Photoprotection in immunocompetent and immunocompromised people.

Ultraviolet radiation (UVR) exposure from the sun and artificial UV sources has been widely acknowledged as the major culprit for skin cancer and premature skin ageing. Skin cancers are among the most dangerous (cutaneous malignant melanoma) and the most numerous (basal cell carcinoma, actinic keratosis and invasive squamous cell carcinoma) of all neoplasms in the caucasian population worldwide. Skin cancers therefore have a significant impact on public health and healthcare costs, and will continue to do so. It is obvious that adequate photoprotection - seeking shade, wearing protective clothing and using sunscreens - is the key to reducing the harmful effects of UVR in both immunocompetent and immunocompromised people. This article provides background information on UVR, photoprotection (including the concept of topical sunscreen formulations), associated concerns regarding efficacy and safety, and behavioural and educational aspects of photoprotection and skin cancer prevention in immunocompetent and immunocompromised people. Certain persistent misconceptions and mistakes regarding photoprotection are also addressed.

Health literacy, sunscreen and sunbed use: an uneasy association.

BACKGROUND: Skin cancer can largely be prevented by avoiding unsafe ultraviolet radiation (UVR) exposure. The evidence on potential drivers of sunscreen and sunbed use is extensive, yet in some cases, such as education, remains rather unclear. Health literacy is receiving increasing attention, but its effect on tanning decisions has not yet been explored. OBJECTIVES: To explore the association between health literacy and tanning behaviour, in terms of sunscreen and sunbed use. METHODS: Self-reported data were collected through a common questionnaire in eight European countries under a common protocol. A three-item measure was used to assess health literacy; one item was collected to measure current sunscreen use and one item to measure current sunbed use. Descriptive statistics and analysis of variance tests were applied to explore the profile of sunbed and sunscreen users and health literacy among a number of variables. Univariate and multivariate logistic regressions were used to assess the relation between health literacy and sunscreen and sunbed use. RESULTS: Univariate results suggested that health literacy has opposite effects on sunscreen use vs. sunbed use. Increased health literacy was associated with the skin cancer protective practice of using sunscreen, but also with more sunbed use. In the multivariate models, health literacy had a significant effect only on sunscreen use. CONCLUSIONS: The findings suggest that health literacy can be an interesting approach for influencing sunscreen use. In the case of sunbeds, based on the findings and contrary to what was expected, it can be argued that interventions targeting health literacy seem less likely to reduce sunbed use. More research is needed to elucidate the effect of health literacy on sunscreen and sunbed use in order to improve UVR prevention strategies.

Potential impact of interventions resulting in reduced exposure to ultraviolet (UV) radiation (UVA and UVB) on skin cancer incidence in four European countries, 2010-2050.

BACKGROUND: Behavioural interventions to reduce exposure to ultraviolet radiation (UVR) can reduce risk of skin cancer. OBJECTIVES: To integrate the data and to evaluate the impact of interventions to limit exposure to UVR on skin cancer incidence in four selected countries. METHODS: Using PREVENT, a dynamic simulation model, we modelled the potential for skin cancer prevention in four European countries under various scenarios to avoid damage by UVR. RESULTS: In general, the most effective interventions were those aimed at protecting people during outdoor work and outdoor hobbies against the harmful effects of UVR, and combinations of several interventions. These could in theory lead to reductions of up to 45% in skin cancer cases projected for the year 2050. CONCLUSIONS: The scope for prevention depends on the prevalence of the risk factors in the different countries, as well as the associated risk factors and time lags modelled.

Getting in early: primary skin cancer prevention at 55 German kindergartens.

