A content review of state tobacco pre-emption laws in the US.

OBJECTIVES: State ceiling pre-emption laws effectively limit the authority of local governments to regulate numerous public health issues, including tobacco. While general trends in the number of state tobacco pre-emption laws have been well-documented, less is known about the specific content of these laws. This study provides a comprehensive analysis of the content of current state tobacco pre-emption laws and captures the salient features of these laws. STUDY DESIGN: This was a comparative analysis of tobacco pre-emption laws in the United States. METHODS: The study team collected data about tobacco pre-emption laws from the Centers for Disease Control and Prevention's State Tobacco Activities Tracking and Evaluation System. Trained legal researchers further verified and reviewed each law's content using the Westlaw database. A coding scheme was developed to capture and analyse these laws' most salient features. RESULTS: State tobacco pre-emption laws use various terms to indicate the pre-emption of a local authority, including supersede, pre-empt, uniform, exclusive, and consistent. State laws cover numerous general topics and vary widely in explicit terminology of authorities and fields pre-empted. Several state laws included grandfathering exceptions and a few allowed exceptions for particular local jurisdictions. CONCLUSIONS: State laws that undermine local tobacco control efforts from implementing more stringent laws pose a threat to public health. These laws vary widely in their scope across the U.S., and local jurisdictions should be empowered to enact and maintain tobacco control measures that protect their communities from the harms of tobacco use and exposure.

Simulation-based point-of-care ultrasound training: a matter of competency rather than volume.

BACKGROUND: Point-of-care ultrasonography plays an increasingly important role in the initial resuscitation of critically ill patients but acquisition of the skill is associated with long learning curves. The skills required to perform ultrasound examinations can be practiced in a simulated setting before being performed on actual patients. The aim of this study was to investigate the learning curves for novices training the FAST protocol on a virtual-reality simulator. METHODS: Ultrasound novices (N = 25) were instructed to complete a FAST training program on a virtual-reality ultrasound simulator. Participants were instructed to continue training until they reached a previously established mastery learning level, which corresponds to the performance level of a group of ultrasound experts. Performance scores and time used during each FAST examination were used to determine participants' learning curves. RESULTS: The participants attained the mastery learning level within a median of three (range two to four) attempts corresponding to a median of 1 h 46 min (range 1 h 2 min to 3 h 37 min) of simulation training. The ultrasound novices' examination speed improved significantly with training, and continued to improve even after they attained the mastery learning level (P = 0.011). Twenty-three participants attained the mastery learning level. CONCLUSION: Novices can attain mastery learning levels using simulation-based ultrasound training with less than, on average, 2 h of practice. However, we found large variations in the amount of training needed, which raises questions about the adequacy of current volume-based models for determining ultrasound competency.

Pressure-actuated microfluidic devices for electrophoretic separation of pre-term birth biomarkers.

We have developed microfluidic devices with pressure-driven injection for electrophoretic analysis of amino acids, peptides, and proteins. The novelty of our approach lies in the use of an externally actuated on-chip peristaltic pump and closely spaced pneumatic valves that allow well-defined, small-volume sample plugs to be injected and separated by microchip electrophoresis. We fabricated three-layer poly(dimethylsiloxane) (PDMS) microfluidic devices. The fluidic layer had injection and separation channels, and the control layer had an externally actuated on-chip peristaltic pump and four pneumatic valves around the T-intersection to carry out sample injection. An unpatterned PDMS membrane layer was sandwiched between the fluidic and control layers as the actuated component in pumps and valves. Devices with the same peristaltic pump design but different valve spacings (100, 200, 300, and 400 µm) from the injection intersection were fabricated using soft lithographic techniques. Devices were characterized through fluorescent imaging of captured plugs of a fluorescein-labeled amino acid mixture and through microchip electrophoresis separations. A suitable combination of peak height, separation efficiency, and analysis time was obtained with a peristaltic pump actuation rate of 50 ms, an injection time of 30 s, and a 200-µm valve spacing. We demonstrated the injection of samples in different solutions and were able to achieve a 2.4-fold improvement in peak height and a 2.8-fold increase in separation efficiency though sample stacking. A comparison of pressure-driven injection and electrokinetic injection with the same injection time and separation voltage showed a 3.9-fold increase in peak height in pressure-based injection with comparable separation efficiency. Finally, the microchip systems were used to separate biomarkers implicated in pre-term birth. Although these devices have initially been demonstrated as a stand-alone microfluidic separation tool, they have strong potential to be integrated within more complex systems.

