Counseling smoking parents of young children: comparison of pediatricians and family physicians.

BACKGROUND: Secondhand smoke is a major cause of morbidity in young children, and exposure to smoking parents is the principal source. Physician visits for young children present an opportunity to effect behavioral change among smoking parents. OBJECTIVE: To survey pediatricians and family physicians in their knowledge and practice of smoking cessation counseling with parents. DESIGN: Cross-sectional mail survey. SETTING: Urban California. PARTICIPANTS: Pediatricians and family physicians in urban areas of California, younger than 65 years, practicing in an ambulatory setting, and randomly selected from the American Medical Association Physician Masterfile. MAIN OUTCOME MEASURES: Reported frequency of asking about tobacco use, using cessation counseling techniques with smokers, and perceived barriers to providing cessation services. RESULTS: Of the 1000 mailed surveys, 899 were eligible and 499 (56% response rate) were returned and completed. A higher proportion of pediatricians compared with family physicians were women (44% vs 29%; P<.01) and nonwhite (44% vs 32%; P =.01). Family physicians compared with pediatricians were more likely to report referring a parent to a smoking cessation program (41% vs 30%), giving pamphlets on smoking cessation (40% vs 28%), asking for a quit date (41% vs 18%), scheduling a follow-up visit to discuss quitting (27% vs 5%), and recommending nicotine replacement therapy (41% vs 13%) (for each comparison, P<.001). Pediatricians were more likely to report recording in the medical record smoking by a parent as a problem for the child (65% vs 48%; P<.001), but a higher proportion of pediatricians perceived that parents would ignore the advice (39% vs 24%; P<.001) and lacked interest in quitting smoking (45% vs 27%; P<.001). Pediatricians were more likely to agree that they lacked smoking cessation counseling skills (26% vs 7%; P<.001). Multivariate models showed that pediatricians were less likely to report performing 5 of 14 smoking cessation techniques in at least 50% of smoking parents. CONCLUSIONS: Pediatricians appear to lack training to implement smoking cessation counseling with smoking parents. Physicians in private practice are less likely to counsel smoking parents. Educational interventions for pediatricians are needed to decrease secondhand smoke exposure for young children.

Irradiation of the cervix uteri: value of unenhanced and contrast-enhanced MR imaging.

PURPOSE: To analyze the value of magnetic resonance (MR) imaging after radiation therapy for cancer of the cervix. MATERIALS AND METHODS: Eighty-nine MR images were retrospectively studied in 69 patients aged 46.3 years +/- 11.5. MR findings of tumor recurrence and irradiation changes were correlated with time after radiation therapy; paracentral radiation dose (dose to point A); and in patients with pretreatment images, primary tumor size and stage. RESULTS: Overall accuracy of MR in diagnosis of tumor recurrence was 78% (positive predictive value, 65%; negative predictive value, 97%). In MR examinations less than 6 months after the beginning of radiation therapy, accuracy (69%) and specificity (46%) were significantly lower than in examinations more than 6 months later (88%, P = .0032; 81%, P = .0166, respectively). Comparison of pre- and posttreatment MR findings and knowledge of stage or initial tumor size did not affect MR results. CONCLUSION: Overall, diagnosis was best with unenhanced T2-weighted images, but in patients with adnexal or pelvic sidewall recurrence and in patients with treatment complications (eg, fistula formation), contrast enhancement did help.

Carcinoma of the cervix: predictive value of clinical and magnetic resonance (MR) imaging assessment of prognostic factors.

