strong, especially in deep cortex and white matter which is more inhibitory for axon regeneration. Conversely the MMPs produced may not be adequate to promote migration of cells and axons within the glial scar.

Factors limiting the rate of living-related kidney donation to children in an inner city setting

A recent review of our center experience revealed that only 38% of our pediatric renal transplants come from living-related donors (LRD), which is 11% lower than the national average. The present study was designed to identify factors that limit the availability of LRD in our population pool. Retrospective chart reviews and subsequent telephone interviews were conducted with parents of all children who received renal replacement therapy (RRT) at our institution from 1990 to 1999. The availability of parents and their willingness to donate a kidney were noted. Self-reported willingness was defined as the verbal expression of a desire to donate. Firm willingness was defined as the completion of the steps necessary for donation, unless excluded by the medical team. Factors that may impact the ability to donate, such as donor age, ethnicity, religion, educational attainment, employment, and presence of other siblings younger than 18 yr of age, were evaluated. Statistical analyses were performed using the Student's t-test and chi-square analysis. Significant results were entered into a single-step multiple regression analysis. Sixty children were identified with RRT, of whom 60% were Blacks, 30% Hispanics, 7% Caucasians, and 3% Asian. Fifty-five mothers were available for interview. Forty-four mothers reported a desire to donate, nine were unwilling to donate, and two were undecided. However, only 35 attended for screening. Only 30 fathers were available and, of these, 27 reported willingness to donate, yet only 20 attended for screening. Seventy-four per cent (26 out of 35) of mothers screened and 55% (11 out of 20) of fathers screened were medically unsuitable for kidney donation. Nineteen potential donors had hypertension, diabetes and/or obesity, seven had renal disease, four had anemia, two had hepatitis C, and five had other conditions. Expressed unwillingness to donate was associated with a greater number of children (3.1 compared to 1.5 children in addition to the child with end-stage renal disease [ESRD]) (odds ratio 2.91, p < 0.05) and employment (26.3% vs. 4.0%, p < 0.05) (odds ratio 31.2, p = 0.05). Comparing mothers who were firmly willing to donate with mothers who did not complete screening and evaluation, unwilling mothers had, likewise, a greater number of children (2.9 vs. 1.2 in addition to the child with ESRD) (odds ratio 3.23, p < 0.01) and a greater number of years of education (12.4 vs. 10.4) (odds ratio 2.14, p < 0.05). Hence, the availability of living kidney donors for our inner city children is severely limited by a high rate of single parenthood and a high rate of comorbid conditions in the parental donor pool. Furthermore, there is a diminished capacity of the available parent, particularly the mother, to donate as she tends to have numerous other dependents.

Hypopituitarism and atherosclerosis

In the last decade, retrospective cohort data has provided evidence of premature atherosclerosis in patients with hypopituitarism which may account for the recently observed increased death rate from vascular events in these patients. The exact mechanism(s) for such propensity to atherosclerotic vascular disease is not yet completely clear. It is possible that hormonal factors may be the initiating mechanisms with subsequent secondary metabolic abnormalities acting as risk factors for development of atherosclerosis. This seems to be more evident in female hypopituitary patients compared with their male counterparts. Female patients have higher frequency and more pronounced abnormalities of various risk factors as well as surrogate markers of early vascular disease. This may explain why morbidity and mortality in women is in excess of men in retrospective epidemiological studies. Addressing abnormal hormonal factors, especially in females, is a primary objective in managing these patients both in the clinical arena as well as in trials designed to reduce the risk of atherosclerotic vascular disease in these patients. While short-term growth hormone treatment may ameliorate some of the vascular risk factors and improve endothelial function, it remains to be shown whether this translates into long-term reduction in morbidity and mortality from vascular, especially cerebrovascular, disease.

Experimental models to investigate the pathology of antisperm antibodies: approaches and problems

Antisperm antibodies (ASA) can interfere with sperm function and fertilization. But we still know relatively little about the specific mechanisms that elicit an auto-immune response and we have a poor appreciation of the profile of ASA that lead to antibody-mediated infertility in the male. This brief review explores some of the experimental models, the current approaches and the problems associated with investigations of ASA.

