Changes in treatment of advanced laryngeal cancer 1985-2001

OBJECTIVE: In 1991, a randomized study was published and demonstrated that use of nonsurgical therapy (chemoradiation) provided similar survival to total laryngectomy (the gold standard) for patients with advanced-stage laryngeal cancer. The purpose of this study was to assess how treatment of advanced laryngeal cancer was influenced by such developments in non-surgical therapy. STUDY DESIGN: Patterns of care study using National Cancer Database (1985-2001). RESULTS: The percentage of advanced-stage patients treated with chemoradiation increased from 8.3% to 20.8% while the proportion treated with radiation alone decreased from 38.9% to 23.0%. Use of chemoradiation increased at a significantly faster rate after the 1991 publication at both community cancer centers and teaching research facilities. The use of total laryngectomy decreased slightly during this period. CONCLUSIONS: The use of chemoradiation increased after the 1991 publication. It was impossible to determine from the NCDB whether additional patients who could benefit from chemo-RT were not offered or did not complete this treatment option. We recommend that treatment recommendations discussed at tumor boards be recorded in cancer registries.     

Detection of stenoses in the internal carotid artery by waveform analysis of continuous wave ultrasound signals (II)

Analysis of the morphological aspects of continuous-wave Doppler examination is a reliable means of detecting carotid stenosis involving 50% or more of the diameter of the arterial lumen. This study was undertaken to evaluate the indexes likely to increase the diagnostic accuracy of this noninvasive investigation method. The indexes studied were the variations of the maximal frequency and the systolic peak frequencies, measured proximal to and at the level of stenosis, and the ratio of the systolic peak frequency measured in the internal carotid artery and in the common carotid artery. After obtaining data on an experimental model, the study was conducted in healthy volunteers (n = 24) and in patients with carotid atherosclerotic disease (n = 23). The experimental study confirmed that stenosis greater than 50% leads to a reduction of blood flow and that there is a mathematical relationship between the frequency measured proximal to and at the level of the stenosis and the degree of stenosis. Clinical data showed that there was a significant decrease in the frequency of the systolic peak in elderly "healthy" subjects as compared with younger subjects. However there was no difference between patients with and without stenosis. The index was 0.8 in young subjects, 1.3 in healthy elderly subjects, and greater than 1.3 in subjects who had a stenosis. There was no statistically significant difference between these two last groups. At the threshold value of 2.3, the sensitivity of the FI index was 22% and the specificity was 94% in the detection of carotid artery stenosis. In the assessment of the tight stenosis, sensitivity was 44%.     

Timebanking and the co-production of preventive social care with adults; what can we learn from the challenges of implementing person-to-person timebanks in England?

This paper explores the potential contribution of timebanking, an innovative volunteering scheme, to the co-production of preventive social care with adults in England. Interest in volunteering in social care has increased as one proposed solution to the international crisis of a rising demand for services in juxtaposition with decreased resources. Volunteering has been particularly promoted in preventive services that prevent or delay care needs arising. Despite sustained interest in volunteering and co-production in social care, little is known about how theory translates into practice. Reporting implementation data from a Realistic Evaluation of six case studies in England, this paper explores one volunteering scheme, timebanking. The research explores how timebanks were working, what contribution they can make to adult social care, and whether they are an example of co-production. Data collected included interviews, focus groups or open question responses on surveys from 84 timebank members, and semi-structured interviews with 13 timebank staff. Each timebank was visited at least twice, and all timebank activity was analysed for a period of 12 months. Data were triangulated to improve reliability. The research found that in practice, timebanks were not working as described in theory, there were small numbers of person-to-person exchanges and some timebanks had abandoned this exchange model. Timebanks faced significant implementation challenges including managing risk and safeguarding and the associated bureaucracy, a paternalistic professional culture and the complexity of the timebank mechanism which required adequate resources. Lessons for timebanks are identified, as well as transferable lessons about co-production and volunteering in social care if such schemes are to be successful in the future.     