PURPOSE: This retrospective study assesses the predictive value of magnetic resonance imaging (MRI) to identify high risk cervical cancer patients. METHODS AND MATERIALS: The MRI evaluation of morphologic risk factors in patients with invasive cervical carcinoma treated with definitive radiation therapy were correlated with clinical factors and with complete tumor regression (CTR) at 6 months, tumor local control (TLC), and patient outcome at 12 months after irradiation. Sixty-six patients, median age 44.5 years, with bulky Stage I or greater disease were included in the study. RESULTS: In univariate analysis, clinical International Federation of Gynecology and Obstetrics (FIGO) stage had significant correlation with patient outcome, but it correlated poorly with complete tumor regression and tumor local control. In contrast, MRI stage showed significant correlation with complete tumor regression, tumor local control, and disease-free survival at 12 months. When each stage was analyzed separately, the greatest difference was demonstrated between clinical and MRI assignment of stage Ib disease. MRI Stage Ib disease significantly correlated with all three categories analyzed, while clinical Stage Ib did not. Superiority of MRI assessment of low stage disease was also evident in the detection of lymph node metastasis. Significant risk for nodal metastasis was related to tumor size greater than 4 cm, invasion of the parametria and urinary bladder, and stage of the disease. CONCLUSION: The multivariate analysis demonstrated that the most related variables in order of significance were the presence of juxta-regional and paraaortic lymph nodes, patient age, tumor size, and MRI tumor stage. This study demonstrates the value of MR imaging as an adjunct to clinical assessment of bulky invasive cervical cancer, rendering more complete assessment of morphologic risk factors important in patient prognosis.

Neuroendocrine responses to hypertonic saline/dextran resuscitation following hemorrhage.

The neuroendocrine responses to resuscitation with 7.5% hypertonic saline/6% Dextran-70 (HSD) following hemorrhagic hypotension were evaluated in conscious swine. Following hemorrhage (37.5 ml/kg/60 min) animals received 4 ml/kg of HSD (n = 6) or 0.9% saline (n = 8). Administration of normal saline did not alter cardiovascular function nor attenuate an increase in hormones. HSD rapidly improved cardiovascular function and acutely decreased ACTH, plasma renin activity (PRA), cortisol, norepinephrine (NE), epinephrine (E), aldosterone, and lysine vasopressin levels (LVP). The initial decreased in ACTH, cortisol, and aldosterone levels was due primarily to hemodilution associated with the expansion of plasma volume. The reductions in NE, E, LVP, and PRA were greater than those attributed to hemodilution alone. Values for LVP, NE, and E remained at values below those at the end of hemorrhage, but greater than basal levels, while PRA returned to values similar to these at the end of hemorrhage. The decrease in LVP, NE, and E following HSD resuscitation for the treatment of hemorrhagic hypotension may result from and contribute to the rectification of cardiovascular and metabolic function.

Resuscitation of conscious pigs following hemorrhage: comparative efficacy of small-volume resuscitation.

Efficacy of small-volume resuscitation (4 ml/kg) with 7.5% NaCl in 6% Dextran 70 (HSD), 7.5% NaCl (HS), dextran (D), and 0.9% NaCl (NS) was evaluated in conscious swine bled 37.5 ml/kg over 60 min. Hemorrhage reduced cardiac index (CI), stroke volume (SV), and mean arterial pressure (MAP). Four-hour survival after HSD (67%) was significantly (P less than 0.05) greater than after HS (25%), D (17%), or NS (0%). The superior performance of HSD, and to a lesser extent HS, was associated with rapid plasma volume expansion, improved CI and SV, and decreased heart rate. The acute increases in cardiac index and stroke volume were greater following treatment with HSD and the improvement persisted for 4 hr. HSD also produced a transient increase in MAP. Plasma Na+ concentration and osmolality were increased to a similar extent with HSD and HS, while plasma K+ levels were initially decreased, returning to control levels within 60 min. HSD appears to be a superior small-volume resuscitation solution compared to the other treatments with no detrimental effects.

Predictors of excessive blood use after coronary artery bypass grafting. A multivariate analysis.

