Safety of a High-Efficiency Electrical Fence Energizer.

INTRODUCTION: Our primary goal was to evaluate the performance of a new high-efficiency electric fence energizer unit using resistive load changes. Our secondary goal was to test for compliance with the classical energy limits and the newer charge-based limits for output. METHODS: We tested 4 units of the Nemtek Druid energizer with 2 channels each. We used a wide load-resistance range to cover the worst-case scenario of a barefoot child making a chest contact (400 Ω) up to an adult merely touching the fence (2 kΩ). RESULTS: The energy output was quite consistent between the 8 sources. Even at the lowest resistance, 400 Ω, the outputs were well below the IEC 60335-2-76 limit of 5 J/pulse. The charge delivered was also quite consistent. Even at the lowest resistance, 400 Ω, the outputs (679 ± 23 µC) were well below the proposed limits of 4 mC for short pulses. CONCLUSIONS: The high-efficiency electric fence energizers satisfied all relevant safety limits. Charge, energy, voltage, and current outputs were consistent between channels and units.

Physiotherapists deliver management broadly consistent with recommended practice in rotator cuff tendinopathy: An observational study.

BACKGROUND: Rotator cuff tendinopathy is a common and disabling cause of shoulder pain. While conservative treatment is recommended as initial management, recent findings suggest that general practitioners and rheumatologists do not consistently align with recommended care. This study aimed to survey Australian physiotherapists to explore the extent to which recommended management is being applied. METHODS: A cross-sectional online survey. RESULTS: Five hundred and two Australian physiotherapists completed the survey. Results demonstrated the majority of physiotherapists provide conservative management consistent with guideline recommendations, through delivery of exercise and education, comparable to management by physiotherapists in the United Kingdom, Belgium and the Netherlands. Parameters and construction of exercise treatment programs were highly variable within the cohort, qualitative analysis highlighting varied reasoning underpinning these management decisions. CONCLUSIONS: Australian physiotherapists are broadly consistent with providing recommended management, however heterogeneity exists in the methods and parameters of treatment delivery.

Identification of key residues involved in mediating the in vivo anti-tumor/anti-endothelial activity of Alphastatin.

BACKGROUND: We have recently shown that Alphastatin, a 24-amino-acid peptide (ADSGEGDFLAEGGGVRGPRVVERH) derived from human fibrinogen has anti-endothelial properties in vitro and in vivo. OBJECTIVES: The aim of this study was to determine the activity of a terminally modified (stabilized) form of Alphastatin in vitro and in vivo and to identify the key residues required for this activity. METHODS: The in vitro activity of modified Alphastatin, truncates and mutants was determined by endothelial cell (HuDMEC) tubule formation and migration. Active peptides were then assessed in vivo using syngeneic murine subcutaneous 4T1 mammary carcinomas. RESULTS: Modified Alphastatin-inhibited HuDMEC migration and tubule formation in response to multiple growth factors and caused a 45% inhibition in tumor growth when administered intravenously at 0.25 mg kg(-1) (three times per week). Intravenous (i.v.) administration proved non-toxic at all doses investigated, whereas oral and intraperitoneal (i.p.) administration demonstrated neither anti-tumor activity nor toxicity. Truncations of Alphastatin revealed an 11-amino-acid peptide (DFLAEGGGVRG), termed AHN419, which inhibited endothelial cell activity in vitro; however, intravenous AHN419 caused a non-significant growth inhibition in vivo. Single amino acid substitutions to alanine along the entire length of Alphastatin indicated that additional residues outside the AHN419 sequence were required for full activity. CONCLUSIONS: Terminal modification of Alphastatin altered the in vivo efficacy and these studies suggest that a hydrophobic cluster (Phe8, Leu9, Ala10 and Val15) is essential for the biological activity, but additional residues, including Ser3-Gly14, Pro18-Val20 and Arg23 are required for full inhibitory activity of Alphastatin.

Cervical epidural analgesia via a thoracic approach using nerve-stimulation guidance in adult patients undergoing total shoulder replacement surgery.

