Low-cost simulation training program for endoscopic sinus surgery: optimizing the basic skills level

Background: The purpose of this study is to develop and validate a low-cost simulation model and training program for the acquisition of basic skills in endoscopic sinus surgery. Methodology: Experimental study. An eight-task low-cost simulation model was developed based on feeding bottles. Junior residents, general otolaryngologists, and fellowship-trained rhinologists (experts) were recorded performing each task. Operative time and number of errors were measured. Videos were evaluated by two blinded experts using a validated global rating scale (GRS) and a specific rating scale (SRS). A group of residents completed a six-session training program and then were recorded and evaluated using the same methodology. Results: Twenty-five participants were recruited. Statistically significant higher scores in the GRS and SRS and lower operative time and errors at higher levels of expertise were found. A significant correlation between SRS and GRS was found. Seven residents completed the training program. A significant improvement of SRS and GRS scores and reduction of operative time and errors were observed after training. Moreover, compared to experts, statistically significant fewer errors were made by residents after training, and no significant differences were found in terms of performance quality and operative time among these groups. Conclusions: Our low-cost simulation model can be accurately used as a validated objective assessment and training tool for basic endoscopic skills necessary for FESS, and can be potentially used in any otolaryngology surgical training program for residents.

Glucocorticoid therapy rather than the inflammatory state is associated with pulmonary embolism and deep vein thrombosis in cardiac sarcoid

Background

Sarcoidosis is an infiltrative inflammatory condition affecting multiple organs, with cardiac involvement designated as cardiac sarcoidosis (CS). It has been proposed that inflammatory conditions like sarcoid increase the risk of venous thromboembolism (VTE), defined as pulmonary embolism (PE) and deep vein thrombosis (DVT) due to the hypercoagulable environment created by inflammation.

Purpose

Although previous studies have demonstrated an association with sarcoidosis and VTE, these studies failed to account for steroid use (crucial for sarcoid treatment) as an important confounder. Also, no major studies have been done previously assessing the risk of VTE in CS specifically. The objective of this investigation is to determine the association between CS, steroid treatment for CS, and VTE.

Methods

Patients referred to our institution with concern for sarcoid/CS were retrospectively assessed. Specific variables of interest including general baseline characteristics and those specific to CS were analyzed for their association with VTE development.

Results

Using Heart Rhythm Society guidelines, 649 patients were split into three categories: 235 with no sarcoid (NS), 91 with extra-cardiac sarcoid (ECS) only, and 323 with CS. In univariate analysis, 39 (12%) CS patients developed a PE vs 9 (4%) NS patients (OR 3.44, p=0.0003) and 44 (14%) CS patients developed DVT vs 18 (8%) NS patients (OR 1.90, p=0.02). In multivariate regression analysis however, neither CS nor ECS was an independent risk factor for VTE (p>0.05) but steroid use was a strong predictor of VTE (HR 3.12, p=0.007 for PE, HR 6.17, p<0.0001 for DVT). Also, steroid dose was found to be an independent predictor for both PE (p=0.001) and DVT (p=0.007) in a Cox proportionate hazards model (significance appeared at >17.5 mg daily on a receiver operating characteristic curve).

Conclusion

Contrary to previous studies, the current study found that neither sarcoidosis nor CS is an independent risk factor for VTE. Rather, steroid therapy for CS treatment leads to an increased prevalence of VTE, specifically at a dose above 17.5 mg daily. More research is required to clarify this relationship and assess the importance of steroid-sparing immunosuppressive therapy and potentially VTE prophylaxis in CS management.

Steroid use and time to PE/DVT

Funding Acknowledgement

Type of funding source: None

P1805Troponin-T, NT-proBNP and creatinine at presentation predict outcomes in patients with cardiac sarcoidosis

Background

Cardiac sarcoidosis (CS) is an infiltrative inflammatory condition defined by infiltration of noncaseating granulomas into the heart. Based on the location of sarcoid lesion involvement, patients can present with symptoms of congestive heart failure, arrhythmias, and even sudden cardiac death.

Purpose

Diagnosis of CS has been somewhat challenging, with the Heart Rhythm Society (HRS) and Japanese Ministry of Health and Welfare (JMHW) being the 2 widely accepted diagnostic guidelines. Endomyocardial biopsy is the gold standard to prove definite CS but has a low sensitivity. Imaging studies have been helpful as non-invasive methods to diagnose probable CS but these can be logistically difficult and expensive. Thus, investigating for laboratory biomarkers that can act as both diagnostic and prognostic can be crucial in how we diagnose and manage CS in the future.

