Top studies of 2023 relevant to primary care: From the PEER team

OBJECTIVE

To provide a summary of the noteworthy medical articles published in 2023 that are relevant to family physicians.

SELECTING THE EVIDENCE

Articles were chosen and ranked by the PEER (Patients, Experience, Evidence, Research) team, a group of primary care health professionals focused on evidence-based medicine. The selection process involved routine surveillance of tables of contents in high-impact medical journals and continuous monitoring of EvidenceAlerts. Articles were prioritized based on their direct applicability to and potential to influence primary care practice.

MAIN MESSAGE

Selected articles addressed various clinical areas of primary care. The topics included a comparison of a treat-to-target approach versus a high-intensity statins prescription for lipid management; semaglutide and its impact on cardiovascular outcomes; respiratory syncytial virus vaccine for older adults; chlorthalidone versus hydrochlorothiazide in preventing cardiovascular events; amitriptyline for irritable bowel syndrome; the role of opioids in acute back pain; safety of oral penicillin challenges in patients allergic to penicillin; spironolactone for facial acne; strategies to reverse frailty in older adults; and identifying the provider of chronic disease management. Two "up and coming" medications are also mentioned: retatrutide for weight loss and fezolinetant for vasomotor symptoms of menopause.

CONCLUSION

Research published in 2023 yielded several high-quality articles with topics relevant to primary care, including cardiovascular care, irritable bowel syndrome, care of the elderly, and acne management.

Iontophoresis and topical application of 8% arginine-calcium carbonate to treat dentinal hypersensitivity

Aim and objectives

The aim and the objectives were. (1) to assess the efficacy of a desensitizing toothpaste containing 8.0% arginine-calcium carbonate (Colgate® Sensitive Pro-Relief™), (2) to assess the efficacy of a desensitizing toothpaste containing 8.0% arginine-calcium carbonate (Colgate® Sensitive Pro-Relief™) used in combination with iontophoresis, and (3) to compare the effectiveness of the above methods.

Subjects and Methods

Two groups of 40 patients each having dentinal hypersensitivity were treated using 8% proarginine and iontophoresis. The patients were recalled after 1, 2, and 4 weeks. The scores were tabulated and the results were analyzed using SPSS statistical software.

Results

Visual analog scale between the two groups showed a significant difference from the 1^st week till the 4^th week. ANOVA values showed the reduction in the dentinal hypersensitivity in Group 2 using the iontophoresis along with the 8.0% arginine-calcium carbonate toothpaste. The Cochran-Mantel-Haenszel correlation test of the Schiff's dentinal hypersensitivity cross-tabulation showed P < 0.001 which was statistically significant reduction after the 4^th week following the application of 8.0% arginine-calcium carbonate along with iontophoresis.

Conclusion

Iontophoresis, when used along with Colgate® Sensitive Pro-Relief™ toothpaste, can provide additional benefit as this provides a better sealing effect.

IL-6 promotes CD4+ T-cell and B-cell activation during Plasmodium infection

Humoral immunity develops in the spleen during blood-stage Plasmodium infection. This elicits parasite-specific IgM and IgG, which control parasites and protect against malaria. Studies in mice have elucidated cells and molecules driving humoral immunity to Plasmodium, including CD4⁺ T cells, B cells, interleukin (IL)-21 and ICOS. IL-6, a cytokine readily detected in Plasmodium-infected mice and humans, is recognized in other systems as a driver of humoral immunity. Here, we examined the effect of infection-induced IL-6 on humoral immunity to Plasmodium. Using P. chabaudi chabaudi AS (PcAS) infection of wild-type and IL-6^-/- mice, we found that IL-6 helped to control parasites during primary infection. IL-6 promoted early production of parasite-specific IgM but not IgG. Notably, splenic CD138⁺ plasmablast development was more dependent on IL-6 than germinal centre (GC) B-cell differentiation. IL-6 also promoted ICOS expression by CD4⁺ T cells, as well as their localization close to splenic B cells, but was not required for early Tfh-cell development. Finally, IL-6 promoted parasite control, IgM and IgG production, GC B-cell development and ICOS expression by Tfh cells in a second model, Py17XNL infection. IL-6 promotes CD4⁺ T-cell activation and B-cell responses during blood-stage Plasmodium infection, which encourages parasite-specific antibody production.

