Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) in children: a randomized controlled trial.

BACKGROUND: Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) was introduced to adult anaesthesia to improve the safety of airway management during apnoea before intubation. The objective of our study was to determine whether THRIVE safely prolongs apnoeic oxygenation in children. METHODS: This was a randomized controlled trial in 48 healthy children, with normal airways and cardiorespiratory function, in age groups 0-6 and 7-24 months, 2-5 and 6-10 yr old, presenting for elective surgery or imaging under general anaesthesia. All children were induced with sevoflurane, O2, and N2O, followed by muscle relaxation with rocuronium, and standardized preoxygenation with bag-and-mask ventilation. The control arm received jaw support during apnoea, whereas the THRIVE arm received jaw support during apnoea and age-specific flow rates. The primary outcome was to demonstrate that children allocated to THRIVE maintain transcutaneous haemoglobin saturation at least twice as long as the expected age-dependent apnoea time in the control group. RESULTS: Both study arms (each n=24) were similar in age and weight. The apnoea time was significantly shorter in the control arm: average 109.2 (95% CI 28.8) s in the control arm and 192 s in the THRIVE arm (0-6 months), 147.3 (95% CI 18.9) and 237 s (7-24 months), 190.5 (95% CI 15.3) and 320 s (2-5 yr), and 260.8 (95% CI 37.5) and 430 s (6-10 yr), respectively. Average transcutaneous haemoglobin saturation remained at 99.6% (95% CI 0.2) during THRIVE. Transcutaneous CO2 increased to a similar extent in both arms, with 2.4 (95% CI 0.5) mm Hg min-1 for the control arm and 2.4 (95% CI 0.4) mm Hg min-1 for the THRIVE arm. CONCLUSION: Transnasal humidified rapid-insufflation ventilatory exchange prolongs the safe apnoea time in healthy children but has no effect to improve CO2 clearance. CLINICAL TRIAL REGISTRATION: ACTRN12615001319561.

Challenging cognitive cases among physician populations: case vignettes and recommendations.

BACKGROUND: Physicians are not immune to cognitive impairment. Because of the risks created by practising doctors with these issues, some have suggested developing objective, population-specific measures of evaluation and screening guidelines to assess dysfunction. However, there is very little published information from which to construct such resources. AIMS: To highlight the presentation characteristics and provide evaluation recommendations specific to the needs of physicians with actual or presumed cognitive impairment. METHODS: A retrospective database and chart review of cognitively impaired doctors who presented to a physician health programme (PHP). Complex cases were highlighted using simple descriptives and clinical vignettes. RESULTS: A total of 124 cases were included. Clients presented with a variety of issues other than cognitive concerns. We identified four principal domains of impairment: (i) diseases of (or in) the brain (48%); (ii) mood/ anxiety disorders or treatment side effects (28%); (iii) substance use (9%) and (iv) traumatic brain injury (7%). Age was not a good predictor of impairment and brief screening using the Montreal Cognitive Assessment demonstrated a ceiling effect with this cohort. Although many clients underwent some type of professional or personal transition, impairment did not necessarily indicate worse functioning after care. CONCLUSIONS: Physician cognitive evaluations should consider a variety of secondary sources of information, particularly vocational performance reports. It may take time before cognitive impairment can be diagnosed or ruled-out in this population. Prior assumptions, especially for non-cognitive referrals, can lead to inaccurate diagnosis and referrals. PHPs must manage cognitive cases carefully, not only in their clinical complexity but also in their psychosocial aspects.

Technical Note on the Role of Kambin's Triangle in the Evolution of Total Joint Replacement of the Lumbar Spine.

We provide a historical and technical perspective on the evolution of Kambin's triangle as a safe working corridor for percutaneous access to the intervertebral disc to an anatomically expanded space to accommodate and facilitate open lumbar total joint replacement. The nearly 6-decade progression from intradiscal access in the intact lumbar spine to an enlarged working space following facetectomy to accommodate a transforaminal lumbar interbody fusion, and eventual further expansion via pedicle vertebral body osteotomy to support motion preservation with total joint replacement, represents a unique evolutionary pathway in surgical technique development. For each of these steps in evolution, we detail and provide the historical context of the corresponding surgical modifications required to expand the original anatomical boundaries of Kambin's triangle. It is postulated that the introduction of machine learning technologies coupled with innovations in robotics, materials science, and advanced imaging will further accelerate and refine the adaptation of more complex, precise, and efficacious surgical procedures to treat spinal degeneration via this working corridor.