Methods

Patients meeting HRS for CS were evaluated at a single institution (n=217). Biomarkers of interest included angiotensin-converting enzyme (ACE), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), N-terminal pro B-type natriuretic peptide (NT-proBNP), troponin-T, 1,25 dihydroxyvitamin D (1,25-OHVit-D), and creatinine. Biomarkers were stratified by clinical variables of interest and their association with prognosis was examined. The primary endpoint was LVAD implantation, transplantation, or death.

Results

Mean values on presentation were: ACE 32.9±28, ESR 12±13, CRP 7.4±19, NT-proBNP 1630±2923, Troponin-T 0.03±0.1, 1,25-OHVit-D 55.5±20, and creatinine 1.12±0.3. None of the biomarkers differed by sex, definite or probable CS, or a history of immunosuppression. ACE levels were associated with the presence of cardiac fibrosis on cardiac MRI (mean difference 14.7, p=0.032). Troponin-T (p=0.006; HR 1.06 per 0.01 ng/mL), NT-proBNP (p=0.0003; HR 1.31 per 1,000 pg/mL), and creatinine (p=0.01; HR 4.02 per mg/dL) were each associated with the primary endpoint (52/217 patients).

Biomarkers associated with long term outcomes in patients with cardiac sarcoidosis Biomarker Hazard ratio P value Troponin-T 1.06 (1.02–1.11)* 0.006 NT-pro BNP 1.31 (1.15–1.48)** 0.0003 Creatinine 4.02 (1.41–9.94)*** 0.01 *Per 0.01 ng/mL change; 99th percentile upper reference limit <0.01 ng/mL; **per 1,000 pg/mL change; ***per 1 mg/dL change.

Conclusion

Troponin-T, NT-proBNP, and creatinine at presentation predict outcomes in patients with CS. Further investigation on the utility of biomarkers for assessment of disease activity and treatment response is warranted.

[Percutaneous Endoscopic Gastrostomy (PEG)]

Percutaneous endoscopic gastrostomy represents a standard for long-term enteral nutrition. In our detailed instructions indications and contra-indications of the method are listed and the correct procedure is explained step-by-step.

Sedation with propofol for interventional endoscopy by trained nurses in high-risk octogenarians: a prospective, randomized, controlled study

BACKGROUND AND STUDY AIMS

Sedation with the short-acting anesthetic agent propofol has shown several advantages, particularly in interventional endoscopy. So far, however, there are no valid data on the safety of nurse-administered propofol sedation (NAPS) during interventional endoscopy in elderly high-risk patients.

PATIENTS AND METHODS

A total of 150 patients aged > 80 years with high comorbidity were randomized to receive midazolam plus meperidine (n = 75) or propofol alone (n = 76) for sedation during endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), or double-balloon endoscopy (DBE). Sedation was supervised by a trained nurse and a trained physician both of whom were not involved in the endoscopic procedure. Vital signs were continuously monitored as well as patient cooperation and tolerance. Mortality and morbidity at 30 days was analyzed.

RESULTS

The overall cardiopulmonary complication rate was 16 % in the midazolam group and 23.7 % in the propofol group ( P > 0.05). The mean decline in oxygen saturation (initial vs. lowest O (2) saturation) and the mean decline of blood pressure (initial vs. lowest blood pressure) were significantly greater with propofol (7 % +/- 3 % vs. 4 % +/- 2 % [ P < 0.05] and 10 % +/- 2 % vs. 8 % +/- 2 %, respectively [ P < 0.05]). No procedure had to be interrupted due to serious adverse events. Patient cooperation was statistically significantly better in the propofol group (7 +/- 2 vs. 5 +/- 2 points). Patients sedated with propofol showed a significantly lower oxygen saturation rate during recovery time (8 % vs. 28 %; P < or = 0.01).

CONCLUSION

NAPS during interventional endoscopy is as safe as midazolam/pethidine sedation even in high-risk patients aged > 80 years.