BACKGROUND: Continuous cervical epidural anesthesia can provide excellent peri- and post-operative analgesia, although several factors prevent its widespread use. Advancing catheters from thoracic levels to the cervical region may circumvent these barriers, provided they are accurately positioned. We hypothesize that guiding catheters from thoracic to cervical regions using low-current epidural stimulation will have a high success rate and enable excellent analgesia in adults undergoing total shoulder arthroplasty. METHODS: After Institutional Review Board approval, adult patients were studied consecutively. A 17-G Tuohy needle was inserted into the thoracic epidural space using a right paramedian approach with loss of resistance. A 20-G styletted epidural catheter, with an attached nerve stimulator, was primed with saline and a 1-10 mA current was applied as it advanced in a cephalad direction towards the cervical spine. Muscle twitch responses were observed and post-operative X-ray confirmed final placement. After a test dose, an infusion (2-8 ml/h) of ropivacaine 2 mg/ml and morphine 0.05 mg/ml (or equivalent) was initiated. Verbal analog pain scale scores were collected over 72 h. RESULTS: Cervical epidural anesthesia was performed on 10 patients. Average current required to elicit a motor response was 4.8 +/- 2.0mA. Post-operative X-ray of catheter positions confirmed all catheter tips reached the desired region (C4-7). The technical success rate for catheter placement was 100% and excellent pain control was achieved. Catheters were positioned two to the left, four to the right and four to the midline. CONCLUSION: This epidural technique provided highly effective post-operative analgesia in a patient group that traditionally experiences severe post-operative pain and can benefit from early mobilization.

[Adjuvant chemotherapy for Dukes B2 and C colon cancer combining 5-fluorouracil and folinic acid with or without carboplatin. Feasibility and comparison between standard and chronomodulated deliveries]. / Chimiothérapie adjuvante pour le cancer du colon de stades Dukes B2 et C comportant du 5-fluorouracile et de l'acide folinique, avec ou sans carboplatine. Faisabilité et comparaison d'une administration standard à une administration chronomodulée.

Thirty-seven patients operated from a Dukes B2-C colon cancer were randomised to receive as adjuvant infusional chemotherapy, nine 5 FU and folinic acid courses with or without carboplatin, as standard (de Gramont; 2 days every 2 weeks) or chronomodulated administration (4 days every 2 weeks). The overall tolerance was judged excellent with less than 7% courses with dose-adaptations. The two carboplatin arms presented an enhanced haematological toxicity, while some more cutaneous toxicity was observed in the chronomodulated arm with the three drugs.

Pentoxyfylline in and prevention and treatment of chronic lung disease.

The anti-inflammatory effects of pentoxfylline are associated with a number of clinical benefits. These include reduction in mortality in patients who have undergone bone marrow transplants or suffer peritonitis. In infants with sepsis, a reduction in mortality has also been associated with pentoxyfylline administration. The anti-inflammatory effects of pentoxyfylline, as well as its bronchodilator, diuretic and respiratory muscle stimulant effects suggest it may have a useful role in BPD. Interim analysis of a prophylactic trial suggests pentoxyfylline may reduce treatment requirements after the neonatal period and that, in established BPD, pentoxyfylline and dexamethasone may be of similar efficacy.

Audit of bloodborne virus prevention activity with drug users seen in primary care.

Drug misuse is increasingly being managed in general practice. It has been proposed that better use could be made of this contact to identify people with bloodborne virus (BBV) morbidity and to deliver prevention strategies. The Hepatitis B and C Prevention Project was designed to enhance the work of primary healthcare teams in preventing transmission of BBVs in people known to have a history of problem drug use. As part of this work a baseline audit of current provision was undertaken and the results are reported here. Primary care records of 1278 people with a history of illicit drug use were audited to establish the levels of hepatitis B immunisation and testing for BBVs and to determine whether there was a record of any professional discussion of BBV issues with the patient. Records were drawn from rural and city-based general practices. Audit feedback, training, and advice were offered to raise awareness and discussion of how this work was currently being undertaken, and how it might be improved. This baseline audit showed that 90% (n = 1153) of the patients had been questioned about injecting drug use and of these 50% (579/1153) reported injecting at some point in the past. Only 4% (54/1278) had completed a course of hepatitis B immunisation and of these three quarters gave a history of injecting drug use. Another 6% (74/1278) of patients tested for hepatitis B virus (HBV) showed markers of natural immunity. Up to 90% of this group therefore remained vulnerable to this preventable disease. A discussion of BBV issues with a professional was recorded in41% (523/1278) of cases, and was more likely to have occurred in those with a known history of injecting. Individuals were less likely to have been tested for hepatitis C virus (HCV) than for HIV or HBV despite its high prevalence in this group. Only 28% (354/1278) were tested for HCV compared with 33% (416/1278) tested for HBV and 36% (454/1278) tested for HIV. Prevalence of anti-HCV for people with a history of injecting was 51% (137/268) compared to 11% (9/83) in those with no history of injecting. Prevalence of anti-HIV in those with a history of injecting was 10% (29/294) compared 0.7% (1/137) in those with no history of injecting. Prevalence of HBV markers in those with a history of injecting was 23% (65/279) compared with 7% (8/114) in those with no history of injecting. Of the 530 patients with test results, only 52% (275/530) had been tested for all three viruses despite the common transmission routes.