Gambling as an addictive disorder among athletes: clinical issues in sports medicine

This article examines the role of gambling as an addictive disorder experienced by athletes, both college and professional. Gambling may often be seen as a comorbid factor with other addictions and with depression among athletes. The focus on addictions among athletes has gained considerable attention among sports medicine clinicians. Diagnostic indicators, risk and protective factors, and a stage model of addiction among athletes are addressed. An algorithm and pathway of care for athletes with an addictive disorder is offered as are recommendations that sports physicians, sports medicine specialists, coaches and counsellors need to address athletes who have an addictive disorder.

Ethanol sensitivity of recombinant human N-methyl-D-aspartate receptors

In this study, the ethanol sensitivity of human N-methyl-D-aspartate (NMDA) receptors stably expressed in L(tk-) cells, or transiently expressed in HEK 293 cells and Xenopus oocytes was determined. NMDA receptor function was measured using fura-2 calcium imaging for L(tk-) cells, whole cell voltage-clamp for HEK 293 cells, and two-electrode voltage clamp for oocytes. Ethanol inhibited NMDA receptor function in all three expression system, but was less potent for receptors expressed in L(tk-) cells. NMDA receptors composed of NR1a/2B subunits were inhibited to a greater extent by ethanol than NR1a/2A receptors when expressed in L(tk-) cells and HEK 293 cells, but not in oocytes. These results suggest that the method of receptor expression and assay system used may influence the degree of ethanol inhibition of recombinant NMDA receptors.

Sustainability of prevention

This paper outlines the guidelines for sustaining prevention and makes suggestions for getting from the field's current status to greater levels of permanence for prevention. The paper begins by reviewing the status of prevention, then focuses on major considerations for achieving sustainability, including two processes of institutionalization, comprehensive programming and professionalism.

Prevention and health promotion on the international scene: the need for a more effective and comprehensive approach

The last decade has shown a boom in international networks and projects in health promotion and prevention. The growth of international collaboration is considered to be of crucial importance for the future development of the field. Several arguments are discussed in support of a further expansion of collaboration across countries and regions. The author criticizes the current lack of effectiveness in international collaboration in health promotion and prevention and identifies main barriers to effective collaboration. To make significant progress in research, evidence-based programs and policies, and their implementation worldwide, the creation of a comprehensive system of functional and effective linkages is needed across the core task areas, across disciplines, across system levels, and across countries and cultures. The quality of prevention and health promotion research as well as its impact on the health of communities depends on the degree to which research institutes and other stakeholders are embedded in an effective network of interorganizational and international relationships capable of performing a broad range of essential and functionally related tasks. It is critical that the dynamics of effective international collaboration become a legitimate subject of prevention and health promotion science.

Violence in the schools: clinical issues and case analysis for high-risk children

School violence in rural communities has gained considerable attention nationally. Examined are theoretical considerations involving escape theory, the risk and protective factors for school violence, case analyses of recent case studies, and discussion of recent school violence involving fatal injuries to others. Also discussed are diagnostic issues in understanding children who are at-risk for school violence and ways school violence maybe managed in the schools. Suggestions and recommendations including recommendations provided by the National School Safety Center for school personnel are offered, as are steps to be taken in creating a safe school environment. This information may be helpful to child psychiatry and clinical personnel who provide services to school aged children.

Differences in young adult psychopathology among drug abstainers, experimenters, and frequent users

Shedler and Block offered the provocative proposal that individuals who experiment with drugs are psychologically healthier than either those who abstain completely or those who are frequent users. Not all studies have come to such conclusions, however. In an effort to specify under what conditions Shedler and Block's conclusions might hold, the present study examined three groups of drug users (abstainers, experimenters, frequent users) classified according to three different criteria: (a) marijuana use at age 20; (b) alcohol use during 10th grade; and (c) alcohol use at age 20. The three groups were compared at age 20 in terms of personality, deviant behavior, and psychopathology. The results revealed that abstainers were never more psychologically impaired, and were occasionally healthier, than experimenters. Frequent users of marijuana were consistently more imparied than both the abstainers and experimenters, in terms of both internalizing and externalizing disorders. Classification according to marijuana use appeared to be more related to psychopathology than did classification according to alcohol use.

