Commonly collected thermal performance data can inform species distributions in a data-limited invader

Predicting potential distributions of species in new areas is challenging. Physiological data can improve interpretation of predicted distributions and can be used in directed distribution models. Nonnative species provide useful case studies. Panther chameleons (Furcifer pardalis) are native to Madagascar and have established populations in Florida, USA, but standard correlative distribution modeling predicts no suitable habitat for F. pardalis there. We evaluated commonly collected thermal traits- thermal performance, tolerance, and preference-of F. pardalis and the acclimatization potential of these traits during exposure to naturally-occurring environmental conditions in North Central Florida. Though we observed temperature-dependent thermal performance, chameleons maintained similar thermal limits, performance, and preferences across seasons, despite long-term exposure to cool temperatures. Using the physiological data collected, we developed distribution models that varied in restriction: time-dependent exposure near and below critical thermal minima, predicted activity windows, and predicted performance thresholds. Our application of commonly collected physiological data improved interpretations on potential distributions of F. pardalis, compared with correlative distribution modeling approaches that predicted no suitable area in Florida. These straightforward approaches can be applied to other species with existing physiological data or after brief experiments on a limited number of individuals, as demonstrated here.

Dermatomycosis Caused by Paranannizziopsis australasiensis in Nonnative Panther Chameleons (Furcifer pardalis) Captured in Central Florida, USA

Emergent fungal pathogens in herpetofauna are a concern in both wild and captive populations. We diagnosed dermatomycosis by Paranannizziopsis australasiensis in two panther chameleons (Furcifer pardalis) and suspected it in eight others captured from an established free-living nonnative population in Florida, USA. Chameleons developed skin lesions following recent exposure to cold weather conditions while housed in captivity, approximately 10 mo after capture and 12 wk after being placed in outdoor enclosures. Affected animals were treated with oral voriconazole and terbinafine until most cases resolved; however, medications were ultimately discontinued. Paranannizziopsis australasiensis has not previously been described in chameleons, nor in animals originating from a free-ranging population in the USA. Although the source of P. australasiensis infection is uncertain, we discuss several scenarios related to the pet trade and unique situation of chameleon "ranching" present in the USA.

Haematuria investigation based on a standard protocol: emphasis on the diagnosis of urological malignancy

OBJECTIVE

To audit the findings of a standard investigation protocol for haematuria with emphasis on the diagnosis of urological malignancy.

METHODS

Data were prospectively collected on haematuria referrals to one centre over a 5 year period. The standard protocol of investigation included flexible cystoscopy, urine cytology and culture, upper tract imaging, consisting of a renal tract ultrasound scan and a radiograph of kidney-ureter-bladder (KUB), proceeding to an intravenous urogram (IVU) in selected patients.

RESULTS

1046 patients were examined; 63% (n = 657) had microscopic haematuria and 37% (n = 389) had frank haematuria. No malignancy was found in patients with microscopic haematuria below 50 years of age. The findings of malignancy were not associated with either the sex or duration of symptoms in either groups. No association between the presence of symptoms and the finding of malignancy was observed in the microscopic haematuria group. Twenty five percent of patients presenting with frank haematuria had malignancy compared with 3.7% of patients with microscopic haematuria (p < 0.0001). The type of haematuria (frank or microscopic) was not predictive of grade or stage of malignancy. Of patients under 70 years with frank haematuria, males were more likely than females to have malignancy. This higher risk was not observed in older patients. Urine cytology had a poor predictive value for detection of malignancy with a sensitivity of only 25%.

CONCLUSION

Full investigation of all patients with frank haematuria and those with microscopic haematuria above 50 years of age, is well justified. Patients under 50 years with microscopic haematuria should have a lower priority for investigation.