BACKGROUND: Skin neoplasms are the most frequent types of neoplasms in white populations, and their incidence is increasing. Epidemiological studies have shown that the major environmental aetiological factor for their development is sunlight exposure. Sun protection programmes are urgently needed to raise awareness of the health hazards of ultraviolet radiation. In 2010 the 'SunPass' project was implemented at 55 kindergartens in Germany. This is the first nationwide environmental education programme for sun safety designed to teach children in kindergartens and their caregivers how to protect themselves from overexposure to the sun. OBJECTIVES: An interventional lecture, site inspections and a certification were part of the programme. Effects of these interventions were studied. METHODS: The gain in knowledge and changed sun-behavioural attributes were quantified by questionnaires administered before and after the 'SunPass' interventions. RESULTS: The total number of children was 5424. Sun-protection behaviour after the intervention improved significantly (P < 0·001). Among parents, 22·2% reported one to five sunburns of their child since birth. There was a significant increase in hat use by children in kindergartens (P = 0·029), as well as some significantly improved shade practices. There was a significantly increased demand for protective clothing for children (P < 0·001). The change in sunscreen use in kindergartens was not significant. CONCLUSIONS: Although some aims of the 'SunPass' project were not fulfilled, such as the precise knowledge of skin types and a change of sunscreen use, the study had some positive outcomes in increasing the awareness of skin cancer and its prevention possibilities. The findings of the present study suggest that relatively brief interventions in kindergartens lead to improved sun protection of children. The whole investigation reaching over 5400 children and their parents underlines the importance of learning appropriate sun-protective behaviour in early childhood in order to decrease the risk for skin cancer.

Assessing physicians' preferences on skin cancer treatment in Europe.

BACKGROUND: A wide variety of both surgical and nonsurgical therapies is currently available for patients with skin cancer. OBJECTIVES: This part of the EPIDERM (European Prevention Initiative for Dermatological Malignancies) project is aimed at the evaluation of the treatment preferences for skin cancer in eight countries of the European Union. METHODS: A multicentre hospital-based case-control study was carried out at dermatology departments in Finland, Germany, Greece, Italy, Malta, Poland, Scotland and Spain. Patients with skin cancer (basal cell carcinoma, actinic keratosis, squamous cell carcinoma, cutaneous malignant melanoma and Bowen disease) were consecutively enrolled between July 2008 and July 2010. Information on the study variables (sex, age, country, tumour type, anatomical location and treatment) was obtained from questionnaires designed by the EPIDERM project. RESULTS: In total, 1708 patients with skin cancer were included. Surgery was the first treatment option in 76·5% of the patients (P = 0·001). Actinic keratosis was the only tumour type in which nonsurgical treatment was more frequent than surgery (91·4%). Tumours on the head were less likely to be surgically excised than those at other locations (odds ratio 0·25, P = 0·001). Simple excision or curettage was the most common surgical procedure (65·4%), followed by graft and flaps (22·4%). Cryotherapy was the most common nonsurgical option (52·4%), followed by imiquimod (18·0%), photodynamic therapy (PDT; 12·0%), 5-fluorouracil (5-FU; 5·7%), and diclofenac with hyaluronic acid (4·0%). CONCLUSIONS: Surgery remains the first-choice treatment of skin cancer. Regarding nonsurgical treatments, the conservative treatments available (imiquimod, 5-FU, PDT and diclofenac gel) have not yet exceeded the use of ablative options such as cryotherapy despite their accepted benefit of treating field cancerization.

Known and potential new risk factors for skin cancer in European populations: a multicentre case-control study.