Auditory and Nonauditory Effects of Ultrasonic Scaler Use and Its Role in the Development of Permanent Hearing Loss

PURPOSE

To evaluate the negative auditory and non-auditory effects developed immediately after using ultrasonic scalers and their potential role in the development of permanent hearing loss.

MATERIALS AND METHODS

The auditory functions of 60 dental clinicians were evaluated with the pure tone audiometry test (PTA), tympanogram and the otoacoustic emission test (OAE) before and immediately after using ultrasonic scalers. The paired t-test was used to evaluate the difference in the pre- and post-exposure recordings for all three tests.

RESULTS

There was a significant increase in the PTA and tympanogram test results, along with reduced OAE values immediately after using ultrasonic scalers. Hearing ability dropped by 63% to 66% immediately after using ultrasonic scalers. The maximum hearing disability was noted for low-frequency thresholds. The reduction was greater in the left than in the right ear.

CONCLUSIONS

Noise-emitting devices such as ultrasonic scalers produce significant immediate auditory and non-auditory changes. It is important that dentists recognise the initial signs of hearing damage and adopt appropriate measures while working to prevent the development of permanent hearing impairment in future.

Green Tea Intake as an Adjunct to Mechanical Periodontal Therapy for the Management of Mild to Moderate Chronic Periodontitis: A Randomized Controlled Clinical Trial

PURPOSE

To evaluate and compare the beneficial effects of green tea intake on the total antioxidant capacity of gingival crevicular fluid (GCF) and plasma, and to examine its role as an adjunct to nonsurgical periodontal therapy for the management of chronic periodontitis.

MATERIALS AND METHODS

120 subjects with mild to moderate chronic periodontitis were divided equally into two groups. After scaling and root planing in all subjects, green tea supplements were given to the case group and a placebo to the control group. The clinical parameters gingival index, plaque index, clinical probing depth, clinical attachment loss, percentage of sites with bleeding on probing, along with total antioxidant capacity of GCF and plasma were recorded at baseline, one and three months.

RESULTS

There was a significant improvement in all clinical parameters along with an 8-fold greater antioxidant capacity in GCF in the case group than in the control group.

CONCLUSION

Green tea intake as a component of nonsurgical periodontal therapy is promising for superior and rapid resolution of the disease process. Green tea increases the total antioxidant capacity of GCF and plasma along with potent anti-inflammatory, astringent and anti-plaque effects.

Herpes zoster of gingiva in an older woman: a rare case report

OBJECTIVE

The aim of the article is to highlight the distinguishing features of secondary varicella gingival infection in an older women.

BACKGROUND

Herpes zoster is an acute sporadic, painful viral infection in older people caused by the reactivation of the latent varicella zoster virus. Herpes zoster affecting the gingiva without any dermal lesions is a rare pathological condition that mimics many intraoral vesiculobullous lesions. The ambiguous nature of this condition creates a diagnostic dilemma.

MATERIALS AND METHODS

A 58-year-old woman presented with an acute, unilateral and persistent burning sensation and pain in the gingiva with desqaumating vesicullobulous lesion.

RESULTS

The women was diagnosed with secondary varicella zoster infection.

CONCLUSION

Herpes zoster of the gingiva could manifest as painful desquamative vesicular lesions, pulpal or other painful neuralgic condition in older individuals which need careful diagnosis before formulating appropiate treatment plan.

Rapid emergence of daptomycin resistance in clinical isolates of Corynebacterium striatum… a cautionary tale

The objective of this study was to investigate the observation of daptomycin resistance in Corynebacterium striatum, both in vivo and in vitro. We describe a case of C. striatum bacteremia in a patient with a left ventricular assist device (LVAD); the initial isolate recovered was daptomycin susceptible with a minimum inhibitory concentration (MIC) of 0.125 μg/ml. Two months later, and after daptomycin therapy, the individual became bacteremic with an isolate of C. striatum with a daptomycin MIC of >256 μg/ml. To study the prevalence of daptomycin resistance in C. striatum, clinical isolates of C. striatum were grown in broth culture containing daptomycin to investigate the emergence of resistance to this antimicrobial. Molecular typing was used to evaluate serial isolates from the index patient and the clinical isolates of C. striatum we assayed. In vitro analysis of isolates from the index patient and 7 of 11 additional C. striatum isolates exhibited the emergence of high-level daptomycin resistance, despite initially demonstrating low MICs to this antimicrobial agent. This phenotype was persistent even after serial subculture in the absence of daptomycin. Together, these data demonstrate that caution should be taken when using daptomycin to treat high-inoculum infections and/or infections of indwelling medical devices with C. striatum. To our knowledge, this is the first report characterizing the emergence of daptomycin resistance in C. striatum.

