Implementation of a personalized workplace smoking cessation programme.

BACKGROUND: Providing smoking cessation programmes through workplaces is an effective method of assisting employees to quit smoking; however, few employers provide such services, and achieving long-term success remains challenging. AIMS: To evaluate the effectiveness of a workplace-based tailored smoking cessation programme that combined telephone-based counselling with group behaviour therapy sessions in helping employees to quit. METHODS: A smoking cessation programme was offered to employees of a large corporation that is respons ible for the passenger rail network in New South Wales (NSW), Australia. Two hundred and thirty participants enrolled in the programme, which offered telephone-based coaching and group sessions designed around cognitive behavioural therapy principles. One hundred and eight participants (47%) completed the 6 month follow-up assessment. RESULTS: Of the estimated 2850 smokers in the organization, 8% (230) registered for the smoking cessation programme, with 77% (176) participating in telephone-based coaching and/or group sessions. Intention-to-treat analysis indicated 22% of participants achieved 7 day point prevalence abstinence and 10% achieved 3 month prolonged abstinence at the 6 month follow-up. Over 75% of those still smoking at follow-up reported intentions to quit in the next 6 months. Psychological distress was also significantly lower at 6 month follow-up. Participants reported high levels of satisfaction with the programme. CONCLUSIONS: The smoking cessation programme successfully assisted employees to quit smoking. Unique aspects of the programme such as continuity of care were valued by participants and may have contributed to the programme's success.

Long term follow up of BRCA1 and BRCA2 mutation carriers with unsuspected neoplasia identified at risk reducing salpingo-oophorectomy.

OBJECTIVES: The reported incidence of neoplasia identified at the time of risk-reducing salpingo-oophorectomy (RRSO) in germline BRCA1/2 mutation carriers ranges from 4 to 12% but long-term outcomes have not been described. We evaluated recurrence and survival outcomes of mutation carriers with neoplastic lesions identified at RRSO. METHODS: We identified BRCA1/2 mutation carriers with neoplasia at RRSO at three institutions. Data was collected on clinical variables, adjuvant treatment and follow-up. RESULTS: We identified 32 mutation carriers with invasive carcinomas (n=15) or high-grade intraepithelial neoplasia (n=17) that were not suspected prior to surgery. 26 occurred in BRCA1 and 6 in BRCA2 mutation carriers. Median and mean age for carcinomas were 50 years and 49.3 respectively, significantly younger than for intraepithelial neoplasm, median 53 years, and mean 55 years (p=0.04). For the 15 invasive carcinomas, median follow up was 88 months (range 45-172 months), 7 recurred (47%), median time to recurrence was 32.5 months and 3 have died of disease; 1 additional patient died of breast cancer. Overall survival was 73%, disease specific overall survival was 80% and disease free survival was 66%. For the 17 high-grade intraepithelial neoplasms, median follow up was 80 months (range 40-150), 4 were treated with chemotherapy. One recurred at 43 months and is currently not on therapy with a normal CA125, 16 months later. All patients with noninvasive neoplasia are alive. CONCLUSIONS: BRCA1 and BRCA2 mutation carriers with unsuspected invasive carcinoma at RRSO have a relatively high rate of recurrence despite predominantly early stage, small volume disease. High-grade intraepithelial neoplasms rarely recur as carcinoma and may not require adjuvant chemotherapy.

Predictors of contralateral breast cancer in BRCA1 and BRCA2 mutation carriers.

PURPOSE: The objective of this study was to estimate the risk of contralateral breast cancer in BRCA1 and BRCA2 carriers; and measure the extent to which host, family history, and cancer treatment-related factors modify the risk. PATIENTS AND METHODS: Patients were 810 women, with stage I or II breast cancer, for whom a BRCA1 or BRCA2 mutation had been identified in the family. Patients were followed from the initial diagnosis of cancer until contralateral mastectomy, contralateral breast cancer, death, or last follow-up. RESULTS: Overall, 149 subjects (18.4%) developed a contralateral breast cancer. The 15-year actuarial risk of contralateral breast cancer was 36.1% for women with a BRCA1 mutation and was 28.5% for women with a BRCA2 mutation. Women younger than 50 years of age at the time of breast cancer diagnosis were significantly more likely to develop a contralateral breast cancer at 15 years, compared with those older than 50 years (37.6 vs 16.8%; P=0.003). Women aged <50 years with two or more first-degree relatives with early-onset breast cancer were at high risk of contralateral breast cancer, compared with women with fewer, or no first-degree relatives with breast cancer (50 vs 36%; P=0.005). The risk of contralateral breast cancer was reduced with oophorectomy (RR 0.47; 95% CI 0.30-0.76; P=0.002). CONCLUSION: The risk of contralateral breast cancer risk in BRCA mutation carriers declines with the age of diagnosis and increases with the number of first-degree relatives affected with breast cancer. Oophorectomy reduces the risk of contralateral breast cancer in young women with a BRCA mutation.

Participation in a parent education programme in the Dominican Republic: utilization and barriers.