Rectus abdominis muscle flaps used successfully for median sternotomy wounds after ipsilateral internal mammary artery ligation

Use of the rectus abdominis muscle for reconstruction based on its superior blood supply has been said by some to be contraindicated if the ipsilateral internal mammary artery (IMA) has been divided for reasons such as coronary artery bypass grafting. The authors describe 5 patients in whom either both IMAs were used for coronary revascularization or in whom there was a contralateral subcostal incision, and they were thus compelled to perform sternal reconstruction using at least one rectus abdominis muscle ipsilateral to prior IMA ligation. In all patients the muscle flap was used to reconstruct an open median sternotomy wound successfully. An injection study as well as a fresh cadaveric dissection revealed rich collateral circulation to the superior epigastric vascular pedicle through the musculophrenic artery as well as through the lower intercostal arteries. This case report and the series of 5 patients indicate that if elevation of the rectus muscle and division of the lateral segmental vessels is done only up to the costal margin, one can reliably maintain a viable rectus muscle flap, even in the face of prior ipsilateral IMA ligation. This enables useful reconstruction to the lower half of a sternal wound using the rectus abdominis muscle, requiring a pectoralis major muscle flap for the superior part of the wound.

Comparison of carpal canal pressure in paraplegic and nonparaplegic subjects: clinical implications

The purpose of this study was to evaluate the pressure within the carpal tunnel that was generated with certain tasks in paraplegic versus nonparaplegic subjects. Four groups of subjects were evaluated: 10 wrists in six paraplegic subjects with carpal tunnel syndrome, 11 wrists in six paraplegics without the syndrome, 12 wrists in nine nonparaplegics with the syndrome, and 17 wrists in 11 nonparaplegics without the syndrome. Carpal canal pressures were measured in the wrists in three positions (neutral, 45-degree flexion, 45-degree extension) and during two dynamic tasks [wheelchair propulsion and RAISE (relief of anatomic ischial skin embarrassment) maneuver]. External force resistors were placed over the carpal canal and correlated with internal tunnel pressures. At each wrist position, paraplegics with carpal tunnel syndrome consistently had higher carpal canal pressure than did the other groups at the corresponding wrist position; statistical significance was evident with regard to the neutral wrist position (p < 0.05). Within each group of subjects, wrist extension and wrist flexion produced a statistically significant increase in carpal canal pressure (p < 0.05), compared with the neutral wrist position. Dynamic tasks (wheelchair propulsion and the RAISE maneuver) significantly elevated the carpal canal pressure in paraplegics with carpal tunnel syndrome, compared with the other groups (p < 0.05). Lastly, there is a linear positive correlation between carpal canal pressure and external force resistance.

Patterns of referral, management and survival of patients diagnosed with prostate cancer in Scotland during 1988 and 1993: results of a national, retrospective population-based audit

OBJECTIVES

To examine patterns of referral, management and survival of men with prostate cancer, and to document changes over time.

PATIENTS AND METHODS

All men registered with prostate cancer in 1988 and 1993 were identified from the Scottish Cancer Registry. Data were abstracted according to standard definitions from the available medical records of 930 men in 1988 and 1355 in 1993.

RESULTS

There was limited evidence of multidisciplinary care, with only 8% of patients in 1988 being managed by both a urologist and a clinical oncologist within a year of diagnosis, increasing to 13% in 1993. Only a small proportion of patients were managed by clinical oncologists during the first year of care (14% in 1988 and 20% in 1993). Documentation of thorough staging information was poor, with a T stage being recorded in <30% of cases in both years. Documentation of metastatic status increased from 53% to 63% between 1988 and 1993, paralleling an increase in the use of bone scans. The proportion of cases with pathological grading obtained at diagnosis increased from 63% in 1988 to 68% by 1993. The use of PSA testing and core biopsies increased between the years while the use of transurethral prostatectomy decreased. More patients received radical radiotherapy within a year of diagnosis in 1993 than 1988, increasing from 6% to 9%, and more radical prostatectomies were also undertaken (0.2% to 2.3%). Nonetheless, most patients (81% in 1993) with no documented evidence of metastases received no active intervention (radical radiotherapy, radical prostatectomy, or 'watchful waiting'). The survival at 5 years increased nonsignificantly from 34% for the 1988 cohort to 38% for the 1993 cohort.