Inter- relationship between rheumatoid arthritis and periodontitis

BACKGROUND

Periodontal medicine defines a rapidly emerging branch of Periodontology focusing on establishing a strong relationship between periodontal health and systemic health. It is speculated that the major common dysregulation which links Periodontitis with Rheumatoid arthritis (RA) is being played by the mediators of immune inflammatory response.

OBJECTIVES

To determine whether there is any relationship between periodontal disease and Rheumatoid arthritis.

METHODS

A total of 100 patients were included for the present study which was divided into two groups: one group (cases) included 50 patients attending the Department of Orthopedics, Kasturba Medical College, Manipal who were diagnosed of Rheumatoid arthritis. Another subject population included 50 patients as controls attending the Department of Oral Medicine, Manipal College of Dental Sciences, Manipal with age and gender matched with those of rheumatoid arthritis group. Specific measures for periodontitis included plaque index, gingival index, number of missing teeth, and radiographic alveolar bone loss scores. Measures of rheumatoid arthritis included health assessment questionaires, levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Various periodontal parameters were compared between the cases and controls.

RESULTS

The average alveolar bone loss was statistically more severe in Rheumatoid arthritis (RA) group than in the controls although there were similar plaque index in both the groups. The gingival index was statistically higher in the RA group. The Erythrocyte Sedimentation Rate (ESR) and C- Reactive Protein (CRP) levels of RA patients were also significantly associated with the severity of periodontal disease.

CONCLUSION

There was a significant association between Rheumatoid arthritis and Periodontitis which may be due to a common underlying deregulation of the inflammatory response in these individuals.

Garlic burn as self-inflicted mucosal injury--a case report and review of the literature

Garlic is considered a valuable herbal medicine and has been used for centuries for treatment of various ailments. Along with its benefits comes some adverse effects. The present case describes chemical burn of oral mucosa caused by crushed garlic. To relieve toothache, the patient placed crushed garlic cloves in the buccal vestibule overnight and developed garlic burn injury manifesting as slough and ulceration in that region. Diagnosis was made on the basis of definitive history elicited from the patient. Topical anesthetic and antibacterial agents were advised for local application, and systemic analgesic was prescribed. The patient was referred to the Department of Endodontics for further treatment of the toothache. Garlic burn should be considered in the differential diagnosis for chemical burn if the burn is not found to be associated with other common factors, and history taking should include questions regarding use of herbal products, home remedies, and alternative medicine. Possible adverse effects of these methods should be considered.

Esthetic management of the upper labial frenum: a novel frenectomy technique

An abnormal upper labial frenum is capable of retracting the gingival margin, creating a diastema, limiting lip movement, and in cases of a high smile line, affecting esthetics also. When an abnormal frenum is present, frenectomy is advised. This technique has been modified in many ways. But in most of the techniques the zone of attached gingiva and esthetics are not considered. This case report highlights a new technique of frenectomy that results in good esthetics, excellent color match, gain in attached gingiva, and healing by primary intention at the site of the thick, extensive abnormal frenum.

Periodontal diseases and awareness among patients

Awareness of periodontal problems and how they interpret this and their timely intervention affects periodontal health. Many people neither recognize the symptoms of periodontal disease nor do they associate existing symptoms with the disease. Hence one should ensure that the routes of science transfer are open so that the appropriate knowledge regarding the prevention and control of periodontal diseases are available to the public.