Highly sensitive troponin T in patients with acute ischemic stroke.

BACKGROUND: Newly developed troponin assays have superior diagnostic and prognostic performance in acute coronary syndrome (ACS), when compared to conventional troponin assays; however, highly sensitive troponin has not been evaluated in patients with acute ischemic stroke. METHODS: Highly sensitive troponin T (hsTnT) was measured daily during the first 4 days in 193 consecutive patients with acute ischemic stroke without overt ACS or atrial fibrillation. The patients were previously tested normal with a fourth-generation TnT assay. The patients were followed for 47 months, with all-cause and cardiovascular mortality end-points. RESULTS: A total of 33.7% of the patients had hsTnT levels >14 ng/l following admission. Patients with increased hsTnT were older, had decreased hemoglobin levels and increased creatinine, NT-proBNP and CRP levels. hsTnT concentrations at admission were significantly higher in decedents than in survivors. After adjustment for stroke severity, C-reactive protein, age, NT-proBNP and prior heart and/or renal failure, hsTnT levels were not a significant predictor of long-term all-cause or cardiovascular mortality. CONCLUSION: Elevated levels of hsTnT are frequently present in patients with acute ischemic stroke previously tested normal with a fourth-generation TnT assay. hsTnT did not provide additional prognostic information in these subjects.

Micropollutants in stormwater runoff and combined sewer overflow in the Copenhagen area, Denmark.

Stormwater runoff contains a broad range of micropollutants. In Europe a number of these substances are regulated through the Water Framework Directive, which establishes Environmental Quality Standards (EQSs) for surface waters. Knowledge about discharge of these substances through stormwater runoff and combined sewer overflows (CSOs) is essential to ensure compliance with the EQSs. Results from a screening campaign including more than 50 substances at four stormwater discharge locations and one CSO in Copenhagen are reported here. Heavy metal concentrations were detected at levels similar to earlier findings, e.g., with copper found at concentrations up to 13 times greater than the Danish standard for surface waters. The concentration of polyaromatic hydrocarbons (PAHs) exceeded the EQSs by factors up to 500 times for stormwater and 2,000 times for the CSO. Glyphosate was found in all samples whilst diuron, isoproturon, terbutylazine and MCPA were found only in some of the samples. Diethylhexylphthalate (DEHP) was also found at all five locations in concentrations exceeding the EQS. The results give a valuable background for designing further monitoring programmes focusing on the chemical status of surface waters in urban areas.

Osteoprotegerin concentrations and prognosis in acute ischaemic stroke.

AIM: Concentrations of osteoprotegerin (OPG) have been associated with the presence of vascular and cardiovascular diseases, but the knowledge of this marker in the setting of ischaemic stroke is limited. METHODS AND RESULTS: In 244 patients with acute ischaemic stroke (age: 69 +/- 13 years), samples of OPG were obtained serially from presentation to day 5. Patients with overt ischaemic heart disease and atrial fibrillation were excluded. The patients were followed for 47 months, with all-cause mortality as the sole end-point. Multivariable predictors of OPG values at presentation included haemoglobin (T = -2.82; P = 0.005), creatinine (T = 4.56; P < 0.001), age (T = 9.66; P < 0.001), active smoking (T = 2.25; P = 0.025) and pulse rate (T = 3.23; P = 0.001). At follow-up 72 patients (29%) had died. Patients with OPG < or =2945 pg mL(-1) at baseline had a significantly improved survival rate on univariate analysis (P < 0.0001); other time-points did not add further prognostic information. In multivariate analysis, after adjustment for age, stroke severity, C-reactive protein levels, troponin T levels, heart and renal failure concentrations of OPG independently predicted long-term mortality after stroke (adjusted hazard ratio, 2.3; 95% CI: 1.1 to 4.9; P = 0.024). CONCLUSION: Osteoprotegerin concentrations measured at admission of acute ischaemic stroke are associated with long-term mortality.

The effect of the triple monoamine reuptake inhibitor tesofensine on energy metabolism and appetite in overweight and moderately obese men.