Are We Finally Ready for Total Joint Replacement of the Spine? An Extension of Charnley's Vision.

Professor Sir John Charnley has been rightfully hailed as a visionary innovator for conceiving, designing, and validating the Operation of the Century-the total hip arthroplasty. His groundbreaking achievement forever changed the orthopedic management of chronically painful and dysfunctional arthritic joints. However, the well-accepted surgical approach of completely removing the diseased joint and replacing it with a durable and anatomically based implant never translated to the treatment of the degenerated spine. Instead, decompression coupled with fusion evolved into the workhorse intervention. In this commentary, the authors explore the reasons why arthrodesis has remained the mainstay over arthroplasty in the field of spine surgery as well as discuss the potential shift in the paradigm when it comes to treating degenerative lumbar disease.

Pregnant women's use of information and communications technologies to access pregnancy-related health information in South Australia.

This paper examines how pregnant women living in South Australia use information and communication technologies (ICTs), principally Internet and mobile phones, to access pregnancy-related information. It draws on 35 semistructured interviews conducted as part of the 'Health-e Baby' project, a qualitative study designed to assess the information needs and ICT preferences of pregnant women cared for at a South Australian metropolitan teaching hospital. Our research shows that although ICTs offer exciting possibilities for health promotion and the potential for new forms of communication, networking and connection, we cannot assume the effectiveness of communicating through such channels, despite near universal levels of ICT access. In turn, this highlights that if e-mediated health promotion is to be effective, health promoters and practitioners need to better understand ICT access, usage and content preferences of their clients.

A novel lumbar total joint replacement may be an improvement over fusion for degenerative lumbar conditions: a comparative analysis of patient-reported outcomes at one year.

BACKGROUND CONTEXT: Effective alternatives to lumbar fusion for degenerative conditions have remained elusive. Anterior total disc replacement does not address facet pathology or central/recess stenosis, resulting in limited indications. A posterior-based motion-preserving option that allows for neural decompression, facetectomy, and reconstruction of the disc and facets may have a role. PURPOSE: The purpose was to compare one-year patient-reported outcomes for a novel, all-posterior, lumbar total joint replacement (LTJR - replacing both the disc and facet joints) against transforaminal lumbar interbody fusion (TLIF) for degenerative lumbar conditions warranting fusion (degenerative spondylolisthesis, recurrent disc herniation, severe foraminal stenosis requiring facet removal, and adjacent segment degeneration). STUDY DESIGN/SETTING: A retrospective analysis of prospectively collected data comparing outcomes for LTJR patients to TLIF patients at an academic teaching hospital. PATIENT SAMPLE: Analysis was conducted on 156 adult TLIF patients who were propensity matched to the 52 LTJR patients for a total sample of 208. OUTCOME MEASURES: Self-reported Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS) for back and leg pain were compared preoperatively, 3 months and 1 year after surgery. METHODS: The implant is a motion-preserving lumbar reconstruction that replaces the function of both the disc and facets and is implanted using a bilateral transforaminal approach with complete facetectomies. Adult patients with degenerative lumbar pathology undergoing either LTJR or open TLIF were analyzed. These degenerative conditions included: grade 1 degenerative spondylolisthesis, recurrent disc herniation, adjacent segment disease, disc degeneration with severe foraminal stenosis). Trauma, tumor, grade 2 or higher spondylolisthesis, spinal deformity, and infection cases were excluded. Propensity score matching was performed to ensure parity between the cohorts. Multivariable regression analyses were done to compare the 1-year results as measured by 3 different standards to assess procedure success. RESULTS: At 3 months, both the LTJR and TLIF cohorts showed significant and similar improvements in ODI and NRS back and leg pain. At 1 year, the LTJR cohort showed continued improvement in ODI and NRS back pain, while the TLIF group showed a plateau for ODI, back and leg pain. In a series of three multivariable logistic regressions, LTJR was shown to provide 3.3 times greater odds of achieving the minimal clinical symptom state in disability and pain (ODI <20%, NRS back and leg pain <2) and 2.4 and 4.1 times greater odds of achieving substantial clinical benefit (18% reduction in ODI) and minimal clinically important difference (30% reduction in ODI) as compared to TLIF. CONCLUSIONS: Here we present a comparative analysis for the first 52 patients undergoing a novel, posterior-based LTJR for the lumbar spine versus TLIF for degenerative pathology. The approach for the LTJR allows for wide neural decompression, facetectomy, and complete discectomy, with the implant working to replace the function of the disc and facets to preserve motion. At 1 year, the LTJR cohort showed significant improvement in ODI and NRS back and leg pain as compared to TLIF. These results suggest that wide neural decompression combined with motion preservation using this novel LTJR may represent a viable alternative to TLIF for treating certain degenerative conditions. A prospective controlled trial is under development to further evaluate the efficacy, safety, and durability of this procedure.