CONCLUSION

This audit reveals considerable inconsistency in the management of men with prostate cancer in Scotland. Against a background of controversy about numerous aspects of the management of this disease, the need for a multidisciplinary approach, comprehensive staging and appropriate documentation is highlighted.

Physical and psychosocial symptoms among 88 volunteer subjects compared with patients seeking plastic surgery procedures to the breast

In an investigation of the relationship between macromastia and physical and psychosocial symptoms, 88 female university students, 21 augmentation mammaplasty patients, and 31 breast reduction patients graded somatic and psychosocial symptoms. The intent of the study was to discover which complaints were most common among women presenting for reduction mammaplasty and to determine whether height/weight index and brassiere chest measurement and cup size might affect their symptoms. Both the student group and the augmentation mammaplasty patients differed significantly from the breast reduction patients. Eighty-one percent of the reduction patients complained of neck and back pain. Seventy-seven percent complained of shoulder pain, 58 percent complained of chafing or rash; 45 percent reported significant limitation in their activity; and 52 percent were unhappy with their appearance (p < 0.001 compared with augmentation and student groups). Physical symptoms were related to height/weight index and bra chest and cup sizes in each of the three participating groups. It was found that patients who present for symptom-related reduction mammaplasty have a disease-specific group of physical and psychosocial complaints that are more directly related to large breast size than to being overweight.

Quality of life and disease-specific functional status following microvascular reconstruction for advanced (T3 and T4) oropharyngeal cancers

In an effort to evaluate quality-of-life benefits of ablative head and neck cancer surgery and microvascular reconstruction, a longitudinal study was undertaken in which patients with T3 or T4 oropharyngeal cancers without systemic metastases at presentation were administered both general and disease-specific quality-of-life instruments preoperatively and postoperatively. In an initial prospective pilot study, 17 cancer patients were evaluated both preoperatively and postoperatively using the Medical Outcomes Short-Form Health Survey questionnaire (SF-36) and the Performance Status Scale for Head and Neck Cancer Patients. In the second part of the study, the need was recognized for a different disease-specific measure, for more frequent intervals of longitudinal follow-up (rather than be limited by a single data collection point), and for a noncancer control group. Since then, 17 more cancer patients were evaluated in the second part of the study and were compared with patients who had similar reconstructions after suffering head and neck trauma and also with age-matched controls. Instead of the performance status scale, the University of Washington Head and Neck Quality of Life questionnaire was substituted. Interval assessments were done at 1, 3, 6, and 12 months and preoperatively. Whereas many of the general and disease-specific quality of life subclasses initially worsened following extensive surgery and radiation therapy, most returned to the preoperative baseline by 6 months following conclusion of treatment and surpassed pretreatment values at 1 year. It can be concluded, based on this study, that large resections and reconstructions for head and neck cancer patients are justified in terms of outcome; the resection controls the local disease, and the microvascular reconstruction restores quality of life and functional status.

Evaluation of results and treatment variables for pressure ulcers in 48 veteran spinal cord-injured patients

This retrospective study of 48 spinal cord-injured patients with pressure ulcers seen at a tertiary referral Veterans Hospital spinal cord injury unit between 1992 and 1997 correlates a number of variables (co-morbid conditions, nutritional status, smoking history, type of repair performed, type of bed used postoperatively, ulcer location and severity, duration of postoperative antibiotic therapy, time elapsed before sitting rehabilitation began, and length of hospital stay) with ulcer repair outcome measures, including postoperative systemic and wound-healing complications, recurrence rates, and the development of new ulcers at different sites. Surgical complication rates were high, occurring in 19 patients (39.6%), and ulcer recurrence or new ulcer development occurred in 38 patients (79.2%). Correlations were found between ulcer location and postoperative wound separation and the length of hospitalization. The hospital course was shorter if the ulcer was new rather than recurrent. Other than the finding that chronic smokers had longer courses of antibiotic therapy, smoking did not correlate statistically with other outcome variables, including wound-healing complications. No significant correlations were found between any postoperative systemic or wound complications, ulcer recurrence, or new ulcer development and patient age, level of spinal cord injury, number of ulcers and grade, laboratory values, mental status, cardiac or pulmonary disease, diabetes, and presence or absence of osteomyelitis.

