Exploring adults' experiences of sedentary behaviour and participation in non-workplace interventions designed to reduce sedentary behaviour: a thematic synthesis of qualitative studies

BACKGROUND

Sedentary behaviour is any waking behaviour characterised by an energy expenditure of ≤1.5 metabolic equivalent of task while in a sitting or reclining posture. Prolonged bouts of sedentary behaviour have been associated with negative health outcomes in all age groups. We examined qualitative research investigating perceptions and experiences of sedentary behaviour and of participation in non-workplace interventions designed to reduce sedentary behaviour in adult populations.

METHOD

A systematic search of seven databases (MEDLINE, AMED, Cochrane, PsychINFO, SPORTDiscus, CINAHL and Web of Science) was conducted in September 2017. Studies were assessed for methodological quality and a thematic synthesis was conducted. Prospero database ID: CRD42017083436.

RESULTS

Thirty individual studies capturing the experiences of 918 individuals were included. Eleven studies examined experiences and/or perceptions of sedentary behaviour in older adults (typically ≥60 years); ten studies focused on sedentary behaviour in people experiencing a clinical condition, four explored influences on sedentary behaviour in adults living in socio-economically disadvantaged communities, two examined university students' experiences of sedentary behaviour, two on those of working-age adults, and one focused on cultural influences on sedentary behaviour. Three analytical themes were identified: 1) the impact of different life stages on sedentary behaviour 2) lifestyle factors influencing sedentary behaviour and 3) barriers and facilitators to changing sedentary behaviour.

CONCLUSIONS

Sedentary behaviour is multifaceted and influenced by a complex interaction between individual, environmental and socio-cultural factors. Micro and macro pressures are experienced at different life stages and in the context of illness; these shape individuals' beliefs and behaviour related to sedentariness. Knowledge of sedentary behaviour and the associated health consequences appears limited in adult populations, therefore there is a need for provision of accessible information about ways in which sedentary behaviour reduction can be integrated in people's daily lives. Interventions targeting a reduction in sedentary behaviour need to consider the multiple influences on sedentariness when designing and implementing interventions.

Serum total hCGβ level is an independent prognostic factor in transitional cell carcinoma of the urothelial tract

Background:

Serum total human chorionic gonadotrophin β subunit (hCGβ) level might have prognostic value in urothelial transitional cell carcinoma (TCC) but has not been investigated for independence from other prognostic variables.

Methods:

We utilised a clinical database of patients receiving chemotherapy between 2005 and 2011 for urothelial TCC and an independent cohort of radical cystectomy patients for validation purposes. Prognostic variables were tested by univariate Kaplan–Meier analyses and log-rank tests. Statistically significant variables were then assessed by multivariate Cox regression. Total hCGβ level was dichotomised at < vs ⩾2 IU l⁻¹.

Results:

A total of 235 chemotherapy patients were eligible. For neoadjuvant chemotherapy, established prognostic factors including low ECOG performance status, normal haemoglobin, lower T stage and suitability for cisplatin-based chemotherapy were associated with favourable survival in univariate analyses. In addition, low hCGβ level was favourable when assessed either before (median survival not reached vs 1.86 years, P=0.001) or on completion of chemotherapy (4.27 vs 0.42 years, P=0.000002). This was confirmed in multivariate analyses and in patients receiving first- and second-line palliative chemotherapy, and in a radical cystectomy validation set.

Conclusions:

Serum total hCGβ level is an independent prognostic factor in patients receiving chemotherapy for urothelial TCC in both curative and palliative settings.

A survey of community exercise programmes for stroke survivors in Scotland

Stroke is the most common cause of complex disability in the community. Physical fitness is often reduced after stroke, but training can improve fitness and function. UK and international stroke clinical guidelines recommend long-term exercise participation for stroke survivors. However, there has been no previous research into what services are available to support this. In 2009, we conducted the first European survey of community Exercise after Stroke services. A link to our web-based survey was emailed to health, leisure service and stroke charity contacts in Scotland with email and telephone follow-up to non-respondents. The overall response rate was 64% (230/361). A total of 14 Exercise after Stroke services were identified, the majority of which were run by charity collaborations (7/14), followed by leisure centre services (4/14) and health services (3/14). We sought information on session content, referral and assessment processes, and the qualifications of exercise instructors. This information was cross-referenced with current clinical and exercise guidelines to determine whether existing resources were sufficient to meet stroke survivors' needs for safe, effective and sustainable access to exercise. The results indicated a shortage of stroke-specific community exercise programmes. Further service development is required to ensure appropriate instructor training and referral pathways are in place to enable stroke survivors to access exercise services in accordance with current guidelines.

