SCI health care provider attitudes about pressure ulcer management

BACKGROUND/OBJECTIVE: To evaluate the variability in clinical decisions about pressure ulcer management for persons with spinal cord injury (SCI) and expand understanding of the various factors influencing variability. METHODS: Eighty-one SCI physicians and nurses completed a survey on pressure ulcer management. Patient scenarios were used to assess the effect of patient characteristics on provider decisions regarding inpatient treatment of severe pressure ulcers, surgery vs medical management, and amount of healing before discharge. RESULTS: The availability of social support to facilitate bed rest appears to be a more important factor in deciding whether the patient is managed at home vs in the hospital than is the level of injury. Medical condition does not appear to influence surgical vs medical management of severe pressure ulcers. For patients with poor social support, more healing was required before discharge, regardless of their medical condition. Providers were queried about other issues that influence management, including inpatient resource availability, patient preferences, the availability and quality of local home care, and the availability and use of formal care protocols. Respondents were virtually unanimous in their agreement that patients who are compliant with prevention measures can avoid ulcer development. CONCLUSION: Like many health care providers, those who provide care to people with SCI are struggling to provide quality care to improve their patients' lives in the absence of good evidence to guide their treatment decisions. The results of the present study indicate that in situations in which there is no strong empirical evidence, variation in care provided is extensive.     

X-ray volumetric imaging in image-guided radiotherapy: the new standard in on-treatment imaging

PURPOSE: X-ray volumetric imaging (XVI) for the first time allows for the on-treatment acquisition of three-dimensional (3D) kV cone beam computed tomography (CT) images. Clinical imaging using the Synergy System (Elekta, Crawley, UK) commenced in July 2003. This study evaluated image quality and dose delivered and assessed clinical utility for treatment verification at a range of anatomic sites. METHODS AND MATERIALS: Single XVIs were acquired from 30 patients undergoing radiotherapy for tumors at 10 different anatomic sites. Patients were imaged in their setup position. Radiation doses received were measured using TLDs on the skin surface. The utility of XVI in verifying target volume coverage was qualitatively assessed by experienced clinicians. RESULTS: X-ray volumetric imaging acquisition was completed in the treatment position at all anatomic sites. At sites where a full gantry rotation was not possible, XVIs were reconstructed from projection images acquired from partial rotations. Soft-tissue definition of organ boundaries allowed direct assessment of 3D target volume coverage at all sites. Individual image quality depended on both imaging parameters and patient characteristics. Radiation dose ranged from 0.003 Gy in the head to 0.03 Gy in the pelvis. CONCLUSIONS: On-treatment XVI provided 3D verification images with soft-tissue definition at all anatomic sites at acceptably low radiation doses. This technology sets a new standard in treatment verification and will facilitate novel adaptive radiotherapy techniques.     

Use of a cyclo-oxygenase 2 inhibitor for prophylaxis of cystoid macular oedema following cataract surgery: a randomized placebo-controlled trial

BACKGROUND: To assess the efficacy of Celecoxib, a cyclo-oxygenase 2 (COX-2) inhibitor, as prophylaxis for cystoid macular oedema after routine cataract surgery. METHODS: A prospective, randomized, double-blind placebo-controlled trial of 69 hospital patients undergoing cataract surgery. Celecoxib 200 mg twice daily or placebo was given immediately after surgery for 14 days. Optical coherence tomography was used to quantify macular thickness before surgery and on day 1, week 2 and week 6 after surgery. RESULTS: Sixty-nine patients were enrolled, of which 33 received placebo and 36 received active drug. Clinically apparent cystoid macular oedema occurred in four of the treatment group and two of the placebo group (P = 0.68). No difference in best-corrected visual acuity was seen at 6 weeks (P = 0.37). Covariate analysis of the results at 2 weeks and 6 weeks showed a macular thickness of 3% less in the treatment group compared with placebo (P = 0.050). CONCLUSION: Celecoxib may decrease macular thickening following routine cataract surgery at 2 and 6 weeks after surgery as measured by Stratus OCT III. No difference in best-corrected visual acuity or clinically apparent cystoid macular oedema was seen. Further investigation of COX-2 inhibitors in a larger prospective randomized trial is required.     