Loading of the lumbar spine during transition from standing to sitting: effect of fusion versus motion preservation at L4-L5 and L5-S1.

BACKGROUND CONTEXT: Transition from standing to sitting significantly decreases lumbar lordosis with the greatest lordosis-loss occurring at L4-S1. Fusing L4-S1 eliminates motion and thus the proximal mobile segments maybe recruited during transition from standing to sitting to compensate for the loss of L4-S1 mobility. This may subject proximal segments to supra-physiologic flexion loading. PURPOSE: Assess effects of instrumented fusion versus motion preservation at L4-L5 and L5-S1 on lumbar spine loads and proximal segment motions during transition from standing to sitting. STUDY DESIGN: Biomechanical study using human thoracolumbar spine specimens. METHODS: A novel laboratory model was used to simulate lumbosacral alignment changes caused by a person's transition from standing to sitting in eight T10-sacrum spine specimens. The sacrum was tilted in the sagittal plane while constraining anterior-posterior translation of T10. Continuous loading-data and segmental motion-data were collected over a range of sacral slope values, which represented transition from standing to different sitting postures. We compared different constructs involving fusions and motion preserving prostheses across L4-S1. RESULTS: After L4-S1 fusion, the sacrum could not be tilted as far posteriorly compared to the intact spine for the same applied moment (p<.001). For the same reduction in sacral slope, L4-S1 fusion induced 2.9 times the flexion moment in the lumbar spine and required 2.4 times the flexion motion of the proximal segments as the intact condition (p<.001). Conversely, motion preservation at L4-S1 restored lumbar spine loads and proximal segment motions to intact specimen levels during transition from standing to sitting. CONCLUSIONS: In general, sitting requires lower lumbar segments to undergo flexion, thereby increasing load on the lumbar disks. L4-S1 fusion induced greater moments and increased flexion of proximal segments to attain a comparable seated posture. Motion preservation using a total joint replacement prosthesis at L4-S1 restored the lumbar spine loads and proximal segment motion to intact specimen levels during transition from standing to sitting. CLINICAL SIGNIFICANCE: After L4-S1 fusion, increased proximal segment loading during sitting may cause discomfort in some patients and may lead to junctional breakdown over time. Preserving motion at L4-S1 may improve patient comfort and function during activities of daily living, and potentially decrease the need for adjacent level surgery.

Markers of de novo lipogenesis in adipose tissue: associations with small adipocytes and insulin sensitivity in humans.