[Bowel imaging--capsule endoscopy]

The small bowel has ever since been the "black box" of endoscopy. The long distance from mouth to anus limits the use of conventional endoscopy for the multiple complex looped configurations. For some years now the new technology of wireless capsule endoscopy allows the endoscopic imaging of the complete small bowel. After ingestion of a small pill-size video capsule a continuous series of images is transmitted to an external recorder, whose data can be reviewed after completion of the examination. Compared to other diagnostic tools like push-enteroscopy, capsule endoscopy proves higher diagnostic yield for the detection of bleeding sources in obscure gastrointestinal bleeding. Its results for this task seem to be comparable to those of intraoperative endoscopy, so far considered as gold standard. Capsule endoscopy also opens up new horizons in diagnosing different small-bowel affections like Crohn's disease and polyposis syndromes. Complication rate is low, the main problem being the entrapment of the capsule in a previous unknown stricture which limits its use in Crohn's disease considerably. To date capsule endoscopy needs further evaluation in respect to outcome and cost-effectiveness in order to confirm its role as an important diagnostic tool for the small bowel.

Levels of analysis for the study of environmental health disparities

Reducing racial/ethnic and socioeconomic environmental health disparities requires a comprehensive multilevel conceptual and quantitative approach that recognizes the various levels through which environmental health disparities are produced and perpetuated. We propose a conceptual framework that incorporates the micro level, contained within the local level, which in turn is contained within the macro level. We discuss the utility of multilevel techniques to examine environmental level (both physical and social) and individual-level factors to appropriately quantify and improve our understanding of environmental health disparities. We discuss the reasoning and the methodological approach behind multilevel modeling, including differentiating between individual and contextual influences on individual outcomes. Next we address the questions and principles that guide the choice of levels or geographic units in multilevel studies. Finally, we address the ways in which different data sources can be combined to produce suitable data for multilevel analyses. We provide some examples of how such data sources can be linked to create multilevel data structures, and offer suggestions to facilitate the integration of multilevel techniques in environmental health disparities research and monitoring.

Slaughterhouse survey of pyelonephritis in dairy cows

Twenty-one rejected kidneys from 2426 slaughtered dairy cows (0.87 per cent) had gross signs of pyelonephritis that were confirmed by histopathology. In all the kidneys the findings were consistent with a chronic rather than an acute infection. One species of bacteria was cultured from 12 of the kidneys and two species of bacteria were cultured from six. The most commonly isolated bacteria were Escherichia coli, from eight kidneys, Arcanobacterium pyogenes, from seven kidneys and Corynebacterium renale, from five kidneys. The other bacteria cultured were Corynebacterium cystitidis, Corynebacterium species, Streptococcus species group G and Enterococcus faecalis. E. coli was cultured from all the kidneys from which two species were isolated; the accompanying bacteria were A. pyogenes in three kidneys, C. renale in two and C. cystitidis in one. No bacteria were cultured from two of the kidneys and no significant bacteria were cultured from another. The kidneys with pyelonephritis were slightly larger than a comparison group of 72 kidneys without nephritis.

Does Cytokeratin7/20 immunoreactivity help to distinguish Barrett's esophagus from gastric intestinal metaplasia? Results of a prospective study of 75 patients

Barrett's esophagus is a recognized risk factor for the development of esophageal dysplasia and carcinoma. Unfortunately, gastric incomplete intestinal metaplasia arising in Short Segment Barrett's esophagus can be indistinguishable histologically on hematoxylin/eosin stains. Distinct patterns of CK 7 and CK 20 immunohistochemical expression have been demonstrated to be both highly sensitive and specific for Barrett's esophagus, but have not been found in gastric metaplasia. The aim of our study was to test whether immunostaining with CK 7/20 helps to distinguish between Barrett's epithelium and gastric incomplete metaplasia. Cases of long segment Barrett's esophagus, short segment Barrett's esophagus, and cases with a normal gastroesophageal junction, as well as specimens with gastric antral intestninal metaplasia, were examined: three patterns were defined. Barrett's pattern (superficial CK 20 staining; superficial and crypt CK 7 staining); gastric pattern (superficial and crypt staining of both markers); other patterns (different from Barrett and gastric types). Seventy-five patients were enrolled in this study, 26 with long segment Barrett's esophagus, 21 with short segment esophagus, 13 with intestinal metaplasia of the cardia, and 18 with antral intestinal metaplasia. The Barrett pattern showed a high specificity of 97%, but a sensitivity of only 30% in patients with short segment Barrett esophagus. Our results do not confirm the hypothesis that CK 7/20 immunostaining can be used for a reliable differentiation between incomplete intestinal metaplasia and Barrett's epithelium.

