Treatment of Acquired Bilateral Nevus of Ota-Like Macules (Hori''s Nevus) with a Combination of the 532 nm Q-Switched Nd:YAG Laser Followed by the 1,064 nm Q-Switched Nd:YAG Is More Effective: Prospective Study

BACKGROUND: Acquired bilateral nevus of Ota-like macules (Hori's nevus) is a common dyschromatosis among Asian women. Q-switched lasers have been used successfully as a treatment modality. OBJECTIVE: The purpose of this study was to compare the efficacy of using the Q-switched 532 nm neodymium:yttrium-aluminum-garnet (Nd:YAG) laser followed by the 1,064 nm laser versus the Q-switched 1,064 nm Nd:YAG laser alone in the treatment of Hori's nevus. METHODS: This is a prospective left-right comparative study. Ten women with bilateral Hori's nevus were recruited and treated with a combination of the Q-switched 532 and 1,064 nm Nd:YAG lasers on the right cheek and the Q-switched 1,064 nm Nd:YAG laser alone on the left cheek. Only one laser treatment session was performed. The degree of pigmentation was objectively recorded with a mexameter. Subjective assessment was made by both patients and two blinded, nontreating dermatologists. RESULTS: At 6 months, there was a statistically significant difference (p = .009) of 35.10 points using objective mexameter measurements between the two sides, favoring the side treated with a combination of 532 and 1,064 nm laser treatment. Subjective grading by the patients and blinded dermatologists also confirmed that combination therapy was more successful after one treatment. Although combination treatment had a higher incidence of mild postinflammatory changes, this disappeared within 2 months. CONCLUSIONS: Concurrent use of the Q-switched 532 nm Nd:YAG laser in combination with the 1,064 nm laser is more effective in pigment clearance than the Q-switched 1,064 nm Nd:YAG laser alone for Hori's nevi.     

Methylene blue soldered microvascular anastomoses in vivo.

OBJECTIVES: solders containing chromophores and proteins enhance the strength of lasered anastomoses. Methylene blue (MB) solder anastomoses in vitro are strong but no in vivo work has been reported. We used an MB solder in vivo and studied the effects of two laser powers on patency and histological appearance. DESIGN, MATERIALS AND METHODS: two groups of 15 rabbits had unilateral end-to-end carotid anastomoses (1.5-2.0 mm) formed using three stay sutures and MB solder. Group 1 anastomoses were formed at 5.7 Wcm(-1) and Group 2 at 2.8 Wcm(-1). The vessels were examined at various points by necropsy for patency and gross macroscopic appearance, with subsequent histological examination. RESULTS: group 2 showed patency of 93.3% v 0% ( p<0.001) endothelialisation of 100% v 26.6% ( p<0.001), giant cell formation 0% v 40.0% ( p<0.01), but stenosis was not significantly different (0% v 13.3% p=0.06). Group 2 showed a higher rate of intimal hyperplasia (IH) (66.6% v 20.0% p<0.05) but neither group exhibited thermal injury or aneurysm formation. CONCLUSIONS: laser soldered microvascular anastomoses were formed in vessels of 1.5-2.0 mm with a high degree of patency. A relationship appears to exist between laser power and anastomotic patency. Methylene blue fading has the potential to act as a switch against over exposure and a visual indicator of solder activation.     

Undergraduate surgical training: variations in program objectives and curriculum implementation across Canada.

BACKGROUND: Although nationally recognized learning objectives for undergraduate surgical education exist, the extent to which Canadian medical schools follow these guidelines has never been established. METHODS: We distributed a survey to all program directors and clinical-teaching-unit coordinators for undergraduate surgery at Canada's 16 medical schools, and subsequently assessed the perceived emphasis placed on learning objectives and student performance, and the impact of instructional tools and teaching locations. RESULTS: Program directors in 15 medical schools responded to the survey. We identified a wide variation in the emphasis placed on basic learning objectives as well as specialty specific learning objectives. The length of rotations, methods of instruction and tools used to grade student performance also varied widely. CONCLUSIONS: Our findings suggest significant variation in the design and implementation of undergraduate surgical education in Canada. This study may serve as a basis for reassessing learning objectives in Canadian undergraduate surgical education.     

'Good prognosis tumours' in breast cancer screening.

The Forrest Report led to the introduction of the breast screening programme with the aim of reducing mortality from breast cancer. In 1989 a breast screening programme was introduced to the South Bucks District and now two cycles have been completed. The findings are of a high yield of good prognosis tumours 71% and 72%, respectively. These encouraging figures are reflected in a high response rate and with a fall in the incidence of non-screen-detected tumours.     

Defining the practice population in fee-for-service practice.

