Are the school prevention programmes - aimed at de-normalizing smoking among youths - beneficial in the long term? An example from the Smoke Free Class Competition in Italy.

Tobacco smoking by young people is of great concern because it usually leads to regular smoking, nicotine addiction and quitting difficulties. Young people "hooked" by tobacco maintain the profits of the tobacco industry by replacing smokers who quit or die. If new generations could be tobacco-free, as supported by tobacco endgame strategies, the tobacco epidemic could end within decades. Smoking prevention programmes for teens are offered by schools with the aim to prevent or delay smoking onset. Among these, the Smoke Free Class Competition (SFC) was widely implemented in Europe. Its effectiveness yielded conflicting results, but it was only evaluated at short/medium term (6 - 18 months). The aim of this study is to evaluate its effectiveness after a longer follow-up (3 to 5 years) in order to allow enough time for the maturing of the students and the internalization of the experience and its contents. Fifteen classes were randomly sampled from two Italian high schools of Bologna province that regularly offered the SFC to first year students; 382 students (174 participating in the SFC and 208 controls) were retrospectively followed-up and provided their "smoking histories". At the end of their last year of school (after 5 years from the SFC), the percentage of students who stated that they were regular smokers was lower among the SFC students than in controls: 13.5% vs 32.9% (p=0.03). From the students' "smoking histories", statistically significant protective ORs were observed for SFC students at the end of 1st and 5th year: 0.42 (95% CI 0.19-0.93) and 0.32 (95% CI 0.11-0.91) respectively. Absence of smokers in the family was also a strongly statistically significant factor associated with being a non-smoker student. These results suggest that SFC may have a positive impact on lowering the prevalence of smoking in the long term (5 years).

Brain metastases in renal cell carcinoma: management with gamma knife radiosurgery.

PURPOSE: The purpose of this study was to evaluate survival and local control of brain metastases in patients with renal cell carcinoma. METHODS AND MATERIALS: From November 1993 through March 1999, 38 radiosurgical treatments using the Leksell gamma knife unit were performed on 22 patients with renal cell carcinoma. The indications for treatment were failure after whole-brain radiation therapy or de novo treatment. All radiosurgical treatments were given on an outpatient basis. The workup included computed tomography and magnetic resonance imaging. The age of the patients ranged from 38 to 80 years (median age, 60 years). The mean minimum tumor dose was 18 Gy, and the mean volume was 3.9 cc. Previous whole-brain radiation therapy was used in 11/22 (50%) patients. Four of 22 patients presented with single metastasis. Thirteen patients were treated once, one patient was treated four times and one patient seven times for new lesions. The number of lesions treated ranged from one to 21. RESULTS: One patient is al ive at 63 months of fol low-up. Twenty-one patients died, with a median survival of 8 months (range, 1-38 months). Eighteen of 21 patients died of nonneurologic causes. Overall local control was 98.5%. One patient developed radiation necrosis. CONCLUSIONS The long-term survival achieved in patients with renal cell carcinoma requires aggressive management, even in the presence of multiple brain metastases. Gamma knife radiosurgery for renal cell carcinoma is an effective noninvasive modality of treatment. It offers high local control rate and improved quality of life and survival.

Gamma knife radiosurgery in the treatment of patients with single and multiple brain metastases from carcinoma of the breast.