Nodulisporic acid opens insect glutamate-gated chloride channels: identification of a new high affinity modulator

Nodulisporic acid (NA) is an indole diterpene fungal product with insecticidal activity. NA activates a glutamate-gated chloride channel (GluCl) in grasshopper neurons and potentiates channel opening by glutamate. The endectocide ivermectin (IVM) induces a similar, but larger current than NA. Using Drosophila melanogaster head membranes, a high affinity binding site for NA was identified. Equilibrium binding studies show that an amide analogue, N-(2-hydroxyethyl-2,2-(3)H)nodulisporamide ([(3)H]NAmide), binds to a single population of sites in head membranes with a K(D) of 12 pM and a B(max) of 1.4 pmol/mg of protein. A similar K(D) is determined from the kinetics of ligand binding and dissociation. Four lines of evidence indicate that the binding site is a GluCl. First, NA potentiates opening of a glutamate-gated chloride current in grasshopper neurons. Second, glutamate inhibits the binding of [(3)H]NAmide by increasing the rate of dissociation 3-fold. Third, IVM potently inhibits the binding of [(3)H]NAmide and IVM binds to GluCls. Finally, the binding of [(3)H]IVM is inhibited by NA. The B(max) of [(3)H]IVM is twice that of [(3)H]NAmide, and about half of the [(3)H]IVM binding sites are inhibited by NA with high affinity (K(I) = 25 pM). In contrast, [(3)H]IVM binding to Caenorhabditis elegans membranes is not inhibited by NA at 100 nM, and there are no high affinity binding sites for NA on these membranes. Thus, half of the Drosophila IVM receptors and all of the NA receptors are associated with GluCl. NA distinguishes between nematode and insect GluCls and identifies subpopulations of IVM binding sites.

Urinary androgens and breast cancer risk: results from a long-term prospective study based in Guernsey

Between 1961 and 1967 a cohort of over 5000 women volunteered for a prospective study to determine the relationship between the urinary androgen metabolites, androsterone (A) and aetiocholanolone (E), and risk of breast cancer. During the first 10 years of the study the concentration of urinary A and E was determined in 1887 of the urine specimens. In 1971 we reported that subnormal amounts of urinary A and E were associated with a significantly increased risk of breast cancer. The cohort has been followed regularly during the 37 years since inception of the study and, by May 1998, 248 women had been diagnosed with breast cancer. Urinary androgen metabolites had been measured in 116 of these cases. Analysis of these data confirmed that women diagnosed in the first decade of the study were more likely to have low levels of urinary androgen metabolites. In the following decades, however, those who developed breast cancer were more likely to have manifested an increased A and E excretion. The reversal in the relationship between androgen metabolite excretion and risk suggests that age, or probably more importantly, menopausal status at diagnosis is an important modifying factor. Dichotomizing at age 50 it was found that in the younger age group (predominantly premenopausal) the rate ratios in the lowest tertile of A or E excretion were two- to threefold greater than for those in the highest tertile (chi2(1) = 3.57; P = 0.06: chi2(1) = 4.70; P = 0.03 for A and E respectively). In contrast, in the older age group comprising predominantly post-menopausal women, the rate ratios associated with the lowest tertile of A or E were half that of those in the highest tertile (chi2(1) = 4.10; P = 0.04; chi2(1) = 8.72; P = 0.003 for A and E respectively). This suggests that there may be different endocrine promotional factors for pre-and post-menopausal breast cancer. Hormonal risk factors may vary during the lifetime of an individual woman and this may have profound consequences for prevention strategies.

Efficacy of minocycline as a root conditioner in comparison to citric acid and tetracycline. An in vitro evaluation

This study compared the root surface characteristics produced by Minocycline HCl, Citric acid and Tetracycline HCl. when used as a root conditioner. This study included 5 groups of 10 extracted teeth each with advanced periodontal disease. Diseased root surfaces of group B,C,D and E were planed with Gracy curets and solutions of Citric acid, Tetracycline HCl, Monocycline Hcl and Tween 80 of PH 2.5, were applied to the surface in respective groups with cotton pellets for 5 mts. Group A was not subjected to root planning or application of any root conditioner and was used as a control. The teeth in all five groups were then washed, sectioned processed and examined under scanning electron microscope. These results revealed that the surfaces of acid treated sites differed from each other and with specimens treated sites differed from each other and with specimens treated with root panning alone. The efficacy of Minocycline and tetracycline in the removal of smear layer and exposure of dentinal tubules were comparable and Minocycline HCl though not as effective as Citric acid can probably be recommended in view of its antibactrial activity, anti collagense and substantivity properties.