Photodynamic therapy with 5-aminolevulinic acid is not effective in bile duct cancer

BACKGROUND

The results of preliminary studies of photodynamic therapy (PDT) for palliation of patients with bile duct cancer with hematoporphyrin derivative have been good. Rapid elimination of a photosensitizer could potentially shorten the time requirement for shielding from light. This would enhance the benefit of this form of palliative treatment. Therefore the feasibility of PDT was investigated for nonresectable bile duct cancer by using 5-aminolevulinic acid.

METHODS

Four patients with nonresectable bile duct cancer underwent cholangiography, cholangioscopy, and intraductal US before PDT. Light activation was performed 5 to 7 hours after oral administration of 5-aminolevulinic acid. All patients had an endoprosthesis placed in the bile duct after PDT.

RESULTS

Cholangioscopy 72 hours after PDT revealed superficial fibrinoid necrosis. However, 4 weeks after PDT there was no significant reduction in bile duct stenoses. Two patients had infectious complications develop, but phototoxicity was not observed.

CONCLUSIONS

Although superficial tumor necrosis was evident, PDT with 5-aminolevulinic acid failed to significantly reduce malignant bile duct obstruction. Therefore 5-aminolevulinic acid-PDT cannot be recommended for the palliative treatment of bile duct cancer.

Intravenous midazolam significantly enhances the lethal effect of thiopental but not that of ketamine in mice

Intravenous (i.v.) drug combinations are used in clinical anaesthesia in order to combine the desired effects and minimize toxicity from large doses of single agents. This fundamental assumption has not been systematically evaluated. We examined its validity by testing the influence of midazolam on the lethal effect of i.v. thiopental and ketamine in mice. Dose-response curves were constructed for the lethal effect of i.v. thiopental and ketamine, and for the loss of righting reflex effect by midazolam, in sexually mature male ICR mice weighing 20-40 g. For each curve, six or seven groups of eight to 10 mice each were used. A quarter of the median effective dose (ED50) for loss of righting reflex by midazolam was combined with the two other drugs to deduce dose-response curves for the lethal effect of the combinations. The ED50 for loss of righting reflex by i.v. midazolam was 43.5 mg x kg(-1) (95% confidence interval [CI], 40.4-46.5). The median lethal dose (LD 50) of i.v. thiopental was 50.6 mg x kg(-1) (95% CI, 50.0-54.9) and that of ketamine 42.9 mg x kg(-1) (95% CI, 32.3-52). In the presence of 10 mg x kg(-1) midazolam, the LD50 of thiopental was reduced to 20 mg x kg(-1) (17.7-22.2), but that of ketamine remained 44.4 mg x kg(-1) (37.7-54.9). Midazolam increased the lethal effect of thiopental 2.5-fold, but did not affect that of ketamine. Interactions at the toxic level between commonly used anaesthetic agents may differ from those at the hypnotic or analgesic levels, which should prompt evaluation of such combinations before their introduction to routine clinical use.

[Photodynamic therapy of dysplasias and early carcinomas in Barrett esophagus with a diode laser system--a pilot study]

BACKGROUND

Photodynamic therapy (PDT) of dysplasia and early cancer of the esophagus could show good results in the potential of ablation. Unfortunately, the existing expensive and temperamental dye laser systems foiled a broad clinical use. In this pilot study, we investigated the feasibility of an inexpensive and maintenance-free diode laser system for PDT of dysplasia and early cancer in Barrett's esophagus.

PATIENTS AND METHODS

Eight patients with Barrett's esophagus and/or early cancer were treated. As light source we used a diode laser system with a maximum power output of 2 W and a wavelength of 633 +/- 3 nm. One patient was treated initially with Photosan-3, seven patients received 5-aminolevulinic acid.

RESULTS

In all patients we could achieve reduction in length and/or histologically proven downgrading. In three quarters of the patients, complete eradication of adenocarcinoma could be attained. Columnar-lined metaplastic epithelium could also be completely eradicated.

CONCLUSION

PDT using a diode laser system is comparably effective in Barrett's esophagus/early cancer as PDT with dye laser systems. PDT is a gentle and effective technique with little side effects.

