The impact of educational interventions on clinicians' knowledge of radiation protection: An integrative review.

OBJECTIVES: The aim of this review is to explore the impact of educational interventions on clinicians' knowledge of radiation protection. KEY FINDINGS: Following a comprehensive search of MEDLINE and EMBASE from 2000 to 2018, 1795 studies were identified, eight of which met the criteria for this review. All eight studies utilised pretest-posttest designs and involved the education of medical students or doctors. All studies reported an increase in participants' knowledge of radiation protection, five of which were statistically significant. In two studies, over half of participants stated that education received would impact on their future imaging requesting practice. CONCLUSION: Whilst a range of educational interventions have been shown to improve knowledge of radiation protection, there was wide variation in the study settings and type of educational programmes delivered. No studies assessed long-term knowledge retention or the impact on clinical practice. Therefore, robust research is needed to accurately measure the impact of educational programmes on knowledge of radiation protection in the UK and the implications this may have on referral practices. IMPLICATIONS FOR PRACTICE: This review revealed that educational interventions are effective in increasing participants' knowledge levels of radiation protection. It is necessary to assess and ensure that this improvement in knowledge actually translates into an impact on referral practice/behaviour. The ideal outcome being that fewer unnecessary examinations are requested and our patients are protected from a needless increased radiation burden.

Detection of messenger RNA in routinely processed tissue sections with biotinylated oligonucleotide probes.

In situ hybridization (ISH) with a radioactively 35S-labeled probe and a biotinylated oligonucleotide probe for human calcitonin was used to analyze eight cases of medullary thyroid carcinoma (MTC) in paraffin sections. Three of these cases were also studied with frozen tissue sections. The biotinylated probe readily detected calcitonin messenger RNA (mRNA) in routinely processed formalin-fixed paraffin-embedded tissue section within 24 hours. Northern hybridization and other control studies demonstrated the specificity of the calcitonin probe. Biotinylated oligonucleotide probes for other mRNAs present in high abundance such as adrenocorticotroipic hormone (ACTH), prolactin, and growth hormone also detected the respective mRNAs in pituitary tissues. These result show that biotinylated oligonucleotide cDNA probes can be used to detect specific mRNAs present in large amounts in some endocrine cells and tumors by ISH. This approach offers an alternative that does not require the use of molecular cloning or radioactive probes for this investigative and diagnostic technique.

Ploidy analysis of products of conception by image and flow cytometry with cytogenetic correlation.

Ploidy analysis of hydropic placentas is used in conjunction with morphology and clinical data to classify hydatidiform moles and hydropic abortuses. In most studies, ploidy has been assessed by flow cytometry (FCM). To validate image cytometry (ICM) as a method to determine ploidy in this setting, the authors used both FCM and ICM to study 19 hydropic placentas in which cytogenetic analysis was available. Nuclear suspensions from paraffin-embedded tissue were used for both ICM and FCM. Image cytometry of tissue sections was performed in some cases. Image cytometry and FCM were concordant in all 19 cases, but discordant with cytogenetics in 2 of 19 cases. Two hydropic abortuses (HA) with a diploid karyotype were triploid and tetraploid, respectively, by both ICM and FCM, which suggested that the cultured tissue was not representative. DNA indices were most accurate when an internal diploid control was used as the reference. In ICM, higher resolution was achieved by analyzing cell suspensions rather than tissue sections. This study shows that ICM is a valid method of determining ploidy of hydropic placentas and partial hydatidiform moles in archival tissue.

Endocervical glandular atypia: does a preneoplastic lesion of adenocarcinoma in situ exist?

Some believe endocervical glandular atypia (EGA), purportedly composed of cells that are less atypical than cells of adenocarcinoma in situ (AIS), is a preneoplastic precursor of AIS. We examined 246 neoplastic and nonneoplastic cervical cone biopsy and hysterectomy specimens from 221 patients for lesions composed of glandular cells with less atypia than AIS to define and characterize their association with other glandular processes. To avoid the circular argument of high-grade EGA (dysplasia) vs AIS, we set the minimum degree of AIS cells as the degree of atypia of the cells constituting a moderately differentiated invasive adenocarcinoma. Only 4 endocervical glandular lesions with mild atypia were found, 3 in patients with AIS or invasive endocervical-primary adenocarcinoma and 1 in a patient with invasive endometrial-primary, adenocarcinoma with endocervical extension. There were no lesions with high-grade atypia, nor was there a morphologic spectrum of cells with less atypia than AIS. Of the specimens, 14% had benign endocervical cell changes. The percentage of specimens in each group with benign endocervical cell changes was approximately equal. Although our study is small and retrospective, it suggests that no morphologic evidence exists to support the existence of a spectrum of endocervical glandular changes that culminates in AIS.