Risk factors associated withSalmonella entericasubsp.entericacontamination of chicken carcases in Senegal

The objective of this study was to identify the risk factors for Salmonella spp. contamination of Senegalese chicken carcases during slaughtering. One hundred and twenty traditional slaughterhouses were studied from January 2000 to December 2002 in and around Dakar. A questionnaire was administered to the slaughterers and samples of breast skin were taken to assess the Salmonella spp. status of chicken carcases. Results showed that 43.3% of the chicken batches were contaminated with Salmonella spp., with Salmonella Hadar and Salmonella Brancaster as the two main serovars. Salmonella spp. contamination of the live birds before slaughtering was related to contamination of the carcases after slaughtering. Feed withdrawal before slaughtering and thorough cleaning and disinfection procedures decreased the risk of Salmonella contamination. One individual worker for each slaughtering stage was also associated with a decreased risk of Salmonella contamination. Using scalding water for plucking increased the risk of contamination. These results will help slaughterers to produce safer products for local consumers.

Randomized phase II/III trial comparing gemcitabine/carboplatin (GC) and methotrexate/carboplatin/vinblastine (M-CAVI) in patients (pts) with advanced urothelial cancer (UC) unfit for cisplatin-based chemotherapy (CHT): Phase III results of EORTC study 30986

LBA4519

Background: About 50% of pts with advanced UC are not eligible for cisplatin based CHT (“unfit”) due to impaired renal function, performance status (PS) or comorbidity. This is the first randomized phase II/III trial comparing two chemotherapy regimens in this pts group.

Methods: The primary objective of the phase III part of this study was to compare the overall survival (OS) of CHT naïve pts with measurable disease and an impaired renal function (GFR<60 but >30 ml/min) and/or PS 2 who were randomized to receive either GC (G 1000 mg/m2 d1 and 8 and C AUC 4.5) q21 days or M-CAVI (M 30 mg/m2 d1 and 15 and 22, C AUC 4.5 d1 and VI 3 mg/m2 d1 and 15 and 22) q28 days. In order to detect an increase of 50% in median survival on GC compared to M-CAVI (13.5 versus 9 months) based on a two sided logrank test at error rates alpha=0.05 and beta=0.20, 225 pts were required. Secondary endpoints were overall response rate (ORR) and progression free survival (PFS).

Results: 238 pts, 119 in each arm, were randomized between January 2001 and March 2008 by 29 institutions. The median follow-up is 4.5 years. Two pts were ineligible and two other pts never started treatment. Best ORRs (CR + PR) were 41.2% (36.1% confirmed response) on GC versus 30.3% (21.0% confirmed response) on M-CAVI (p = 0.08). Median OS was 9.3 months on GC and 8.1 months on M-CAVI (p = 0.64). There was no difference in PFS between the two arms (p = 0.78). OS, PFS and ORR were similar in each of the risk groups (reason unfit for cisplatin and Bajorin risk group). Severe acute toxicity (SAT) (death, grade 4 thrombocytopenia with bleeding, or grade 3/4 renal toxicity, neutropenic fever or mucositis) was observed in 9.3% of pts on GC (2 toxic deaths) and 21.2% on M-CAVI (4 toxic deaths). The most common grade 3/4 toxicities were leucopenia (44.9%, 46.6%), neutropenia (52.5%, 63.5%), febrile neutropenia (4.2%, 14.4%), thrombocytopenia (48.3%, 19.4%), and infection (11.8%, 12.7%) on GC and M-CAVI, respectively.

Conclusions: There were no significant differences in efficacy between the two treatment groups. The incidence of SATs was slightly higher on M-CAVI.

[Table: see text]

Genetic characterization and antibiotic resistance of Campylobacter spp. isolated from poultry and humans in Senegal

AIMS

The main objectives of this study were to investigate the diversity of Campylobacter genotypes circulating in Senegal and to determine the frequency of antibiotic resistance.

METHODS AND RESULTS

Strains of Campylobacter jejuni isolated from poultry (n = 99) and from patients (n = 10) and Campylobacter coli isolated from poultry (n = 72) were subtyped by pulsed-field gel electrophoresis (PFGE). The pulsotypes obtained after digestion by SmaI and KpnI revealed a significant genetic diversity in both species, but without any predominant pulsotypes. However, farm-specific clones were identified in the majority of poultry houses (76.5%). Human and poultry isolates of C. jejuni had common PFGE patterns. High quinolone-resistance rates were observed for C. jejuni (43.4%) and C. coli (48.6%) isolates obtained from poultry.

CONCLUSIONS

The results showed a genetic diversity of Campylobacter between farms indicating multiple sources of infection; but specific clones had the ability to colonize the broiler farms. The antimicrobial resistance patterns were not related to any specific PFGE pattern suggesting that resistance was due to the selective pressure of antibiotic usage. Campylobacter with similar genotypes were circulating in both human and poultry.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study is important for the understanding of the epidemiology of Campylobacter in broiler farms in Senegal. It also emphasizes the need for a more stringent policy in the use of antimicrobial agents in food animals.