Photodynamic therapy for palliation of nonresectable bile duct cancer--preliminary results with a new diode laser system

OBJECTIVES

Preliminary results of photodynamic therapy (PDT) of bile duct cancer have shown astonishingly good results in the reduction of cholestasis, improvement of quality of life, and even prolongation of the survival time. Unfortunately, the existing dye laser systems are large and costly, and their maintenance is expensive. Therefore, we investigated the feasibility of a diode laser system for PDT of nonresectable bile duct cancer.

METHODS

Eight patients with nonresectable bile duct cancer were treated. Forty-eight hours after i. v. application of 2 mg/kg body weight of Photosan-3, light activation was performed by a transpapillary (four patients) or percutaneus (four patients) access. We used a cylindrical diffusor tip and illuminated using a wavelength of 633+/-3 nm and a total energy of 200 J/cm2. All patients were additionally provided with bile duct endoprostheses after PDT.

RESULTS

Four weeks after initial PDT all patients showed a marked reduction of bile duct stenosis. The median serum bilirubin value declined from 5.8 mg/dl (2.0-10.1) to 1.0 mg/dl (0.8-4.4). The median survival time at the time of writing is 119 days (52-443). Five patients are still alive. In four patients we could change from percutaneous to transpapillary drainage after PDT, two patients showed infectious complications.

CONCLUSION

PDT with the diode laser system seems to be effective in reducing malignant bile duct stenosis. This treatment is minimally invasive and has a low specific complication rate. Randomized, controlled studies comparing PDT with the insertion of endoprostheses and long term follow-up of results are needed to confirm the promising short term results.

[Prevention of colorectal carcinoma. Annual hemoccult test and sigmoidoscopy every 5 years]

The slow development of colorectal carcinoma from adenoma over dysplastic state to malignancy within 10-15 years results in a long preclinical phase during which the tumor is readily detectable and curable. Therefore and because of the lack of early alerting signs colorectal cancer is highly suited to screening. The faecal occult blood test has been added to the yearly program of cancer prevention for each individual age 45 and higher. This test has been evaluated in controlled prospective trials. For several reasons the combination of faecal occult blood test with flexible sigmoidoscopy at five year intervals is recommended. Concerning colonoscopy as a screening test to date no data from controlled trails are available. Virtual colonoscopy and gene-based screening which are currently being developed may be future options.

Pseudotumor of the sigmoid mimicking carcinoma

On colonoscopy, the macroscopic aspect of a lesion is an important criterion for the differential diagnosis. We present a case of an apparently malignant tumor in the sigmoid. Histological investigation failed to support the diagnosis made from the gross appearance seen on colonoscopy. After surgical resection, the lesion turned out to be a reactive pseudotumor caused by fibroepithelial hyperplasia related to a severe diverticulitis with perforation of the intestinal wall.

The role of Doppler ultrasound in gastrointestinal bleeding

The management of acute gastrointestinal bleeding is the domain of endoscopy. More than half of all episodes of upper gastrointestinal bleeding are attributed to bleeding peptic ulcers, and it is important to assess the risk of recurrent bleeding and to determine the appropriate treatment. However, the visual assessment of lesions (Forrest classification) is not always accurate and shows high interobserver variability (especially for visible vessels at the ulcer base, associated with a high rate of re-bleeding). Doppler ultrasound was thus introduced, and several studies have demonstrated that, with Doppler examination, these vessels can be identified. Doppler ultrasound is also used to monitor the effects of endoscopic therapy. In a prospective randomized trial, Doppler ultrasound proved superior to the Forrest classification. Treatment based on this technique resulted in significantly lower rates of re-bleeding and mortality. The Doppler classification may be able to contribute to a safer and more cost-effective management of patients with acute peptic ulcer bleeding.

The types and frequencies of improved nonmusculoskeletal symptoms reported after chiropractic spinal manipulative therapy

OBJECTIVE

To investigate the frequency and types of improved nonmusculoskeletal symptoms reported after chiropractic spinal manipulative therapy.

DESIGN

Retrospective information obtained by chiropractors through standardized interview of patients on return visit within 2 weeks of previous treatment.

SETTING

The private practice of 87 Swedish chiropractors (response rate 81%).

SUBJECTS

Twenty consecutive (presumably naive) patients per chiropractor (1504 valid questionnaires returned, 86% of optimal number of replies).

INTERVENTION

Spinal manipulation with or without additional therapy provided by chiropractors.