BACKGROUND: During recent years numerous studies have suggested that personal and environmental factors might influence cancer development. OBJECTIVES: To investigate environmental and personal characteristics associated with skin cancer risk. METHODS: A multicentre hospital-based case-control study was performed in Finland, Germany, Greece, Italy, Malta, Poland, Scotland and Spain, including 409 patients with squamous cell carcinoma (SCC), 602 with basal cell carcinoma (BCC) and 360 with cutaneous malignant melanoma (CMM) and 1550 control persons. Exposures were assessed by questionnaires that were partly self-administered, partly completed by dermatologists. Unconditional logistic regression modelling was used to assess associations including the influence of certain drugs and food items on skin cancer risk. RESULTS: The usual associations were observed for sun exposure and pigmentation characteristics, with chronic sun exposure being most strongly associated with SCC risk, and naevi and atypical naevi with CMM risk. Use of ciprofloxacin was associated with a decreased risk of BCC [odds ratio (OR) 0·33] and use of thiazide diuretics was associated with an increased risk of SCC (OR 1·66). Ciprofloxacin was also associated with SCC (OR 0·34) and thiazines with BCC (OR 2·04), but these associations lost significance after correction for multiple testing. Consumption of pomegranate, rich in antioxidants, was associated with decreased BCC and SCC risk, also after correcting for multiple testing. Recent experience of stressful events was associated with increased risk, particularly of CMM. CONCLUSIONS: In this large case-control study from across Europe the expected associations were observed for known risk factors. Some new potential protective factors and potential risk factors were identified for consumption of certain food items, medication use and stress, which deserve further investigation in future studies.

Risk factors for actinic keratosis in eight European centres: a case-control study.

BACKGROUND: There are limited data regarding the association of actinic keratosis (AK) and other types of nonmelanoma skin cancer (NMSC); studies investigating possible correlation of AK with melanocytic naevi are even scarcer. To our knowledge, there are no data examining the risk of AK in people using specific medications. OBJECTIVE: To investigate constitutional and exposure risk factors leading to AK and the coexistence of AK with NMSC and melanoma. METHODS: A multicentre hospital-based case-control study was performed in Finland, Germany, Greece, Italy, Malta, Poland, Scotland and Spain, including 343 patients with actinic keratosis (AK), 409 with squamous cell carcinoma (SCC), 602 with basal cell carcinoma (BCC), 360 with invasive melanoma and 119 with in situ melanoma, and 686 control subjects. Exposures were assessed by questionnaires that were partly self-administered and partly filled out by dermatologists. Unconditional logistic regression modelling was used to assess associations including the influence of phenotypic characteristics, presence of naevi, sun-exposure habits and certain drugs on AK risk. RESULTS: Differences in hair and eye coloration variably influenced the risk for AK, with red hair signifying a seven times higher risk [odds ratio (OR) 6·9, 95% confidence interval (CI) 4·34-11·00), and brown - compared with blue - eyes, about a 40% reduced risk (OR 0·61, 95% CI 0·13-0·92). The darker the skin phototype, the lower the risk for AK, with phototype IV exhibiting nine times less risk of developing AK. Some and many freckles on the arms were associated with an OR of 1·8 (95% CI 1·08-2·81) and 3·0 (95% CI 1·10-3·54), respectively, while overall number of naevi and high educational level were inversely associated with AK. Sun exposure, thiazide diuretics and cardiac drugs had a higher risk for AK. SCC was the most frequent (58%) skin neoplasm coexisting with AKs, followed by BCC (30%), melanoma in situ (12%) and invasive melanoma (6%). CONCLUSION: In this large case-control study from across Europe the expected associations were confirmed for known risk factors. Some possible new risk factors, including cardiac and diuretic drugs, were identified, creating a new field for further investigation in future studies.

The patient journey: a report of skin cancer care across Europe.

BACKGROUND: There are poorly documented variations in the journey a skin cancer patient will follow from diagnosis to treatment in the European Union. OBJECTIVES: To investigate the possible difficulties or obstacles that a person with a skin malignancy in the European Union may have to overcome in order to receive adequate medical screening and care for his/her condition. In addition, we wished to explore differences in European health systems, which may lead to health inequalities and health inequities within Europe. METHODS: Ten European countries took part in this investigation (in alphabetical order): Finland, Germany, Greece, Italy, Malta, Poland, Romania, Spain, the Netherlands and the U.K. The individual participants undertook local and national enquiries within their own country and completed a questionnaire. RESULTS: This exercise has identified important differences in the management of a skin cancer patient, reflecting major disparities in health care between European countries. CONCLUSIONS: Further investigation of health disparities and efforts to address health inequalities should lead to improvements in European health care quality and reduction in morbidity from skin cancer.