Direct and indirect effects of selected risk factors in producing adverse consequences of drug use

A path analysis was performed to examine the usefulness of multiple pathway risk factors in explaining and predicting youthful alcohol, tobacco, and other drug (ATOD) misuse and its adverse consequences. The risk factors alienation, trait anger, interaction anxiety, and cognitive motivation for drinking were used as exogenous variables with earliness of onset, ATOD use, and adverse consequences of ATOD use serving as endogenous variables. Firm support emerged for both direct and indirect effects of the risk factors on both use and adverse consequences of use.

A path analysis of gender differences in adolescent onset of alcohol, tobacco and other drug use (ATOD), reported ATOD use and adverse consequences of ATOD use

Gender differences in the ways a risk factor approach explains onset of using alcohol, tobacco and other drugs (ATOD), reported use of ATOD and adverse consequences from ATOD use were investigated by means of separate path analyses for male and female adolescents. A fully recursive model was specified in which alienation, trait anger, interaction anxiety and cognitive motivation for ATOD use comprised the first column variables which were used to predict earliness of onset. For the second step, column one variables plus onset were used to predict ATOD use. In the final step, column one variables plus onset and ATOD use were used to predict adverse consequences of ATOD use. An ex post facto design was used in surveying 796 high school students in a single Midwestern community. The data from this sample supported the predictive validity of the theoretical model. In addition to the expected indirect or mediated effects of the risk factors via onset of ATOD use on ATOD use and via onset and ATOD use on adverse consequences of ATOD use, there were direct effects of column on risk factors on both ATOD use and on adverse consequences of ATOD use for both males and females, lending support to the concept of multiple pathway risk factors. The three gender differences that emerged in the separate path analyses were entirely consistent with the gendered deviance model.

The effectiveness of selected risk factors in mediating gender differences in drinking and it problems

PURPOSE

The purpose of this study was to investigate gender differences in adolescents' alcohol use, adverse consequences of alcohol and other drug (AOD) use and the effectiveness of selected risk factors in mediating gender differences.

METHODS

A cross-sectional survey design was adopted. Data were collected from a sample of high school students (n=919) in one midwestern community. Four criteria for examining potential mediated relationships were addressed.

RESULTS

Expected differences in relation to males' higher levels of frequent and heavy drinking, adverse consequences of AOD use and risk factors were found. All risk factors were significantly related to adverse consequences, but alienation was not related to drinking behavior. In a one-way ANOVA, the main effects of gender were significant for both drinking behavior and adverse consequences of AOD use. In a two-way ANOVA, the main effects of a risk factor index reduced the main effects of gender substantially.

CONCLUSIONS

Controlling risk factor levels mediates gender differences in the outcomes, drinking behavior and adverse consequences of AOD use.

The role of selected risk factors in predicting adolescent drug use and its adverse consequences

The purpose of this study was to examine the effectiveness of selected risk factors in predicting alcohol and other drug (AOD) use and adverse consequences of use. Three regression analyses were performed on four categories of risk factors: individual, family related, school related, and social related. The sample size was 887 (99%). Significant predictors for AOD use were grade level, participation in religious services, GPA, frequency of dating and driving, trouble at school, mastery, and family management index. Predictors for adverse consequences were GPA, frequency of dating, trouble at school, family management index, risk taking, alienation, susceptibility to peer pressure, and living arrangements.

The role of free fatty acids in regulating the tissue availability and synthesis of sex steroids