PURPOSE: The purpose of the study was to evaluate the results of gamma knife radiosurgery for treatment of brain metastases from carcinoma of the breast. MATERIALS AND METHODS: From December 1993 to July 1998, 68 women with breast carcinoma metastatic to the brain were treated with gamma knife radiosurgery at Miami Neuroscience Center in Coral Gables, Florida. The ages ranged from 25 to 80 years, with a median age of 52 years. Thirty-eight patients had previously received conventional modalities of treatment for brain metastases including whole-brain irradiation. A total of 110 treatments were given to the 68 women to an average of eight tumor sites per patient. Minimum doses ranged from 6 to 25 Gy to the 35% to 85% isodose line, with 95% of the prescribed minimum doses ranging from 15 to 24 Gy. Patients were treated for one to three lesions (n = 26), four to seven lesions (n = 18), and eight or more lesions (n = 24). RESULTS: The median overall actuarial survival for the entire group was 7.8 months. The actuarial survival was 32% at 1 year. The median follow-up was 7.8 months. Overall local control by lesion was 94% (485/518 lesions), and average tumor volume was 3.3 cm3. Twenty-seven (40%) of 68 eligible patients survived 1 year, nine (13%) survived 2 years, and two (3%) survived more than 3 years. Fifty-one of 56 documented deaths (91%) were unrelated to brain metastases. In a subgroup of 15 patients with single brain metastases, the average tumor volume was 16.6 cm3, and local control was 73% (11/15 lesions). The 15 patients who died had a median survival of 7.7 months (range, 3 to 45.7 months). CONCLUSIONS: Gamma knife radiosurgical treatment of patients with brain metastases from carcinoma of the breast has shifted the question of survival to that of systemic control. There was no radiation-induced dementia, and a remarkably low incidence of local failure was seen. Survival has been found to be independent of the number of lesions treated.

Imaging of nontraumatic hemorrhagic hepatic lesions.

Spontaneous hepatic bleeding is a rare condition. In the absence of trauma or anticoagulant therapy, hepatic hemorrhage may be due to underlying liver disease. The most common causes of nontraumatic hepatic hemorrhage are hepatocellular carcinoma and hepatic adenoma. Such hemorrhage can also occur in patients with other liver tumors, such as focal nodular hyperplasia, hemangiomas, and metastases. Other conditions associated with this entity include HELLP syndrome, amyloidosis, and miscellaneous causes. Imaging plays a significant role in the diagnosis and management of this potentially lethal entity. In the appropriate clinical setting, the diagnosis of a hemorrhagic liver lesion is suggested when a hyperechoic mass or a mass with hyperechoic areas is seen at ultrasonography, a hyperattenuating mass is seen at computed tomography (CT), or a mass with high-signal-intensity areas is seen at T1-weighted magnetic resonance (MR) imaging. The signal intensity of blood can be increased or decreased on MR images depending on when the hemorrhage is imaged. The presence and extent of commonly associated subcapsular hematomas and hemoperitoneum can be easily ascertained with CT. During the first 24-72 hours, acute hematomas are hyperattenuating on nonenhanced CT scans; later, they decrease in attenuation and sometimes develop a pseudocapsule.

Myelocystocele-cloacal exstrophy in a pedigree with a mitochondrial 12S rRNA mutation, aminoglycoside-induced deafness, pigmentary disturbances, and spinal anomalies.

A large Filipino-American family with progressive matrilineal hearing loss, premature graying, depigmented patches, and digital anomalies was ascertained through a survey of a spina bifida clinic for neural crest disorders. Deafness followed a matrilineal pattern of inheritance and was associated with the A1555G mutation in the 12S rRNA gene (MTRNR1) in affected individuals as well as unaffected maternal relatives. Several other malformations were found in carriers of the mutation. The proband had a myelocystocele, Arnold-Chiari type I malformation, cloacal exstrophy, and severe early-onset hearing loss. Several family members had premature graying, white forelock, congenital leukoderma with or without telecanthus, somewhat suggestive of a Waardenburg syndrome variant. In addition to the patient with myelocystocele, two individuals had scoliosis and one had segmentation defects of spinal vertebrae. The syndromic characteristics reported here are novel for the mitochondrial A1555G substitution, and may result from dysfunction of mitochondrial genes during early development. However, the mitochondrial A1555G mutation is only rarely associated with neural tube defects as it was not found in a screen of 218 additional individuals with spina bifida, four of whom had congenital hearing loss.

[Absence of bleeding recurrence of peptic ulcer after long term follow-up of successful eradication of Helicobacter pylori]. / Ausencia de recidiva de sangrado por úlcera péptica en el largo plazo luego de una erradicación exitosa del Helicobacter pylori.

