Should specialized oncogeriatric surgeons operate older unfit cancer patients?

This rapidly expanding cancer patient group benefits of specialist care. The use of frailty assessment tools is mandatory in clinical practice and in medical reporting. A fair risk-benefits balance should be kept in mind at all times; patients' requests and expectations should be prioritised. Aggressive surgical treatment should not be neglected in principle, but alterative management should be considered at all times.

Increased prevalence of otitis media following respiratory syncytial virus infection.

AIM: The aim of this study was to analyse whether, during the 18 months following a respiratory syncytial virus (RSV) infection in infants, there were differences in the prevalence of common infections such as acute otitis media (AOM), compared with controls. We also wanted to see whether passive smoking could be a contributory factor. METHODS: In a longitudinal study, 33 children who attended the emergency room with an RSV infection (age < or = 7 months) were compared with 37 age-matched controls recruited from routine infant check-ups. The 18-month follow-up consisted of a questionnaire focusing on environmental factors and the child's health during the last 12 months. An allergy skin prick test (SPT) was performed and venous blood was obtained. RESULTS: The prevalence of AOM and the use of antibiotics were higher in the RSV group than in the controls (p = 0.009 and p = 0.027 respectively). The number of AOMs and the use of antibiotics correlated, r = 0.8. In the RSV group, one or both parents smoked in 52% compared with 14% in the controls (p < 0.001). There were no differences in allergy SPT results. CONCLUSION: The infants with RSV infection had AOM and were prescribed antibiotics more frequently during the follow-up period. Furthermore, smoking was far more common among the parents of the RSV group. We speculate that passive smoking could be a contributory factor to the infections noted here.

Transtheoretical model: investigation of adolescents' sunbathing behaviour.

The incidence of malignant melanoma and non-melanoma skin cancers has increased rapidly in Sweden as well as in other western countries during the last 20 years. Adolescents are an important group in skin cancer prevention. Interventions targeting this group have been reported to affect knowledge and attitudes, but the effect on sun protection behaviour has been slight. The aim of this study was to investigate the applicability of the Transtheoretical Model (TTM) for skin cancer prevention for adolescents. A random sample of 1200 18-year-olds living in Stockholm County was selected from the national census registry. A questionnaire that included three of the major constructs of the TTM (i.e. stages of change, processes of change and decisional balance) was sent by mail. The majority of the teenagers were in the precontemplation stage for giving up intentional tanning. The relations between the stages of change and two other major constructs of the TTM, processes of change and decisional balance, were consistent with data on other health behaviours. The results may aid in developing successful skin cancer prevention programmes. The results give support for the stages of change measurement used in this study and that utilizing the TTM in skin cancer prevention may be appropriate.

'You and your skin': a short-duration presentation of skin cancer prevention for teenagers.

The effectiveness of a short-duration presentation of the educational material 'You and Your Skin' was tested on 184 adolescents (age 13-15) at the Year 7 and 8 levels. A non-equivalent control group design was used with pre-testing and post-testing 3 months after the intervention. The intervention increased the students' knowledge of known risks factors for skin cancers. However, the students' attitudes to abstaining from sunbathing and tanning was not significantly affected. The effect of the intervention on the stage of change was primarily a progression from the precontemplation stage to the contemplation stage regarding avoiding the mid-day sun. We conclude that a brief presentation of the educational kit 'You and Your Skin' can be used to increase knowledge, but there is a need for a more extensive intervention effort to affect students' readiness to change their behavior and attitude towards sunbathing and tanning. Therefore, it is important to emphasize the necessity of using the educational kit as a multi-lesson programme with its several group exercises.

Stability of questionnaire items measuring behaviours, attitudes and stages of change related to sun exposure.