The effect of endometriosis and its radical laparoscopic excision on quality of life indicators

OBJECTIVE

To assess the effect of endometriosis and radical laparoscopic excision on the quality of life of women with this condition.

DESIGN

A prospective study.

SETTING

The Northern Endometriosis Centre at South Cleveland Hospital, Middlesbrough and St. James's University Hospital, Leeds.

POPULATION

Fifty-seven consecutive patients undergoing laparoscopic excision of invasive endometriosis.

METHODS

Questionnaires, both pre-operatively and four-month post-operatively, for a number of different symptoms associated with endometriosis were completed by patients. Details of fertility, previous treatments and quality of life as measured by SF12 and EuroQOL (EQ-5D) and sexual activity questionnaire, as well as linear pain scores for several symptoms, were recorded. Details of intra-operative findings was also collected.

MAIN OUTCOME MEASURES

Effect of laparoscopic excision on pain scores and quality of life, operative findings, type of surgery, length of surgery and incidence of intra- and post-operative complications.

RESULTS

Patients with endometriosis were severely ill with significant pain and impairment of quality of life and sexual activity. Four months after radical laparoscopic excision for deep endometriosis there was significant improvement in all the parameters measured including their quality of life based on EuroQOL evaluation: EQ-5D (0 x 595:0 x 729, P = 0 x 002) and EQ thermometer (68 x 9:77 x 7, P = 0 x 008); SF12 physical score (44 x 8:51 x 9, P = 0 x 015); sexual activity (habit P = 0 x 002, pleasure P = 0 x 002 and discomfort P < or = 0 x 001). Only the mental health score of SF12 failed to show any statistical improvement (47 x 1:48 x 4, P = 0 x 84). Symptomatically, there was a significant reduction in dysmenorrhoea (median 8 x 0:4 x 0, P < or = 0 x 001), pelvic pain (median 7 x 0:2 x 0, P < or = 0 x 001), dyspareunia (median 6 x 0:0 x 0, P < 0 x 001) and rectal pain scores (median 4 x 0:0 x 0, P < 0 x 001). Complications were noted, but were deemed to be acceptable for the extent of the surgery.

CONCLUSIONS

This is an early analysis of the first 57 cases studied, but structured evaluation suggests that meaningful improvements in clinical symptoms and quality of life can be obtained with this approach with acceptable levels of operative morbidity. Further follow up of this series is required, but early evidence would suggest that the technique should be further evaluated as part of a randomised trial.

Effects of ethanol on three endogenous membrane conductances present in Xenopus laevis oocytes

The Xenopus oocyte expression and recording system has allowed a detailed analysis of the physiology and pharmacology of neuronal ion channels including their sensitivity to ethanol. It is important however, to ascertain the effects of a particular drug on the channels inherently expressed by oocytes to ensure that drug effects ascribed to the expressed recombinant receptors are manifested solely through those receptors. In this study, the effects of ethanol were determined on three endogenous currents that can be elicited in oocytes and other cells by various manipulations. The inward cation current, IC, was activated by perfusing naive oocytes with a divalent-free recording solution. Ethanol (25-100 mM) modestly inhibited IC with 100 mM ethanol producing a 7-8% inhibition of steady state currents. The store-operated or capacitative calcium current (I(SOC)) was activated in thapsigargin-treated oocytes by switching from a calcium-free solution to one containing 10 mM calcium. In thapsigargin-treated oocytes also injected with EGTA to block calcium-activated chloride currents, ethanol (100 mM) had no effect on the store-operated calcium current. In contrast, ethanol (10-100 mM) dose-dependently inhibited the calcium-dependent chloride current (I(Cl(Ca)) in thapsigargin-treated oocytes. A voltage-jump protocol was used to separate the two components of I(Cl(Ca)), I(Cl-1) and I(Cl-2). Under these conditions, ethanol (100 mM) inhibited I(Cl-1) currents to a greater extent (38%) than it did I(Cl-2) currents (14%). These results show that Xenopus oocytes express endogenous ion channels that are differentially sensitive to ethanol.