MAIN OUTCOME MEASURES

Self-reported improved nonmusculoskeletal symptoms (reactions).

RESULTS

At least I reaction was reported after the previous treatment in 21% to 25% of cases. Of these responses, 26% were related to the airway passages (usually reported as "easier to breathe"), 25% were related to the digestive system (mostly reported as "improved function"), 14% were classified under eyes/vision (usually reported as "improved vision"), and 14% under heart/ circulation (about half of these reported as "improved circulation"). The number of spinal areas treated was positively associated with the number of reactions.

CONCLUSION

A minority of chiropractic patients report having positive nonmusculoskeletal reactions after spinal manipulative therapy but such reports cluster predominantly around specific symptoms. It would be interesting to find out if these can be verified objectively and, if so, to investigate if they are caused by the treatment or if they are signs of natural variations in human physiology.

Image-injected frameless stereotactic approach to the anterior craniovertebral junction

Transoral odontoidectomy is often performed in the treatment of cervicomedullary junction disease. The operating microscope is frequently used to improve visualization in this narrow field of view. In the setting of complex anatomy or surgical revision the authors hypothesized that combining frameless stereotactic technique with intraoperative microscopy would improve the ability to visualize and identify intraoperative anatomy. In addition they believed that the ability to visualize the targeted region directly in the operating microscope "image injection" would be of particular interest in this setting, provided that sufficient accuracy for use could be obtained in the registration process. The authors assessed the efficacy of this approach in a cadaveric model and obtained sufficient accuracy to warrant use in the operating room. This technique was applied in the surgical management of a 56-year-old woman with rheumatoid arthritis who had undergone a previous decompressive transoral procedure. Subsequently she suffered progressive deterioration and was found to have residual bony compression of the anterior cervicomedullary junction. The authors performed decompressive surgery and obtained satisfactory results by using the image-injected technique, and the patient experienced subsequent clinical improvement. The authors conclude that the image-injected frameless stereotactic technique is of potential benefit, particularly in the narrow window of approach of the transoral odontoidectomy.

Neuropsychological correlates of domestic violence

Neuropsychological functioning was assessed in 39 males who had committed domestic violence (batterers) and compared to 63 nonviolent (both maritally discordant and satisfied) subjects recruited by advertisement. Subjects were subsequently divided into two groups (head injured, nonhead injured) and these groups were also contrasted as a function of batterer status. Tests were administered to assess for cognitive and behavioral functions, including executive dysfunction, hypothesized to be a factor contributing to propensity for violence. Questionnaires and structured clinical interviews were used to assess marital discord, emotional distress, and violent behaviors. Batterers differed from nonbatterers across several cognitive domains: executive, learning, memory, and verbal functioning. Batterers were reliably discriminated from nonbatterers based on three neuropsychological tasks: Digit Symbol, Recognition Memory Test-Words, Wisconsin Card Sorting Test. Neuropsychological performance was the strongest correlate of domestic violence of all clinical variables measured. However, the inclusion of two other variables, severity of emotional distress and history of head injury, together with the neuropsychological indices provided the strongest correlation with batterers status. Among batterers, neuropsychological performance did not vary as a function of head injury status, indicating that while prior head injury was correlated with batterer status, it was not the sole basis for their impairments. The findings suggest that current cognitive status, prior brain injury, childhood academic problems, as well as psychosocial influences, contribute along with coexisting emotional distress to a propensity for domestic violence.

Public health implications of 1990 air toxics concentrations across the United States

Occupational and toxicological studies have demonstrated adverse health effects from exposure to toxic air contaminants. Data on outdoor levels of toxic air contaminants have not been available for most communities in the United States, making it difficult to assess the potential for adverse human health effects from general population exposures. Emissions data from stationary and mobile sources are used in an atmospheric dispersion model to estimate outdoor concentrations of 148 toxic air contaminants for each of the 60,803 census tracts in the contiguous United States for 1990. Outdoor concentrations of air toxics were compared to previously defined benchmark concentrations for cancer and noncancer health effects. Benchmark concentrations are based on standard toxicological references and represent air toxic levels above which health risks may occur. The number of benchmark concentrations exceeded by modeled concentrations ranged from 8 to 32 per census tract, with a mean of 14. Estimated concentrations of benzene, formaldehyde, and 1,3-butadiene were greater than cancer benchmark concentrations in over 90% of the census tracts. Approximately 10% of all census tracts had estimated concentrations of one or more carcinogenic HAPs greater than a 1-in-10,000 risk level. Twenty-two pollutants with chronic toxicity benchmark concentrations had modeled concentrations in excess of these benchmarks, and approximately 200 census tracts had a modeled concentration 100 times the benchmark for at least one of these pollutants. This comprehensive assessment of air toxics concentrations across the United States indicates hazardous air pollutants may pose a potential public health problem.