Certification of sun protection practices in a German child day-care centre improves children's sun protection--the 'SunPass' pilot study.

BACKGROUND: Nonmelanoma skin cancer (NMSC) and malignant melanoma (CMM) are among the most common malignancies in the white population. The major risk factor for those malignancies is ultraviolet radiation (UV) causing directly DNA damage and promoting the development of skin cancer. It is suggested that the exposure to UV during childhood elevates an individual's lifetime risk of developing skin cancer more than exposure in adulthood. Since an increasing number of children spend the time of the most intense UV in a day-care centre, it seems an excellent place for establishing primary skin cancer prevention. Important targets are staff members and parents of the day-care centre, since sun protection of children depends directly on their knowledge and their attitude towards sun protection practices. OBJECTIVES: To establish a feasible certification program for sun protection in a German child day-care centre, for a better sun protection of the children and the reduction of skin cancer incidence in the long term. METHODS: Initially sun protection practices of the centre at baseline were assessed. A written sun protection policy was developed in consultation with all members of the day-care centre as basis for certification. It was followed by training sessions for staff members (n=12) and parents (n=46). After a fixed period of time the final assessment of the child day-care centre was conducted and the centre then was certified for improved sun protection practices and better protection of the children. The primary assessed outcomes were the gain in knowledge of staff members and parents after the training sessions, the number of children wearing a hat when playing outside, the use of sunscreen and the percentage of shaded areas on the playground. RESULTS: Sun protection was an issue more discussed during the time of intervention than before. Staff members (n=12) and parents (n=27) had a significant gain in knowledge (staff members: P=0.002; parents: P=0.001) concerning sun related issues. The number of children wearing a hat increased from 13.2% to 73%. The sunscreen use increased, 58.8% of staff members reported a more regular application of sunscreen to the children. There was a higher percentage of shaded area on the playground (70-80% before intervention, 90% after intervention). The intervention failed in keeping the children inside during the most intense UV and in educating the staff members to be a convincing example of sun protection by wearing appropriate clothes. CONCLUSIONS: The intervention showed that the introduction of a simple certification program including a written sun protection policy and training sessions for staff members and parents helps to improve children's sun protection. We suggest that a certificate for adequate sun protection acts as a motivating factor. It seems important to refresh sun protection practices each year by repeating training sessions and reviewing the sun protection policy.

Pulmonary interstitial glycogenosis - A systematic analysis of new cases.

BACKGROUND: Pulmonary interstitial glycogenosis (PIG) is a rare paediatric interstitial lung disease of unknown cause. The diagnosis can only be made by lung biopsy. Less than 100 cases have been reported. Clinical features, treatment and outcomes have rarely been assessed systematically in decent cohorts of patients. METHODS: In this retrospective multicentre study, the clinical presentation, radiologic findings, pattern of lung biopsy, extrapulmonary comorbidities, treatment and outcome of eleven children with PIG were collected systematically. RESULTS: 10/11 children presented with respiratory distress immediatly after birth and 8/11 needed invasive ventilation. In 8/11 children extrapulmonary comorbidities were present, congenital heart defects being the most common. 7/11 children received systemic glucocorticoids and of these four showed a clear favorable response. During a median follow-up of 3.0 years (range 0.42-12.0) one child died, while 10 patients improved. Chest CT-scans showed ground-glass opacities (7/10), consolidations (6/10), linear opacities (5/10) and mosaic attenuation (4/10) without uniform pattern. Besides interstitial thickening related to undifferentiated glycogen positive mesenchymal cells all tissue samples showed growth abnormalities with reduced alveolarization. CONCLUSIONS: PIG is associated with alveolar growth abnormalities and has to be considered in all newborns with unexplained respiratory distress. Apparent treatment benefit of glucocorticosteroids needs to be evaluated systematically.

Expression of early placenta insulin-like growth factor in breast cancer cells provides an autocrine loop that predominantly enhances invasiveness and motility.