Serum alpha-fetoprotein levels in patients with chronic hepatitis C. Relationships with serum alanine aminotransferase values, histologic activity index, and hepatocyte MIB-1 scores.

Patients with chronic viral hepatitis and cirrhosis often have elevated serum alpha-fetoprotein (AFP) values, the causes of which are unclear. We studied 81 patients with chronic hepatitis C and the relationships of serum AFP and alanine aminotransferase (ALT) values, hepatic histologic features, and hepatocyte proliferation activity scores. Twenty-two patients had nil to mild fibrosis, 34 had moderate fibrosis, and 25 had marked fibrosis-cirrhosis. The mean serum AFP value was significantly greater in patients with more fibrosis. Serum ALT values were slightly greater in the marked fibrosis-cirrhosis patient group. The differences in the HAI and in hepatocyte MIB-1 scores were not significant. Among all patients, increasing serum AFP values significantly correlated with increasing ALT values. However, there were no significant correlations with serum ALT or HAI and serum AFP values. There was no association between serum AFP values and immunohistochemical staining for AFP within hepatocytes. These results suggest that elevated serum AFP values are the result of altered hepatocyte-hepatocyte interaction and loss of normal architectural arrangements. The presence of marked fibrosis or cirrhosis, a state of significant altered hepatocyte architecture, may be the underlying cause of increased serum AFP, rather than necrosis or active regeneration.

Hepatosplenic gamma/delta T-cell lymphoma in immunocompromised patients. Report of two cases and review of literature.

We describe 2 male patients in whom hepatosplenic gamma/delta T-cell lymphoma (HSTL) developed 6 and 10 years after renal transplantation. The onset was abrupt with systemic symptoms, cytopenia, and hepatosplenomegaly. The histologic examination of the spleen (case 1), liver, and bone marrow revealed sinusoidal infiltrates of markedly abnormal lymphocytes. The neoplastic cells in these cases were CD2+, CD3+, CD4-, CD5-, CD7+, CD8+, CD16+, CD56+, beta F1-negative, and TIA-1-negative. Both cases displayed clonal rearrangement of the T-cell receptor (TCR) delta gene and the TCR beta gene. The spleen in case 1 was positive for Epstein-Barr virus genome and showed TCR-gamma gene rearrangement by polymerase chain reaction. Isochromosome 7 [i(7)(q10)] was found in each case. Both patients died within 4 months of diagnosis. HSTL has been reported in only 5 renal transplant recipients. HSTL may be relatively more frequent in immunocompromised patients compared with the general population.

Rules governing pharmaceuticals in the European Community.

In the interest of public health, the European community has progressively established common scientific criteria for the evaluation of human and veterinary medicines and harmonized the national authorization procedures. One major consequence of this has been that neither the tests and trials carried out to obtain authorization nor batch controls need be repeated within the European community. Henceforth the pharmaceutical industry may benefit from two types of procedures intended to facilitate the registration of their medicinal products in the member states. One, reserved for biotechnology/high technology medicinal products, involves community coordination prior to any national decision together with special protection against copies for ten years, irrespective of the position under patent law. The other enables firms to request the recognition by the other member states of an authorization previously granted by one member state. The experience gained from these two procedures will lead to the choice of the most appropriate European registration procedure for the next decade. In the interests of the European consumer, cooperation between the 12 member states and the Commission of the European Communities has progressively increased within the Committee for Proprietary Medicinal Products (adverse effects of medicines/pharmacovigilance) and the Committee for Veterinary Medicinal Products (residues). In association with these committees, several working groups of experts attempt to approximate and codify practices in the evaluation of the quality, safety, and efficacy of medicinal products (guidelines).(ABSTRACT TRUNCATED AT 250 WORDS)

Nonhuman primate bites.

Nonhuman primate (monkey) bites to researchers and attending animal care staff may present problems in patient management. Such inoculations can transmit serious bacterial and viral infections to the human handlers. Significant local and systemic manifestations can subsequently develop following such an injury. Since Herpesvirus simiae (B virus) is enzootic in Asiatic monkeys of the genus Macaca, and since B virus infection in humans is usually fatal, additional prophylactic and therapeutic measures must be taken when persons are bitten by macaque monkeys. Primate bites require early aggressive intervention.