Public health training in Europe. Development of European masters degrees in public health.

BACKGROUND: Changing political and economic relations in Europe mean that there are new challenges for public health and public health training. There have been several attempts to develop training at the master's level in public health which is focused on meeting the new needs. These have failed due to being too inflexible to allow participation by schools of public health. METHODS: A project funded by the European Union involving public health trainers has developed a new approach which allows participating schools to retain their national differences and work within local rules and traditions, but which aims to introduce the European dimension into public health training. This paper reports the conclusions of this project. CONCLUSIONS: A network of schools wishing to develop European Master's degrees is being established and other schools offering good quality programmes will be able to join.

Publets: clinical judgement on the web.

The Internet is now a major channel for publishing medical research data and documents, including clinical practice guidelines. It is now possible to capture guidelines in a computer interpretable form opening up the capability of using the internet (and intra/extranets etc.) to deliver patient-specific advice and other services. A development lifecycle and technology for publishing and delivering services at the point of care ("publets") are described. As with all new technologies, however, these new methods entail risks as well as opportunities. The paper closes with a discussion of quality requirements and an argument that publets should include a safety case as an integral part of their content.

A quality and safety framework for point-of-care clinical guidelines.

The electronic dissemination of medical knowledge in the form of executable clinical guidelines and decision support systems must be accompanied by comprehensive methods for ensuring the quality of their knowledge content and their safety in use. This paper outlines a set of quality and safety requirements, and reviews three current guideline technologies, the Arden Syntax, GLIF and PROforma, against these requirements. The approaches used in these technologies have different strengths, and we propose a general framework for ensuring quality and safety that combines them. This framework brings together the normal documentation standards of medical publishing, rigorous design methods from software engineering, and active safety management techniques from artificial intelligence.

Evaluation of an automated hemostasis testing analyzer, the Trombolyzer Combi.

We evaluated the Trombolyzer Combi (Behnk Elektronik, Norderstedt, Germany), an automated hemostasis analyzer, in a clinical setting. Determination of prothrombin time (PT), activated partial prothrombin time (APTT), fibrinogen (FIB) and antithrombin (AT) were performed using Organon Teknika reagents. Determination of PT, APTT and FIB on a KC4 (Amelung, Germany) using Dade reagent (Dade Behring, The Netherlands) and determination of AT on a Hitachi 912 using Chromogenix reagent (Nodia, The Netherlands) were used as reference methods. Within-run and total precision of the tests were determined by measuring pooled plasma samples at various levels in duplicate twice daily for twenty days. For all tests the within-run and total precision of the Trombolyzer Combi was comparable or superior to the reference methods. Methods comparison was performed with 100 patient samples for PT, APTT and FIB and with 50 patient samples for AT. The correlation coefficients between the Trombolyzer Combi values and the results from the reference methods were between 0.87 and 0.98. No effect of hemolysis on the determination of the studied parameters was detected. However, bilirubinemia above 260 micromol/L and triglycerides above 9 mmol/L resulted in erroneous test results. In conclusion, it is shown that the Trombolyzer Combi performs equivalently or better than the reference methods and can be used as a state-of-the-art hemostasis analyzer in a clinical laboratory.

Adjuvant intraportal chemotherapy for Dukes B2 and C colorectal cancer also receiving systemic treatment: results of a multicenter randomized trial. Groupe Régional d'Etude du Cancer Colo-Rectal (Belgium).