The life span of silicone gel breast implants and a comparison of mammography, ultrasonography, and magnetic resonance imaging in detecting implant rupture: a meta-analysis

Because of the growing concern surrounding the integrity and life span of silicone gel breast implants and the reported variations in the diagnostic accuracy of various imaging techniques in identifying ruptured implants, the authors undertook a meta-analysis of articles in the scientific literature to examine these concerns. They were able to include reports from the literature that detailed the condition and removal of 1,099 breast implants during the past 7 years. The median life span of a silicone gel implant was estimated to be 16.4 years. Of the implants, 79.1% were intact at 10 years, falling to 48.7% by 15 years. The sensitivities and specificities of three imaging modalities used in the diagnosis of implant rupture (mammography, ultrasonography, and magnetic resonance imaging [MRI]) were also evaluated and compared statistically in an effort to discover which of the three techniques might serve as the most reliable screening tool in the diagnosis of gel implant rupture. The sensitivity of mammography for finding a ruptured implant is 28.4% with a specificity of 92.9%. Ultrasonography has a sensitivity and specificity of 59.0% and 76.8% respectively compared with MRI, which was 78.1% and 80.0% respectively. For implants in place for 10 years, one would need to image 3.3 implants by ultrasound to identify a single possible rupture. However, because of the 76.8% specificity, 8.1 implants would need to be imaged to find a confirmed intraoperative rupture. This was similar to MRI, in which 3.1 implants would need to be imaged to detect one suspected rupture, and 6.1 implants would need to be imaged to find one intraoperatively confirmed rupture. The authors do not recommend either ultrasound or MRI as a screening tool based on their meta-analysis.

Microscopic haematuria: urological investigation using a standard protocol

OBJECTIVE

To determine which patients with asymptomatic microscopic haematuria (AMH) should be investigated to exclude significant urological pathology.

PATIENTS AND METHODS

The study comprised a prospective audit of a standard protocol for investigating all patients referred with haematuria over one year in a haematuria clinic in the urology department serving Tayside, Scotland. Investigations included urine culture and cytology, flexible cystoscopy, and upper tract imaging which consisted of both excretory urography and renal ultrasonography in many of the patients.

RESULTS

A total of 381 patients with microscopic haematuria was investigated. No malignancy was found in any < 50 years of age (n = 131); in patients aged > 50 years the overall incidence of malignancy was 7.5% (19/250). The asymptomatic patients in this group had a lower incidence (5%, 6/126) of malignancy than the symptomatic patients (10.5%, 13/124) but this difference did not reach statistical significance. There was no statistically significant difference in the incidence of urological malignancy between men and in women with microscopic haematuria. During the same period, 233 patients were referred with frank haematuria; in these patients, those aged < 50 years had a 10% incidence of malignancy (6/60), while in those aged > 50 years the incidence was 34.5% (60/173). A total of 18 patients (4.7%) with microscopic haematuria had upper tract calculi, comprising 5.3% (7/131) of patients aged < 50 years and 4.4% (11/250) of those > 50 years with microscopic haematuria.

CONCLUSIONS

The investigation of older patients with microscopic haematuria (and all those with frank haematuria) is well justified, as malignancy will be found in a significant proportion even if they are asymptomatic. The benefit of a full urological investigation of younger patients with microscopic haematuria is debatable.