Sex steroids and dietary fat intake have been implicated in the growth of breast tumours. We have previously shown that the plasma free oestradiol fraction is increased in women with breast cancer and that the addition of free fatty acids (FFA) to plasma can increase the free oestradiol fraction in vitro. In the present study we have examined the distribution of oestradiol and testosterone in serum obtained from European women (EW) and Asian (Gujarati) women (GW) living in north-west London. Fat intake by these women is similar but GW, who are vegetarians, consume a greater proportion of unsaturated fats. In serum from perimenopausal GW, the free testosterone concentration was significantly higher than for EW (11.1 +/- 3.6 pmol/l vs 8.7 +/- 3.4 pmol/l, p < 0.05). Although a significant correlation was found between the free testosterone and FFA concentrations for GW (r = 0.49, p < 0.05), concentrations of sex-hormone binding globulin (SHBG) were significantly lower in GW than EW. The finding of lower SHBG concentration in GW was confirmed in a second study in postmenopausal women (EW, 60.1 +/- 34.1 nmol/l; GW, 37.8 +/- 20.5 nmol/l, p < 0.05). However, no difference in the free oestradiol fraction or concentration was detected for EW and GW and no correlations with total or individual FFA were found. It is concluded from this study that while dietary fats may have an important role in the development of breast tumours, it is unlikely to be mediated by FFA inhibiting the binding of sex steroids to plasma proteins.

Drug use in a small midwestern community and relationships to selected characteristics

A description of 1074 high school students' alcohol and other drug (AOD) use along with the consequences of such use was supplemented with comparisons of grade level and gender differences and analyses of the relationships between AOD use and incidence of adverse consequences with grade point average, attendance at religious services, frequency of dating, frequency of driving a car and frequency of having trouble at school. Alcohol was clearly the drug of choice and produced a variety of adverse consequences. Most frequently reported were arguments, trouble with parents and at school and nausea or vomiting. Grade level differences were found, but few significant gender differences emerged. Significant relationships between AOD use and consequences with all other independent variables were found.

The Affective Outcomes of Course Work on Computer Technology in Nursing

At the University of Iowa, nursing students are introduced to computer technology as one unit in a course designed to explore nursing as a profession. A single group, pretest/posttest design was used to evaluate changes in attitudes associated with the course work. Relationships of attitudes scores and eight background variables were studied. Posttest attitudes scores were significantly higher than pretest scores. The attitudes scores were positively related to skills scores at a statistically significant level of .05, with no significant relationship between attitudes scores and knowledge base scores. Four of the eight background factors were related to the attitudes scores at a statistically significant level of .05.

Cigarette smoking and steroid hormones in women

Epidemiological evidence has suggested that cigarette smoking has an anti-oestrogenic effect in women, but the effects of smoking on steroid hormone metabolism are not fully understood. We compared serum concentrations of oestradiol, progesterone (luteal phase) and dehydroepiandrosterone sulphate (DHEA-S), and urinary excretion rates of six steroids of predominantly adrenal origin, in healthy premenopausal and postmenopausal female smokers and non-smokers. Serum concentrations of oestradiol, progesterone and DHEA-S did not differ between smokers and non-smokers by greater than 5%, and none of these differences was statistically significant. Mean urinary excretion rates of androsterone, aetiocholanolone, DHEA, 11-keto-aetiocholanolone, 11-hydroxyandrosterone and 11-hydroxyaetiocholanolone were very similar in smokers and non-smokers in premenopausal women, but were from 2-44% higher in smokers than non-smokers in postmenopausal women. The difference was statistically significant only for 11-hydroxyandrosterone. These results confirm previous reports that cigarette smoking does not affect serum oestradiol in premenopausal or postmenopausal women, but provide only weak evidence to support previous findings of increased levels of some adrenal steroids in postmenopausal women smokers. The mechanism for the apparent anti-oestrogenic effect of cigarette smoking remains unclear.

Computer-assisted decision making: a strategy for primary prevention of substance abuse

A series of six computer-assisted instruction (CAI) programs were developed for primary prevention of substance abuse. The target population, objectives, content, and strategies for the programs were determined from three sources: a literature review of prevention research, theories of learning, and principles of instructional design regarding use of computer technology. Because the focus of the programs is on helping children make responsible choices, the central theme of the programs is on improving decision making.