One hundred fifty-nine consecutive patients who underwent coronary artery bypass grafting were studied to determine clinical and laboratory predictors of excessive postoperative packed red blood cell transfusion. Consideration of the distribution of packed red blood cells administered revealed that the patients could be divided into two groups: those patients who received 5 units of red blood cells or less (group I, n = 139) and those patients who received more than 5 units of packed red blood cells (group II, n = 20). The Mann-Whitney test or Fisher's exact test was used whenever appropriate to test differences between these two groups with respect to twelve patient variables. Patients in group II were found to have a significantly longer preoperative template bleeding time and decreased preoperative packed red blood cell volume (p less than 0.0008 for both variables). In addition, group II patients were significantly older (p = 0.026), were more likely to have had preoperative heparin therapy (p = 0.049), and contained a greater proportion of women (p = 0.0048). Of interest, variables that did not achieve statistical significance between groups were partial thromboplastin time, prothrombin time, platelet count, preoperative hematocrit level, urgency of operation, recent ingestion of aspirin, and recent heparin administration. All of the measured variables were used in a stepwise logistic regression analysis to identify the best predictors of the need for more than 5 units of packed red blood cells after operation. Of the variables examined, bleeding time (p less than 0.001; chi 2 improvement = 15.1) and red blood cell volume (p = 0.009; chi 2 improvement = 6.8) were the best predictors of excessive postoperative packed red blood cell use. On the basis of a 50% logistic probability level, the specificity and sensitivity of these two variables in predicting greater than a 5-unit transfusion requirement were 85% and 99%, respectively. A clinically useful nomogram based on this logistic model is presented. This nomogram suggests that a ratio of bleeding time to red blood cell volume of 0.0071 or greater is associated with a greater than 70% chance of requiring more than 5 units of packed red blood cells. We conclude that preoperative bleeding time and red blood cell volume are useful predictors of excessive postoperative blood transfusion. These results suggest that factors other than aspirin therapy may be associated with bleeding time prolongation leading to excessive postoperative transfusion.

Blood lactate as a prognosticator of survival following hemorrhage in conscious swine.

Arterial blood lactate concentration at the end of fixed volume hemorrhage was evaluated as a predictor of survival in unmedicated chronically instrumented immature swine. Compared to basal values, 8.4 +/- 4.5 mg/dl (means +/- SD, n = 52), hemorrhaged animals (n = 71) with a lactate of 43.9 +/- 37.1 mg/dl lived while animals (n = 65) with a lactate of 106.5 +/- 40.4 mg/dl died. Lactate concentration at the end of hemorrhage successfully predicted survival (81.0%). Prospective evaluation, using a blood lactate concentration of 125 mg/dl (n = 27), showed a predictive success of 81.0%. Arterial plasma lactate concentration at the end of hemorrhage thus may be used to predict survival in the conscious swine.

An in vivo comparison of CPD and CPDA-2 preserved platelet concentrates after an 8-hour preprocess hold of whole blood.

To see if citrate-phosphate-dextrose-adenine-two (CPDA-2) anticoagulant-preservative had an effect on the viability of platelets, we studied autologous in vivo recovery and survival in humans for platelet concentrates prepared from six units of blood drawn into CPDA-2 and compared them to six units drawn into citrate-phosphate-dextrose (CPD). These units were prepared from whole blood held at room temperature for 8 hours after collection and were then stored for 3 days at 22 +/- 2 degrees C. The recovery for platelets preserved in CPD was 39.0 +/0 4.8 percent and for platelets preserved in CPDA-2, 32.5 +/- 4.4 percent. The difference was not significant (p greater than 0.10). In order to estimate population differences, in vitro effects on in vivo viability were also evaluated. Six in vitro variables were studied but only pH at 72 hours (r = 0.77), platelet count (r = 0.64), and morphology score (r = 0.66) correlated to recovery. Only pH at 72 hours significantly influenced recovery (p = 0.007). By adjusting for individual pH differences, mean recovery for platelets stored in CPD was 37.5 percent, and for platelets stored in CPDA-2, 34.0 percent. The mean lifespan was 6.7 +/- 0.7 days for platelets preserved in CPD and 6.1 +/- 1.0 days for those preserved in CPDA-2. Although hemostatic function was not studied, these data support in vitro observations that platelets preserved with CPDA-2 are not different from platelets preserved with CPD, even after 8-hours of storage of whole blood at room temperature prior to platelet concentrate preparation.

Exercise effects on the strength of the rat anterior cruciate ligament.

Seventy-five rats were divided into a control and four exercise groups of differing frequency and duration. After 8 weeks of endurance-type exercise on a motorized treadmill, the rats were sacrificed and the anterior cruciate ligaments were tested to failure on an Instron materials testing machine at a strain rate of 95% sec-1. Of the 121 ligaments tested, 119 failed by pure interstitial failure. There was significant increase in both the strength and stiffness of the anterior cruciate ligaments in the exercised rats but those rats exercised more frequently (daily vs. every other day) and for shorter duration (30 min rather than 60 min) had the greatest increase in strength. This study has shown that endurance-type exercise is beneficial to the anterior cruciate ligament as both strength and stiffness are increased and functionally the ligament remains unchanged by exercise.