BACKGROUND: Tesofensine (TE) is a new drug producing twice the weight loss in obese individuals as seen with currently marketed drugs. It inhibits the presynaptic reuptake of the neurotransmitters noradrenaline, dopamine and serotonin, and is thought to enhance the neurotransmission of all three monoamines. The mechanisms by which it produces weight loss in humans are unresolved. OBJECTIVE: The aim of this study is to investigate the mechanism(s) behind weight reduction by measuring energy expenditure and appetite sensations in overweight and obese individuals. DESIGN: Thirty-two healthy, overweight or moderately obese men were treated with 2.0 mg TE daily for 7 days followed by an additional 7 days with 1.0 mg TE daily or corresponding placebo (PL) in a randomized, controlled trial. They were instructed to maintain habitual food intake and physical activity throughout. Twenty-four-hour energy expenditure (24-h EE), fat oxidation and spontaneous physical activity were measured in a respiration chamber before and after treatment. Body composition was assessed by dual-energy X-ray absorption and appetite was evaluated by visual analogue scales in conjunction with a standardized dinner. RESULTS: Despite efforts to keep body weight and composition constant, TE induced a 1.8 kg weight loss above PL after 2 weeks' treatment (P<0.0001). TE also induced higher ratings of satiety and fullness and concomitantly lower prospective food intake than placebo. No significant effect of TE on total 24-h EE could be demonstrated compared with PL, but higher energy expenditure was observed during the night period (4.6%; P<0.05) when adjusted for changes in body composition. Furthermore, TE increased 24-h fat oxidation as compared with PL (18 g; P<0.001). CONCLUSION: TE has a pronounced effect on appetite sensations and a slight effect on energy expenditure at night-both effects can contribute to the strong weight-reducing effect of TE.

A slow-cycling subpopulation of melanoma cells with highly invasive properties.

Melanoma is a heterogeneous tumor with different subpopulations showing different proliferation rates. Slow-cycling cells were previously identified in melanoma, but not fully biologically characterized. Using the label-retention method, we identified a subpopulation of slow-cycling cells, defined as label-retaining cells (LRC), with strong invasive properties. We demonstrate through live imaging that LRC are leaving the primary tumor mass at a very early stage and disseminate to peripheral organs. Through global proteome analyses, we identified the secreted protein SerpinE2/protease nexin-1 as causative for the highly invasive potential of LRC in melanomas.

The influence of anaemia on stroke prognosis and its relation to N-terminal pro-brain natriuretic peptide.

Anaemia is a negative prognostic factor for patients with heart failure and impaired renal function, but its role in stroke patients is unknown. Furthermore, anaemia has been shown to influence the level of N-terminal pro-brain natriuretic peptide (NT-proBNP), but this is only investigated in patients with heart failure, not in stroke patients. Two-hundred-and-fifty consecutive, well-defined ischemic stroke patients were investigated. Mortality was recorded at 6 months follow-up. Anaemia was diagnosed in 37 patients (15%) in whom stroke severity was worse than in the non-anaemic group, whilst the prevalence of renal affection, smoking and heart failure was lower. At 6 months follow-up, 23 patients were dead, and anaemia had an odds ratio of 4.7 when adjusted for age, Scandinavian Stroke Scale and a combined variable of heart and/or renal failure and/or elevation of troponin T using logistic regression. The median NT-proBNP level in the anaemic group was significantly higher than in the non-anaemic group, and in a multivariate linear regression model, anaemia remained an independent predictor of NT-proBNP. Conclusively, anaemia was found to be a negative prognostic factor for ischemic stroke patients. Furthermore, anaemia influenced the NT-proBNP level in ischemic stroke patients, an important aspect when interpreting NT-proBNP in these patients.

Subsurface nitrate reduction under wetlands takes place in narrow superficial zones.

This study aims to investigate the depth distribution of the Nitrate Reduction Potential (NRP) on a natural and a re-established wetland. The obtained NRP provides a valuable data of the driving factors affecting denitrification, the Dissimilatory Nitrate Reduction to Ammonium (DNRA) process and the performance of a re-established wetland. Intact soil cores were collected and divided in slices for the determination of Organic Matter (OM) through Loss of Ignition (LOI) as well as Dissolved Organic Carbon (DOC) and NRP spiking nitrate in batch tests. The Nitrate Reduction (NR) was fitted as a pseudo-first order rate constant (k) from where NRPs were obtained. NR took place in a narrow superficial zone showing a dropping natural logarithmic trend along depth. The main driving factor of denitrification, besides depth, was OM. Although, DOC and LOI could not express by themselves and absolute correlation with NRP, high amounts of DOC ensured enough quantity and quality of labile OM for NR. Besides, high concentration of LOI but a scarce abundance of DOC failed to drive NR. DNRA was only important in superficial samples with high contents of OM. Lastly, the high NRP of the re-established wetland confirms that wetlands can be restored satisfactorily.