The use of questionnaires in epidemiological studies needs more methodological research. The time and effort spent on questionnaire design is often limited. Studies on the construction of questionnaires could lead to a higher quality of data, enhanced comparability and improved credibility of epidemiological findings. The aim of the present study was to examine the test-retest reliability of some common items measuring sun-related variables. A sample of 52 female Swedish nurses attending a postgraduate course in research methodology was chosen. They completed a questionnaire on two occasions spaced 3 weeks apart in the winter of 2000. When the results were analysed, items on sun-related behaviours and sunbed use were sufficiently reliable. The items on skin type and sunburn showed moderate stability. Stage of change related to sunlight exposure, items measuring beliefs about sunbathing along with items assessing self-efficacy and risk perception with regards to sunbathing showed lower stability. The results showed that many essential items concerning exposure to ultraviolet radiation and sunburns were sufficiently stable, but other items were less stable and could be improved upon; suggestions for improving these items are presented. The study illustrates the value of reliability testing in the process of item construction. Using methodological studies to improve the reliability and validity of data is an important step toward higher standards for questionnaire surveys.

Tanning habits and sunburn in a Swedish population age 13-50 years.

As part of a skin cancer control programme, we studied the occurrence of self-reported outdoor tanning, sunbed use and ultraviolet (UV)-induced erythema in an urban area. A cross-sectional questionnaire study of 6000 adolescents aged 13-19 years, and 4000 adults aged 20-50 years was applied. Non-response was analysed for outdoor tanning and sunbed use. Results, in general, did not differ between responders and non-responders. Females aged 17-29 years tanned outdoors most frequently. Sunbed use and related erythema was twice as common in young females. In males, outdoor tanning was not age-related. In the past 12 months, 55% reported sunburn and/or burn from sunbed use, one-third were burned in Sweden, one-quarter on sunny resorts abroad. Sunburn occurs frequently. Compliance with recommendations for sunbed use is poor, especially among adolescents and young adults. To reduce the occurrence of erythema, the influence of risk settings upon behaviours is a critical issue for exploration.

Readiness to change sun-protective behaviour.

The incidence of malignant melanoma and non-melanoma skin cancers has increased rapidly in Sweden during the last 20 years. The best-known way to revert this trend is primary prevention. Matching health messages to readiness to change in the population may enhance the effect of community-based prevention. The aims of this study were to investigate readiness to change sun-protective behaviour in two groups (visitors to mobile screening units and beach-goers) and to test a single-item algorithm in assessing the stage of change in sun-protective behaviour. Seven hundred and forty-two visitors to the mobile screening units and 202 individuals on nearby beaches answered a short questionnaire. The assessment of readiness to change was based on stages of change in sun-protective behaviour modified from the Transtheoretical Model of Behaviour Change. As expected, the visitors to the screening units were more often in action/maintenance stages than the beach group for most sun-protective behaviours. In conclusion, the single-item algorithm method appears to be sensitive to assess readiness to change sun-protective behaviour, based on the Transtheoretical Model of Behaviour Change. This method can be incorporated into population surveys and may aid in developing successful skin cancer prevention programmes.

Analysis of 76Br-BrdU in DNA of brain tumors after a PET study does not support its use as a proliferation marker.

76Br-bromodeoxyuridine has previously been suggested as a PET tracer to characterize proliferation potential. However, in animal studies a large fraction of the tissue radioactivity is due to 76Br-bromide, which remains extracellular for extensive periods and contributes significantly to the level of radioactivity. The present project aimed at investigating whether in human brain tumors, sufficient amounts of 76Br-bromodeoxyuridine would be incorporated into DNA, to motivate further attempts with this tracer. Eight patients with brain tumors: 3 meningiomas, 2 astrocytoma grade IV, 1 astrocytoma oligodendroglioma grade II-IV and 2 metastases, were examined with PET and 76Br-BrdU on three occasions: immediately after injection of the tracer, at 4-6, and at 18-20 hours after administration. After the first PET study, diuresis was introduced and maintained for about 12 hours. About 20 hours after tracer administration, 200 mg/m(2) bromodeoxyuridine was administered to 7 patients median 5.8 (range 1-22) hours prior to operation allowing the immunohistochemical analysis of the proliferation potential. During the operation, tumor samples were taken and radioactivity in DNA extracted and measured. The uptake of radioactivity was higher in the tumors than in brain parenchyma. However, in the operative samples only 1-27% (average: 9%) of the radioactivity was found in the DNA fraction. The plasma radioactivity remained high throughout the study with only minimal signs of elimination by the diuresis. 76Br-BrdU is extensively metabolized to 76Br-bromide, and only a minor fraction of the radioactivity is found in the DNA fraction, making it unlikely that this tracer can be used for assessment of proliferation potential.