Defining Burkitt’s lymphoma (BL) with cytogenetics: LY10, a prospective clinicopathological study of dose-reduced (dr) CODOX-M/IVAC in patients with 100% Ki-67 staining B-cell non-Hodgkin’s lymphoma (NHL)

7557

Background: Previous studies suggest that CODOX-M/IVAC is effective therapy for BL (Ann Onc 2002 13:1264–74), however the diagnosis of BL in this and other studies was not based on modern immunochemistry and cytogenetics and is unreliable. To re-evaluate this question we prospectively studied a population of patients (pts) with aggressive B-cell lymphoma (100% Ki-67+) uniformly treated with dr CODOX-M/IVAC. Methods: Pts ≤65 years with B-cell lymphomas showing 100% Ki-67, considered fit for chemotherapy, received either dr CODOX-M x 3 or dr CODOX-M/IVAC x 4 according to a modified international prognostic index (IPI). Chemotherapy was modified by methotrexate dose reduction to 3g/m2. Pts >65 years had further dose reductions; unfit pts were studied pathologically only. Tumours were characterised using both an extended panel of antibodies and interphase FISH on paraffin sections for the presence of the C-MYC and BCL-2 rearrangements. Results: Of 126 pts reviewed centrally, 5 were ineligible; 53 were diagnosed as BL, each based on the combination of the presence of re-arrangement of C-MYC as a sole abnormality, germinal centre phenotype and p53 abnormality. The final 68 cases were highly heterogenous with respect to tumour phenotype and cytogenetics and were diagnosed as diffuse large B-cell lymphoma (DLBCL). Median age (all pts) was 44 years (range 17–83), with 23 aged >65. Compared with the DLBCL pts, BL pts were significantly younger (mean 38yrs vs 53 yrs, p < 0.001), had more marrow involvement (45% vs 24%, p = 0.02) and male predominance (83% vs 65%, p = 0.03). Of 104 pts entered into the clincal study, 32 pts (10 BL, 22 DLBCL, IPI 0,1) received dr CODOX-M x 3 and 72 (39 BL, 33 DLBCL, IPI >1) received dr CODOX-M/IVAC x 4. With median follow-up of 15 months (range 1 to 37), 1 year progression-free survival was 58%, 95% CI 48%-68% (54% BL vs 62% DLBCL) and 1 year survival 61% 95% CI 51%-71% (55% BL vs 66% DLBC). Conclusions: The study shows Ki67 is not an accurate approach to the diagnosis of BL and the use of immunocytochemistry and FISH is essential. BL and DLBCL as defined differ markedly clinically. Preliminary data suggest that dr CODOX-M/IVAC has similar activity in both histologies.

No significant financial relationships to disclose.

A prospective study of 18FDG PET in the prediction of relapse in patients with high risk clinical stage I (CS1) non-seminomatous germ cell cancer (NSGCT): MRC study TE22

4520

Background: High risk stage I NSGCT is characterised by vascular or lymphatic invasion within the primary tumour. This group comprises ∼50% of stage I pts with, (untreated) a relapse rate of 35–40%. Options for the management of such pts include adjuvant chemotherapy, retroperitoneal lymph node dissection (± adjuvant chemotherapy) and surveillance, each achieving similarly high cure rates. An FDG PET scan may be able to aid discrimination between pts without occult metastatic disease, for whom surveillance is an attractive option, and those requiring immediate therapy. Methods: High risk (vascular invasion +ve) CS1 NSGCT pts underwent FDG PET scanning within ∼8 weeks of orchidectomy. PET+ve pts went off study, PET -ve pts were followed on surveillance. The primary outcome measure was the -ve predictive value of PET, defined as the 2-year relapse-free rate (RFR) in pts with a negative PET scan. Assuming a RFR of ∼90%, to exclude a RFR < 80% with 80% power (5% significance), ∼100 PET negative pts were required from ∼135 scanned pts. All baseline CT scans were subject to central review blinded to PET result and relapse status and, in relapsed pts, a retrospective comparison of the CT and PET scan results. Results: Pts were registered between 5/02 and 1/05, when the trial was stopped early by the independent Data Monitoring Committee due to an unacceptably high relapse rate in the PET-ve pts. 116 pts were registered of whom 111 underwent PET scans. 88 pts (79%) were PET-ve; 87 proceeded to surveillance and one requested adjuvant chemotherapy. With median follow-up of 11 months, 33 of the 87 pts on surveillance relapsed for a one-year relapse-free rate of 63% 90% CI (54%, 72%). The PET +ve/relapse rate was 69% in patients with normal markers pre-orchidectomy (n = 36) and 41% in those with raised markers (n = 66). There has been one death (suicide) amongst the PET -ve pts. The radiology and PET scan review will be completed by May 2006. Conclusions: Though PET identified a proportion of pts with disease not detected by CT scan the relapse rate amongst PET -ve pts remains high. The study results therefore suggest that 18FDG PET scanning is not able to identify pts at sufficiently low risk of relapse to replace other treatment options in this setting.