Autonomic involvement in inherited neuropathies

The inherited peripheral neuropathies constitute a large group of disorders, in some of which the causative metabolic defect has been identified whereas in the majority it is still unknown. Amongst the former, autonomic involvement is an important component in porphyric neuropathy, in the familial amyloid polyneuropathies, in Fabry's disease and in dopamine-hydroxylase deficiency. The latter group includes the hereditary sensory and autonomic neuropathies in some of which, such as the Riley-Day syndrome, autonomic disturbances are prominent, whereas in others they constitute only a minor component of the symptomatology. Autonomic dysfunction is an important component of the neurological manifestations in multiple endocrine neoplasia type IIB.     

The types of heterosexual gender identity disorder

The rationale for dividing the clinical spectrum of DSM-III-R male heterosexual gender identity disorder into three types was examined. The DSM-III-R category of fetishism for female attire, was included in the analysis. There were 266 male participants divided into three groups: 172 fetishists for female attire or gender identity patients, 52 androphiles, and 42 gynephiles. A 16 item questionnaire was used to examine the groups. A three factor scale ("Fetishism", "Gender Dysphoria" and "Androphilia") was derived from the questionnaire. Only the Gender Dysphoria Factor Scale successfully differentiated between all four conditions, supporting the notion that the three types of gender identity disorder represent a continuum of degree of severity of gender dysphoria. Defining two of the three types of gender identity disorder in terms of the patients' self-reports on fetishism, as DSM-III-R does, is therefore unnecessary.     

Treatment of Mammary Duct Fistula by Fistulectomy and Saucerization

This study was designed to assess the efficacy and long-term outcome of fistulectomy and saucerization for treatment of mammary duct fistulae. Mammary fistula is a chronic condition that represents the final step in what has been termed “mammary duct associated inflammatory disease sequence.” The treatment is primarily surgical and may include healing by secondary intention or primary closure with or without antibiotics. Reported series are small and often include variable surgical strategies applied without consistency. A consecutive series of 53 patients who had 59 mammary duct fistulae were treated by fistulectomy with saucerization. The median age was 32 years. Wounds were allowed to heal by secondary intention and antibiotics were not used. We reviewed the case records to establish the incidence of recurrent fistula and the time to complete healing. The long-term cosmetic outcome was determined by a postal survey. After a median follow-up of 6 years there had been no relapse in 92%. There was significant delay in healing in six cases (range: 10 to 30 weeks). Thirty-eight patients (83%) gave a definite history of regularly smoking between 10 and 20 cigarettes a day. Two thirds of the patients were either pleased or satisfied with the final cosmetic result of the surgery, but more than 90% said that it left them with some distortion of the nipple. Fistulectomy and saucerization achieves long-term cure in the majority of patients with mammary duct fistula, but it results in some degree of distortion of the nipple. The strong relationship between smoking and the occurrence of mammary duct fistulae is again demonstrated.     

On the psychosocial dimension of the IPPNW meeting in Coventry

Science and Conscience

In the Shadow of the Bomb: Oppenheimer, Bethe, and the Moral Responsibility of the Scientist By Silvan S. Schweber Princeton University Press, Princeton NJ, 2000, 260 pp., £15.95, ISBN 0–691–04989–0.

Sanctions

Iraq Under Siege: The Deadly Impact of Sanctions and War Edited by Anthony Amove Pluto, London, 2000, 224 pp., £10.99 pbk. ISBN 0–7453–16S9‐X, £35.00 hbk, ISBN 0–7453–1660–3.

Nurses at War

Nurses at War: Women on the Frontline 1939–45 By Penny Starns Sutton, Stroud, 2000, xvii + 174 pp., £19.99 hbk, ISBN 0–7509–23873.

Peace Education

Saying No to Violence — Children and Peace: Activities for a Peaceful World By Jan Melichar and Margaret Melicharova Peace Pledge Union, London, 2000, 58 pp., £9.99, ISBN 0–902680–46–3.