Increased wheeze but not bronchial hyperreactivity near power stations.

STUDY OBJECTIVE: In a previous study a higher than expected prevalence of asthma was found in Lake Munmorah, a coastal town near two power stations, compared with another coastal control town. This study aimed to compare atopy, bronchial hyperreactivity, and reported symptoms of asthma in the power station town and a second control area with greater socioeconomic similarity. DESIGN: A cross sectional survey was undertaken. SETTINGS: Lake Munmorah, a coastal town near two power stations, and Dungog, a country town in the Hunter Valley, NSW, Australia. PARTICIPANTS: All children attending kindergarten to year 6 at all schools in the two towns were invited to participate in 1990. The response rates for the questionnaire for reported symptoms and associated demographic data were 92% in Lake Munmorah and 93% in Dungog, with 84% and 90% of children respectively being measured for lung function, atopy, and bronchial reactivity. There were 419 boys and 432 girls aged 5 to 12 years. MEASUREMENTS AND MAIN RESULTS: Main outcome measures were current wheeze and bronchial hyper-reactivity, defined as a fall in forced expiratory volume in 1 second (FEV1) or peak expiratory flow (PEF) of 20% or more. Current wheeze was reported in 24.8% of the Lake Munmorah children compared with 14.6% of the Dungog children. Bronchial hyper-reactivity was similar for both groups--25.2% in Lake Munmorah and 22.3% in Dungog. The mean baseline FEV1 was lower in Lake Munmorah than in Dungog (p < 0.001). Dungog children were more likely to have positive skin test to house dust mite (Dungog 27.0%, Lake Munmorah 20.2%, p = 0.028) but there were no other differences in skin test atopy in the two towns. After adjusting for age, gender, any smoker in the house, and positive dust mite skin test, the odds of current wheeze in Lake Munmorah compared with Dungog was 2.16 (95% confidence interval 1.45, 3.15). CONCLUSIONS: Baseline lung function was lower and reported symptoms of asthma were higher in the power station town, but bronchial hyper-reactivity and skin test defined atopy were similar in the two communities. These results are consistent with the previous study and confirm the increased presence of reported symptomatic illness in the town near power stations.

Chemotherapy for malignancy induces a remission in asthma symptoms and airway inflammation but not airway hyperresponsiveness.

Inflammation with infiltrations of eosinophils and mast cells into the walls of airways is considered to increase airway hyperresponsiveness (AHR), which in turn characterizes asthma. We present a child with AHR in whom the clinical course of asthma was related to eosinophilic bronchitis. Our patient was admitted at age 6 months with bronchiolitis and at age 4 years with asthma. Inhaled corticosteroids were begun at age 7 years. At age 8 he developed a meningeal sarcoma. While on chemotherapy, his asthma symptoms resolved and he no longer required prophylactic asthma treatment. After 14 months off all chemotherapy, he again had mild episodic asthma. While receiving chemotherapy for malignancy, he had an admission with a coagulase negative staphylococcal bacteremia. During sputum induction with 4.5% saline, he developed cough, wheeze, and a 20% reduction in peak expiratory flow (220 to 180 L/min) that reversed after treatment with salbutamol. The sputum cell count was 1.7 x 10(6)/ml with 1.1 x 10(6) being neutrophils. Two weeks later and prior to the induction of the second sputum, a 21% increase in FEV1 was recorded after bronchodilator inhalation (82% to 99% of predicted). The second sputum contained 2.7 x 10(6)/ml cells with 1.6 x 10(6)/ml neutrophils. Neither eosinophils nor mast cells were identified in the sputum. A third sputum obtained 14 months after the cessation of chemotherapy showed a sputum cell count of 16 x 10(6)/ml, with 11.6 x 10(6) neutrophils and 0.4 x 10(6) eosinophils; no mast cells were detected. A reversible 15% reduction in FEV1 was detected on hypertonic saline challenge testing. This boy had persistent airway hyperreactivity and reversible airways obstruction on three occasions during and following chemotherapy. When he developed asthma symptoms, his sputum contained neutrophils and eosinophils; while on chemotherapy his sputum did not contain eosinophils and he was symptom-free and off all asthma therapy. One can speculate that chemotherapy for malignancy can induce a remission in asthma symptoms but not AHR, and remission in symptoms is associated with a lack of eosinophilic or mast cell infiltrates in the sputum.