Erythrocyte membrane stearic acid: oleic acid ratios in colorectal cancer using tube capillary column gas liquid chromatography

Erythrocyte fatty acids were measured in 32 patients with colorectal cancer (four with recurrent disease), four patients with large colorectal adenomas, and 42 hospitalised patients without cancer. No significant differences were found with respect to any of the fatty acids between these groups. In particular there was no difference between the erythrocyte stearic acid: oleic acid ratios (mean +/- SD) between the cancer cases (1.07 +/- 0.31) and the control cases (1.09 +/- 0.31, 2-tailed Mann-Whitney U test). No difference in this ratio was observed with respect to age or sex and in the case of colorectal cancer, to the Dukes' stage, degree of tumour differentiation, or recurrence. A significant correlation was found between stearic acid concentrations in plasma and erythrocytes from fasting individuals (r = 0.477, n = 24, P less than 0.05). This study provides further evidence that the erythrocyte stearic acid: oleic acid ratio is of no value for diagnosing primary or recurrent colorectal cancer.

Hormones are ambiguous risk factors for breast cancer

Women with breast cancer whose blood and urinary androgens are at the lower end of the normal range have an early age at diagnosis, a rapid recurrence rate after mastectomy and tumours that are unresponsive to endocrine therapy. The most plausible explanation for these results is that the androgens are not involved in tumour initiation but control tumour growth rates after the malignant transformation has occurred. If this is so, endocrine case/control studies in which growth rates are not measured are an inefficient way of studying the endocrinology of breast cancer. It is suggested that the oestrogens and androgens should be considered as a single functional unit in future research.

Erythrocyte membrane stearic and oleic acid ratios in breast cancer

A case control study has been conducted to determine the value of stearic/oleic acid ratios in the erythrocyte membranes of women at the time of presentation with breast cancer. No difference was found between the stearic/oleic acid ratio of cases and that of controls with benign breast condition or normal volunteers. Furthermore, within clinical stages of breast cancer, no differences were detected. This ratio does not appear to be of value as a marker of malignancy, or of tumour burden.

Sex hormone-binding globulin and the natural history of breast cancer

Low concentrations of SHBG in the blood appear to be related to rapid tumour growth rates whereas normal values are associated with slower rates. The inferences drawn from these and other experimental results are as follows: 1. It is no longer necessary to postulate that an abnormal endocrine environment is related to the risk of breast cancer. 2. Variation within the normal range of endocrine function may be sufficient to account for marked differences in the growth rates of transformed cells. 3. It is suggested that women whose tumours arise in an environment characterised by SHBG concentrations at the lower end of the normal range (and, hence, non-SHBG-bound oestradiol levels at the top end of the range) will tend to have an earlier age at diagnosis, a lower frequency of oestrogen-receptor positive tumours and a lower proportion of hormone responsive tumours than women with SHBG levels at the top of the range. 4. Case/control studies in which growth rates are not taken into account may be difficult to interpret.

An autoimmune aetiology for hypothyroidism following interferon therapy for breast cancer

Alpha-interferon has been administered as an adjuvant treatment for women with loco-regional relapse of breast cancer. During the course of treatment 5/10 (50%) of women receiving interferon developed de novo thyroid autoantibodies. Three patients became clinically myxoedematous, with biochemical evidence of hypothyroidism which responded to thyroxine replacement therapy. The leucocyte alpha-interferon preparations used in the trial enhanced Class I but not Class II MHC antigens on thyrocytes in vitro. These data strongly suggest that patients receiving alpha-interferon therapy should be closely monitored for the possible development of thyroid dysfunction and that thyroid antibody determination can greatly help to predict overt thyroid clinical abnormalities.

Urinary epidermal growth factor excretion and breast cancer risk

The amount of urinary epidermal growth factor (EGF) excreted was determined in 350 normal women of whom 37 subsequently developed breast cancer. These were a group of women selected on a case-control basis from 5000 volunteers who had participated in a prospective epidemiological study. Urinary EGF excretion was not correlated with known risk factors such as age at menarche or menopause, age at first or last full-term child or parity. Neither was it associated with day or length of menstrual cycle, breast mammographic parenchymal pattern or the blood concentration of prolactin, dehydroepiandrosterone or its sulphate ester. Univariate analysis indicated that the amount of urinary EGF was significantly correlated with urinary creatinine (P less than 0.001), age (P less than 0.001), urinary androsterone (P less than 0.02) or aetiocholanolone (P less than 0.02), height (P less than 0.05) and weight (P less than 0.05). However, multivariate analysis showed that the amount of urinary EGF was correlated only with creatinine excretion (P less than 0.001) and age (P less than 0.001) and that the significance of the other correlations were probably due to the confounding influence of creatinine.