Technetium-99m Q4: a prototype cationic perfusion radiotracer with myocardial washout

Technetium-99m Q4 is derived from an existing mixed ligand myocardial tracer (99mTc-Q3) by the addition of an ester group to promote myocardial washout. Six subjects with single-vessel coronary disease documented by angiography and/or Q wave myocardial infarction documented by electrocardiography were studied with 99mTc-Q4 injection during exercise and with comparative thallium-201 tomography. Six healthy volunteers were also studied with 99mTc-Q4 imaging following injection at peak exercise. Tomographic images with 99mTc-Q4 and 201Tl each provided correct assessment of the presence or absence of coronary disease in 22 of 30 myocardial segments (73.3%). Six myocardial segments showed defect reversibility with 99mTc-Q4, whereas 14 segments showed reversibility with 201Tl, but the latter included three segments with no angiographic or electrocardiographic evidence of disease. In both normals and subjects with coronary artery disease, significant global washout of 99mTc-Q4 was observed over 4 h. For five patients with angiographic evidence of unrevascularized coronary artery stenosis, the ischemic to normal zone count ratio increased from 0. 782+/-0.107 at 45 min postexercise to 0.891+/-0.115 at 4 h postexercise (P = 0.016), suggesting occurrence of differential washout. It is concluded that addition of an ester group functionality to a previously studied mixed ligand cardiac tracer promotes global and regional myocardial tracer washout. Nevertheless, demonstration of perfusion defect reversibility with comparable frequency to that observed with 201Tl stress and reinjection images, required separate injections of 99mTc-Q4 at peak stress and at rest.

[Effects of micronized natural progesterone on the liver during the third trimester of pregnancy]

In France, prescription of micronized progesterone at high doses of 900 to 1200 mg/day is common practice in the case of preterm delivery, even though this is neither an indication nor a posology given for marketing authorisation. A few cases of gestational pruritus have been reported during such use, associated with cholestasic and/or cytolytic hepatic disorders. We report here the results of a controlled, double-blind study versus a placebo, aimed at assessing the effects on the liver of micronized progesterone administered orally at high doses (900-1200 mg/day), conducted in a population of 201 women presenting moderate menace of preterm delivery during the third trimester of pregnancy. 85 patients received micronized progesterone and 116 the placebo. The increase above normal levels of total biliary acids (TBA) and aminotransferases (ASAT, ALAT), was significantly more frequent in the micronized progesterone than in the placebo group. Among the 26 patients (14%) with a level of TBA superior to 10 mumoles/l during treatment, 18 belonged to the progesterone and 8 to the placebo group (p = 0.004); the 6 patients (3.4%) with increased ASAT were all under micronized progesterone (p < 0.001), as were the 10 patients (5.6%) with increased ALAT (p < 0.001). However, there is no statistically significant difference between the two groups regarding the occurrence of clinical manifestations (icterus, pruritus) which could be attributed to gravid cholestasis. We may conclude from this prospective study that, during the third trimester of pregnancy, micronized progesterone is associated with a significant risk of biological cholestasis. This would suggest that in patients genetically predisposed towards gravid cholestasis, micronized progesterone could be a factor favoursing this disease.

Experiences of battered women in health care settings: a qualitative study

Interventions to help battered women seek and receive optimal health care must be informed by battered women's experiences in health care settings. In this study, we used a Systems Model to categorize the barriers battered women encounter in health care settings into patient, provider, and organizational levels. We conducted in-depth, face-to-face interviews with 31 battered women recruited by random digit dialing of households and by a publicity recruitment campaign. The data revealed that at the patient level, many women chose to conceal their abuse from their health care professionals, some fearing retaliation from their partners if they revealed the source of their injuries. At the provider level, the women perceived health care professionals to be disinterested or unsympathetic toward the needs of battered women, causing the women to feel ignored or trivialized. And at an organizational level, battered women believed that the structure of the health care system did not allow health care professionals enough time to deal with issues beyond treating their immediate presenting injuries. To ensure that battered women seek and receive optimal health care, multicomponent interventions should be designed to address the complex barriers at the three levels. We conclude by suggesting possible ways to help battered women get the tools they need to raise the issue of domestic violence with their health care professional. We also suggest ways to enable these professionals to identify battered women, validate their experiences, and provide appropriate referrals.