Levels of brominated flame retardants in Northern Fulmar (Fulmarus glacialis) eggs from the Faroe Islands.

Eggs from Northern Fulmars (Fulmarus glacialis) were sampled in the Faroe Islands. The content of the brominated flame retardants tri- to decabromodiphenyl ethers (BDEs) and 1,2-bis(2,4,6-tribromophenoxy)ethane (BTBPE) were determined in nine samples in concentrations ranging from non-detectable to 7 ng g-1(l.w.). The BDE levels were similar as in an earlier study of BDE levels in the fulmar eggs from the Faroe Islands but 10-1000 times lower compared to studies of eggs from seabirds and birds of prey from Europe. The two hexaBDEs #153 and #154 were the most abundant congeners, which represented around 50% of the total mean BDE concentration. The levels of BDE #209 were below the limit of detection (1.24 ng g-1 l.w.) except for one sample, which showed a concentration of 7.18 ng g-1 l.w. BTBPE was detected in eight samples and the mean level was 0.11 ng g-1 l.w. This concentration was 150 times lower than the average total BDE concentration (including BDEs #28, #47, #100, #99, #154, #153, #183, #209). BTBPE has only been detected once before in biota. Also other bromo-containing compounds were detected in the fulmar eggs. One group identified was the polybrominated biphenyls (PBBs), but because of the absence of reference standards in the lab, these could not be quantified.

The effect of patient position on proximal urethral mobility.

OBJECTIVE: To determine the effect of patient position on the mobility of the urethrovesical junction. METHODS: Q-tip tests in the supine and standing positions were performed on forty-six consecutive female patients with a variety of urogynecologic complaints. Wilcoxon signed-rank test and McNemar test were used to compare urethral mobility in the supine and standing positions. RESULTS: Both the maximum straining Q-tip angle and the difference between the resting and straining angles were significantly greater in the supine position than in the standing position (P < .01). Thirty-four subjects had a positive Q-tip test in the supine position (defined as a maximal straining angle of at least 30 degrees), but only 24 (71%) of these women had a positive Q-tip test in the standing position. CONCLUSION: Patient position has a significant effect on mobility of the urethrovesical junction, in that the female urethra is more mobile in the supine than in the standing position. Because the selection of a surgical procedure for a woman with genuine stress incontinence depends in part on the presence or absence of urethral hypermobility, this observation has important implications for the evaluation of women with genuine stress incontinence.

The role of patient history in the diagnosis of urinary incontinence.

OBJECTIVE: To assess the clinical usefulness and validity of patient history in the diagnosis of genuine stress incontinence and detrusor overactivity. DATA SOURCES: A literature search was performed for publications addressing the clinical evaluation of urinary incontinence between 1975-1992. METHODS OF STUDY SELECTION: Nineteen of 29 articles during this period reported data in such a manner as to allow statistical comparison of patient history to the diagnosis based on urodynamic evaluation. DATA EXTRACTION AND SYNTHESIS: Each article was assessed for the following information: inclusion and exclusion criteria, method of obtaining patient history, clinical evaluation, and diagnostic criteria. Patients in each article were classified according to their history and urodynamic diagnosis. Sensitivity, specificity, and predictive values were calculated for each article, as well as for the combined data from all articles. Combined data from all 19 articles produced a total of 3092 and 2950 patients evaluated for genuine stress incontinence and detrusor overactivity, respectively. A clinical history consistent with stress incontinence, when compared to a urodynamically based diagnosis, showed a sensitivity of 0.906, a specificity of 0.511, a positive predictive value of 0.749, and a negative predictive value of 0.771. A comparison of clinical history suggestive of an overactive detrusor and urodynamic evidence of spontaneous bladder activity revealed a sensitivity of 0.735, specificity of 0.552, positive predictive value of 0.561, and negative predictive value of 0.728. CONCLUSION: Patient history alone is not an accurate tool in the diagnosis of genuine stress incontinence or detrusor overactivity, and should not be the sole determinant of diagnosis or treatment.

Banked human fascia lata for the suburethral sling procedure: a preliminary report.