There has been a limited assessment of the extent of participation in parent education programmes and the factors influencing attendance. This is particularly the case for low- and middle-income countries. Experiences with an eight-session education programme offered to caregivers of malnourished children in the Dominican Republic were examined. Overall, 57% of a total of 143 caregivers completed more than half of the programme. This value increased from 41% to 79% following a midstream change in service delivery, which entailed concentrating the programme into a shorter period of time and pairing it with a more intensive child nutrition component. Other hypothesized variables did not predict attendance. Key barriers to attendance identified in qualitative interviews included lack of money for transportation, lack of an acceptable babysitter for other children and competing demands on the caregivers' time. Efforts to eliminate caregiver identified barriers may improve participation levels.

Age at first birth and the risk of breast cancer in BRCA1 and BRCA2 mutation carriers.

An early age at first full-term birth is associated with a reduction in the subsequent development of breast cancer among women in the general population. A similar effect has not yet been reported among women who carry an inherited BRCA1 or BRCA2 mutation. We conducted a matched case-control study on 1816 pairs of women with a BRCA1 (n = 1405) or BRCA2 (n = 411) mutation in an attempt to elucidate the relationship between age at first full-term pregnancy and the risk of developing breast cancer. Information about the age at first childbirth and other pregnancy-related variables was derived from a questionnaire administered to women during the course of genetic counselling. There was no difference in the mean age at first full-term birth in the cases and controls (24.9 years vs. 24.8 years; P = 0.81, respectively). Compared to women whose first child was born at or before 18 years of age, a later age at first full-term birth did not influence the risk of developing breast cancer (OR = 1.00 per year; 95% CI 0.98-1.03; P-trend = 0.67). Stratification by mutation status did not affect the results. These findings suggest that an early first full-term birth does not confer protection against breast cancer in BRCA mutation carriers. Nonetheless, BRCA mutation carriers opting for a prophylactic oophorectomy as a breast and/or ovarian cancer risk-reducing strategy should complete childbearing prior to age 40 when this prevention modality is most effective.

Lessons learned after second-look arthroscopy in type III fractures of the tibial spine.

UNLABELLED: Ten patients with type III intercondylar eminence fractures with 6 years of follow-up underwent second-look arthroscopy after new injuries or complaints. Initial treatment was closed reduction (group I), arthroscopic reduction (group II), and arthroscopic reduction with internal fixation (group III). Lysholm ratings and one leg hop tests were normal in groups II and III and < 90% in group I. Tegner levels were 8, 9, and 10 in groups I, II, and III, respectively. International Knee Documentation Committee ratings were grades C, B, and A for groups I, II, and III, respectively. Arthroscopy revealed > 3 mm offset in groups I and II, suggesting loss of reduction, and grades II and III retropatellar chondromalacia. The fracture "footprint" is not congruous with the femoral condyle in extension or flexion. Loss of reduction led to laxity and prolonged morbidity. CLINICAL RELEVANCE: Loss of reduction is common after closed treatment of tibial spine fractures and should be closely monitored. Type III fractures that are unreducible or displaced require reduction, appropriate tensioning, internal fixation, and aggressive rehabilitation.

A new approach to the treatment of ankle fractures. The Inyo nail.

The Inyo nail is a new intramedullary device for the treatment of fractures of the distal fibula. It is a tapered V-shaped nail made of malleable stainless steel, which provides rigid fracture fixation. Torsional stress is resisted because of its triflanged shape. It may be introduced closed, using the image intensifier. Two groups of patients were evaluated: Group I was treated with the Inyo nail and Group II was treated by the Association For the Study of Internal Fixation (ASIF) technique. Eighty-five percent of the patients in Group I were rated as good, compared with 63% in Group II. There was significantly less morbidity and complications in Group I. Several factors must be observed in the treatment of ankle fractures. Stress radiographs must be obtained intraoperative. Surgery may be indicated in unstable supination lateral rotation Type II injuries, if these occur in patients with high physical demands. Anatomic reduction of the lateral malleolus must be obtained. Early weight-bearing and motion produces the best result. Late reconstruction of malunions can be accomplished using the Inyo nail.

Bone grafting of the secondary cleft lip and palate deformity.

A series of 112 cases of bone grafting in secondary cleft lip and palate deformities is presented with a follow-up averaging 7.5 years. The orthodontic management of these patients is described. The advantages of this procedure, in terms of secure fistula closure, maxillary stability, ease of subsequent orthodontic and prosthodontic management and the benefits from an aesthetic point of view are analysed and their relevance in total patient management discussed.

Pneumothorax complicating fracture of the scapula.

We evaluated thirty patients with a fracture of the scapula in a prospective study over a seven-year period. Sixteen patients were found to have an associated pneumothorax, of which more than two-thirds were associated with a fracture of the left scapula. Ten of the pneumothoraces were delayed for one to three days. All of the scapular fractures were treated using a shoulder immobilizer, and early range-of-motion exercises of the involved extremity were instituted as tolerated. Information obtained from pulmonary auscultation and percussion, determination of initial values for arterial blood gases, and daily chest radiographs for three days after injury confirmed the diagnosis. Closed suction drainage using anteriorly or laterally placed thoracostomy tubes was performed successfully in all patients and avoided the potential sequelae of shock, respiratory failure, and pneumonia, as well as recurrence.