Relationship between respiratory syncytial virus bronchiolitis and future obstructive airway diseases.

Evidence from a large number of prospective case-control studies shows that respiratory syncytial virus (RSV) bronchiolitis in infancy is often associated with recurrent wheezing and asthma during subsequent years. However, wheezing tends to diminish and most studies show no significant increase in wheezing compared to controls by school age or adolescence. An unresolved question is whether severe RSV infection during infancy causes the respiratory sequelae or inherent abnormalities predispose an infant to develop severe respiratory infection and sequelae, i.e. RSV is associated with the development of pulmonary sequelae. Studies on long-term outcome of RSV bronchiolitis are reviewed from an evidence-based perspective. The majority of prospective placebo-controlled studies do not show any long-term beneficial effects of corticosteroid treatment, i.e. the risk of subsequent wheezing is not diminished by the treatment. The evidence for an increased risk of allergic sensitization after RSV bronchiolitis is not nearly as strong as the evidence for an increased risk of subsequent wheezing. In fact, most studies do not show any significant increase in atopy after RSV bronchiolitis. This suggests that the increased risk of wheezing after RSV is not linked to an increased risk of atopy. There are some indications that infants who develop severe RSV and subsequent wheezing may have aberrations that predate the RSV infection. To decide whether respiratory syncytial virus bronchiolitis causes, or is associated with the respiratory sequelae (or with subsequent allergy), it will be necessary to conduct prospective, randomized studies, where the cytokine profile prior to bronchiolitis onset is known. Such studies should preferably include some form of intervention against respiratory syncytial virus. A more complete understanding of the risk factors for severe respiratory syncytial virus infection and the role of respiratory syncytial virus infection in the initiation of asthma is needed as a basis for large-scale and cost-effective programmes to prevent respiratory syncytial virus-related morbidity.

Observation of stable cylindrical modes in electrically pumped circular grating-coupled surface-emitting lasers.

We present the results of a comprehensive experimental study of the modal behavior of electrically pumped circular grating-coupled surface-emitting lasers with resonant second-order gratings. Our results show stable cylindrical mode operation with azimuthal orders m = 1 and m = 52. We have found that, when a passive, unpumped 0.7-microm-deep indentation is included at the center of the circular resonator contact, the modal behavior becomes more stable with respect to increasing current. This result manifests itself in the lasing of two orthogonal m = 1 modes along with one higher-order mode from threshold to 2.2 times threshold or more. The spatial coherence of the cylindrical modes over the area of the resonator leads to better beam quality. Lasers without passive central indentations exhibit mode hopping between quasi-linear modes and higher-order cylindrical modes as the current is increased.

Inflammatory markers in childhood asthma.

The importance of airway inflammation in the pathogenesis of asthma is clearly established. Studies in adults as well as in children have led to the concept that asthma is a chronic inflammatory disease. Airway inflammation is found even in mild asthma. Bronchoconstriction and hyper-reactivity appear to be secondary to the release of inflammatory mediators. The changed view of the pathogenesis of asthma and current emphasis on anti-inflammatory treatment have raised a need for markers that reflect the inflammatory status in the airways. This is of special importance in paediatric practice because lung function tests are less easily performed in young children, and it is preferable to keep steroid doses as low as possible. The eosinophil granulocyte has a multitude of proinflammatory functions and plays a key role in the asthmatic inflammation. It secretes toxic proteins and produces cytokines, which have important roles in airway inflammation. Use of eosinophil granula proteins to monitor inflammation is now finding its place. Measurement of eosinophil cationic protein (ECP) seems to be a valuable complement to the recording of lung function. For paediatric use, measurement of urinary eosinophil protein X (EPX) is promising because it does not require blood sampling.