No significant financial relationships to disclose.

Risk factors associated with Salmonella enterica subsp. enterica contamination of chicken carcases in Senegal

This study was to identify the risk factors for Salmonella spp. contamination of Senegalese chicken carcases during slaughtering. One hundred and twenty traditional slaughterhouses were studied from January 2000 to December 2002 in and around Dakar. A questionnaire was answered by the slaughterers, and samples of breast skin were taken to assess the Salmonella status of chicken carcases. Results showed that 43.3% of the batches were contaminated with Salmonella, indicating Salmonella Hadar and Salmonella Brancaster as the two main serovars. Salmonella contamination of the carcases after slaughtering was related to contamination of the live birds. Feed withdrawal before slaughtering and thorough cleaning and disinfection procedures decreased the risk of contamination. One individual worker for each slaughtering stage was also associated with a decreasing risk of contamination. Using scalding water for plucking the chicken carcases increased contamination risk. These results will help slaughters to produce safer products for local consumers.

Pharmacological cardioversion for atrial fibrillation and flutter

BACKGROUND

Atrial fibrillation is the commonest cardiac dysrhythmia. It is associated with significant morbidity and mortality. There are two approaches to the management of atrial fibrillation: controlling the ventricular rate or converting to sinus rhythm in the expectation that this would abolish its adverse effects.

OBJECTIVES

To assess the effects of pharmacological cardioversion of atrial fibrillation in adults on the annual risk of stroke, peripheral embolism, and mortality.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (Issue 3, 2002), MEDLINE (2000 to 2002), EMBASE (1998 to 2002), CINAHL (1982 to 2002), Web of Science (1981 to 2002). We hand searched the following journals: Circulation (1997 to 2002), Heart (1997 to 2002), European Heart Journal (1997-2002), Journal of the American College of Cardiology (1997-2002) and selected abstracts published on the web site of the North American Society of Pacing and Electrophysiology (2001, 2002).

SELECTION CRITERIA

Randomised controlled trials or controlled clinical trials of pharmacological cardioversion versus rate control in adults (>18 years) with acute, paroxysmal or sustained atrial fibrillation or atrial flutter, of any duration and of any aetiology.

DATA COLLECTION AND ANALYSIS

One reviewer applied the inclusion criteria and extracted the data. Trial quality was assessed and the data were entered into RevMan.

MAIN RESULTS

We identified two completed studies AFFIRM (n=4060) and PIAF (n=252). We found no difference in mortality between rhythm control and rate control relative risk 1.14 (95% confidence interval 1.00 to 1.31). Both studies show significantly higher rates of hospitalisation and adverse events in the rhythm control group and no difference in quality of life between the two treatment groups. In AFFIRM there was a similar incidence of ischaemic stroke, bleeding and systemic embolism in the two groups. Certain malignant dysrhythmias were significantly more likely to occur in the rhythm control group. There were similar scores of cognitive assessment. In PIAF, cardioverted patients enjoyed an improved exercise tolerance but there was no overall benefit in terms of symptom control or quality of life.

AUTHORS' CONCLUSIONS

There is no evidence that pharmacological cardioversion of atrial fibrillation to sinus rhythm is superior to rate control. Rhythm control is associated with more adverse effects and increased hospitalisation. It does not reduce the risk of stroke. The conclusions cannot be generalised to all people with atrial fibrillation. Most of the patients included in these studies were relatively older (>60 years) with significant cardiovascular risk factors.

Early Carotid Surgery in Acute Stroke: A Multicentre Randomised Pilot Study

BACKGROUND

Standard practice has been to delay carotid endarterectomy (CEA) for 2 months following acute stroke to avoid a perceived risk of cerebral haemorrhage. We investigated whether early CEA reduces early recurrent stroke and improves outcome in partial anterior circulation infarction (PACI).

METHODS

Patients with PACI and a Barthel score of >18 before stroke underwent carotid duplex and CT imaging within 7 days of stroke. Forty consenting patients fit for surgery with greater than 70% ipsilateral carotid stenosis were randomised, 19 to 'early' (within 24 h) and 21 to 'delayed' surgery (at 8 weeks). Modified Rankin and Barthel scores were recorded at 1 week, 2 months, 6 and 12 months.

RESULTS

Rankin scores improved more rapidly following 'early' surgery to a score of 1 (0-4) at 2 and 6 months compared with 2.5 and 2 (1-4), respectively, for delayed surgery (p < 0.05). Barthel scores were also significantly improved following 'early' CEA at 7 days but both groups reached a median score of 20 by 2 months. Four 'delayed' and 3 'early' patients suffered extension or recurrence of neurological deficits with 1 death in each group.