The role of arthroscopic surgery in the treatment of fractures of the intercondylar eminence of the tibia.

Thirty-five patients were treated for Type III fractures of the intercondylar eminence of the tibia and were followed up for two to seven years. There were 20 Type IIIA fractures and 15 Type IIIB fractures. The avulsed fragment was reduced by operative arthroscopy and maintained either by extension and immobilisation in a cast or by crossed percutaneous pin fixation. Involvement of the medial collateral ligament or lateral meniscus was confirmed by valgus stress radiographs and by arthroscopy. Primary surgical repair through a separate incision was required in a significant number of patients. At follow-up, few patients suffered ligamentous instability, lack of extension, atrophy of the quadriceps, pain or effusion, and symptoms were minimal. Patients requiring surgical repairs of collateral ligaments or of peripheral detachments of the meniscus generally required a longer period of rehabilitation. Arthroscopic reduction and percutaneous pin fixation provided an effective treatment and significantly decreased the time spent in hospital and the morbidity experienced after alternative treatments.

Bone marrow grafting in the secondary closure of alveolar-palatal defects in children.

The material presented in this paper is a preliminary report on the use of bone marrow grafting in the secondary closure of alveolar palatal defects in young children with mixed dentition. A group of patients is presented in whom successful closure of an alveolar fistula was achieved with improvement of the eruption pattern of the teeth adjacent to the cleft due to new bone formation that allowed early orthodontic alignment. The concept of the formation of a dynamic growing bone from bone marrow grafting is discussed.

Transcranial enucleation for optic nerve tumor.

Tumors involving both the eye and the optic nerve present a special surgical problem. Conventional enucleation techniques neither permit the surgical exploration of the optic nerve nor assure the complete removal of tumor within the orbit, and they often involve transection through tumor-containing tissue. Transcranial enucleation permits the inspection of the tumor from the back of the globe to the chiasm and its en bloc removal.

Cerebral abscess in children.

We reviewed 94 consecutive episodes of pyogenic brain abscess seen at Children's Hospital Medical Center, Boston, between 1945 and 1980. After 1970, the mortality as reduced from 36% to 14%. Predisposing factors included congenital heart disease, otitic and sinus infections, closed head injuries, and cystic fibrosis. There were seven patients younger than 5 months of age. In one patient with Fallot's tetralogy, an abscess recurred at the site of retained thorium dioxide (Thorotrast) after an 11-year interval. The continuing substantial mortality is attributed to the presence of coma at the time of treatment, hemorrhagic complications of tapping abscesses, and the location of abscesses in deep brain structures. The early detection and successful treatment of brain abscesses in children remains a clinical challenge.

Intracranial blood clot volume and geometric parameters determined from CT images.

A method of determining intracranial blood vlot volumes from CT images data is presented. This technique avoids dependence on regular geometric volume approximations. Studies are presented on phantoms of known volume (ranging from 3.5 to 108 cm3) but with varying size, shape, and density relative to the surrounding medium. For a wide range of differential densities across the boundary, these phantom results indicate that volumes may be calculated to an accuracy generally better than +/- 2 cm3. A series of clinical cases, principally hypertensive intracranial hemorrhages, have been studied to demonstrate the technique. Three-dimensional axes, which allow clot localization relative to cerebral anatomy, are defined using the anterior/posterior falx attachment points and the dorsum sellae. Clot volume, center of mass, vector of clot expansion, and shift of anatomical structures are determined. Correlation of these data with clinical outcome and surgery is discussed.

Cortical vein thrombosis in Wegener's granulomatosis. Case report.

A patient with Wegener's granulomatosis is reported in whom a life-threatening cortical vein thrombosis was identified as the process causing acute neurological deterioration. The literature dealing with the neurological and neuropathological manifestations in Wegener's granulomatosis is reviewed.

Rib anomalies in myelodysplasia. An approach to embryologic inference.

An embryologic teratogenic mechanism is reconstructed by utilizing the distribution of anomalous ribs in children with lumbosacral myelomeningocele. This methodology may help to coalesce information from experimental models of teratogenesis and from descriptive human embryology. It provides an approach to deductive reasoning about human structural anomalies based on dynamic embryonic models of teratogenesis. Availability of a developmental time scale, based for example on the distribution of defective ribs, may be useful in the study of other teratogenic and developmental processes.

Malignant teratoma arising within a lipomeningocele. Case report.

The authors report the case of an 11-year-old, neurologically normal girl, followed since birth for lipomeningocele, who developed a malignant teratoma within the lymbosacral lesion and presented with metastases to the lungs and groin. This rare occurrence is discussed from an embryological and management viewpoint.