Urinary eosinophil protein X in children with atopic asthma: a useful marker of antiinflammatory treatment.

BACKGROUND: Bronchial asthma is associated with elevated serum levels of eosinophil products, such as eosinophil protein X (EPX), but the occurrence in urine of this substance in patients with asthma has not previously been studied. OBJECTIVE: This study was performed to clarify whether increased amounts of eosinophil granulocyte proteins in urine and serum reflect ongoing asthmatic inflammation and whether decreasing values reflect successful treatment. METHODS: Twelve children with a median age of 12.5 years who had mild or moderate atopic asthma were studied for 3 months. At the time of inclusion in the study, treatment with inhaled budesonide was initiated. Nine children of the same age without atopic disease served as control subjects. Levels of EPX, eosinophil cationic protein (ECP), and myeloperoxidase in serum and in urine (urinary EPX) were determined at inclusion and then after 3 months of treatment. Spirometry was performed on the same occasions. RESULTS: At the time of inclusion, urinary EPX and serum ECP were significantly higher in children with atopic asthma than in the control subjects (mean, 116.4 vs 43.0 micrograms/mmol creatinine [p = 0.004] and 37.0 vs 14.8 micrograms/L [p = 0.004]). In the asthma group urinary EPX, as well as serum ECP, decreased significantly after 3 months of treatment with budesonide (116.4 to 68.4 micrograms/mmol creatinine [p = 0.005] and 37.0 to 24.0 micrograms/L [p = 0.04]). At the same time, peak expiratory flow values increased significantly in the children with asthma (76.0% to 87.8% of predicted value [p = 0.005]) but not in the control subjects (87.0% to 90.1%). In the asthma group the levels of myeloperoxidase were similar to those in the control group, both at inclusion and after 3 months. CONCLUSION: Increased urinary EPX and serum ECP levels seem to reflect active atopic asthma, whereas decreased levels after antiinflammatory treatment probably reflect normalization of airway inflammation, and indirectly, improved lung function.

Decrease in hospitalization for treatment of childhood asthma with increased use of antiinflammatory treatment, despite an increase in prevalence of asthma.

BACKGROUND: During the past 15 years, the prevalence of asthma in children in Sweden has doubled. However, since 1985, antiinflammatory treatment with inhaled steroids has increased continuously. OBJECTIVE: The aim of this study was to analyze the net effect of these changes in terms of hospitalization of children for treatment of asthma. METHODS: The numbers of hospital days, admissions, and individual patients admitted to the Children's Hospital in Göteborg because of acute asthma were recorded from 1985 through 1993. all the in-patient treatment of children is centralized at this hospital (i.e., the study was population-based). Göteborg has half a million inhabitants. Hospitalization policies were not altered during the study period. RESULTS: In children aged 2 to 18 years, the number of hospital days per year gradually decreased to less than a third (r = 0.9; p less than 0.001), and admissions decreased by 45% (r = 0.7; p less than 0.05). The decrease in hospitalization was most marked in the group older than the age of 5 years in which hospital days were reduced to one fifth (r = 0.9; p less than 0.0001) and admissions were halved (r = 0.8; p less than 0.05). A decreasing trend in number of hospital days was also seen in the 2- to 5-year-old group. The number of individual patients admitted did not show a statistically significant decreasing trend. In children under the age of 2 years, the number of hospital days fluctuated, and there was no clear-cut change with time. CONCLUSION: Although increased concentration on the education of parents and patients may have been a contributing factor, the major reason for the decrease in hospitalization in the group of children aged 2 to 18 years is most probably antiinflammatory treatment with inhaled steroids. The results suggest that this is a very cost-effective therapeutic approach.

Electrical muscle stimulation on the spine. Three-dimensional effects in rabbits.