AIMS/HYPOTHESIS: Previous studies have shown relationships between fatty acid ratios in adipose tissue triacylglycerol (TG), adipocyte size and measures of insulin sensitivity. We hypothesised that variations in adipose tissue de novo lipogenesis (DNL) in relation to adiposity might explain some of these observations. METHODS: In a cross-sectional study, subcutaneous abdominal adipose tissue biopsies from 59 people were examined in relation to fasting and post-glucose insulin sensitivity. Adipocyte size, TG fatty acid composition and mRNA expression of lipogenic genes were determined. RESULTS: We found strong positive relationships between adipose tissue TG content of the fatty acids myristic acid (14:0) and stearic acid (18:0) with insulin sensitivity (HOMA model) (p < 0.01 for each), and inverse relationships with adipocyte size (p < 0.01, p < 0.05, respectively). Variation in 18:0 content was the determinant of the adipose tissue TG 18:1 n-9/18:0 ratio, which correlated negatively with insulin sensitivity (p < 0.01), as observed previously. Adipose tissue 18:0 content correlated positively with the mRNA expression of lipogenic genes (e.g. FASN, p < 0.01). Lipogenic gene expression (a composite measure derived from principal components analysis) was inversely correlated with adipocyte cell size (p < 0.001). There was no relationship between dietary saturated fatty acid intake and adipose tissue 18:0 content. CONCLUSIONS/INTERPRETATION: Our data suggest a physiological mechanism whereby DNL is downregulated as adipocytes expand. Taken together with other data, they also suggest that hepatic and adipose tissue DNL are not regulated in parallel. We also confirm a strong relationship between small adipocytes and insulin sensitivity, which is independent of BMI.

Increased weight loss with reduced viral replication in interleukin-10 knock-out mice infected with murine cytomegalovirus.

The anti-inflammatory cytokine interleukin (IL)-10 plays an important role in the regulation of host-immune responses. Here we studied the role IL-10 plays in host responses to cytomegalovirus (CMV) infection. We demonstrate that manifestations of murine CMV (MCMV) disease are more severe in IL-10 knock-out mice, despite significantly reduced levels of viral replication. Cytokine analysis of serum revealed increased levels of interferon (IFN)-gamma, monocyte chemotactic protein 1 (MCP-1) and IL-6, all of which are potent stimulators of inflammatory responses. Depletion of IFN-gamma by monoclonal antibodies in IL-10 knock-out mice failed to improve the physical condition of the mice, while increasing viral replication. In contrast, serum levels of IL-6 in the knock-out animals were unaffected by IFN-gamma depletion and remained significantly elevated early in the course of infection. These data suggest that increased weight loss observed in IL-10 knock-out mice may be attributed to the uncontrolled production of proinflammatory cytokines, including IL-6.

Comparison of vertebroplasty and balloon kyphoplasty for treatment of vertebral compression fractures: a meta-analysis of the literature.

BACKGROUND CONTEXT: Previous investigators have reported on benefits and risks associated with vertebroplasty and kyphoplasty, but there are limited comparison data available. Additionally, much of the data is from retrospective studies and case series. PURPOSE: The purpose of this study is to review the literature and perform a meta-analysis of pain relief and risk of complications associated with vertebroplasty versus kyphoplasty. STUDY DESIGN: A meta-analysis of the literature on effectiveness of pain control and risk of complications after vertebroplasty versus balloon kyphoplasty. Outcomes measures include visual analog scale and complications. METHODS: A comprehensive review of the literature was performed. All studies providing information on pain relief and complications were included. Preoperative, postoperative, and change in visual analog scale (VAS) scores were tabulated. Data were analyzed to identify if a significant improvement in the VAS score occurred. Changes in the VAS scores were compared for vertebroplasty and kyphoplasty to determine if there was a significant difference. RESULTS: A total of 1,036 abstracts were identified. Of these, 168 studies met the inclusion criteria. Mean pre- and postoperative VAS scores for vertebroplasty were 8.36 and 2.68, respectively, with a mean change of 5.68 (p<.001). The mean pre- and postoperative VAS scores for kyphoplasty were 8.06 and 3.46, respectively, with a mean change of 4.60 (p<.001). There was statistically greater improvement found with vertebroplasty versus kyphoplasty (p<.001). The risk of new fracture was 17.9% with vertebroplasty versus 14.1% with kyphoplasty (p<.01). The risk of cement leak was 19.7% with vertebroplasty versus 7.0% with kyphoplasty (p<.001). CONCLUSIONS: Both vertebroplasty and kyphoplasty provided significant improvement in VAS pain scores. Vertebroplasty had a significantly greater improvement in pain scores but also had statistically greater risk of cement leakage and new fracture.

Minimally invasive lumbar spinal fusion.