Mantle cell lymphoma.

OBJECTIVE: This article summarizes the most useful ancillary immunohistochemical and molecular assays for use in the diagnosis of mantle cell lymphoma. DATA SOURCES: The English language literature was surveyed, with an emphasis on recent publications, for articles presenting key advances in the molecular characterization of mantle cell lymphomas and for series of cases testing the utility of molecular diagnostic tests. The authors' series of 26 small B-cell lymphomas, analyzed for the cyclin D1 protein by paraffin immunohistochemistry and for t(11;14) by polymerase chain reaction, is included. CONCLUSIONS: Mantle cell lymphoma, a B-cell lymphoma now recognized in the 1994 Revised European-American Classification of Lymphoid Neoplasms (REAL) classification, is a relatively aggressive lymphoma with a poor prognosis. Its characteristic t(11;14)(q13;q32) translocation has a role in oncogenesis and has been exploited for molecular diagnostic tests, but these tests vary in sensitivity, specificity, and ease of use. Improved immunohistochemical tests are sufficient to confirm the diagnosis in most cases. Conventional cytogenetics and molecular diagnostic tests for t(11;14)-Southern blot and polymerase chain reaction analysis-may be helpful in selected cases, but are laborious or of limited sensitivity. Other methods, such as fluorescence in situ hybridization, need further development to provide faster, more sensitive diagnosis.

TWODEE: the Health and Safety Laboratory's shallow layer model for heavy gas dispersion. Part 1. Mathematical basis and physical assumptions.

The Major Hazard Assessment Unit of the Health and Safety Executive (HSE) provides advice to local planning authorities on land use planning in the vicinity of major hazard sites. For sites with the potential for large scale releases of toxic heavy gases such as chlorine this advice is based on risk levels and is informed by use of the computerised risk assessment tool RISKAT [C. Nussey, M. Pantony, R. Smallwood, HSE's risk assessment tool RISKAT, Major Hazards: Onshore and Offshore, October, 1992]. At present RISKAT uses consequence models for heavy gas dispersion that assume flat terrain. This paper is the first part of a three part paper. Part 1 describes the mathematical basis of TWODEE, the Health and Safety Laboratory's shallow layer model for heavy gas dispersion. The shallow layer approach used by TWODEE is a compromise between the complexity of CFD models and the simpler integral models. Motivated by the low aspect ratio of typical heavy gas clouds, shallow layer models use depth-averaged variables to describe the flow behaviour. This approach is particularly well suited to assess the effect of complex terrain because the downslope buoyancy force is easily included. Entrainment may be incorporated into a shallow layer model by the use of empirical formulae. Part 2 of this paper presents the numerical scheme used to solve the TWODEE mathematical model, and validated against theoretical results. Part 3 compares the results of the TWODEE model with the experimental results taken at Thorney Island [J. McQuaid, B. Roebuck, The dispersion of heavier-than-air gas from a fenced enclosure. Final report to the US Coast Guard on contract with the Health and Safety Executive, Technical Report RPG 1185, Safety Engineering Laboratory, Research and Laboratory Services Division, Broad Lane, Sheffield S3 7HQ, UK, 1985].

TWODEE: the Health and Safety Laboratory's shallow layer model for heavy gas dispersion. Part 2: outline and validation of the computational scheme.

Part 1 of this three part paper described the mathematical and physical basis of TWODEE, the Health and Safety Laboratory's shallow layer model for heavy gas dispersion. In this part, the numerical solution method used to simulate the TWODEE mathematical model is developed. The boundary conditions for the leading edge, discussed in part 1, make demanding requirements on the computational scheme used. The flux correction scheme of Zalesak [S.T. Zalesak, Fully multidimensional flux-corrected transport algorithms for fluids, Journal of Computational Physics, 31 (1979) 335-362] is used in TWODEE as this has all the required properties. The TWODEE code is then tested against a number of theoretical and computational benchmark problems.

TWODEE: the Health and Safety Laboratory's shallow layer model for heavy gas dispersion. Part 3: experimental validation (Thorney Island).