Comparison of long-term outcomes of atrial repair of simple transposition with implications for a late arterial switch strategy

BACKGROUND

We report the single-institution, long-term results of 358 patients with simple transposition of the great arteries surviving >30 days after a Mustard (n=226, 1965 to 1980) or Senning (n=132, 1978 to 1992) procedure.

METHODS AND RESULTS

Outcome measures included late death, reintervention, ECG and ambulatory ECG rhythm, new arrhythmia, and functional status. Average follow-up was 13.4 (range 0.32 to 17.9) years for the Senning group and 11.7 (range 0.04 to 23.9) years for the Mustard group. The Senning group had a better survival rate at 5, 10, and 15 years (95% versus 86%, 94% versus 82%, and 94% versus 77%, respectively). In both groups, the majority of late deaths were sudden, without preceding ventricular dysfunction. Survival and survival free of reintervention were significantly better in the Senning group (relative risk [RR] 0.34, P=0.06 versus RR 0.39, P=0.027). Loss of sinus rhythm was comparable and unrelated to death. After era correction, the incidence of atrial flutter was similar and strongly associated with late death in both groups. Clinical systemic ventricular failure was uncommon, and at last follow-up, 92% of the Senning group and 89% of the Mustard group were in New York Heart Association class I. In a model exploring the implications of elective arterial switch conversion, this would only be beneficial if the hazard late after switch was markedly reduced and/or the hazard after the Senning procedure increased with time.

CONCLUSIONS

Late outcomes after the Senning procedure are superior to those after the Mustard procedure. Both groups had late sudden deaths that were not associated with clinical systemic ventricular failure. Good functional status after the Senning procedure suggests that a strategy of elective switch conversion cannot be justified for patients with isolated transposition.

Managing alcohol problems and risky drinking

While overall alcohol consumption and alcohol-related automobile deaths have declined, rates of alcohol dependence, liver cirrhosis, and alcohol-related problems remain high among adults, and binge drinking continues as a major health risk for high school and college students. Some individual-level downstream interventions have been evaluated with sufficient rigor to recommend widespread dissemination, and widened availability of new pharmacotherapies could further increase effectiveness. Midstream population-based programs, such as screening and brief interventions in hospitals and managed care organizations, may have greater public health impact than tertiary treatment because of early identification and low cost. Upstream programs and policies that place limits on alcohol availability (e.g., higher legal purchasing age) have the greatest potential to reduce morbidity and mortality at the least cost to society.

Treatment and prevention of use and abuse of illegal drugs: progress on interventions and future directions

State-of-the-art downstream interventions are generally successful for half of drug-abusing clients. But, only one in four abusers actually receives treatment. In the midstream, one setting (schools), one type of prevention ("one size fits all"), and a limited age-range focus (adolescence and preadolescence) have predominated. Accumulating evidence casts doubt on the effectiveness of widely disseminated school-based prevention approaches, although theory-based programs that emphasize skills training and adjunctive parent and neighborhood interventions fare better. Newer pursuits include intervening very early with higher risk children and expanding to primary health care settings and workplaces. Popular but unproven community approaches need more rigorous evaluation. Upstream national and state public policy and environmental interventions should be reexamined in light of their success for preventing tobacco and alcohol use.

Laparoscopic-assisted Doderlein hysterectomy: retrospective analysis of 300 consecutive cases

OBJECTIVE

To assess the clinical outcomes of the Doderlein laparoscopic-assisted hysterectomy.

DESIGN

A retrospective study.

SETTING

Women's Endoscopic Laser Foundation at South Cleveland Hospital, Middlesbrough and St James's University Hospital, Leeds.

POPULATION

Three hundred consecutive women who had a laparoscopic-assisted Doderlein hysterectomy.

METHODS

Patients were identified from the laparoscopic hysterectomy theatre log at both sites. Case notes were requested and examined.

MAIN OUTCOME MEASURES

Operative time, uterine weight, associated pelvic pathology, blood loss, hospital stay, intra-operative and post-operative complications.