OBJECTIVE: To develop and validate a technique for defining a practice population of discrete individuals based on multiyear family practice fee-for-service billings data. DATA SOURCES/STUDY SETTING: Nineteen family physicians in Ontario, Canada who converted from fee-for-service to capitation payment. Data sources were fee-for-service billings data for the three-year period prior to the conversion from fee-for-service to capitation payment and the rosters of enrolled patients for the first and third years after the change to capitation payment. STUDY DESIGN: The billings-based definition of the physician's practice population was compared against the Year 1 roster. We also compared the billings-based practice population and the Year 1 roster to the physician's Year 3 roster to identify patients who might have been missed during the roster development process. Our principal analyses were an assessment of the sensitivity of the billings-based definition of the practice population (EPP), the positive predictive value of EPP, and the agreement between EPP and the rostered patient population (RPP). We also examined the ratio between EPP and RPP to determine EPP's accuracy in estimating the practice denominator. DATA COLLECTION/EXTRACTION METHODS: The practice population for each physician at the time of conversion from fee-for-service to capitation payment was defined as (a) all persons for whom the physician billed the provincial health insurance plan for at least one visit during the year immediately prior to joining the capitation-funded program; and (b) all additional patients for whom the physician billed the plan for at least one service in each of the two preceding years. Data extraction was carried out within the Ministry of Health in order to preserve the anonymity of patients and physicians. Data were provided to the investigators stripped of patient and physician identifiers. PRINCIPAL FINDINGS: The mean sensitivity and positive predictive value of EPP were 95.3 percent and 87.4 percent, respectively. The level of agreement between EPP and RPP averaged 84.4 percent. The mean ratio of EPP to RPP was 1.21 (95 percent C.I. 1.030-1.213). Correction for roster false-negatives increased the sensitivity, positive predictive value, and agreement between EPP and the practice population, and reduced the mean ratio of EPP to the practice population to 1.068 (95 percent C.I. 1.010-1.127). CONCLUSIONS: The practice population can usefully be defined in fee-for-service family practice on the basis of multiyear fee-for-service billings data. Further research examining alternative encounter-based practice population definitions would be valuable.     

The A-wave of the human electroretinogram and rod receptor function

The amplitude of the leading edge of the a-wave of the human electroretinogram (ERG) was compared with predictions from a computational model of the light-induced responses of rod mammalian receptors. According to this model, a linear process describes the amplitude and time course of the response to relatively low flash intensities and at brief times after the onset of the flash. At higher flash intensities, a nonlinear process, described by the Naka-Rushton function or a saturating exponential, is involved. The primary focus here is on intensity-response data recorded with a clinical ganzfeld apparatus. The leading edge of the rod a-wave recorded from normal observers and patients with congenital stationary night blindness (CSNB) was described by a linear process for flash intensities up to the maximum available flash intensity, 2.0 log scot td-sec. This finding is consistent with the model of the rod's response. It suggests, however, that when ERGs are recorded with clinical systems limited to 2.0 log scot td-sec, these data cannot be used to distinguish between changes in the parameters (eg, semisaturation intensity versus maximum response) of the human rod receptors. Responses to flash intensities up to 3.4 log scot td-sec were recorded using a custom, high-intensity ganzfeld system. Both the linear and nonlinear components of the model were needed to fit the ERGs recorded with this system. This suggests that changes in different receptor parameters can be distinguished with higher intensity flashes.     

The Inter-Regional Epidemiological Study of Childhood Cancer (IRESCC): past medical history in children with cancer.

The Inter-Regional Epidemiological Study of Childhood Cancer (IRESCC) collected interview and medical information relating to the child's past medical experiences from parents of 555 children diagnosed with cancer and parents of 1110 unaffected matched controls. No significant associations emerged overall for ante-natal care, place and mode of delivery, length of gestation, birth weight, condition at birth, special care, neonatal procedures or breast-feeding. Few risk factors relating to previous illnesses and medication were found, although increasing numbers of illnesses appeared to be associated with an increased risk of childhood cancer, particularly acute lymphoblastic leukaemia. A highly significant excess of case children had not been immunised (p = 0.005). In general, these results indicate that past medical experiences have little influence on the development of cancer in children.     

Parental influences on young girls' fruit and vegetable, micronutrient, and fat intakes.

OBJECTIVE: To evaluate parents' fruit and vegetable intake and their use of pressure to eat in child feeding as predictors of their 5-year-old daughters' fruit and vegetable, micronutrient, and fat intakes. SUBJECTS: Data were obtained from 191 non-Hispanic white families with 5-year-old girls. DESIGN: Parent data included reports of pressure in child feeding and their own fruit and vegetable intake. Girls' intakes of fruits and vegetables, selected micronutrients, and fat were the main outcomes of interest. STATISTICAL ANALYSIS: Structural equation modeling was used to test a model describing relationships among parents' fruit and vegetable intake, parents' use of pressure in child feeding, and daughters' fruit and vegetable, micronutrient, and fat intakes. RESULTS: The model provided a good fit to the data, revealing that girls' fruit and vegetable intake was positively related to their parents' reported fruit and vegetable intake. Parents who consumed fewer fruits and vegetables tended to report greater pressure in child feeding and had daughters who consumed fewer fruits and vegetables. Girls' reported fruit and vegetable intakes were positively related to their micronutrient intakes and negatively associated with fat intake. APPLICATIONS/CONCLUSIONS: This research demonstrates that parents' own fruit and vegetable intake may encourage fruit and vegetable intake in their daughters, leading to higher micronutrient intakes and lower dietary fat intakes. Conversely, pressure to eat may discourage fruit and vegetable intake among young girls.     

Cyclosporin-A nephrotoxicity and acute cellular rejection in renal transplant recipients: correlation between radionuclide and histologic findings

Serial radionuclide studies using both Tc-99m DTPA (perfusion) and I-131 hippuran (tubular function) were correlated with histologic findings in 25 patients with renal transplants. These cases included 15 cases of cyclosporin-A nephrotoxicity (CsA-NT) and ten cases of acute cellular rejection that were retrospectively selected on the basis of biopsy findings and favorable clinical response to therapy specific for each of these conditions. The serial radionuclide studies enabled the correct diagnosis in 12 of 15 cases of CsA-NT and eight of ten cases of acute rejection. Posttherapy radionuclide studies, furthermore, demonstrated improvement consistent with clinical response. In all cases, the radionuclide results were available at least 24 hours before biopsy findings. These results indicate that serial radionuclide studies evaluating interval changes in both perfusion and tubular function are of significant value in the diagnosis and follow-up of CsA-NT and acute cellular rejection in transplant recipients. This initial experience suggests a sensitivity of 80%.