Respiratory syncytial virus disease burden in community-dwelling and long-term care facility older adults in Europe and the United States: A prospective study

Respiratory syncytial virus (RSV) causes respiratory illnesses, which can lead to serious complications in older adults. We estimated how common infections due to RSV are in adults living in the community or long-term care facilities. For 2 years, we followed approximately 2000 adults 50 years and older in Europe and the United States. Between October 2019 and March 2020, about 2 in 100 adults in this study had RSV infections; of these, fewer than one fifth had complications and there were no hospitalizations or deaths. Other viruses were present for less than one fifth of RSV infections. Between October 2020 and June 2021, during COVID-19 restrictions, we detected RSV infection in one adult, living in a long-term care facility, with no complications. RSV causes respiratory disease among adults 50 years and older and therefore programs to prevent RSV infection are needed in this age group.

356 OLDER PERSONS LIVING ALONE IN INTEGRATED CARE: DEPRESSION, LOW EDUCATION AND FUEL POVERTY

Background

An important consequence of population ageing has been the increasing number of older adults who live alone. According to TILDA data, older adults with the lowest levels of education tend to experience most social isolation and there is a strong association between living alone and loneliness. We sought to compare the cohort of patients open to the Integrated Care for Older Persons (ICPOP) team in a University Teaching Hospital serving a community area of approx. 300,000 population, to this national dataset.

Methods

A convenience sample of 174 patients who underwent comprehensive geriatric assessment via domiciliary visit between July 2021-May 2022 by was analysed. Data was anonymised and analysis was performed using SPSS v.27.

Results

The average age was 81.5 (±8.1) with 63% women in the sample. Eighty-five older adults i.e. 49% of the sample either lived alone or spent more than 21 hours alone per 24-hour period. Compared to those who live with someone, those who lived alone had higher rates of likely depression as determined by Geriatric Depression Score (6.6 vs 4.8 p=0.007). They were also likely to have less educational attainment, as determined by years spent in full time education (11.81 vs 10.42 42 p= 0.0016) and those living alone had overall less central heating in their homes than those not living alone (64/85 vs 81/89 p=0.0109). There were no significant differences in the rates of polypharmacy, falls, dementia and home ownership between groups. There were higher levels of frailty in the group living with someone than those living alone as determined by Clinical Frailty Scale (6.14 vs 5.23 p<0.001).

Conclusion

A high proportion of patients seen by our ICPOP team live alone and have complex care needs that require an innovative, multidisciplinary approach. Financial vulnerability in this group is likely to compound isolation and loneliness.

140 FAMILY DEMENTIA SUPPORT TRAINING—AN INTEGRATED CARE APPROACH

Background

There are approximately 64,000 people living with a diagnosis of dementia in Ireland. This number is expected to double to 150,000 by 2045. The growing need for post diagnostic support has been accentuated by the fact that we are living through an unprecedented Pandemic. Our Dementia Training Network identified the need for a localised educational resource for families supporting those diagnosed with dementia across our service.

Methods

Following a successful pilot in association with the Alzheimer’s Society of Ireland, staff from the Specialist Memory Service, Integrated Care Team, and Primary Care created a service-informed 6 week course aimed at supporting families. A focus group preceded the first course to establish preferred content. The course delivered education on Dementia; Post Diagnostic Steps; Communication; Non cognitive symptoms; Nutrition & hydration; Assistive Technology; Forward planning and Self-care. The multi-dimensional nature of staff delivering the course creates a rich tapestry of advice and information. All staff involved work together to identify, refer and support families living with dementia in the local area. The group takes place in an accessible location and time which accommodates families. Each course attendee completes a questionnaire prior to and after commencing the group. The level of satisfaction will be measured following every course.

Results

By the end of 2021, the group will have delivered education and support to 36 families. The automatic referral of all families to this resource will assist in building up confidence to support and enhance self-care. The combined participants from the catchment area will become a network of families joined together on their journey.

Conclusion

This innovative service collaboration enhances the integrated nature of the Post Diagnostic Care pathway. The Integrated care approach has served to enrich the programme and allow for timely support and advice regarding localised supports.

Decoupling Carrier Concentration and Electron-Phonon Coupling in Oxide Heterostructures Observed with Resonant Inelastic X-Ray Scattering

We report the observation of multiple phonon satellite features in ultrathin superlattices of the form nSrIrO_{3}/mSrTiO_{3} using resonant inelastic x-ray scattering (RIXS). As the values of n and m vary, the energy loss spectra show a systematic evolution in the relative intensity of the phonon satellites. Using a closed-form solution for the RIXS cross section, we extract the variation in the electron-phonon coupling strength as a function of n and m. Combined with the negligible carrier doping into the SrTiO_{3} layers, these results indicate that the tuning of the electron-phonon coupling can be effectively decoupled from doping. This work both showcases a feasible method to extract the electron-phonon coupling in superlattices and unveils a potential route for tuning this coupling, which is often associated with superconductivity in SrTiO_{3}-based systems.