RESULTS

The operations were performed by eight different surgeons, seven of whom were laparoscopic trainees. The mean operating time was 102 minutes (SD 30). Additional surgery including unilateral or bilateral salpingo-oophorectomy, was carried out in 247 patients (82%). The mean uterine weight was 140 g (SD 74). One hundred and thirty-two women (44%) had a normal pelvis at hysterectomy. The mean drop in haemoglobin and haematocrit was 1.46 g (SD 0.95) and 4.4% (SD 2.8), respectively. The overall complication rate was 18%, of which 6.2% were classed as major. The major complications included four cystotomies, five unscheduled laparotomies, seven post-operative blood transfusions, one pulmonary embolus and two re-operations (within six weeks). The mean hospital stay was three days.

CONCLUSIONS

Laparoscopic-assisted Doderlein hysterectomy is an alternative to standard laparoscopic hysterectomy techniques. It has the advantage of being easy to learn and is associated with low complication rates, compared with other laparoscopic and traditional techniques for hysterectomy.

Project DARE: no effects at 10-year follow-up

The present study examined the impact of Project DARE (Drug Abuse Resistance Education), a widespread drug-prevention program, 10 years after administration. A total of 1,002 individuals who in 6th grade had either received DARE or a standard drug-education curriculum, were reevaluated at age 20. Few differences were found between the 2 groups in terms of actual drug use, drug attitudes, or self-esteem, and in no case did the DARE group have a more successful outcome than the comparison group. Possible reasons why DARE remains so popular, despite the lack of documented efficacy, are offered.

Project DARE: no effects at 10-year follow-up

The present study examined the impact of Project DARE (Drug Abuse Resistance Education), a widespread drug-prevention program, 10 years after administration. A total of 1,002 individuals who in 6th grade had either received DARE or a standard drug-education curriculum, were reevaluated at age 20. Few differences were found between the 2 groups in terms of actual drug use, drug attitudes, or self-esteem, and in no case did the DARE group have a more successful outcome than the comparison group. Possible reasons why DARE remains so popular, despite the lack of documented efficacy, are offered.

Risky sex behavior and substance use among young adults

Many young adults, despite widespread prevention and education efforts that target this age group, engage in behaviors that place them at risk of HIV infection. These behaviors include frequent experimentation with alcohol and other drugs before sex, sexual activity with different partners, and inconsistent safe-sex practices. The combination of these risky behaviors causes increased concern about the spread of HIV among this age group. The study discussed in this article examined the relationship between substance use during adolescence and HIV risk behavior among young adults ages 19 to 21 with and without a college education. Results indicated that increased use of alcohol and marijuana at younger ages is related to riskier sexual activity and increased use of alcohol and marijuana as young adults. Recommendations for interventions are made.

Treating the drug-abusing offender

The association between drug abuse treatment and criminal justice control is examined in this article. A framework is presented for mental health administrators and policy-makers to examine and appreciate the use of authority derived from the criminal justice system for drug abusers involved in community treatment. In addition, an overview of relevant literature is provided to encapsulate the literature related to the drug-abusing criminal offender which is most useful for mental health administrators and policy-makers.

Identification of a vibrio cholerae RTX toxin gene cluster that is tightly linked to the cholera toxin prophage

We identify and characterize a gene cluster in El Tor Vibrio cholerae that encodes a cytotoxic activity for HEp-2 cells in vitro. This gene cluster contains four genes and is physically linked to the cholera toxin (CTX) element in the V. cholerae genome. We demonstrate by using insertional mutagenesis that this gene cluster is required for the cytotoxic activity. The toxin, RtxA, resembles members of the RTX (repeats in toxin) toxin family in that it contains a GD-rich repeated motif. Like other RTX toxins, its activity depends on an activator, RtxC, and an associated ABC transporter system, RtxB and RtxD. In V. cholerae strains of the classical biotype, a deletion within the gene cluster removes rtxC and eliminates cytotoxic activity. Other strains, including those of the current cholera pandemic, contain a functional gene cluster and display cytotoxic activity. Thus, the RTX gene cluster in El Tor O1 and O139 strains might have contributed significantly to their emergence. Furthermore, the RTX toxin of V. cholerae may be associated with residual adverse properties displayed by certain live, attenuated cholera vaccines.