CONCLUSIONS

Early CEA within 7 days of ischaemic stroke improved functional outcome with earlier hospital discharge. A large multicentre study is needed to exclude the possibility that 'early' CEA increases the risk of cerebral haemorrhage or death.

Stevens-Johnson syndrome after treatment with rituximab

Rituximab is a chimeric mouse/human anti-CD20 antibody licensed for the treatment of low-grade non-Hodgkin's lymphoma and has recently also been shown to have a role in the treatment of diffuse large B-cell lymphoma. We report a case of Stevens-Johnson syndrome after treatment with rituximab, which occurred in a 36-year-old man with relapsed follicular lymphoma. The patient developed mucositis and fevers after the first two injections, followed by a florid maculopapular rash with severe orogenital ulceration after the third infusion. Over several weeks his symptoms progressed with severe cutaneous, orogenital and conjunctival ulceration, leading to visual problems and malnutrition. No improvement occurred with steroids and immunosuppressant therapy. A review of the literature reveals this to be the first reported case of Stevens-Johnson syndrome associated with rituximab therapy.

Magnetic resonance brain imaging in people with dizziness: a comparison with non-dizzy people

BACKGROUND

Dizziness is a common symptom affecting about 30% of people over the age of 65.

OBJECTIVE

To investigate the hypothesis that structural abnormalities of the brain and cervical cord are more common in dizzy than in non-dizzy subjects.

METHODS

A case-control study of subjects over the age of 65 with and without dizziness: 125 dizzy subjects and 86 non-dizzy subjects were recruited from the community through articles in the local press. Magnetic resonance imaging (MRI) of the brain and neck was performed, and was read by a consultant neuroradiologist blind to the clinical details.

RESULTS

All dizzy subjects and all controls had at least one structural abnormality. Cerebral atrophy was found in 86% of dizzy subjects and 85% controls (p = 1.0) At least one white matter lesion was found in 69% of dizzy subjects and 78% controls (p = 0.21). White matter lesions in the midbrain were more common in dizzy than in non-dizzy subjects (22% v 4%, p < 0.001). There were no significant differences in the prevalence of cord compression, cervical subluxation, facet joint degeneration, vertebral artery compression, or vertebral artery occlusion between dizzy and non-dizzy subjects.

CONCLUSIONS

Structural abnormalities of the brain and neck are common in both dizzy and non-dizzy subjects. "Routine" MRI is unlikely to reveal a specific cause for dizziness. The observation of more frequent white matter lesions in the midbrain in dizzy subjects requires further study to determine whether small vessel changes could cause dizziness in older people.

Changes in the carriage of Campylobacter strains by poultry carcasses during processing in abattoirs

The recent development of simple, rapid genotyping techniques for Campylobacter species has enabled investigation of the determinative epidemiology of these organisms in a variety of situations. In this study we have used the technique of fla typing (PCR-restriction fragment length polymorphism analysis of the flaA and flaB genes) to identify the sources of strains contaminating the carcasses of five campylobacter-positive and two campylobacter-negative broiler flocks during abattoir processing. The results confirmed that, in the United Kingdom, individual broiler flocks are colonized by a limited number of subtypes of Campylobacter jejuni or C. coli. In some but not all cases, the same subtypes, isolated from the ceca, contaminated the end product as observed in carcass washes. However, the culture methodology, i.e, use of direct plating or enrichment, affected this subtype distribution. Moreover, the number of isolates analyzed per sample was limited. fla typing also indicated that some campylobacter subtypes survive poultry processing better than others. The extent of resistance to the environmental stresses during processing varied between strains. The more robust subtypes appeared to contaminate the abattoir environment, surviving through carcass chilling, and even carrying over onto subsequent flocks. From these studies it is confirmed that some campylobacter-negative flocks reach the abattoir but the carcasses from such flocks are rapidly contaminated by various campylobacter subtypes during processing. However, only some of these contaminating subtypes appeared to survive processing. The sources of this contamination are not clear, but in both negative flocks, campylobacters of the same subtypes as those recovered from the carcasses were isolated from the crates used to transport the birds. In one case, this crate contamination was shown to be present before the birds were loaded.

The imaging of Burkitt's and Burkitt-like lymphoma

We describe the radiological findings at presentation and follow up in 24 adult patients with Burkitt's and Burkitt-like lymphoma, age range 17-67 years. This is an older age group than previously described in North American series, but the clinical and imaging characteristics appear similar. Disease confined to the abdomen was seen in 12 (50%) at presentation, of whom 11 had bowel or mesenteric tumours. Of those with bowel involvement, five patients had disease that had arisen in the ileocaecal region. Intra-abdominal disease was large volume (greater than 5 cm) in the majority of patients. Four patients (17%) had small isolated masses in the head and neck region, two (8%) had isolated unilateral axillary lymphadenopathy. Six (25%) patients presented with disseminated disease, all with hepatic and/or splenic involvement, intra-abdominal and peripheral lymphadenopathy. Three of these patients with disseminated disease were human immunodeficiency virus (HIV) positive. Neurological symptoms were present in a total of five patients at presentation or relapse but positive imaging findings were present in only two patients who had MRI. Computed tomography (CT) head scans performed in four patients were normal. Disease recurrence most commonly occurred within the abdomen.