Androgen concentrations in expressed prostatic secretions: no correlation with tissue levels

In an attempt to determine whether the androgen profiles of the prostate fluid (EPS) mirror the concentrations in the prostate tissue, we have measured testosterone and dihydrotestosterone (DHT) in EPS and correlated their levels to the concentrations found in hyperplastic prostate tissue (BPH) obtained from the same 19 patients. Although androgen concentrations in EPS were very high (testosterone = 106.7 +/- 81.9 ng/g dry weight; DHT = 54.2 +/- 11.2 ng/g dry weight), they did not reflect the concentrations measured in BPH tissue (testosterone = 7.56 +/- 1.54 ng/g dry weight; DHT = 10.54 +/- 0.63 ng/g dry weight). Additionally the accumulation of tissular DHT usually associated with BPH was not mirrored in the EPS specimens which demonstrated a relatively higher concentration of testosterone when compared to DHT. In EPS, there was also a very strong correlation between testosterone and DHT concentrations (r = 0.89; P less than 0.01). We have also measured zinc concentrations in EPS and BPH tissue but were unable to detect any relationship between the two parameters. Significantly, however, EPS zinc concentrations showed a close correlation with EPS testosterone (r = 0.73; P less than 0.01) and DHT (r = 0.69; P less than 0.01) concentrations.

Prognostic value of raised prostatic acid phosphatase and negative skeletal scintigraphy in prostatic cancer

Of 438 consecutive cases of newly diagnosed prostate cancer, 178 (41%) had skeletal metastases (T0-4 M1) at the time of diagnosis according to skeletal scintigraphy; 139 men had serum prostatic acid phosphatase (PAP) greater than twice the upper limit of normal on 2 separate occasions at the time of diagnosis and 65% of them had metastases on bone scan. However, 49 men with normal bone scans were found to have similarly raised serum PAP. (Such patients are defined as having skeletal metastases in the current Medical Research Council immediate versus deferred orchiectomy study and stratified accordingly). The actuarial survival of this group was calculated by life table methods and was compared with that of 2 other subgroups: those patients having metastases demonstrated on bone scan, and those patients having both normal bone scans and normal serum PAP. The survival of the "metastatic by acid phosphatase" group was significantly better than that of the "metastatic by bone scan" group but did not differ from that of patients having both normal scans and PAP. For patients with no scintigraphic evidence of skeletal metastases at diagnosis, those with a raised PAP were at a significantly greater risk of scan conversion, although this was more powerfully predicted by high histological grade.

Preliminary studies on the use of an ABR amplitude projection procedure for hearing aid selection

Hearing aid selection in young nonverbal children is difficult and objective selection procedures are needed. Kiessling (Scand Audiol 1982;11:269-275; Arch Otorhinolaryngol 1983;238:233-240) has proposed an objective hearing aid selection method based on an unaided ABR amplitude projection procedure. However, Kiessling's ABR projection method is based on the assumption that ABR amplitude is directly related to the loudness of a signal--an assumption which has not been tested. This assumption was investigated in a group of ten normally hearing and three hearing-impaired listeners. The results indicated that ABR amplitude measures obtained in a single trial do not always correlate well with perceived loudness, but ABR amplitudes averaged over several trials do correlate well with estimates of perceived loudness. The hearing-impaired listeners then participated in a second phase of the investigation in which hearing aids chosen by the ABR projection procedure were compared with hearing aids chosen by more conventional methods. The results indicated that the projection procedure prescribed appropriate gain and compression characteristics for two of the three hearing-impaired listeners.

De-differentiation with time in prostate cancer and the influence of treatment on the course of the disease

There is little information on histological changes in prostate cancer during the course of the disease. We have studied 74 patients with carcinoma of the prostate who required 2 transurethral resections of the prostate (mean interval between resections 2.4 years). They constituted 18.4% of all patients with carcinoma of the prostate presenting to our clinic between January 1978 and April 1988. All tumours were staged by conventional methods and graded using the Gleason system. The Gleason sum score in those patients with tumour in both specimens increased in 49, remained constant in 12 and decreased in 7. Within this group were 34 patients who were treated expectantly. The mean Gleason sum scores in this group increased, with a concomitant increase in local tumour stage and development of metastases. Although this was not a randomised trial, there was no significant difference in survival between patients having "deferred" management and those treated immediately, either from time of diagnosis or from time of second resection. There was, however, a significant difference in the time to second resection, with the "deferred" group requiring repeat resection on average 1 year earlier. This study confirmed the concept of tumour de-differentiation with time and showed that this phenomenon occurs in both treated and untreated tumours. Although overall survival was not influenced by the type of initial therapy or its timing, local progression, as assessed by the need for further TURP, occurred earlier in those not receiving immediate therapy.