Early placenta insulin-like growth factor (EPIL) is expressed by a subpopulation of the Her2-positive SKBR3 breast cancer cell line displaying high motility and transendothelial invasiveness in vitro, as recently shown by our group. As a consequence of this, we established cellular models by generating an EPIL-overexpressing SKBR3 cell line, knocked down EPIL by adding specific small interfering RNA (siRNA) to those cells and produced EPIL-enriched and depleted serum-free culture media. EPIL-expressing cells as well as EPIL-induced SKBR3 cells acquired a high capacity for transendothelial invasiveness. We observed a thin and outspread morphology caused by enhanced formation of lamellipodia, i.e. protrusions in the initial phase of motility. In parallel, Her2-positive MDAHer2 breast cancer cells also showed increased invasiveness when induced by EPIL-conditioned medium. A downstream signaling impact of EPIL could be observed in the form of reduced phosphorylation of Her2, erk1/2 and akt, while phospholipase Cgamma1 phophorylation remained unaffected. As an in vivo model for highly motile tumor cells, Paget's disease of the nipple showed simultaneous EPIL and Her2 expression upon immunohistochemical examination using specific antibodies. Such experimental data have been translated to a clinical setting by using a prognostic tissue microarray established from 603 breast cancer cases. Survival data analysis found a significant association between expression levels of EPIL and 5-year overall survival that was dose dependent: EPIL (negative) 84%, EPIL (moderately positive) 77%, EPIL (strongly positive) 48% (P < 0.005). One particular subgroup (7.6% of the cases with full clinical records) that comprised tumors simultaneously expressing EPIL and Her2 represented patients with the poorest 5-year overall survival. The results suggested that EPIL might be a cancer cell-produced growth factor that influences lateral Her2 signaling. Moreover, EPIL may be induced by factors apart from Her2 and may independently provide signaling for cancer invasion and motility.

Normal colony stimulating factor (CSF) production by bone marrow stromal cells and abnormal granulopoiesis with decreased CFUc in S1/S1d mice.

The concentration of CFUC and the production of stromal-derived CSF in the femora of S1/S1d mice were determined. There was a lower concentration CFUC and a smaller total number of nucleated cells in the femoral marrow of WCB6. S1/S1d (S1/S1d) mice than in WCB6. +/+/(+/+) mice or in C57B1/6. +/+ (C57Bl) mice. On the other hand stromal-derived CSF production by femora from S1/S1d mice did not differ significantly from that of +/+'s. These observations indicate that the microenvironmental defect of S1/S1d mice results in decreased growth of granulocytic precursors as well as those of erythroid and megakaryocytic cells. This is consistent with the reported decrease in multipotential stem cell proliferation. Stromal cell derived CSF production was normal and could not be implicated in the decreased production of granulocytic precursors.

Molecular cytogenetic investigations of synchronous bilateral breast cancer.

BACKGROUND: Bilaterality in breast cancer is a rare event and together with an early onset of disease points towards inheritance of the disease. However, most cases seem to occur sporadically, either in a synchronous or metachronous manner. METHODS: Thirty two invasive carcinomas and one in situ carcinoma from 16 patients with synchronous, bilateral breast cancer were investigated by means of comparative genomic hybridisation (CGH) and polymerase chain reaction based multiplex microsatellite analysis. The results were analysed conventionally and were also subjected to a biomathematical cluster analysis. RESULTS: On average, bilateral breast cancer cases showed a low number of genetic alterations, a low frequency of genetic amplifications, and a high rate of chromosomal 16q losses. A distinct, characteristic genetic alteration associated with bilateral breast disease could not be found. Although two tumour pairs appeared to be related using biomathematical processing for microsatellite analysis, this result was reproduced by CGH data processing in one patient only. CONCLUSIONS: Most synchronous, bilateral breast cancer cases seem to represent independent tumours rather than metastatic events. Nevertheless, the possibility of a specific susceptibility remains.

Sex steroids, biochemical markers, bone mineral density and histomorphometry in male osteoporosis patients.