The polyether bistratene A activates protein kinase C-delta and induces growth arrest in HL60 cells

Bistratene A (BisA) induced growth arrest in G2/M in HL60 cells. In addition, BisA-treated cells (50 nM for 48 h) became adherent and expressed the adhesion molecule CD11c, but did not express the monocyte enzyme alpha-napthyl acetate esterase or phagocytose complement coated yeasts. BisA activated protein kinase C (PKC)-delta and induced translocation of PKC-delta to the nucleus. This suggests that activation of PKC-delta can induce growth arrest and cell adhesion, but is insufficient to mediate full differentiation of HL60 cells. BisA has potential as a new probe for determining the function of PKC isoenzymes, specifically PKC-delta.

Patterns of supradiaphragmatic metastases in testicular germ cell tumours

The imaging and clinical findings of 31 patients with supradiaphragmatic nodal metastases from primary testicular germ cell cancers were reviewed. In 11 patients the primary testicular tumor was a seminoma, and in 20 a non-seminomatous germ cell tumour (NSGCT). The patterns of spread of these tumour types were compared. All patients had chest radiographs (CXR): 27 had chest computed tomography (CT). One patient with seminoma and eight with NSGCT (40%) had lung metastases. Mediastinal lymphadenopathy was seen on CT in seven patients with seminoma (64%) and in nine patients with NSGCT (45%). Neck lymphadenopathy was present in 10 of 11 (91%) patients with seminoma, and 13 of 20 (65%) patients with NSGCT. Neck disease co-existed with mediastinal disease in six of 11 (55%) patients with seminoma, but in only two of 20 (10%) patients with NSGCT (P=0.012). This study gives further supporting evidence for the relative importance of haematogenous spread in teratoma, and lymphatic spread in seminoma. The contiguous nature of disease spread from abdomen to chest and neck in seminoma is confirmed. In NSGCT, supradiaphragmatic spread is more random but tends to occur in the paraoesophageal and subcarinal groups.

The influence of contralateral carotid stenosis and occlusion on cerebral oxygen saturation during carotid artery surgery

OBJECTIVES

To study the effect of contralateral carotid stenosis on oxygen saturation (CsO2) of both cerebral hemispheres monitored by reflective near-infrared spectroscopy (NIRS) during carotid surgery.

METHODS

NIRS was compared to ipsilateral transcranial Doppler ultrasonography (TCD) of the middle cerebral artery and jugular bulb venous oxygen saturation (JvSO2) in 54 patients undergoing carotid endarterectomy.

RESULTS

Median operated side and contralateral CsO2 were 68(54-88)% and 69(55-85)% before carotid clamping falling to 63(44-80)% and 69(55-84)% respectively on clamping the carotid (p < 0.0001 and p = NS). JvSO2 fell from 78(38-98)% to 72(30-97)% on carotid clamping with a percentage fall in peak TCD of -28(0 to -100)% (p < 0.0001). Patients with a contralateral carotid artery occlusion experienced falls in ipsi and contralateral CsO2 of -8(-4 to -10)% and -3(2 to -7)% compared to -4(0 to -14)% and 0(-5 to 4)% in those with a lesser stenosis (p < 0.05). On declamping, median ipsilateral and contralateral CsO2 rose from 65(46-82)% and 67(52-87)% to 68(53-84)% respectively (p < 0.0001 and p = NS). JvSO2 increased from 75(33-95)% to 79(42-95)% (p < 0.0001) with an increase in median peak TCD of 35(-34 to 506)%.

CONCLUSIONS

The greatest changes in CsO2 occurred in the operated side cerebral hemispheres in those with a contralateral carotid artery occlusion. However, a contralateral carotid artery occlusion does not reliably predict the need for a shunt and cerebral monitoring remains essential; although is only required on the operated side.

Testicular cancer

Despite the overall cure rate now in excess of 90%, innovation in management of germ cell tumors continues. The report that 80% of patients with extragonadal germ cell tumors have either carcinoma in situ or atrophic tubules as evidence of tumor rejection emphasizes the need to investigate the testis in patients with undiagnosed primary cancer because even today treatment delay is worsening prognosis. The evidence that testicular atrophy is a precursor of malignancy may explain why testis cancer has increased while normal sperm count has fallen over the past 50 years and why there is an association between exposure during service in Vietnam to agents that damage spermatogenesis and development of testis cancer. The improved prognostication from analysis of large databases and salvage with high-dose chemotherapy and bone marrow rescue are giving confidence to explore new innovations, eg, carboplatin instead of cisplatin. In addition, as the database on patients with stage I disease on surveillance enlarges, so does interest in adjuvant chemotherapy, encouraging the search for better markers to predict poor response. Linkage between overproduction of the tumor marker lactate dehydrogenase-1 and the increased copy number of the isochrome 12p in the tumor may be of use in this respect. Reports that germ cell tumor patients exposed to etoposide, eg, leukemic, lung, and ovarian cancer patients, can develop an acute myeloid leukemia with a marker on chromosome 11 are tempering enthusiasm for its use in adjuvant therapy. However, the observation that radiotherapy or chemotherapy may reduce second testis tumor incidence more effectively than surgery does encourages more detailed exploration of the results of adjuvant treatment.