Minimally invasive techniques for lumbar spine fusion have been developed in an attempt to decrease the complications related to traditional open exposures (eg, infection, wound healing problems). Anterior minimally invasive procedures include laparoscopic and mini-open anterior lumbar interbody fusion as well as the lateral transpsoas and percutaneous presacral approaches. Posterior techniques typically use a tubular retractor system that avoids the muscle stripping associated with open procedures. These techniques can be applied to both posterior and transforaminal lumbar interbody fusion procedures. Many initial reports have shown similar clinical results in terms of spinal fusion rates for both traditional open and minimally invasive posterior approaches. However, the anterior minimally invasive procedures are often associated with significantly greater incidence of complications and technical difficulty than their associated open approaches. There is a steep learning curve associated with minimally invasive techniques, and surgeons should not expect to master them in the first several cases.

Effect of lower two-level anterior cervical fusion on the superior adjacent level.

OBJECT: Symptomatic multisegment disease is most common at the C5-6 and C6-7 levels, and two-level anterior cervical discectomy and fusion (ACDF) is performed most often at these levels. Therefore, it may be clinically important to know whether a C5-7 fusion affects the superior C4-5 segment. A biomechanical study was carried out using cadaveric cervical spine specimens to determine the effect of lower two-level anterior cervical fusion on intradiscal pressure and segmental motion at the superior adjacent vertebral level. METHODS: Five cadaveric cervical spine specimens were used in this study. The specimens were stabilized at T-1 and loaded at C-3 to 15 degrees flexion, 10 degrees extension, and 10 degrees lateral bending before and after simulated two-level ACDF with plate placement at C5-7. Intradiscal pressure was recorded at the C4-5 level, and segmental motion was recorded from C-4 through C-7. Differences in mean intradiscal pressures were calculated and analyzed using a paired Student t-test. When the maximum calibrated intradiscal pressures were exceeded ("overshot") during measurements, data from the specimens involved were analyzed using the motion data with a Student t-test. Values for pressure and motion obtained before and after simulated ACDF were compared. RESULTS: During flexion, the mean intradiscal pressure changes (+/- standard deviations) in the pre- and post-ACDF measurements were 1275 (+/- 225) mm Hg and 2475 (+/- 75) mm Hg, respectively (p < 0.05). When the results of pre-ACDF testing were compared with post-ACDF results, no significant difference was found in the mean changes in the intradiscal pressure during extension and lateral bending. The maximum calibrated intradiscal pressures were exceeded during the post-ACDF testing in four specimens in extension, three in flexion, and two in lateral bending. Comparison of pre- and post-ACDF data for all five specimens revealed significant differences in motion and intradiscal pressure (p < 0.05) during flexion, significant differences in motion (p < 0.05) but not in intradiscal pressure during extension, and significant differences in intradiscal pressure changes (p < 0.05) but not in motion during lateral bending. CONCLUSIONS: Simulated C5-7 ACDF caused a significant increase in intradiscal pressure and segmental motion in the superior adjacent C4-5 level during physiological motion. The increased pressure and hypermobility might accelerate normal degenerative changes in the vertebral levels adjacent to the anterior cervical fusion.

Redundant publications in the orthopedic literature.

Rates of redundant publications in the general surgery literature are approximately 14%. This article identifies the rate of redundant publications in the orthopedic literature. All original articles published during the year 2000 in The Journal of Bone and Joint Surgery (American Volume), Journal of Orthopaedic Trauma, Journal of Spinal Disorders, and Spine were searched using PubMed. Redundancy rate was 4 (3.15%) of 127 for The Journal of Bone and Joint Surgery (American volume), zero (0%) of 70 for Journal of Orthopaedic Trauma, 2 (2.90%) of 69 for Journal of Spinal Disorders, and 11 (3.12%) of 353 for Spine.

Transforaminal lumbar interbody fusion: a retrospective study of long-term pain relief and fusion outcomes.

No long-term studies exist on the effectiveness of transforaminal lumbar interbody fusion. This study sought to determine postoperative pain, disability, and fusion status of transforaminal lumbar interbody fusion patients after > or = 4 years to establish long-term outcomes. A retrospective analysis of 42 patients with minimum 4-year follow-up was conducted. Patients completed visual analog pain scale (VAS) and Oswestry functional capacity evaluation pre- and postoperatively. Statistically significant improvement was noted in VAS and Oswestry functional capacity evaluation scores. Transforaminal lumbar interbody fusion is effective in alleviating intractable back pain over an extended time period. Solid radiographic fusion is unnecessary for clinically successful outcomes.