The present study investigates the role of sex steroids, especially serum estradiol and serum testosterone in male osteoporosis patients and their association to established markers of bone turnover as also to BMD results and histomorphometric findings. Included were patients with secondary osteoporosis due to steroid medication, anticonvulsive medication and alcohol consumption, and heavy smoking patients. 100 males aged from 30 to 78 years were investigated for osteodensitometry (DEXA) and assessment of biochemical bone turnover markers (venous blood samples, 24 hour urine samples). In 40 of these patients bone biopsies were taken for histomorphometry. Laboratory investigations were made for serum Ca, P, parathyroid hormone (PTH), osteocalcin (OC), carboxyterminal extension peptide of type I procollagen (PICP), bone specific alkaline phosphatase (B-ALP), 25OH-vit.D, testosterone, estradiol, gonadotropines, and deoxypyridinoline and hydroxyproline from 24-hour urinary collection. Regions of interest for osteodensitometry with DEXA technique were the lumbar spine L1-L4 and the femoral neck (Ward's triangle). All of the patients examined had low bone mineral density (BMD) values compared to age- and sex-matched controls. Results from descriptive statistics showed hypogonadism in 26.4%, 25 OH-vitamin D deficiency in 26.2% and high serum estradiol in 59.1% of patients, compared to age- and sex-matched controls. 8.5% had elevated PTH levels. Multivariate analysis of data showed no significant correlation between BMD and semiquantitative histomorphometric findings (scaled from 1-5), neither a significant correlation between serum testosterone/estradiol and BMD. A significant correlation was observed between testosterone and estradiol values (r = 0.389, p = 0.008), and between OC and BMD results at ward's triangle (p = 0.008). In steroid treated patients (n = 12) significant differences were found for PTH (P < 0.01), 25 OH-Vit.D (p < 0.05) and urinary deoxypyridinoline (p < 0.05) as compared with the other patient group (n = 88). In summary we found high serum estradiol in 59.1% of our patients collective with low BMD, there was no correlation between BMD and histomorphometric findings. We observe a significant positive correlation between testosterone and estradiol values, but we did not find any association to bone turnover markers or BMD results.

Routine hospital admission for patients undergoing upper aerodigestive tract endoscopy is unwarranted.

Although upper aerodigestive tract endoscopy is commonly performed, the need for hospital admission remains controversial. A retrospective review of endoscopy performed between January 1, 1993, and June 30, 1995, identified 201 patients who underwent 371 procedures. Complications occurred in 34 of 371 (9.2%) procedures in 26 of 201 (12.9%) patients. Of these, 11 of 371 (3.0%) were major (requiring admission for management) and 23 of 371 (6.2%) were minor. For multiple concurrent procedures, the overall complication rate was 19.3% (22/114); 5.3% (6/114) were major and 14.0% (16/114) were minor. All 8 patients (100%) who went on to have major complications and 24 of the 26 (92.3%) who went on to have any complication were successfully identified prior to discharge; 2 required postdischarge outpatient management of urinary retention. Five statistically significant risk factors for complication were identified: preexisting cardiac conditions, American Society of Anesthesiologists rating, airway class rating, anesthesia type, and number of endoscopic procedures performed. A comparison of various approaches to hospital admission demonstrated that selective admission based on clinical judgment was superior to routine admission of all patients. In conclusion, we recommend that upper tract endoscopy be performed on an ambulatory basis because 1) the complication rate is low, 2) complications requiring inpatient management are identifiable in the immediate postoperative period, and 3) of the approaches to hospital admission examined, it was the most economical.

Growth response, reproductive activity, and serum growth hormone in fine-wool ewe lambs treated with triiodothyronine.