Randomised, Double-Blind, Placebo-Controlled Study of a Single Dose of an Amylmetacresol/2,4-dichlorobenzyl Alcohol Plus Lidocaine Lozenge or a Hexylresorcinol Lozenge for the Treatment of Acute Sore Throat Due to Upper Respiratory Tract Infection

Purpose: Sore throat is a frequent reason for seeking medical care but few prescription options are available. Lozenges are effective in delivering active ingredients to the throat. This study was conducted to determine the analgesic efficacy of two lozenges  one containing amylmetacresol (AMC)/2,4-dichlorobenzyl alcohol (DCBA) and lidocaine and one containing hexylresorcinol  versus placebo in patients with acute sore throat due to upper respiratory tract infection (URTI). Methods: This was a multicentre, randomised, double-blind, parallel group, placebo-controlled study. In total, 190 patients were randomised 1:1:1 to a single dose of AMC/DCBA + lidocaine, hexylresorcinol or placebo lozenge. Subjective ratings of throat soreness, difficulty swallowing, swollen throat, numbing, and sore throat relief were obtained up to 2 hours post dose. Patient and investigator global ratings and a consumer questionnaire were also collected. The primary endpoint was the change from baseline in severity of throat soreness for both lozenges versus placebo at 2 hours post dose. Results: The hexylresorcinol lozenge demonstrated superiority over placebo for primary and secondary efficacy variables including those related to throat soreness, sore throat relief and difficulty swallowing; the AMC/DCBA + lidocaine lozenge was also superior to placebo for secondary endpoints at various time points but did not reach significance for the primary efficacy variable. Both lozenges had a rapid onset of action from 1–10 minutes post dose for the AMC/DCBA + lidocaine lozenge and 1–5 minutes post dose for the hexylresorcinol lozenge. Numbness was reported from 1 minute post dose with the AMC/DCBA + lidocaine lozenge and was greatest at 15 minutes. Numbness was reported from 5 minutes post dose with the hexylresorcinol lozenge and was greatest at 10 minutes. Both lozenges were well tolerated. Conclusions: Both AMC/DCBA + lidocaine and hexylresorcinol lozenges provided rapid and effective sore throat relief in patients with URTI. This article is open to POST-PUBLICATION REVIEW. Registered readers (see “For Readers”) may comment by clicking on ABSTRACT on the issue’s contents page.

Rapid relief of acute sore throat with AMC/DCBA throat lozenges: randomised controlled trial

AIM

As antibiotics are generally not recommended for the treatment of acute sore throat, the availability of clinically efficacious, over-the-counter (OTC) treatment alternatives is becoming increasingly important. This study was designed to determine the analgesic properties of amylmetacresol and 2,4-dichlorobenzyl alcohol (AMC/DCBA) throat lozenges (Strepsils) in the relief of acute sore throat caused by upper respiratory tract infections.

METHODS

Patients (n = 310) were randomly assigned to receive AMC/DCBA throat lozenges (n = 155) or non-medicated placebo lozenges (n = 155). After baseline assessments, patients completed three rating assessments at 10 timepoints from 5 to 20 min after first dose. Subsequent lozenges were taken as required, and assessments were made at the end of Day 1, 24 h after first dose, and at the end of Days 2 and 3. Analgesic properties were assessed by comparing severity of throat soreness and sore throat relief ratings. Difficulty in swallowing and functional impairment scores were also assessed.

RESULTS

Amylmetacresol/DCBA throat lozenges reduced throat soreness at 5 min after first dose, which persisted for 2 h and was significantly different vs. non-medicated lozenges at all assessment timepoints for the duration of the 3-day study. Similar significant effects were observed with sore throat relief, easing of difficulty with swallowing and functional impairment scores. There were no differences in adverse events reported between treatment groups.

CONCLUSION

Amylmetacresol/DCBA throat lozenges provide rapid analgesic effects that last for 2 h, providing ongoing relief long after the lozenge has dissolved. The superior analgesic effects and improvements in functional impairment scores observed with AMC/DCBA throat lozenges translate into pain relief benefits that are clinically meaningful and are thus a suitable OTC treatment option for patients in the self-management of acute sore throat.

Patient Characteristics Associated with Use of Monoclonal Antibody Treatment in Women with Metastatic Breast Cancer: A Population-Based Analysis