Helicobacter pylori (HP) eradication reduces dramatically the peptic ulcer relapse rate, but information regarding recurrence of peptic ulcer bleeding after eradication is still scanty. Available data show rebleeding rates of 0-3% per year in successfully eradication patients, compared with figures between 12 and 33% among the non eradicated ones. The aim of this study was to determine the rebleeding rate among successfully eradicated patients with a prior history of rebleeding peptic ulcer. 42 patients (34 male, mean age 49, range 18-74) hospitalised for Hp positive bleeding peptic ulcer undergoing conservative treatment, were given as soon as oral route was re-established, a one-week eradication treatment, followed by the same proton pump inhibitor for three or five weeks for duodenal and gastric ulcer healing respectively. No maintenance antiulcer therapy was indicated. Patients were advised not to take nonsteroideal anti-inflammatory drug. Ulcer healing and Hp eradication was confirmed in all 42 patients by means of endoscopy and biopsies for urease rapid test and histology four weeks after completion of the treatment. After this patients were invited to enter a long-term follow-up program with periodical visits. End point of the study was occurrence of rebleeding. Further endoscopies were planned when rebleeding or symptomatic relapse. Median follow-up time was 24.02 months, ranging from 3 up to 27 months. All patients were compliant with the follow-up visits. None of the patients presented with symptoms suggestive of ulcer relapse or upper gastrointestinal bleeding. Our data suggest, that Hp eradication can prevent bleeding relapses in patients with Hp positive bleeding peptic ulcers.

Ausencia de recidiva de sangrado por úlcera péptica en el largo plazo luego de una erradicación exitosa del Helicobacter pylori. / [Absence of bleeding recurrence of peptic ulcer after long term follow-up of successful eradication of Helicobacter pylori]

Helicobacter pylori (HP) eradication reduces dramatically the peptic ulcer relapse rate, but information regarding recurrence of peptic ulcer bleeding after eradication is still scanty. Available data show rebleeding rates of 0-3

per year in successfully eradication patients, compared with figures between 12 and 33

among the non eradicated ones. The aim of this study was to determine the rebleeding rate among successfully eradicated patients with a prior history of rebleeding peptic ulcer. 42 patients (34 male, mean age 49, range 18-74) hospitalised for Hp positive bleeding peptic ulcer undergoing conservative treatment, were given as soon as oral route was re-established, a one-week eradication treatment, followed by the same proton pump inhibitor for three or five weeks for duodenal and gastric ulcer healing respectively. No maintenance antiulcer therapy was indicated. Patients were advised not to take nonsteroideal anti-inflammatory drug. Ulcer healing and Hp eradication was confirmed in all 42 patients by means of endoscopy and biopsies for urease rapid test and histology four weeks after completion of the treatment. After this patients were invited to enter a long-term follow-up program with periodical visits. End point of the study was occurrence of rebleeding. Further endoscopies were planned when rebleeding or symptomatic relapse. Median follow-up time was 24.02 months, ranging from 3 up to 27 months. All patients were compliant with the follow-up visits. None of the patients presented with symptoms suggestive of ulcer relapse or upper gastrointestinal bleeding. Our data suggest, that Hp eradication can prevent bleeding relapses in patients with Hp positive bleeding peptic ulcers.

Ausencia de Recidiva de sangrado por úlcera péptica en el largo plazo luego de una erradicación exitosa del Helicobacter pylory / Absence of bleeding recurrence by peptic ulcer after long term follow-up of succesfully erradication of Helicobacter pylori

El objetivo de este trabajo fue determinar la tasa de resangrado en pacientes con historia previa de ulcera péptica sangrante H.P. positiva. 42 pacientes hospitalizados por úlceras pépticas sangrante fueron sujetos a tratamiento convencional para el cese de sangrado. Se les efectuó luego taramiento de erradicación del H.P. con triple terapia a 7 días sin mantenimiento posterior. A 4 semanas en el caso de ulcera duodenal y a 6 semanas en casos de ulcera gástrica se comprobó por vía endoscópica e histológica la curación de la úlcera y la erradicación de la bacteria. Los 42 pacientes fueron incluidos en un estudio de seguimiento y al cumplirse 24,02 meses (rango 3-27 meses) no hubo recidiva de la hemorragia en ninguno de ellos. Estos datos sugieren que la erradicación de H.P. puede prevenir la recidiva de sangrado ulceroso en pacientes H.P. positivos.