OBJECTIVE: To report our initial experience with allogenic (human cadaver donor) fascia lata for the suburethral sling procedure. METHODS: Allogenic fascia lata for the suburethral sling procedure has been used in our practice since July 1994. Fascial grafts were obtained from licensed tissue banks. Women who underwent this procedure were followed prospectively to determine the incidence of perioperative complications, the incidence of local wound complications at the sling insertion site, and the subjective and objective cure rates. RESULTS: Sixteen women underwent the suburethral sling procedure with allogenic fascia. Fourteen had genuine stress urinary incontinence and two required replacement of a previously placed synthetic graft because of chronic infection. Follow-up ranged from 6 months to 1 year. No patient developed sinus tract formation or persistent granulation tissue. Two of 16 patients (12%) developed abdominal wound infections, which resolved with local care. The mean duration of postoperative bladder drainage was 29 days. One patient continued to require intermittent catheterization at 187 days. Among the 14 women with preoperative genuine stress incontinence, the subjective cure rate was 86% and the objective cure rate was 79%. The two patients who required replacement of a chronically infected synthetic graft remained subjectively continent. CONCLUSIONS: These preliminary data suggest that allogenic fascia lata is an acceptable material for the suburethral sling procedure. This material may be considered as an alternative to autologous fascia, which must be harvested from the patient intraoperatively, and to synthetic materials, which have been associated with local complications in up to 40% of cases.

Assessment of exposure to EMF in a Danish case-control study of childhood cancer.

In Denmark it is permitted to draw overhead lines across residential areas. In connection with a Danish case-control study we developed a method for estimating the historical values of magnetic fields at residences. The study included 1,707 cases with childhood cancer and 4,788 matched population controls. A total of 16,082 different addresses had been occupied by the families from the time of conception until the date of diagnosis. The values of the extreme, maximum, middle and minimum 50 Hz magnetic field strengths originating from a 50-400 kV high-voltage installation were estimated for each of the dwellings included in a potential exposure area. 30 children were exposed to an average level of magnetic fields of 0.1 microT or more. The evaluated Danish method of exposure assessment was compared with the method for residential wiring codes developed by Wertheimer and Leeper /1/. We concluded that the US wiring codes are inappropriate for use in connection with the Danish electricity transmission system.

Suprapubic needle cystoscopy: a new technique to detect iatrogenic injuries to the lower urinary tract.

Latrogenic injury to the lower urinary tract, specifically the ureter and bladder, is a potential risk of any pelvic surgery. According to the available literature, the incidence of injury to the ureter ranges from 0.5-2.5% for routine pelvic operarions. In actuality, the incidence of ureteral injury during pelvic surgery may even be higher, as many cases are not reported, not detected or are asymptomatic. Injury to the bladder during pelvic surgery most commonly occurs in the form of inadverant laceration or placement of sutures through the bladder wall. Previous pelvic surgery, including Cesearean section, hysterectomy and bladder suspension procedures, and gynecologic conditions such as malignancy, endometriosis and pelvic inflammatory disease increase the risk for bladder trauma.

The efficacy of intraoperative autologous transfusion in major orthopedic surgery: a regression analysis.

Perioperative blood loss associated with 89 cases of major orthopedic surgery was compared with that of a control group of 89 to determine the effectiveness of intraoperative autologous transfusion. Volume of banked blood transfused and hematocrit change were used to determine total blood loss. The orthopedic cases consisted of cemented "virgin" total hip replacement, cemented virgin tricompartmental knee replacement, and spine fusion. Use of an autotransfusion device (Cell Saver) intraoperatively was associated with significantly smaller volumes of transfused banked blood and significantly smaller hematocrit drops in the groups of patients who underwent total hip replacement or spine fusion, but not in the group of patients who underwent total knee replacement. One potential source of bias in the study stems from the fact that four days were allotted for equilibrium from perioperative blood loss in the hip and knee replacement groups, while, for reasons of data availability, equilibrium time in the spine fusion groups was two days.

[Smoking and admission to a department of internal medicine at a county hospital]. / Tobaksrygning og hospitalsindlaeggelse på medicinsk afdeling på et centralsygehus.

On a random day in 1998 all hospitalized unselected patients on the ward of internal medicine, Silkeborg County Hospital were evaluated in relation to possible tobacco-related disease. A total of 56 (71%) of 79 had a smoking-related main diagnosis and of these 23 (29%) of 79 were statistically diseased as a direct consequence of their present and previous use of tobacco.

[Acute myocardial infarction associated with a mild blunt thoracic trauma]. / Akut myokardieinfarkt associeret til mindre fysisk traume mod brystkassen.

A case of acute myocardial infarction associated with a mild blunt thoracic trauma in a 60-year-old woman with normal coronary angiography is described. The underlying potential pathophysiological mechanisms are discussed. Lastly, the clinical and practical consequences of the new consensus document for the redefinition of acute myocardial infarction are briefly commented on.