Introduction: Monoclonal antibodies (MoATB) were FDA approved for the treatment of patients with breast cancer (BrCA) whose tumors over expressed the human epidermal growth factor receptor 2 (HER2) in 1998. We sought to determine if certain patient characteristics and co-morbidities influenced MoATB use in a population-based practice setting of elderly women with metastatic BrCA. Methods: We identified female Medicare beneficiaries aged 66+ years diagnosed with incident metastatic BrCA without prior history for any cancer between 1999 and 2005 in the Surveillance, Epidemiology and End Results cancer registries (SEER). Charlson Co-morbidity index (CCI) and separate conditions within the index were created using linked Medicare claims in the year prior to the BrCA diagnosis. We identified both oral and infused chemotherapy (CH) from the Medicare claims from 1999 to 2006. Patients were categorized into three groups: no CH, MoATB+/-CH, and CH w/out MoATB. We performed bivariate statistics to compare the patient characteristics and comorbidities between the three groups, and the treatments groups only. Results: There were 3,820 women with metastatic BrCA, mean age 77 (SD 7.3) years, 81% were white race, 29% were married and 91% lived in an urban setting. 67% of these women (n=2,562) received no CH, 26% received CH w/out MoATB (n=994) and 7% received MoATB+/-CH (n=264). Overall the CCI was lower for women receiving either treatment as compared to no chemotherapy and between treatment groups for the young old (66-75 years) but not those aged 80+ years. The prevalence of congestive heart failure (CHF) and cerebrovascular disease was significantly lower in women receiving MoATB +/-CH, as compared to only CH, and also lower in both compared to no CH (n=2,462). Few women presenting with COPD or dementia were likely to be treated with either CH and/or MoATB compared to No CH. Other co-morbidity conditions within the CCI were not statistically different between the groups or the cell numbers were too small to analyze. Conclusion: MoATB use in the treatment of metastatic breast cancer steadily increased from 5% in 1999 to 23% in 2004. Use in 2005 was slightly lower but will be recalculated once the 2007 claims are available. In 2008, FDA released a black box warning for trastuzumab, the most frequently prescribed MoATB for BrCA, regarding the potential for the development of cardiomyopathy. Our results suggest that co-morbidities in particular CHF and cerebrovascular disease may influence the decision to use MoATB. Further research is necessary to examine the relationship between co-morbidities and the use of MoATB in the treatment of metastatic breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2057.

Taxane Treatment in Women with Incident Stage IV Breast Cancer

Introduction: The overall benefit of chemotherapy for late stage breast cancer treatment has been demonstrated in clinical trials and “real world” observational studies, but there is less data on chemotherapy use among older women. In addition, estrogen receptor status can influence treatment decisions. Our objective was to explore the clinical and demographic characteristics of women who received chemotherapy, particularly taxanes, in a large population-based cohort of older patients with incident stage IV breast cancer.Methods: Older women (age 66 and over) diagnosed with incident stage IV breast cancer from 1999 to 2005 were identified in the Surveillance, Epidemiology and End Results (SEER) cancer registries. Treatment-related data were linked from Medicare claims. We limited our analysis to ER negative (ER-) women with the assumption that these women would not be receiving tamoxifen as SEER data do not have complete information on receipt of tamoxifen. Receipt of chemotherapy was identified from claims files. Bivariate analyses were performed to compare clinical and demographic characteristics of those who received taxanes, other chemotherapy, or no chemotherapy.Results: Of 3,820 older women diagnosed with incident stage IV breast cancer, 1,518 women (40%) were identified as ER negative, of whom 247 (16%) were treated with taxanes, 312 (21%) with other chemotherapy, and the remainder received neither. Mean age was 78, 84% of the study cohort was white, 27% were married, and 91% lived in urban areas. Fifty four percent of women had HER2 assays performed. Women who received taxanes were substantially younger (Mean=74, SD=5.49) than those who did not (Mean=80, SD=7.79) and had fewer co-morbidities (measured by Charlson co-morbidity index) (bivariate [see above] p=0.0003) than any other group. Individuals who received taxanes were less likely to be married, receive radiation or undergo surgery. Only 8% of those treated with taxanes had 2 or more medical conditions compared to 18% of those receiving other chemotherapy and 74% of those with no chemotherapy. Treatment groups varied in regard to some medical conditions including CHF, cerebrovascular disease, and dementia. For example, only 8% of those receiving taxanes had CHF, compared to 13% among the 'other chemotherapy' group and 78% among those receiving no treatment (bivariate [see above] p=0.0003). A similar trend was revealed with the other medical conditions, with taxane users consistently presenting with lower prevalence for each condition. Interestingly, no one who had dementia received any chemotherapy.Conclusion: Findings from this descriptive study showed that age and co-morbidity were the most important factors associated with receipt of taxanes as well as of other chemotherapy. However, those who received taxanes were the youngest and evidenced the least comorbidity of the 2 groups. Further study is needed to help inform clinicians in making optimum treatment recommendations for their older female patients with incident advanced breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2068.

Chemotherapy Treatment and Survival in Estrogen Receptor Negative Metastatic Breast Cancer: A Population-Based Analysis