Enzyme-linked immunoassay for detection of PCR-amplified DNA of legionellae in bronchoalveolar fluid

A nonradioactive method is described that detects 10 to 100 legionellae in 1 ml of bronchoalveolar lavage fluid. DNA is purified by a proteinase K-phenol protocol or with a commercial DNA preparation kit and amplified by PCR with amplimers specific for the 16S rRNA gene of Legionella pneumophila. The upstream primer is 5' biotinylated. The amplification product is immobilized on streptavidin-coated microtiter plates. Because of the high binding capacity, no removal of nonincorporated biotin from the PCR product is required. After alkaline denaturation, the single-stranded PCR product is hybridized with a 5' digoxigenin-labeled probing oligomer. The amplification product is then detected by using peroxidase-labeled anti-digoxigenin antibodies in a luminescence or colorimetric reaction. The assay detects as few as 10 legionellae in 1-ml bronchoalveolar lavage fluid specimens. It is specific for medically relevant Legionella species, including Legionella pneumophila, L. bozemanii, and L. longbeachae. Of over 250 clinical specimens examined, 8 were positive for legionellae by both culture and the PCR assay. Six further specimens were culture negative but PCR positive for legionellae; of these, five specimens were from patients receiving high-dose erythromycin therapy for suspected or previously diagnosed legionella pneumonia. None of the remaining 240 specimens that were culture negative for legionellae yielded a positive PCR test, although a total of over 30 different bacterial species were cultured from these specimens. The PCR assay therefore appears to exhibit high sensitivity and specificity and thus could prove suitable for use in the routine microbiological diagnostic laboratory.

Head injury in partner-abusive men

Research into etiology of marital aggression has focused primarily on psychosocial, political, and cultural factors, to the exclusion of physiological influences. Fifty-three partner abusive men, 45 maritally satisfied, and 32 maritally discordant, nonviolent men were evaluated for past history of head injury, by a physician who was not informed of group membership and aggression history. Logistic regressions confirmed that head injury was a significant predictor of being a battered. The implications of these findings for both marital aggression and post-head injury rehabilitation are discussed.

Rearrangement of the bcl-6 gene as a prognostic marker in diffuse large-cell lymphoma

BACKGROUND

About 40 percent of non-Hodgkin's lymphomas are diffuse lymphomas with a large-cell component (DLLC). Current therapy can induce a long-term remission in half the patients with DLLC, but more intensive treatment has the potential to improve outcome, particularly in patients at high risk for treatment failure. Clinical and cytogenetic markers can identify subgroups at high or low risk. Rearrangement of a novel candidate proto-oncogene, bcl-6, is a possible prognostic indicator in DLLC.

METHODS

We performed Southern blot hybridization to detect bcl-6 and bcl-2 gene rearrangement in samples of lymphoma from 102 patients with B-cell DLLC. The results were correlated with the patients' histologic features, age, disease stage, tumor sites and bulk of disease, serum lactate dehydrogenase level, and treatment outcome.

RESULTS

Rearranged bcl-6 was found in 23 cases, and rearranged bcl-2 in 21 cases. Nineteen of the patients with rearranged bcl-6 had extranodal DLLC, two had primary splenic lymphomas, and only one had bone marrow involvement. Thirty-six months after diagnosis, the proportion with freedom from progression of disease was projected to be 82 percent (95 percent confidence interval, 66 to 98 percent) among the patients with rearranged bcl-6, as compared with 56 percent (95 percent confidence interval, 43 to 70 percent) for the patients with germ-line bcl-6 and bcl-2 and 31 percent (95 percent confidence interval, 8 to 53 percent) for the patients with rearranged bcl-2. The status of the bcl-6 gene was an independent prognostic marker of survival and freedom from disease progression in a multivariate model and added predictive value to established prognostic signs.

CONCLUSIONS

Rearrangement of the bcl-6 gene correlated with a favorable clinical outcome in DLLC and may thus serve as a prognostic marker in patients with this form of malignant lymphoma.