The NHS breast screening programme (pathology) EQA: experience in recent years relating to issues involved in individual performance appraisal.

BACKGROUND: The original role of the National Health Service breast screening programme (pathology) external quality assessment (EQA) scheme was educational; it aimed to raise standards, reinforce use of common terminology, and assess the consistency of pathology reporting of breast disease in the UK. AIMS/METHODS: To examine the performance (scores) of pathologists participating in the scheme in recent years. The scheme has evolved to help identify poor performers, reliant upon setting an acceptable cutpoint. Therefore, the effects of different cutpoint strategies were evaluated and implications discussed. RESULTS/CONCLUSIONS: Pathologists who joined the scheme improved over time, particularly those who did less well initially. There was no obvious association between performance and the number of breast cancer cases reported each year. This is not unexpected because the EQA does not measure expertise, but was established to demonstrate a common level of performance (conformity to consensus) for routine cases, rather than the ability to diagnose unusual/difficult cases. A new method of establishing cutpoints using interquartile ranges is proposed. The findings also suggest that EQA can alter a pathologist's practice: those who leave the scheme (for whatever reason) have, on average, marginally lower scores. Consequently, with the cutpoint methodology currently used (which is common to several EQA schemes) there is the potential for the cutpoint to drift upwards. In future, individuals previously deemed competent could subsequently be erroneously labelled as poor performers. Due consideration should be given to this issue with future development of schemes.

Impact of a national external quality assessment scheme for breast pathology in the UK.

BACKGROUND: This article presents the results and observed effects of the UK National Health Service Breast Screening Programme (NHSBSP) external quality assurance scheme in breast histopathology. AIMS/METHODS: The major objectives were to monitor and improve the consistency of diagnoses made by pathologists and the quality of prognostic information in pathology reports. The scheme is based on a twice yearly circulation of 12 cases to over 600 registered participants. The level of agreement was generally measured using kappa statistics. RESULTS: Four main situations were encountered with respect to diagnostic consistency, namely: (1) where consistency is naturally very high-this included diagnosing in situ and invasive carcinomas (and certain distinctive subtypes) and uncomplicated benign lesions; (2) where the level of consistency was low but could be improved by making guidelines more detailed and explicit-this included histological grading; (3) where consistency could be improved but only by changing the system of classification-this included classification of ductal carcinoma in situ; and (4) where no improvement in consistency could be achieved-this included diagnosing atypical hyperplasia and reporting vascular invasion. Size measurements were more consistent for invasive than in situ carcinomas. Even in cases where there is a high level of agreement on tumour size, a few widely outlying measurements were encountered, for which no explanation is readily forthcoming. CONCLUSIONS: These results broadly confirm the robustness of the systems of breast disease diagnosis and classification adopted by the NHSBSP, and also identify areas where improvement or new approaches are required.

A comparison of outcomes of anterior cervical discectomy and fusion in patients with and without radicular symptoms.

Anterior cervical discectomy and fusion (ACDF) is commonly performed for degenerative conditions of the cervical spine with good to excellent results. There is controversy over the use of ACDF for patients with axial neck pain alone. A retrospective review of 202 patients from two private practice orthopaedic spine surgeons following ACDF with 39-month mean follow-up was performed. Patients completed pain drawings, pre- and postoperative visual analog pain scales (VAS), Oswestry functional capacity evaluations (OSW), and a postoperative neck disability index. Forty-one patients had axial neck pain alone, and 161 had radicular pain with or without neck pain. There were significant improvements in VAS and OSW scores following surgery for the combined study population as well as the neck pain only and radicular pain groups (p < .01). ACDF can be effectively used for treatment of patients with axial neck pain without radicular symptoms.

Exercise prevents the accumulation of triglyceride-rich lipoproteins and their remnants seen when changing to a high-carbohydrate diet.