Introduction: Although controlled clinical trials have demonstrated a beneficial effect of various chemotherapy regimens on survival in breast cancer (BC), little is known about treatment patterns and survival benefit in the “real world” population of elderly women with metastatic BC. Methods: We identified female Medicare beneficiaries aged ≥66 years with metastatic BC diagnosed from 1999 to 2005 in the Surveillance, Epidemiology and End Results cancer registries (SEER). Patients with a prior history of any cancer were excluded. Treatment-related data were abstracted from linked Medicare claims. Since Medicare claims have incomplete information on oral selective estrogen receptor modulators, we limited our study cohort to estrogen receptor negative (ER-) women. Chemotherapy was defined as the receipt of any chemotherapeutic regimen within 6 months after diagnosis. Initial regimens were characterized based on drugs given during the first 30 days of chemotherapy. We used a continuous-time interval-censored survival analysis to determine the effect of chemotherapy on hazard of any-cause death, controlling for sociodemographic and clinical factors, including proxy measures for performance status. Results: We identified 1518 ER(-) women diagnosed with metastatic BC in SEER. Mean age was 77.6 (SD 7.6) years, 84% were white race and 27% were married at the time of diagnosis. Of the 1518 metastatic ER(-) BC patients, 493 (32%) received chemotherapy. As compared to women who did not receive chemotherapy, women who received chemotherapy were more likely to be younger, married, have lower pre-cancer comorbidity as measured by the Charlson comorbidity index, have seen an oncology specialist and have cancer-directed surgery or radiation prior to chemotherapy. Initial regimens comprised predominantly one (31%) or two (46%) drug classes. The most common regimens were taxanes only (18%), anthracycline+alkylating agents (17%) and antimetabolite+alkylating agent (9%). Overall median followup time was 7 months; 1223 women (81%) died during followup. Median survival time was 5 months among women who did not receive chemotherapy and 15 months among women who received chemotherapy. Chemotherapy was associated with a statistically significant survival benefit (adjusted Hazard Ratio 0.61, 95% confidence interval 0.54, 0.70). Conclusion: In this population-based study of older women, there was a variety of chemotherapy regimens used for metastatic ER(-) BC. Chemotherapy received within 6 months after diagnosis was associated with a 39% reduction in hazard of death. These findings reflect chemotherapy use outside of the clinical trial setting and have important clinical and policy implications for the study of treatments among older women with advanced BC.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2064.

Dual targeting of vascular endothelial growth factor (VEGF) with sorafenib and bevacizumab: Clinical and translational results

3542

Background: VEGF is a major mediator of angiogenesis in malignancy. We targeted the VEGF pathway in series by combining the VEGFR2/Raf kinase inhibitor sorafenib (S) with bevacizumab (B), a selective anti-VEGF antibody. We hypothesized that this combination would suppress angiogenesis and tumor growth, with corresponding changes in correlative dynamic imaging. Methods: Eligible pts had non-curable solid tumors, ECOG performance status 0–1, good end organ function, and no prior exposure to S or B. We enrolled pts at S 200 mg po BID and B 5 mg/kg IV q2weeks (dose level [DL] 1) and escalated each drug sequentially. The MTD was DL1; 24 additional pts were enrolled at this dose and randomized to single agent S (Arm 1) or B (Arm 2) for one month, then S+B thereafter. Serum samples for cytokine analysis, dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) and 18FDG- PET scans were performed at 0, 2, and 6 weeks. DCE-MRI and PET scans measured vascular permeability (Ktrans) and metabolic activity (standardized uptake values [SUV]), respectively. The Wilcoxon signed rank test was used to evaluate the differences between the paired imaging values at the test time points in an exploratory fashion. Results: 7/38 pts (6/14 ovarian ca pts and 1/3 renal cell ca pts) had partial responses (8+-20 mo; median 15). Grade 3–4 toxicities included hypertension (10), proteinuria (2, DLT), and thrombocytopenia (1, DLT). Common grade 2 toxicities were hand-foot syndrome (18), fatigue (13), infection (13), and hypertension (12). DCE-MRI Ktrans decreased with S+B compared to baseline (p<0.03, both arms); no significant change occurred with either S or B treatment alone or between arms. No significant changes in PET SUV measurements occurred with treatment. Correlation of dynamic imaging parameters with response was not possible due to the limited patient numbers. Serial cytokine analysis is presently being performed and will be included at the time of presentation. Conclusions: S+B is active in solid tumors with manageable toxicity. DCE-MRI shows a decrease in vascular permeability with S+B treatment. A larger trial is necessary to evaluate if DCE-MRI changes can be predictive of response and is ongoing now in ovarian cancer.

No significant financial relationships to disclose.

Variation in local treatment of prostate cancer by hospital within New Jersey

14551

Background: Although prostate cancer diagnosis and treatment vary through the US, few studies have assessed variations in local therapy between multiple hospitals located within a very narrow geographic region. Methods: To determine the variation of diagnosis and treatment of prostate cancer between hospitals in a local region, data was derived and analyzed from 1,301 patients from fifteen Cancer Institute of New Jersey Oncology Group network hospitals. Tumor registry data from patients with a histological confirmed diagnosis of prostate cancer accessioned over a one-year period between January 1, 2003 and December 31, 2003 was analyzed by a multivariate logistic regression model. Results: Median age of the cohort was 66 and mean number of cases diagnosed at these hospitals for this period was 87 (26–161). When the cohort was assessed overall, 192 cases assessed were African American, 1049 Caucasian, 51 Hispanic, and 32 Asian. Median Gleason score was 6. A total of 463 patients underwent Prostatectomy, and 538 had radiation therapy. Multivariate analysis demonstrated that age and hospital were associated with use of surgery versus no surgery. Race and Gleason score were not associated with use of surgery in this group of hospitals. Multivariate analysis also demonstrated that age and hospital were associated with utilizing radiation therapy versus not utilizing radiation therapy. Again, race and Gleason score were not associated with utilization of radiation therapy in these NJ hospitals. Conclusions: Overall, the most important factors predicting for surgery, and radiation therapy, were age and hospital, which were independent of race and Gleason score. These data support our ongoing assessment of hospital and geographic characteristics that may be responsible for these associations.