Competitive exclusion in the young bird: challenge models, administration and reciprocal protection

The competitive exclusion (CE) concept has been tested against both non-invasive and invasive salmonella serotypes. Studies with different challenge models indicate that CE treatment is likely to protect the young bird against all serotypes that are capable of intestinal colonization. Spray or 'droplet' application of the CE-treatment material was compared with administration in the first drinking water. Both methods gave a similar degree of protection against Salmonella infantis. A study was made to compare protection of newly hatched chicks and turkey poults by the one commercial CE product Broilact, and two similar preparations involving intestinal microorganisms from an adult turkey. Each preparation protected both avian species when administered orally prior to challenge, but the degree of protection obtained varied with the type of preparation and its host origin.

Direct and indirect measures of memory for modality in young and older adults

In 2 experiments, young and older adults demonstrated modality effects of similar magnitude in perceptual identification tasks. That is, both young and older adults demonstrated more repetition priming when study and test modalities matched than when they were different, suggesting that contextual information was equally available across age. However, when asked explicitly to retrieve modality information, older adults were less accurate than young adults. These results constitute evidence for a dissociation between direct and indirect measures of memory for modality information. They call into question hypotheses that memory impairment in old age is due to deficient encoding of contextual information and challenge current accounts of modality effects in repetition priming.

BOP/VIP--a new platinum-intensive chemotherapy regimen for poor prognosis germ cell tumours

Ninety-one patients with poor prognosis non-seminomatous germ cell tumours (NSGCT) were treated with an initial intensive chemotherapy schedule. Suitable patients fulfilled one or more of the following criteria: lymph node metastases greater than 10 cm diameter; liver, brain or bone metastases; serum HCG level greater than 50,000 IU/L; and extragonadal primary tumours. Treatment consisted of 3 cycles of bleomycin, vincristine and cisplatin (BOP) administered at 10 day intervals, followed by 3 cycles of etoposide, ifosfamide and cisplatin (VIP) at 21 day intervals. A total of 64 patients (70%) achieved a complete remission. This comprised 46 patients who received BOP/VIP only, and 18 patients who received additional chemotherapy after BOP/VIP. Of these 64 patients, 51 underwent complete surgical resection of residual masses, including 11 in whom there was evidence of teratoma with cellular atypia or non-germ cell cancer in the resected tissue. A further 9 patients had persisting unresected radiological masses in the presence of marker complete remission. The overall response rate was 80%. Currently 57 patients (63%) remain alive and free from disease progression. The median follow-up period is 90 weeks (range 24-206 weeks), with a 2 yr actuarial progression-free survival of 66% (95% c.i. 55-77%). Major toxicity was myelosuppression, occurring during the VIP arm of therapy, with a median nadir WBC of 1.1 x 10(9)/L and median platelet count of 51 x 10(9)/L. Other toxicity included peripheral neuropathy (WHO Grade 2 and 3 in 22%). We conclude that treatment results with the BOP/VIP schedule in this poor prognosis patient group are at least comparable with other schedules, and toxicity is manageable.(ABSTRACT TRUNCATED AT 250 WORDS)

Electroconvulsive therapy in octogenarians

Medical records of 81 older patients (65 years of age and over) who underwent electroconvulsive therapy (ECT) at a university-affiliated private geriatric hospital were reviewed to evaluate the safety and efficacy of this treatment for depression in the "young-old" (65 to 80 years) compared with the "old-old" age group (over 80 years), a group that has not yet been adequately studied. Information was obtained regarding demographics, medical and psychiatric diagnosis, medications, indications for ECT, number and laterality of treatments, outcome, and complications. Thirty-nine patients 80+ years of age (mean age, 85 +/- 3.2) were compared with 42 patients 65 to 80 years of age (mean age, 74 +/- 5.2). Statistical analysis was performed using confidence intervals of the difference in proportions of patients in each group. There were no significant differences in the demographics, number and laterality of ECT treatments, indications for ECT treatment, medical diagnosis, medications, or prior history of falls, but psychiatric diagnoses differed slightly. Patients over 80 years had significantly more cardiovascular complications and falls (95% confidence interval) and tended to have a worse ASA (American Society of Anesthesiologists) scale rating and a somewhat less successful outcome. This study confirms the role of ECT as a relatively safe and effective treatment, which may be lifesaving in selected depressed older patients. Prospective studies are needed to understand better the long-term outcome and to prevent the morbidity and mortality associated with ECT in this frail, high-risk older group.