Ausencia de Recidiva de sangrado por úlcera péptica en el largo plazo luego de una erradicación exitosa del Helicobacter pylory / Absence of bleeding recurrence by peptic ulcer after long term follow-up of succesfully erradication of Helicobacter pylori

El objetivo de este trabajo fue determinar la tasa de resangrado en pacientes con historia previa de ulcera péptica sangrante H.P. positiva. 42 pacientes hospitalizados por úlceras pépticas sangrante fueron sujetos a tratamiento convencional para el cese de sangrado. Se les efectuó luego taramiento de erradicación del H.P. con triple terapia a 7 días sin mantenimiento posterior. A 4 semanas en el caso de ulcera duodenal y a 6 semanas en casos de ulcera gástrica se comprobó por vía endoscópica e histológica la curación de la úlcera y la erradicación de la bacteria. Los 42 pacientes fueron incluidos en un estudio de seguimiento y al cumplirse 24,02 meses (rango 3-27 meses) no hubo recidiva de la hemorragia en ninguno de ellos. Estos datos sugieren que la erradicación de H.P. puede prevenir la recidiva de sangrado ulceroso en pacientes H.P. positivos. (AU)

Chronic exertional dyspnea and respiratory muscle function in patients with chronic obstructive pulmonary disease.

The symptom of breathlessness is an important outcome measure in the management of patients with chronic obstructive pulmonary disease (COPD). Clinical ratings of dyspnea and routine lung function are weakly related to each other. However, in the clinical setting breathlessness in COPD is encountered under conditions of increased respiratory effort, impeded respiratory muscle action, or functional weakness. Thus, the present study was carried out to determine whether and to what extent clinical ratings of dyspnea and respiratory muscle dysfunction relate to each other. In 21 patients with COPD two methods were used to rate dyspnea: a modified Medical Research Council Scale (MRC) and the Baseline Dyspnea Index (BDI), which is a multidimensional instrument for measuring dyspnea based on three components: magnitude of task, magnitude of effort, and functional impairment. A baseline focal score was obtained as the sum of the three components. Measures were: pulmonary volumes; arterial blood gases; maximal voluntary ventilation (MVV); maximal inspiratory and expiratory pressures (MIP and MEP, respectively); and breathing patterns ventilation (VE), tidal volume (VT), and respiratory frequency (Rf). In 15 patients pleural pressure was also measured during both quiet breathing (Pplsw) and maximal inspiratory sniff maneuver at FRC (Pplsn). BDI and MRC ratings related to each other and showed comparable weak associations with standard parameters (FEV1, PaCO2, VT), MIP, and MEP. In contrast, MVV closely and similarly related to both ratings. Pplsw (%Pplsn), a measure of respiratory effort, and Pplsw (%Pplsn)/VT(%VC), an index of neuroventilatory dissociation, related significantly to both the BDI (r2 = -0.77 and r2 = -0.75, respectively) and the MRC (r2 = 0.81 and r2 = 0.74, respectively). Using MVV, Pplsw (%Pplsn), and Pplsw (%Pplsn)/VT(%VC) in a stepwise multiple regression as independent variables with BDI rating as dependent variable, MVV explained an additional 14.5% of the variance of the BDI over the 67.8% predicted by Pplsw (%Pplsn). Our results demonstrate that the level of chronic exertional dyspnea in COPD increases as the ventilatory muscle derangement increases. The level of the relationships among dyspnea ratings and MVV and respiratory effort helps to explain some of the mechanisms of chronic dyspnea of COPD. These measures should be considered for therapeutic intervention to reduce dyspnea.

Role of sputum differential cell count in detecting airway inflammation in patients with chronic bronchial asthma or COPD.