A prospective study of the relationship between serum vitamins A and E and risk of breast cancer

In an 8 year prospective study (1977-1985) on breast cancer, blood was taken from 5,086 women resident in Guernsey, and the serum stored at -20 degrees C. During this period 30 women developed the disease and their serum samples were analysed for vitamins A and E, and for retinol-binding protein (RBP). A further 288 age-matched control sera (up to 10 per pre-cancer case) were similarly analysed. No relationship was found between any of these substances and subsequent development of breast cancer. A significant correlation between increasing age and vitamin A (r = 0.46, P less than 0.001) and RBP (r = 0.36, P less than 0.001) concentrations was observed. There was also a trend for increased blood concentrations of vitamin E with age, but this was not significant. Serum RBP and vitamin A concentrations were highly correlated (r = 0.91, P less than 0.0001).

A comparison of the fatty acid profiles of subcutaneous fat from women with breast cancer, benign breast disease and normal controls

Using gas chromatography, the fatty acid profile has been measured in subcutaneous fat obtained from women undergoing biopsy for benign and malignant breast conditions. There was a similar proportion of saturated and unsaturated fatty acids in both types or fat, suggesting that long-term differences in fatty acid constituents of diet are unrelated to risk of breast cancer.

Thyroid function and the incidence of breast cancer in Hawaiian, British and Japanese women

Serum-free thyroxine (FT4) concentrations are lower in Hawaiian and Hawaiian Caucasian women than in Hawaiian Japanese, Hawaiian Filipino, Hawaiian Chinese, and English and Japanese mainland women. There is a high inverse correlation between FT4 and risk of breast cancer in these ethnic groups. Thyroid-stimulating hormone (TSH) concentrations, which are inversely correlated with FT4, generally show the same relationship.

Instructional computing in American nursing programs

This paper summarizes more than a decade of progress on computing in nursing education and reports the results of a two-phase study of instructional computing in American nursing programs. The study reveals an enormous range of activity in nursing education, the importance of various barriers to growth and use of computers and the perceptions of deans and directors of potential remedies and the feasibility of each.

Effect of prednisolone on hormone profiles during primary endocrine treatment of advanced breast cancer

Various plasma hormones were measured in 13 pre- and 20 post-menopausal women with advanced breast cancer before and for 12 months after ovarian irradiation or during continuous administration of tamoxifen at a dose of 10 mg twice a day, respectively; some patients received additional prednisolone at a dose of 5 mg twice a day. These patients were taken from a larger clinical trial which demonstrated a higher response to primary endocrine therapy when prednisolone was added. Levels of dehydropiandrosterone sulfate were depressed in patients receiving prednisolone, confirming adrenal suppression. Estradiol levels were reduced in all patients, while luteinizing hormone and follicular stimulating hormone increased after ovarian irradiation, but all three hormones fell during tamoxifen administration; no further changes were caused by the addition of prednisolone. Prolactin and thyroxine remained constant throughout the study. There were no differences between responders and nonresponders in hormone profiles or in changes in the profiles after treatment.

Identifying priorities for prepared childbirth research

Priorities for research on prepared childbirth were identified by means of a statewide Delphi Study. Sample groups of childbirth educators and maternity nurses formulated research topics and set priorities among the topics. Overall, 50 items were specified in four categories: Prenatal Education/Preparation, Labor and Delivery (normal), Postpartum, and Complications. Data were analyzed to identify priorities in each category and to determine the levels of consensus among samples. The need for research on specific areas of prepared childbirth, as perceived by these sample groups, is reported. Although a high level of consensus is apparent, interesting differences emerged.

Urinary androgen and 17-hydroxylated corticosteroid metabolites and their relation to recurrence rates in early breast cancer

The amounts of urinary androsterone and etiocholanolone are highly correlated with recurrence rates in patients with early breast cancer after treatment by mastectomy. A more efficient means of predicting the clinical course of the disease is obtained by using a ratio of these compounds to the amounts of individual 17-hydroxycorticosteroids in the urine. For instance, the ratio of androsterone to alpha-cortolone is particularly effective in identifying women with a high rate of recurrence, and this is largely independent of pathological stage and tumor grade.