We investigated the 3-dimensional effect of electrostimulation of the latissimus dorsi, the erector spinae and the intercostal muscles on spinal configuration in 16 New Zealand white rabbits. Electrostimulation on the right side of the spine resulted in a left convex, hypokyphotic curve and vertebral body rotation towards the convexity of the curve in all rabbits. The Cobb angle in the coronal plane increased with stimulation of each of the muscles examined. The kyphosis decreased with stimulation of the latissimus dorsi and the erector spinae. The vertebral rotation increased with stimulation of all muscles. Stimulation of the tested muscles resulted in the simultaneous occurrence of a 3-dimensional spinal deformity with the characteristics of idiopathic scoliosis.

Creatine supplementation in chronic heart failure increases skeletal muscle creatine phosphate and muscle performance.

BACKGROUND: Cardiac creatine levels are depressed in chronic heart failure. Oral supplementation of creatine to healthy volunteers has been shown to increase physical performance. AIM: To evaluate the effects of creatine supplementation on ejection fraction, symptom-limited physical endurance and skeletal muscle strength in patients with chronic heart failure. METHODS: With a double-blind, placebo-controlled design 17 patients (age 43-70 years, ejection fraction < 40) were supplemented with creatine 20 g daily for 10 days. Before and on the last day of supplementation ejection fraction was determined by radionuclide angiography as was symptom-limited 1-legged knee extensor and 2-legged exercise performance on the cycle ergometer. Muscle strength as unilateral concentric knee extensor performance (peak torque, Nm at 180 degrees/s) was also evaluated. Skeletal muscle biopsies were taken for the determination of energy-rich phosphagens. RESULTS: Ejection fraction at rest and at work did not change. Performance before creatine supplementation did not differ between placebo and creatine groups. While no change was seen in the placebo group compared to baseline, creatine supplementation increased skeletal muscle total creatine and creatine phosphate by 17 +/- 4% (P < 0.05) and 12 +/- 4% (P < 0.05), respectively. Increments were seen only in patients with < 140 mmol total creatine/kg d.w. (P < 0.05). One-legged performance (21%, P < 0.05), 2-legged performance (10%, P < 0.05), and peak torque, Nm (5%, P < 0.05) increased. Both peak torque and 1-legged performance increased linearly with increased skeletal muscle phosphocreatine (P < 0.05). The increments in 1-legged, 2-legged and peak torque were significant compared to the placebo group, (P < 0.05). CONCLUSIONS: One week of creatine supplementation to patients with chronic heart failure did not increase ejection fraction but increased skeletal muscle energy-rich phosphagens and performance as regards both strength and endurance. This new therapeutic approach merits further attention.

Leukotriene B4 and C4 generation by human leukocytes after ex vivo stimulation with Ca-ionophore and opsonized zymosan in children with atopic asthma.

The ex vivo release of leukotriene B4 (LTB4) and leukotriene C4 (LTC4) from leukocytes was evaluated after stimulation with both Ca-ionophore (Ca-I) and opsonized zymosan (OZ) in children with atopic asthma. Twenty-seven patients with asthma of varying severity were evaluated and divided into three groups: 1) moderate to severe asthma using inhaled steroids and symptom-free for the last 3 weeks (n = 8), 2) mild asthma with sporadic symptoms, only using inhaled beta 2-agonists < 3 times/week (n = 8), and 3) acute asthmatic attacks admitted to hospital (n = 11). A group of children without atopic disease or any other known disease served as controls (n = 15). Total serum IgE levels were significantly increased in the children with asthma compared with the control group. LTC4 production was only significantly increased in the group of children with moderate to severe asthma after stimulation with Ca-I, when compared with controls. In the same group, a trend towards increased LTC4 production after stimulation with OZ was found. LTB4 was not significantly increased in any patient group compared with the control group. A significant correlation between LTC4 production after stimulation with Ca-I, but not OZ, and the relative blood eosinophil count was found in all subjects. LTC4 generation per eosinophilic cell after stimulation with Ca-I or OZ was not statistically different in any patient group compared with the controls. We conclude that the increased leukotriene (LT) levels found after the stimulation of peripheral white blood cells sampled from atopic children with asthma are mainly the result of increased numbers of LT-producing cells, rather than due to increased releasability from these cells.

Horizontal plane morphometry of normal and scoliotic vertebrae. A methodological study.