No significant financial relationships to disclose.

Fear of recurrence and possible cases of anxiety and depression in orofacial cancer patients

Recurrence risk in orofacial cancer patients is relatively high in comparison to other cancers. Little information exists on whether patients are unduly concerned over the possibility of recurrence and the association of this concern with psychological morbidity. Aim of study was to assess fear of recurrence and psychological morbidity in orofacial cancer patients. Two samples of patients with orofacial cancer were followed prospectively. First sample (n = 87) were consecutively drawn 3 months and 7 months following initial treatment. Second sample (n = 100) were cross-sectionally drawn from out-patient list and followed 2 years later. A single question item was employed to assess fear of recurrence used in previous work. Hospital Anxiety and Depression Scale was adopted as the measure of psychological morbidity. A prospective survey design was employed. Over 80% of patients expressed concern over the possibility of recurrence at 3 months post treatment. This level reduced to 72% at 7 months (P=0.06). Approximately two-thirds of patients sampled cross-sectionally were concerned at both assessment occasions. Psychological morbidity was greatest at 3 months post treatment (possible cases: anxiety 37% and depression 28%). Women were more likely to report anxiety (at possible case level) than men 3 months following treatment (P<0.05). Patients aged 65 or more years were less concerned about recurrence. This effect was significant on both occasions that sample two patients were assessed (P's<0.002). Very few patients who expressed no concern about recurrence, at 3 months, were found to report anxiety or depression sufficient to be recognized as a possible case (3 and 0% respectively). The positive association between psychological morbidity and fears of recurrence was significant at the majority of data collection points, with the exception that depression was more independent of these concerns.

Pressure profilometry of the lumbosacral disk in dogs

OBJECTIVE

To investigate the biomechanical behavior of the lumbosacral disk under compressive load in dogs, using pressure profilometry, and to investigate the relationship between pressure profile features and background and disease variables.

SAMPLE POPULATION

23 lumbosacral disks and adjacent vertebrae harvested from medium and large breed dogs.

PROCEDURE

A 1.3-mm unidirectional needle-mounted pressure transducer was inserted into the disk in a ventral-to-dorsal manner while the disk was loaded in compression by a materials testing machine. Withdrawal of the transducer resulted in a pressure profile for cranial and lateral stress. Pressure profiles were analyzed, and relationships to age and gross evidence of degeneration were investigated.

RESULTS

There was a moderate positive correlation between age and degree of nuclear degeneration (r(s) = 0.420, P = 0.046), but no relationship between age and mean nuclear pressure was detected. Mean nuclear pressure correlated negatively with severity of degenerative changes in the nucleus pulposus. Receiver operator characteristic curves to evaluate mean nuclear pressure as a diagnostic test for nuclear degeneration revealed a sensitivity and specificity of 82 and 83%, respectively. In addition, age was moderately correlated with the magnitude of stress peaks (r(s) = -0.571, P = 0.004). Stress peaks were not related to the severity of nuclear degeneration.

CONCLUSIONS AND CLINICAL RELEVANCE

Determination of the mean nuclear pressure by disk profilometry provides information on the severity of lumbosacral disk degeneration with a high degree of sensitivity and specificity. The magnitude of single stress peaks within the dorsal annulus fibrosus is correlated with age and may not necessarily reflect advancing degeneration.

A comparison of aesthetic, functional and patient subjective outcomes following lip-split mandibulotomy and mandibular lingual releasing access procedures

Good access to the site of oral cancer is essential to allow for adequate three-dimensional resection of the tumour. Splitting the lower lip in conjunction with a mandibulotomy offers excellent access to all areas of the mouth and pharynx, but this inevitably produces a facial scar and there is morbidity associated with the healing of the mandibulotomy. An alternative approach is the mandibular lingual releasing technique, which provides good access to the oral cavity and avoids the morbidity associated with lip-split mandibulotomy. The aim of this study was to compare aesthetic, functional and patient subjective outcomes between the two access procedures. One hundred and fifty patients had oral access procedures between 1992-95 (ninety lip-split mandibulotomy and sixty mandibular lingual release). Thirty patients fulfilled selection criteria (primary surgery as treatment, tumour size < 5.1 cm, anterior oral cavity tumours, and reconstructed with a radial forearm free flap) and 10 patients from each group were able to attend a review appointment for objective clinical assessment of their speech, tongue mobility, lip competence and temperomandibular signs. Using items from the University of Washington quality of life questionnaire patient subjective outcomes were assessed. Using standardised photographs the clinician and lay persons assessed the overall post-operative facial appearance. The patients also assessed their own facial appearance using a similar scoring method. Resection margins were similar in both groups and it would seem that both methods provide adequate access to the anterior oral cavity. Clinical examination showed no differences in function between the two access procedures. Although there was a small number, the lip-split mandibulotomy group reported significantly better speech, swallowing and chewing. Previous concerns about a possible detrimental effect on appearance following lip-split, were not borne out in this study.