Survey of antibiotic prophylaxis in European renal transplantation practice

Death and morbidity resulting from infection in the immunosuppressed patient following renal transplantation has been much reduced as immunosuppressive regimens have become less aggressive. Such complications, however, remain a considerable risk to transplant recipients and the use of prophylactic antibiotics has been advocated. This survey documents current practices and attitudes to the use of antibiotic prophylaxis in renal transplantation centres throughout Europe on the basis of response to a postal questionnaire.

Measures of mortality in prostatic cancer

The use of different expressions of mortality in prostate cancer can lead to difficulty in comparing reported data. We have used different measures of mortality in the same group of 438 patients presenting consecutively with histologically proven adenocarcinoma of the prostate, in order to assess the values and deficiencies of each method. The use of expected and relative survival is shown to be valuable in allowing indirect but objective assessment of disease specific mortality in prostatic cancer.

Age, and size and grade of tumour predict prognosis in incidentally diagnosed carcinoma of the prostate

Of 403 consecutive cases of prostatic carcinoma 69 were diagnosed incidentally and were managed with a deferred treatment policy. The mean age at diagnosis was 74 years and mean follow-up was 42 months. Retrospective analysis confirmed that many such patients die of intercurrent disease before symptomatic tumour progression. However, patients aged 70 years or less at diagnosis with diffuse, high grade disease were shown to be at greater risk of symptomatic tumour progression. In this study 60% progressed to skeletal metastases within 3 years. Deferral of treatment in such patients appears inappropriate.

The Delphi technique: a critique

The development of the Delphi technique, as a survey method of research, and examples of its use are described. The technique's key characteristics, anonymity, use of experts and controlled feedback, are examined. The method's usefulness in structuring group communication for the discussion of specific issues and as an aid to policy making is discussed in the light of the technique's perceived drawbacks and limitations.

The Delphi technique: a critique

The development of the Delphi technique, as a survey method of research, and examples of its use are described. The technique's key characteristics, anonymity, use of experts and controlled feedback, are examined. The method's usefulness in structuring group communication for the discussion of specific issues and as an aid to policy making is discussed in the light of the technique's perceived drawbacks and limitations.

Asperger's syndrome: a case report

A case report is presented of an 11-year-old boy who has been diagnosed as having Asperger's syndrome. There follows a review of the clinical features, course, prognosis and management of this condition.

Model for mammalian metallothionein structure

The results of physicochemical studies of mammalian metallothioneins are summarized and used to propose a model of the protein. The primary structures of all mammalian metallothioneins are very homologous; there are 38 invariant residues and 20 of them are cysteines. The results of UV and CD optical studies indicated that all 20 cysteines are involved in the ligation of 7 mol of metal per mol of metallothionein and that the protein does not contain any alpha-helix structure. A theoretical analysis by the Chou-Fasman method has predicted 11 beta-bends, each one involving at least one cysteine residue. The most significant structural data, provided by 113Cd NMR, demonstrated that the 7 mol of bound Cd2+ are arranged in two separate metal clusters, one containing four metal ions and the other containing three, with all Cd2+ tetrahedrally coordinated to cysteine thiolate ligands. The 11 cysteine residues of the carboxyl-terminal portion of the metallothionein chain (residues 30-61) are ligated to the 4-metal cluster as shown by 113Cd NMR of this enzymatically cleaved fragment. The remaining cysteine residues from the amino-terminal polypeptide portion (residues 1-29) form the 3-metal cluster. Such a division of the chain is consistent with the presence of an intron in the mouse metallothionein-1 gene corresponding to residue 32 in the polypeptide chain. A two-domain molecular model has been constructed based on an analysis of all the available data and is described in detail. The accuracy of this model was tested by 1H NMR at 500 MHz and the data are in agreement with our proposed structure.