BACKGROUND: Sputum may provide an alternative source of bronchial cells to investigate characteristics of airway inflammation and its functional correlates in patients with asthma or chronic obstructive pulmonary disease (COPD). METHODS: Two groups of clinically stable patients were studied: a group of 43 patients with mild or moderate asthma and a group of 18 patients with COPD. Twenty normal subjects formed a control group. Sputum production was either spontaneous or induced with inhaled hypertonic saline for five minute periods for up to 20 minutes. The concentration of saline was increased at intervals of 10 minutes from 3% to 4%. Plugs from the lower respiratory tract were selected for differential counting in cytocentrifugation preparations. Bronchial provocation tests were performed by inhaling progressive concentrations of histamine from a DeVilbiss 646 nebuliser and the concentration of histamine which caused a 20% fall in the forced expiratory volume in one second (FEV1) was calculated (PC20FEV1). RESULTS: Neutrophils predominated in the sputum of subjects with COPD while eosinophils predominated in the sputum of those with chronic asthma. However, in 28% of asthmatic subjects an increased percentage of neutrophils was found. In asthmatic patients the differential count of eosinophils was inversely related to the FEV1, FEV1/VC, and bronchial hyperresponsiveness, and directly related to clinical scores. CONCLUSIONS: The cellular profile of sputum in normal subjects and in patients with asthma and COPD is different. The concentration of eosinophils in the sputum correlates with the severity of asthma.

Genitourinary tract gas: imaging evaluation.

Gas-forming infections of the genitourinary tract may manifest as life-threatening conditions, often requiring aggressive medical and surgical management. Accurate interpretation of the radiologic studies is essential for early and accurate diagnosis of gas within the renal parenchyma or collecting system, bladder, uterus, and scrotum. Three distinct entities are associated with renal or perirenal gas: emphysematous pyelonephritis, emphysematous pyelitis, and gas-forming perirenal abscess. Gas in the bladder may occur secondary to emphysematous cystitis or a vesicoenteric fistula and must be differentiated from air introduced by means of instrumentation. Uterine gas usually indicates an underlying infection or a neoplasm. Gas in the scrotum is most commonly due to an infectious process or bowel herniation into the scrotal sac. Before institution of a specific therapeutic regimen, an effort should be made to establish the exact location of gas in the genitourinary tract. Plain radiography, including tomography, and ultrasonography are useful screening modalities. Although in some cases urography, barium enema studies, and other contrast material-enhanced studies enable a diagnosis to be made, in many patients computed tomography is the definitive diagnostic technique.

Percutaneous sclerotherapy of lymphoceles related to renal transplantation.

PURPOSE: To determine the advantages of using transcatheter sclerotherapy to treat renal allograft-related lymphoceles. MATERIALS AND METHODS: Eighteen patients first seen with symptomatic lymphoceles secondary to renal transplantation were treated with povidone-iodine percutaneous sclerotherapy. Percutaneous catheters were place by means of sonographic, computed tomographic, or combined fluoroscopic and sonographic guidance. Sclerotherapy was initiated while patients were in the hospital, and the patients then instilled povidone-iodine twice a day at home. RESULTS: One patient had an inadequate trial period of therapy and was not included in the analysis. Seventeen lymphoceles were adequately sclerosed. Average length of treatment was 35 days. Three lymphoceles recurred and were effectively treated percutaneously. Follow-up studies showed no recurrence 1 month to 2 years after completion of therapy. No patient needed surgery for lymphocele repair. CONCLUSION: Because of its safety and efficacy, percutaneous transcatheter sclerotherapy with povidone-iodine should be the treatment of choice in patients with lymphoceles that develop after renal transplantation.

Fournier's gangrene: CT findings.

Fournier's gangrene is an uncommon gas-forming infection of the scrotum which if not recognized early and treated appropriately may be fatal. In three patients recently seen at our institution, computed tomography (CT) was instrumental in establishing the correct diagnosis and determining the extent of the infectious process prior to surgery. The imaging findings at CT and its differential diagnosis are illustrated. A brief review of the current theories of pathogenesis of this interesting entity is presented.