Surgery after initial chemotherapy for localized small-cell carcinoma of the lung

Despite the high response rates induced by chemotherapy, many patients with limited small-cell lung cancer (SCLC) relapse at the site of primary disease. Failure of radiotherapy to overcome this has led to the use of surgery as part of a combined modality approach. Between December 1981 and December 1985, 189 patients with SCLC were assessed for suitability for surgery after an initial three cycles of chemotherapy (doxorubicin, cyclophosphamide, and etoposide). Fifty-seven were found to have limited disease, and of these, 19 were ineligible or unfit for surgery. Of the 38 eligible patients, 84% had an objective response to three cycles of chemotherapy and 25 were deemed suitable for surgery after restaging. At thoracotomy, four were inoperable, nine had a lobectomy, and 12 had a pneumonectomy. There was no evidence of viable SCLC in four resection specimens (one stage 1, two stage 2, one stage 3 at presentation), no viable SCLC but an entirely separate focus of viable poorly differentiated squamous carcinoma (SqLC) in one, and the remaining specimens contained viable SCLC. Survival of patients selected to undergo tumor resection was excellent (median survival, 33 months; plateau phase, 48% alive at 3 to 5 years), but survival of the entire group with limited SCLC was not dissimilar from that reported in previous series of limited-stage tumor treated with chemotherapy alone. Long-term survival appeared to be largely restricted to those with no evidence of viable SCLC at surgery (no viable SCLC, zero of five relapsed; viable SCLC, 13 of 16 relapsed and/or died). This prospective study confirms the feasibility of the combined modality approach, but suggests that any improvement in overall survival is likely to be small. Until the results from multicenter randomized trials are available, surgery, as part of a combined modality program, should be regarded as experimental.

Early effects of oxygen administration and prognosis in chronic obstructive pulmonary disease and cor pulmonale

The purpose of this study was to develop criteria for predicting survival and clinical improvement with long-term domiciliary home oxygen therapy (LTDO2) in patients with both chronic obstructive pulmonary disease (COPD) and cor pulmonale (CP). Twenty-eight such patients were divided into 2 groups, responders (R) and nonresponders (NR), on the basis of the fall in their mean pulmonary artery pressure (delta PAP) while breathing 28% O2 for 24 h. The R(n = 17) and NR (n = 11) had delta PAP greater than and lesser than 5 mmHg, respectively. Eighty-eight percent of the R, but only 22% of the NR, were alive at the end of 2 yr of LTDO2. Eighty-five percent of R, but only 11% of NR, achieved an end-exercise maximal oxygen consumption (max VO2) greater than 6.5 ml min-1 kg-1. Left ventricular ejection fraction improved while breathing O2 for 48 h in the R only. The NR and R were similar in all other respects. We conclude that delta PAP greater than 5 mmHg and/or max VO2 6.5 ml min-1 kg-1 or greater predict 2-yr survival with LTDO2 in patients with COPD and CP, and it can be useful in planning their management.

Density dependence of expiratory flow and bronchodilator response in asthma

Change in the magnitude of density dependence of the maximal expiratory flow (D/MEF) following inhalation of isoproterenol was used as a test for predicting the long term response to isoproterenol vs atropine in 24 adult patients with longstanding asthma. Eleven subjects showed a decrease in D/MEF manifested by increase in volume of isoflow (VisoV) and/or decrease in Vmax50 Helox/air following isoproterenol inhalation (group 1). Thirteen subjects manifested an opposite response (group 2). Atropine sulphate (0.08 mg/kg) and isoproterenol hydrochloride (2.5 mg) were then administered by inhalation, each four times a day for seven days in a randomized double-blind cross over fashion to all subjects. One of group 1 but ten of group 2 subjects had a greater subjective and objective improvement with atropine than with isoproterenol (P less than .005). An increase in D/MEF following isoproterenol can be used as a test to predict a better response to atropine than to isoproterenol over a one week period. Such a response occurs in almost half of the adult chronic asthmatic patients. The results are consistent with a preferential dilatation of the large airways by atropine.

Myocardial infarction with and without laboratory documentation--one year prognosis

This retrospective study indicates that patients admitted to our CCU with a history typical for myocardial infarction appear to have a comparable in-hospital mortality rate after 48 hours, a comparable one-year mortality rate, and a comparable incidence of recurrent myocardial infarction during the first year, whether or not they develop confirmatory ECG or serum enzyme changes. Patients with chest pain typical of myocardial infarction, who fail to develop confirmatory ECG or serum enzyme changes, would appear to require the same care and follow-up as do those patients admitted with chest pain who do develop such ECG or serum enzyme changes.