Forty-four 6-mo-old, fine-wool ewe lambs were randomly allotted to one of three triiodothyronine (T(3)) treatment groups (14 or 15 ewe lambs/group). Treatments (0, 200, and 400 mug T(3)) were administered daily by subcutaneous injection during a 30-d treatment period in September. Following the treatments, ewe lambs were allowed to mate with Debouillet rams during a 34-d breeding season. Animal weights did not differ (P > 0.10) among treatment groups throughout the study. However, ewe lambs receiving 400 mug T(3)/d gained less (P < 0.05) during the treatment period than did those receiving 200 mug T(3)/d or controls. Grease fleece weights (6-mo clip) were similar (P > 0.10) among treatment groups. Serum growth hormone (GH) values in blood samples collected on Days 7 and 28 of the 30-d treatment were similar (P > 0.10) before treatments were administered and on Day 7 after treatments were administered. However, on Day 28 after treatments were administered, serum GH was lower (P < 0.01) in ewe lambs receiving 400 mug T(3)/d (1.5 ng/ml) than in those receiving 200 mug/d (2.1 ng/ml) or controls (2.2 ng/ml). Ovarian cyclicity was determined by monitoring serum progesterone. Forty percent of control ewe lambs were determined to have cycled during treatment compared with 20% of those receiving 200 mug T(3)/day and none of those receiving 400 mug T(3)/d (P < 0.10). Pregnancy rates were lower (P < 0.10) in ewe lambs receiving 400 mug T(3)/d (29%) compared with those receiving 200 mug T(3)/d (60%) or controls (66.7%). Day of conception, lambs born/ewe exposed, lambs born/ewe lambing, and lambs weaned/ewe lambing did not differ (P > 0.10) among treatments. Preweaning performance of offspring was not altered by maternal treatment with 200 or 400 mug T(3)/d (P > 0.10). These data indicate that 200 and 400 mug T(3)/d will not enhance GH production or improve reproductive performance of ewe lambs.

Reproductive responses, progesterone profiles and ovarian characteristics of cycling, fine-wool ewes treated with an inhibitor of progesterone synthesis (epostane).

In Exp. 1, 45 fine-wool ewes received (sc) either 0, 50 or 100 mg epostane (3-beta-hydroxysteroid dehydrogenase inhibitor) to examine effects on return to estrus and conception rates. Treatments were imposed on d 10 of an estrous cycle (estrus = d 0) and jugular blood samples were collected once daily on d 8 and 9, twice daily on d 10 through 13 and once daily from d 14 until first post-treatment estrus or d 20 (15 ewes/treatment). Intensive samples were obtained hourly for 6 h after treatment (d 10; five ewes/treatment). Serum progesterone (P4) before treatment was similar among groups; but by 2 h after treatment, epostane-treated ewes had lower (P less than .10) values than controls. By 6 h post-treatment, serum P4 in ewes receiving 50 (1.0 ng/ml) and 100 (.9 ng/ml) mg epostane was well below control values (3.2 ng/ml). By 7 d after treatment, 93.3% of ewes treated with 50 mg epostane had recycled compared with 66.7 and 33.3% of those receiving 100 and 0 mg, respectively (P less than .10). Similarly, 93.3, 53.3 and 26.7% of ewes receiving 50, 100 or 0 mg epostane, respectively, lambed to breeding within 7 d of treatment (P less than .05). Overall conception rates during a 34-d breeding season were similar among groups. Preweaning performance of offspring did not differ among maternal treatments.(ABSTRACT TRUNCATED AT 250 WORDS)

Determinants of patient satisfaction with outpatient surgery.

To help understand the determinants of patient satisfaction following outpatient surgery, the authors developed a written survey instrument and administered it to more than 200 patients. The significant predictors of overall satisfaction were the courtesy of the staff and clinical quality. Overall satisfaction was also found to be a significant predictor of intent to recommend.

The importance of annealing 316 LVM stents.

The annealing process is an important key step in the manufacture of high quality and reliable 316 LVM stents. [figure: see text] The methods commonly applied for verifying the outcome of the annealing process such as microhardness testing are inappropriate and should not be used. The tension testing of tubes, processed together with stents, provides reliable results of the final material properties of stents. During the course of the investigation the grain size was reduced significantly and the break elongation improved. The surface of the strain-tested material shows substantial improvements. All results are particularly important for thin-wall stents with filigree struts.