In a randomized trial, the authors evaluated the possible adjuvant activity of intraportal chemotherapy (with 5-fluorouracil 500 mg/m2/day in continuous infusion for 7 days and mitomycin C 10 mg/m2 at day 7) administered after surgery to half of the patients who underwent a full resection for Dukes B2 or C colorectal cancer. The procedure appeared manageable and safe. Two hundred and sixty patients were initially randomized, among whom 173 were finally considered as fully evaluable after having completed six courses of systemic chemotherapy. The reasons for withdrawal were basically tumoral ones and patients or doctors compliance. After a median follow-up of 4.5 years, no difference could be observed in the patients evolution assessed as relapses or deaths rate, or as relapse-free (at 5 years: 68% in the portal treatment group versus 70% in the control group) or overall survival (at 5 years: 76 versus 74%). The frequency of hepatic metastases (21 versus 18%) was also similar in both groups.

Importance of 5-fluorouracil dose-intensity in a double randomised trial on adjuvant portal and systemic chemotherapy for Dukes B2 and C colorectal cancer.

366 patients fully resected from a Dukes B2 or C colorectal cancer were randomised to receive 6 courses of systemic chemotherapy comprising either 5-fluorouracil (5 FU) alone (arm A: 450 mg/m2/day-5/21 days) or combined folinic acid (FOL) and 5 FU (arm B: respectively 200 mg/m2 racemic form or 100 mg/m2-l-form and 370 mg/m2/day-5/21 days). 173 patients had also been initially randomised to receive one course of intraportal chemotherapy just after surgery or no portal treatment. Oral levamisole (150 mg/day; 3 days every other week) was given to all patients for one year. A significantly higher incidence of leuco-granulocytopenia was observed in the arm A (5 FU alone) inducing more frequent dose delays and adaptations as well as levamisole's withdrawal. Then dose-intensities and dose-intensity products were lower in this arm but the dose intensity expressed in mg/m2/week remained higher (631 +/- 107 vs 557 +/- 99; p < 0.001). The median follow-up in the study was 4.5 years. Relapse free (RFS) and overall survivals (OAS) were prolonged in the 5 FU alone group peculiarly in those patients who had not been randomised for portal treatment. Curves diverged progressively with longer follows-up (at 8 years; RFS in arm A: 67-71% vs 59-53% in arm B; OAS in arm A: 72-74% vs 56-46% in arm B). Patients suffering from a colon or a Dukes C cancer benefited the most from the treatment with 5 FU alone. The results are discussed in the light of other recent adjuvant trials. Well dosed 5 FU over a short period of time without folinic acid may be a valuable and inexpensive adjuvant treatment for colorectal cancer. Levamisole may no longer be recommended in this setting.

The heart of the matter: care conferences to promote parent-professional collaboration.

Children who are hospitalized frequently or who have lengthy admissions often require a large number of caregivers to meet their complex health care needs. Even the most organized of teams may experience confusion in their attempt to stay abreast of each other's care of the child. This can be particularly confusing to parents who are trying to cope with the stress of hospitalization, learning to navigate new financial and social service systems, attempting to remember the names and faces of the numerous specialists and their specific recommendations, and caring for their child. The University of New Mexico Children's Hospital in Albuquerque, New Mexico has developed and used a care conference model that includes families, medical staff, social workers, nutritionists, child life specialists, and specialized therapy provides in the process of integrating developmentally appropriate practices within the scope of necessary medical care.

A matter of methods: perspectives on the role of the British general practitioner in the care of people with HIV/AIDS.

This paper is a critique of, and a comment on, the debate about the role of British general practitioners (GPs) in HIV care. We argue that (1) this debate is conducted around arguments which leave significant aspects of GPs' contribution undocumented and unnoticed, and that (2) research has contributed to this omission. The paper reviews the history of the debate about GPs' involvement in HIV care and argues that social research using structured survey methods has reinforced the continuing negative image of GP care. The paper draws on an ethnographic research project in Lothian (Scotland) which found that many people with HIV strongly valued their ongoing personal relationship with their GP. People with HIV also valued the hospital-based outreach system which provided reliable and high quality care, but sometimes experienced the associated interprofessional information sharing and discussion as invasive and controlling. Their GP relationship was valued because it was outside this hospital-based system of care. The paper concludes by suggesting that future developments in GP care should build on this positive aspect of the GP-patient relationship.