Psychiatric status, somatisation, and health care utilization of frequent attenders at the emergency department: a comparison with routine attenders

Seventy-seven frequent attenders at an emergency department (ED) in an inner-city hospital in the UK (defined as seven or more visits in the previous 12 months) were compared with 182 patients who were attending the same department on a routine basis. Patients completed the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and the Short Form (SF)-36. Information was obtained on 64% of the frequent attenders and 45% underwent a detailed psychiatric assessment. Of the frequent attenders, 45% had psychiatric disorder and 49% had some form of an alcohol-related disorder. Compared with routine attenders, frequent attenders reported lower health status, had more psychiatric disorder (odds ratio: OR=8.2, 95% confidence interval: CI=3.8--18.1), had more general hospital admissions (OR=19.9, 95% CI=8.3--47.8), more psychiatric admissions (OR=167.5, 95% CI=9.5--2959.0), and more GP visits (95% CI for difference=-10.2 to -5.7). There was no evidence that frequent attenders had more somatisation than routine attenders. Specific treatment and management strategies need to be developed for this group of patients, although a substantial proportion may be difficult to engage in the treatment process.

Idiopathic pneumonia syndrome following myeloablative chemotherapy and autologous transplantation

OBJECTIVE

To report the outcome as well as the clinical, radiographic, and pathologic features of idiopathic pneumonia syndrome (IPS) following autologous peripheral blood stem cell transplantation (aPBSCT).

CLINICAL FINDINGS

A total of 271 patients with a variety of underlying malignancies received busulfan-containing myeloablative chemotherapy prior to aPBSCT; none of these patients received total body irradiation. Ten individuals developed IPS, with a median time of onset of 102 days after stem cell infusion. The major clinical and radiographic findings included an acute or subacute onset of dyspnea, cough, hypoxemia, and bilateral or unilateral infiltrates with or without pleural effusion. Pathologic findings consisted mainly of diffuse interstitial pneumonitis, organizing alveolitis, and cellular atypia. Nine patients diagnosed with IPS were treated with high doses of glucocorticoids parenterally. Despite heroic measures, eight patients died of IPS. The two remaining individuals recovered without experiencing significant long-term pulmonary sequelae.

DISCUSSION

Chronic low-dose busulfan therapy results in lung injury in 4-6% of patients after several years of treatment and once the cumulative dosage begins to approach 3g. High-dose, short-course busulfan (16 mg/kg)-containing conditioning chemotherapy prior to aPBSCT can also be complicated by IPS. IPS differs from lung damage due to chronic busulfan therapy by its earlier onset, an acute or subacute rather than indolent presentation, characteristic clinical and radiographic features, and lack of multinucleated giant cells on pathologic review. The pathophysiology of IPS secondary to high-dose busulfan-containing myeloablative regimens is not known, but cell-mediated immune reactions and release of cytokines may contribute to the lung injury. Mortality is high (80%) despite the use of heroic measures, including mechanical ventilation. Some patients, however, can respond to high doses of parenteral corticosteroid therapy.

CONCLUSIONS

IPS following high-dose, short-course busulfan-containing regimens exhibits unique clinical, radiographic, and pathologic features that differ from lung damage characteristic of chronic, low-dose busulfan therapy. Mortality from this complication is 80%, but some patients survive without long-term pulmonary sequelae following early treatment with glucocorticoids.

Comparison of technical success and outcome of tunneled catheters inserted via the jugular and subclavian approaches

PURPOSE

To compare the technical success and immediate and long-term outcomes of tunneled central venous catheters placed in comparative cohorts via the subclavian vein (SCV) and the internal jugular vein (IJV) routes.

MATERIALS AND METHODS

This was a prospective observational single-center study of consecutive procedures. Between November 1993 and June 1995, 99 catheters were placed via the SCV and between December 1997 and July 1998, 109 catheters were placed via the IJV. Procedural data were recorded in both cohorts by completion of a proforma by the primary operator.

RESULTS

Follow-up data were available in 96% of the SCV and 87% of the IJV cohorts. The average procedure time was significantly shorter in the IJV group and technical success was 100% versus 97% in the SCV group, but this did not reach statistical significance. The procedure-related pneumothorax rate and the rate of symptomatic venous thrombosis were significantly lower in the IJV cohort (P = .023, P = .015). Fewer catheters were removed prematurely due to sepsis in the IJV group (P = .043).

CONCLUSIONS

The IJV route is associated with comparable technical success, and lower major procedural complication and venous thrombosis rates, with fewer catheters removed prematurely. The right IJV approach with ultrasound guidance is recommended as the route of choice for the placement of tunneled central venous catheters.