Part 1 of this three-part paper described the mathematical and physical basis of TWODEE, the Health and Safety Laboratory's shallow layer model for heavy gas dispersion. In part 2, the numerical solution method used to simulate the TWODEE mathematical model was developed; the flux correction scheme of Zalesak [S.T. Zalesak, Fully multidimensional flux-corrected transport algorithms for fluids, Journal of Computational Physics, 31 (1979) 335-362.] was used in TWODEE. This paper compares results of the TWODEE model to the experimental results taken at Thorney Island [J. McQuaid, B. Roebuck, The dispersion of heavier-than-air gas from a fenced enclosure. Final report to the U.S. Coast Guard on contract with the Health and Safety Executive. Technical Report RPG 1185, Safety Engineering Laboratory, Research and Laboratory Services Division, Broad Lane, Sheffield S3 7HQ, UK, 1985.]. There is no evidence to suggest that TWODEE predictions could be improved by changing any of the entrainment parameters from generally accepted values [R.K.S. Hankin, Heavy gas dispersion over complex terrain, PhD thesis, Cambridge University, 1997.]. The TWODEE model was broadly insensitive to the exact values of the entrainment parameters.

The cost of providing restorative dentistry in an alternative delivery mode.

This study is based on the Forsyth Dental School experiment, where it was shown that dental hygienists can be trained to perform restorative dental functions which are now the exclusive responsibility of dentists. The focus of the Forsyth study was to determine the length of training time required and to measure the qualitative and quantitative aspects of services carried out by the hygienists. As a follow-up to that study, this paper is concerned with the economic aspects of the personnel substitution suggested by the Forsyth project. The basic hypothesis of the study is that there would be a considerable gain from this change, and that this gain can be measured by estimating the costs of operation in the new setting anc comparing them to costs in the conventional setting. Combining estimated clinic costs and productivity data provides a measure of the per-surface supply price for an amalgam restoration. This estimate is 44 percent lower than usual fees and 29 percent lower than current welfare fees. The magnitude of this difference implies that the introduction of Forsyth clinics would lead to considerable economics in the elivery of these services.

Low-grade central osteosarcoma resembling fibrous dysplasia. A report of two cases.

We describe 2 cases of low-grade central osteosarcoma mimicking fibrous dysplasia and present a review of the literature. These cases illustrate the importance of obtaining a large representative sample of tumor in suspicious lesions, because it may be difficult or impossible to histologically distinguish low-grade central osteosarcoma from a benign lesion with limited samples from a core biopsy or needle aspiration. The treatment of choice for low-grade central osteosarcoma is resection with wide surgical margins or, if limb salvage is not technically feasible, amputation.

The future European system for the free circulation of veterinary vaccines in Europe.

Although Community legislation has only recently been extended to cover veterinary biologicals, these products are fully covered by the recent Commission proposals for the free movement of medicinal products after 1992. The proposals are based on more than 25 years of harmonization of national regulations and more than 10 years' experience of coordinating national decisions on individual medicinal products. The proposals envisage the establishment of two new Community authorization procedures: a centralized procedure based on a single scientific evaluation of the highest possible quality to be undertaken within a new European Medicines Evaluation Agency, leading to a binding EEC-wide decision, with the possibility of limited exceptions to take account of differences in disease status in the Member States; a decentralized procedure based on the concept of mutual recognition of national decisions, with binding Community arbitration in the event of a dispute. To provide the Community institutions with the scientific and technical resources necessary to operate these new procedures, the proposals also provide for the establishment of a European Medicines Evaluation Agency.

Comparison of preservative-free and preservative-containing ipratropium bromide.

A double-blind crossover study was performed on 33 children with asthma to compare the effectiveness of nebulized solutions of preservative-containing and preservative-free ipratropium bromide. Both solutions produced bronchodilation. No significant differences were found between the two solutions at any time after nebulization in minimum and maximum changes from baseline value or in the areas under the lung function time curves. The presently formulated preservative-containing ipratropium bromide solution was not shown to be inferior to a preservative-free compound.

Malignant fibrous histiocytoma involving a digit.

A case of malignant fibrous histiocytoma (MFH) involving phalanges of a single digit is reported. MFH of the bones of the hand has not previously been reported. Ten years after wide local excision, the patient remains clinically free of disease.

Clear cell sarcoma presenting as an interdigital neuroma.

The incidence of malignant soft-tissue sarcomas in the general population is approximately 1.4 per 100,000. Approximately 2% of all cancer deaths are attributable to these tumors. Presented is a case history of a soft-tissue malignant neoplasm that was originally thought to be an interdigital neuroma and that eventually required a modified Chopart's amputation. A review of the literature is presented on other soft-tissue malignant tumors that have an affinity for the foot and ankle. The intention of presenting this case is to caution physicians that malignant lesions can simulate a benign process and should always be considered in the differential diagnosis of any foot mass.