The correlation between the grade of dyskaryosis on cervical smear, grade of cervical intraepithelial neoplasia (CIN) on punch biopsy and the final histological diagnosis on cone biopsies of the cervix.

This study was carried out to assess how reliably a punch biopsy of the cervix predicts the maximum grade of CIN present and whether a colposcopically directed punch biopsy is more reliable than cytology in predicting the grade of intraepithelial neoplasia present in the cervix. The grade of CIN in 107 cone biopsy specimens was compared with the grade of CIN and dyskaryosis in punch biopsies and smears from the same patients. Exact correlations were identified between the highest grade lesions on cone biopsy and those in 63% of punch biopsies and 49% of cervical smears. We conclude that punch biopsy provides a more reliable estimate of the highest grade of CIN present in a subsequent cone biopsy than cervical cytology, but nonetheless fails to give a consistent estimate of the final grade of CIN in a significant percentage of cases.

Image analysis of low magnification images of fine needle aspirates of the breast produces useful discrimination between benign and malignant cases.

Fine needle aspirates of the breast (FNAB) (n = 362; 204 malignant, 158 benign), prepared by cytocentrifuge methods and stained by the Papanicolaou technique, were analysed using a semi-automated image analysis system at a low magnification which precluded resolution of nuclear detail. The measured parameters were integrated optical density, fractal textural dimension, number of cellular objects (single cells and contiguous groups of cells), distance between cellular objects (mean, s.d., skewness and kurtosis), area of cellular objects (mean, s.d., skewness, kurtosis) and the nearest neighbour statistic. The cases were divided into a 200-case training set and a 162-case test set. Analysis was performed by logistic regression and the multi-layer Perceptron type of artificial neural network. Logistic regression and the neural network produced similar performances with a sensitivity of 82-83%, specificity 85% and a positive predictive value for a malignant result of 85%. A non-parametric analysis of all the predictor variables showed that all except the mean area of cellular objects and the s.d. of this measurement were significant discriminants (P < 0.05), but most were highly interrelated and this was reflected in the selection of only three predictor variables by forward and backward conditional logistic regression. This study shows that much diagnostic information is present in low power views of FNAB, and that image analysis could form the basis of a semi-automated decision-support aid.

Long term follow-up of patients with acute myelogenous leukemia who received the daunorubicin, vincristine, and cytosine arabinoside regimen.

BACKGROUND: In 1985, the authors published a study of acute myelogenous leukemia (AML) patients treated with a chemotherapeutic regimen that was then considered intensive. Ten years later, the authors reanalyzed the same cohort to determine whether the very promising actuarial results observed at 5 years held after longer follow-up. METHODS: Between 1977 and 1982, 61 patients with AML were treated with a protocol consisting of daunorubicin, vincristine, and cytosine arabinoside induction followed by consolidation and maintenance for a total of 2 years. The complete remission (CR) rate was 66%, 84% in males versus 47% in females (P < 0.005). At the time of the first analysis in 1984, the overall survival (OS) was 17%, the projected 5-year continuous CR rate (CCR) 32%, and the disease free survival (DFS) rate 29%, with the best results observed for males and for patients ages 40-60 years (P < 0.05). RESULTS: When the data were reanalyzed 11 years later in 1995, the results were 14% OS, 23% CCR, and 16% DFS at 5 years. However, these figures dropped to 8%, 18%, and 11% at 10 years and to 8%, 12%, and 7% at 15 years, respectively. Among the 40 CR patients, 31 relapsed (up to 13 years after CR), and all died within 1.6 years after relapse. Nine patients were in CCR: 4 died of unrelated causes (suicide, alcoholic cirrhosis, acute peritonitis, or bladder carcinoma), 1 was lost to follow-up after 11 years, 2 were alive and well at 17 years at last follow-up, and 2 were transplanted in first CR and were doing well at 13 and 14 years at last follow-up. The survival advantage for males over females persisted (P = 0.0197), but the advantage for patients age 40-60 years did not hold. CONCLUSIONS: These long term data indicate that actuarial analysis at 5 years may overestimate the cure rate of AML patients because a number of late relapses do occur. However, the picture is blurred by the incidence of death not related to leukemia or its treatment; and when these patients were censored at the time of death, 17% of CR patients were still projected to be alive and free of leukemia after 17 years.