Laparoscopic cholecystectomy: experience with 303 patients over the initial four years

A total of 303 patients underwent attempted laparoscopic cholecystectomy (LC) over a four-year period by two consultant surgeons or a senior trainee under their supervision. The procedure was completed in 291 with a conversion rate to open cholecystectomy of 3.9% and a median postoperative length of stay of two days, range zero to nine days. In eighteen patients the indication for LC was failure of symptoms to settle, two of whom required conversion (11.1%). Diathermy dissection was avoided in Calot's triangle and dissection started at the junction of Hartmann's pouch and cystic duct with full mobilisation of this area prior to clip application. Pre-operative endoscopic retrograde cholangiopancreatography ERCP was performed in patients suspected of having common bile duct stones without routine intra-operative cholangiography. There was one death in this series (0.3%) and an overall complication rate of 6.3 %. There was no incidence of either bile duct injury or leak. LC can be performed with a low complication rate with attention to careful dissection technique in the region of Calot's triangle.

Psychologic response of the edentulous patient after primary surgery for oral cancer: A cross-sectional study

STATEMENT OF PROBLEM

Edentulous patients can have difficulty in tolerating dentures and this may lead to psychologic disturbance. The problem is potentially more severe for edentulous patients after primary surgery for oral cancer, where treatment can include composite resection and reconstruction, followed by adjuvant radiotherapy.

PURPOSE

This study investigated the psychologic response and oral satisfaction of edentulous patients treated by surgery for oral squamous cell carcinoma, and to make a comparison to edentulous noncancer counterparts.

METHODS AND MATERIAL

The cross-sectional study included patients who were alive and disease-free 2 to 3 years after primary surgery. Seventy patients underwent surgery at the Regional Maxillofacial Unit, Liverpool, in 1993 and 1994. Twenty-eight patients were disease-free; 26 completed questionnaires that included a general health questionnaire (GHQ), a body satisfaction scale, a self-esteem scale, an oral symptom checklist, and a denture satisfaction questionnaire. Comparison was made with 98 noncancer edentulous patients from the same unit.

RESULTS

There were similarities in psychologic and oral satisfaction scores between the noncancer and cancer edentulous patients. Cancer patients reported lower self-esteem (P <.02). Cancer patients who were not rehabilitated with either conventional or implant-retained prostheses had significant psychologic morbidity as measured by the GHQ, self-esteem, and body satisfaction scales. Cancer patients with implant-retained overdentures reported greater satisfaction with their dentures compared with their counterparts who wore conventional dentures (P <.05).

CONCLUSION

Edentulous cancer patients who do not achieve oral rehabilitation after surgery for oral cancer exhibited significant psychologic morbidity. Patients with implant-retained overdentures exhibited a tendency to adopt the same psychologic response with improved denture satisfaction as edentulous patients with conventional dentures, despite the former having more extensive disease that would otherwise make the provision of dentures much more difficult if implants were not used.

Elderly care. Early warning system

In one area in Merseyside, primary care teams were only identifying elderly people with dementia in times of crisis, resulting in earlier than necessary residential or nursing home placements. Employing a social worker to work with primary care teams as a specialist care manager for this group has resulted in earlier and more appropriate care in the view of both carers and care workers. Following the appointment, interviews with 10 carers revealed that eight out of 10 patients were now receiving health and social care when nine out of 10 had previously received none.

Paclitaxel-induced acute bilateral pneumonitis

OBJECTIVE

To report three cases of paclitaxel-induced acute bilateral pneumonitis, as well as to ascertain its incidence and outcome.

CASE SUMMARIES

A total of 239 patients with a variety of underlying malignancies received 528 courses of paclitaxel-containing chemotherapy. Paclitaxel 200 mg/m2 was infused over 3 hours with standard premedication. Three patients developed bilateral interstitial infiltrates either during or within 6 hours of the administration of paclitaxel. Symptoms included a nonproductive cough, dyspnea, and sudden arterial oxygen desaturation. Response to parenteral corticosteroids was dramatic and reversed the process in all 3 patients.

DISCUSSION

Paclitaxel-induced acute bilateral pneumonitis appears to be a rare adverse reaction. It may either be a direct toxic effect of the chemotherapeutic agent or an adverse effect of its Cremophor EL diluent. Although the exact pathophysiology is unclear, a variety of immune and nonimmune mechanisms have been postulated, including hypersensitivity reactions, release of cytokines from macrophages, and the possible role of prior thoracic irradiation.

CONCLUSIONS

Acute bilateral pneumonitis occurs in less than 1% of individuals receiving 3-hour infusions of paclitaxel, and responds dramatically to parenteral corticosteroid therapy.

Thyroidectomy for medullary carcinoma in MEN 2A: positive genetic screening as the sole indicator for surgery

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What voices can do with words: pragmatics of verbal hallucinations

BACKGROUND

In this paper we consider verbal hallucinations as inner speech with pragmatics. The specific pragmatic properties of verbal hallucinations investigated included the number of voices, the characteristics that individuate the voices, the sequential characteristics of the dialogues between voice hearers and their voices, the dialogical positioning of voices hearers, voices and other individuals, and how the voices influence voice hearers' activities.