We tested the hypothesis that daily aerobic exercise opposes the fasting hypertriglyceridemia and exaggerated postprandial lipemia observed after substituting dietary fat with carbohydrate. Eight healthy postmenopausal women aged 51 to 66 years consumed the same high-fat mixed meal on 3 occasions: (1) after 3 days on a low-carbohydrate diet (35%, 50%, and 15% energy from carbohydrate, fat, and protein, respectively); (2) after 3 days on an isoenergetic high-carbohydrate diet (corresponding values 70%, 15%, and 15%); and (3) after 3 days on the same high-carbohydrate diet with 60 minutes of brisk walking daily. Plasma triglycerides were higher after the high-carbohydrate diet than after the low-carbohydrate diet: fasting, 1.58+/-0.19 versus 0.96+/-0.12 mmol/L, respectively; 6-hour postprandial area under concentration versus time curve, 13.74+/-1.57 versus 10.12+/-1.15 (mmol/L)xhour, respectively (both P<0.01). In the fasted and postprandial states, concentrations of apolipoproteins B-48 and B-100 in the triglyceride-rich lipoprotein fraction were significantly higher after the high-carbohydrate diet, as was the concentration of remnant-like lipoprotein particle cholesterol (a measure of lipoprotein remnants). These carbohydrate-induced increases in the number of circulating triglyceride-rich particles and their remnants were abolished when subjects had exercised daily during the high-carbohydrate diet.

Audit of local recurrence rates following 'ultra'-conservative surgery for invasive breast cancer--a boost to the breast?

BACKGROUND: Conservative breast surgery with postoperative radiotherapy and appropriate systemic therapy is associated with similar outcomes when compared with mastectomy. The reported 5 year local recurrence rate varies between 3% and 15%. We prefer a more conservative 'complete' local excision rather than 'wide' local excision combined with post-operative radical radiotherapy and tumour bed boost with the aim of achieving optimal cosmesis. AIMS: Our review was undertaken to assess whether or not this 'ultra' conservative approach was compromising long-term local control. METHODS: Case notes and pathology reports of patients who underwent conservative surgery for breast cancer from January 1983 to February 2001 were accessed for this audit. Patient demographic data and tumour characteristics were noted. The primary outcome data were the number of local recurrences following invasive breast cancer at 5 and 10 years and the distance from the tumour to the closest margin of excision. RESULTS: At 5 and 10 years there were 16/451 and 5/124 local recurrences, with a local recurrence rate of 3.5% (95% CI, 1.7-4.7%) and 4.1% (95% CI, 0.47-6.5%), respectively. Complete data with regards to the closest histological margin of excision were available in 423 patients. One hundred and sixty-five patients (39%) had their tumours excised with a distance of less than 1 mm to the closest margin. Nearly, all tumours (97.8%) were excised with the distance to the closest margin less than 1 cm and 81% with 5 mm or less. CONCLUSION: It is possible to achieve low local recurrence rates after very conservative surgery for breast cancer when this is combined with radical radiotherapy and an additional tumour bed boost.

How midwives tailor health information used in antenatal care.

OBJECTIVE: to examine the informal approaches taken by midwives and other antenatal staff to adapt health communication to the needs of their patients, as well as their perception of the barriers faced when trying to provide tailored health promotion. DESIGN: qualitative research methods (participant observation, individual and group interviews) were utilised to gain an understanding of how media and communication resources were used in practice within the study hospital. SETTING: a major metropolitan teaching hospital located in the Northern suburbs of Adelaide, South Australia. PARTICIPANTS: individual semi-structured interviews with antenatal staff (n=8) were combined with group interviews (n=2; total number of staff=13), and observational research. FINDINGS: midwives and other antenatal staff use a range of strategies to meet the perceived health literacy level of their patients. However, their attempts to tailor health information to individual needs are frequently based on incomplete information about patients' health literacy, may be inconsistent in delivery and content and are seldom assessed to determine whether communication has been understood or led to patient behaviour change. KEY CONCLUSIONS: midwives fully recognise the need to adapt standard printed materials to meet the diverse health literacy needs of patients but lack the resources required to evaluate whether these adaptations have positive effect. IMPLICATIONS FOR PRACTICE: midwives' commitment to improving health communication provides a latent resource that institutions can build on to improve health outcomes for patients with low health literacy. This requires improvements in health communication training, willingness to use a range of validated instruments for measuring health literacy, and commitment to use of innovative approaches to health promotion where these have been shown to have a positive impact on health behaviours.