Computed tomography (CT) scans are widely used for quantification of the morphology of the vertebral body and of the changes of the thoracic cage in the horizontal plane in scoliosis. So far, however, no method exists for precise quantification of the parameters of the posterior elements. We present a method for quantification on the basis of CT scans of different parameters of the morphology of both the vertebral body and posterior elements in the horizontal plane. The precision and accuracy of the method were estimated in a model study by CT scanning of a normal and a scoliotic vertebra in different, controlled, tilted positions. Moreover, in a clinical study CT scans of 19 thoracic vertebrae from non-scoliotic subjects and the apex vertebra from 40 scoliotic subjects were selected to test the applicability of the method to clinical studies. The intra- and interobserver variation of the measurements was analysed. The angle between the longitudinal axis of the vertebral body and that of the whole vertebra was used to evaluate the asymmetry of the vertebral body. The right to left pedicle width index, the right to left hemi-canal width index and the index of transverse process angles related to the axis of the vertebra were used to quantify the asymmetry of the posterior elements. The results indicate that, except for the pedicle width index, the variables under study were not significantly influenced by a 5 degrees or 10 degrees tilt ventrally, dorsally, or laterally of either the normal or the scoliotic vertebra. Hence, the method can be satisfactorily applied to longitudinal group comparisons.(ABSTRACT TRUNCATED AT 250 WORDS)

Inhalation of racemic adrenaline in the treatment of mild and moderately severe croup. Clinical symptom score and oxygen saturation measurements for evaluation of treatment effects.

The aim of this study was to evaluate the immediate effect of inhaling racemic adrenaline to treat croup and to evaluate a scoring system. Two groups were investigated. One group inhaled a racemic adrenaline solution and the other group received the same solution with no racemic adrenaline. The study was double-blinded and placebo-controlled. Fifty-four children (0.4-10.8 years) with mild to moderately severe croup were included in the study after clinical evaluation. The clinical score was useful when evaluating the treatment effects in mild to moderately severe croup and may be used as a quality assurance tool when treatment protocols are re-evaluated. Oxygen saturation before and after treatment did not change significantly in either group and therefore its measurement did not provide additional information on the effect of treatment. In both groups, a significant improvement in total mean clinical scores was seen 30 min after inhalation, compared with before inhalation (p < 0.001). However, racemic adrenaline was significantly better than placebo in terms of improvement in total clinical score, inspiratory stridor, retractions and air entry, and should therefore be used as first-line treatment.

Eosinophil cationic protein, myeloperoxidase and tryptase in children with asthma and atopic dermatitis.

Serum levels of eosinophil cationic protein (ECP), myeloperoxidase (MPO), tryptase, total IgE and differential blood cell counts were studied in atopic children with: 1) moderate to severe asthma using inhaled steroids and symptom-free for the last 3 weeks (n = 13), 2) mild asthma with sporadic symptoms, using only inhaled beta 2-agonists < 3 times/week (n = 15), 3) acute asthmatic attacks admitted to hospital (n = 12), 4) mild to moderate atopic dermatitis (n = 14). Fifteen children without any history of atopy served as controls. ECP, MPO, tryptase and IgE were measured in serum by radioimmunoassays (RIA). The symptom-free children with inhaled steroids had similar median ECP and MPO values as the controls, 8.0 and 360 micrograms/l, vs. 9.0 and 310 micrograms/l, while both ECP and MPO were significantly (p < 0.001) increased in the symptom-free children without anti-inflammatory treatment, 32 and 887 micrograms/l and in those with acute asthma, 28 and 860 micrograms/l. The children with atopic dermatitis had increased ECP but normal MPO levels, 16.0 and 455 micrograms/l. Tryptase in serum was not measurable in any patient. All groups except the control group had significantly elevated total IgE levels. The results indicate that in atopic children serum ECP is a good marker of ongoing asthma or atopic dermatitis. The normal levels of ECP and MPO in the children with asthma using inhaled steroids seem to reflect successful anti-inflammatory treatment. The increased levels of ECP and MPO in the children with mild asthma and no anti-inflammatory treatment may indirectly reflect airway inflammation.