METHODS

These properties were examined in structured interviews with 28 individuals, 14 of whom had a diagnosis of schizophrenia, while 14 were students who did not use psychiatric services.

RESULTS

The analysis showed that voices were most frequently individuated with reference to individuals significant to voice hearers. The talk with voices was typically mundane and related to voice hearers' on-going activities, as is the case for ordinary inner speech. The voices were typically orientated towards the voice hearer, without direct access to each other or to other people. Contrary to received wisdom, the voices typically did not impel actions of voice hearers, rather they influenced voice hearers' decisions on how to act. This was so irrespective of the diagnostic status of informants. Finally, we have found some differences between the voices of informants with, and without, schizophrenia. These concerned the alignment of voices, the type of action required by a voice and the degree of dialogical engagement between voices and voice hearers.

CONCLUSIONS

We conclude that verbal hallucinations can be fruitfully considered to be a genus of inner speech. Pragmatics can be used as a framework to distinguish verbal hallucinations in different populations.

The effect of inhaled albuterol in moderate to severe asthma

BACKGROUND

Some recent clinical investigations suggest that regular use of inhaled bronchodilators may lead to deterioration in asthma control.

OBJECTIVE

The purpose of this study was to evaluate the effect of albuterol dosing schedule on clinical outcome in subjects with moderate to severe stable asthma.

METHODS

Seventeen adults were randomized to two 15-week treatment periods in a double-blind crossover design. Throughout the study, subjects were instructed to take two inhalations four times daily from an unlabeled "test" canister. In the four times daily and as-needed (QID + PRN) period, this canister contained albuterol; in the as-needed (PRN) period, it contained placebo. A "rescue" albuterol canister was available for as-needed use at all times. Inhaler actuations from both the test and rescue canisters were electronically recorded. Outcome measures included prednisone requirements, morning and evening symptoms and peak expiratory flow rates, total and nighttime rescue albuterol use, and asthma-specific quality of life.

RESULTS

The two treatment periods did not differ in symptoms, nighttime albuterol use, or asthma quality of life. During the QID+PRN period both morning and evening peak expiratory flow rates were significantly higher (p < 0.01 and 0.001, respectively) and total rescue use of albuterol was significantly less (p < 0.05) than the PRN period. Days on prednisone tended to be lower in the regular dosing period (p = 0.08).

CONCLUSION

In our sample of patients with moderate to severe asthma, four times daily dosing of albuterol did not lead to deterioration of asthma control.

The career paths of MHSc graduates in health promotion

There is much support for health promotion in Canada, but not much is known about the various academic programs in this field or of their impact on the practice of community health. A census survey was conducted in 1991 to determine the career paths of graduates of the MHSc program in Health Promotion at the University of Toronto. Findings from the study indicate that the career paths of graduates change following completion of their degree. They are more likely to work in health organizations other than hospital or treatment settings, to have more responsibility and authority in their positions as reflected by changes in job titles and to utilize a wider range of health promotion strategies and methods in their work following graduation. The findings indicate that graduate training in health promotion has a positive effect on the planning, implementation and evaluation of community health programs.

Evaluating drug prescribing in a large, ambulatory population: application of an embedded expert system

DUR is a process of problem detection and intervention designed to improve the quality and economy of drug prescribing. Retrospective DUR attempts to detect and address patterns of prescribing that might be indicative of inappropriate therapy. When the process is extended to a largely ambulatory population such as Medicaid beneficiaries, a number of complications are introduced due to the large numbers of patients and sparsity of data. In order to examine the impact of implementing a Medicaid DUR program, we developed a system that would apply screening criteria to prescription claims. It has been used to screen prescribing of groups of two antihypertensive drugs in the 1990 Maryland Medicaid population for 177,409 Medicaid eligible individuals. Potentially significant problems were detected with respect to dosing, duplication of therapeutic agents and drug interactions. The system represents, we believe, a significant improvement in the ability to detect and report prescribing decisions by increasing the specificity of the detection system. By the application of this system to a set of real-world data, we have demonstrated that it is feasible to implement such a system and derive results that are potentially useful in reducing the incidence of inappropriate physician decision-making.

Hepatic metastatic thymoma and myasthenia gravis twenty-two years after the apparent cure of an invasive thymoma. A case report and review of the literature

We report the case of a 62-year-old woman who presented in myasthenic crisis 22 years after radiation- and chemotherapy of an invasive thymoma which occurred during pregnancy. There was no evidence of recurrence of the thymoma at its original site, but an isolated hepatic metastasis was discovered. Biopsy of the mass revealed a spindle cell thymoma, whereas the original histology was that of a mixed round and spindle cell thymoma with moderate lymphocytic infiltration. The patient expired in spite of treatment with steroids, pyridostigmine bromide and plasma exchange on the one hand and cyclophosphamide with adriamycin on the other. To our knowledge, 22 years is the longest reported interval for the appearance of metastatic thymoma and myasthenia gravis after the diagnosis and apparent cure of a primary thymoma. This is also the only reported case of thymoma occurring during pregnancy but not associated with a rapidly fatal outcome.