Descriptive epidemiology of vestibular schwannomas

Vestibular schwannomas, commonly termed acoustic neuromas, arise from the vestibular branch of the eighth cranial nerve (acoustic nerve) and are benign, slow-growing brain tumors that negatively impact patient quality of life. They are thought to account for the majority of intracranial nerve sheath tumors. To describe incidence rate patterns and trends of primary nerve sheath tumors of the brain/CNS and the subset of vestibular schwannomas in two population-based incidence registries, data were obtained from 11 Central Brain Tumor Registry of the United States (CBTRUS) collaborating state registries and the Los Angeles County Cancer Surveillance Program (LACCSP) (1975-1998). Average annual incidence rates were tabulated by age, gender, race, year, and region and were age-adjusted to the year 2000 U.S. standard population. Multiplicative Poisson regression models were used to compare trends in primary nerve sheath tumors of the brain/CNS overall and in subgroups, including vestibular schwannomas, controlling for age, gender, race, microscopic confirmation, and region. Joinpoint regression analysis was used to identify any sharp changes in incidence over time. The overall incidence of primary nerve sheath tumors of the brain/CNS was 1.1 per 100,000 person-years (CBTRUS, 1995-1999 and LACCSP, 1995-1998). The incidence of vestibular schwannomas was similar for both data sets: 0.6 per 100,000 person-years (CBTRUS, 1995-1999) and 0.8 per 100,000 person-years (LACCSP, 1995-1998). Moreover, the incidence of primary nerve sheath tumors of the brain/CNS overall (CBTRUS, 1985-1999 and LACCSP, 1975-1998) and of vestibular schwannomas (CBTRUS, 1992-1999 and LACCSP, 1992-1998) increased over time. However, the incidence of benign schwannomas in sites other than the acoustic nerve either decreased (CBTRUS, 1992-1999) or experienced no significant change (LACCSP, 1992-1998). While improvements in diagnosis and reporting may explain some of these trends, further consideration of potential etiologic factors may be warranted.     

Neuronal organization of the melanin-concentrating hormone system in primitive actinopterygians: evolutionary changes leading to teleosts.

Hypothalamic melanin-concentrating hormone (MCH) neurones occur in all vertebrates and have an apparent neuromodulatory role. In teleost fish, however, MCH is used also as a neurohypophysial hormone, controlling skin color, and as a hypophysiotrophic peptide. This work describes the central location of immunoreactive MCH perikarya and their projections to the pituitary in a range of ancestral fish to determine the phylogenetic stage when the peptide adopted these roles. In all actinopterygians examined, including polypteriformes, chondrosteans, holosteans, and teleosts, immunoreactive fibers were abundant in the median eminence or, in the case of teleosts, within the pars distalis itself, suggesting MCH acquired a hypophysial regulatory role early in vertebrate evolution. MCH fibers appeared to be absent from the posterior neurohypophysis of the polypteriform Calamoichthys but were evident in this region in the chondrostean Acipensor, the holosteans Lepisosteus and Amia, and all teleosts, suggesting its use as a neurohypophysial hormone. The ability of MCH to induce skin pallor seems to have arisen at a later stage, probably in the preholosteans. This hormonal role coincides with the migration of MCH perikarya away from the ventricular surface and their enlargement into magnocellular neurones. In the higher teleosts, magnocellular hypothalamo-neurohypophysial neurones predominate in size and number, whereas smaller periventricular MCH neurones associated with the paraventricular organ, that are prominent in lampreys, early actinopterygians and tetrapods, are reduced in teleosts. The data suggest that, in teleost fish, earlier functions of the peptide may have become subordinate to its novel pigmentary role.     

Vinflunine (20′,20′-difluoro- 3′,4′-dihydrovinorelbine), a novel Vinca alkaloid, which participates in P-glycoprotein (Pgp)-mediated multidrug resistance in vivo and in vitro

Vinflunine (VFL) is a novel derivative of vinorelbine (NVB, Navelbine®), which has shown markedly superior antitumor activity to NVB, in various experimental animal models. To establish whether this new Vinca alkaloid participates in P-glycoprotein (Pgp)-mediated multidrug resistance (MDR), VFL-resistant murine P388 cells (P388/VFL) were established in vivo and used in conjunction with the well established MDR P388/ADR subline, to define the in vivo resistance profile for VFL. P388/VFL cells proved cross-resistant to drugs implicated in MDR (other Vinca alkaloids, doxorubicin, etoposide), but not to campothecin or cisplatin and showed an increased expression of Pgp, without any detectable alterations in topoisomerase II or in glutathione metabolism. The P388/ADR cells proved cross-resistant to VFL both in vivo and in vitro, and this VFL resistance was efficiently modulated by verapamil in vitro. Cellular transport experiments with tritiated-VFL revealed differential uptake by P388 sensitive and P388/ADR resistant cells, comparable with data obtained using tritiated-NVB. In various in vitro models of human MDR tumor cells, whilst full sensitivity was retained in cells expressing alternative non-Pgp-mediated MDR mechanisms, cross resistance was identified in Pgp-overexpressing cells. Differences were, however, noted in terms of the drug resistance profiles relative to the other Vincas, with tumor cell lines proving generally least cross-resistant to VFL. Overall, these results suggest that VFL, like other Vinca alkaloids, participates in Pgp-mediated MDR, with tumor cells selected for resistance to VFL overexpressing Pgp, yet MDR tumor cell lines proved generally less cross resistant to VFL relative to the other Vinca alkaloids.     

Reliability of reporting by women taking part in a prospective contraceptive study

A prospective study is in progress at 17 family planning clinics to try to provide a balanced view of the beneficial and harmful effects of different methods of contraception. During follow-up, data about pregnancies and their outcome, hospital visits, and changes in contraceptive practices are collected from the participants in the study at routine clinic visits, by postal questionnaire, or by home visiting. Whenever a hospital admission is reported, a copy of the discharge letter or summary is obtained.