Dynamic camouflage by Nassau groupers Epinephelus striatus on a Caribbean coral reef.

This field study describes the camouflage pattern repertoire, associated behaviours and speed of pattern change of Nassau groupers Epinephelus striatus at Little Cayman Island, British West Indies. Three basic camouflaged body patterns were observed under natural conditions and characterized quantitatively. The mean speed of pattern change across the entire body was 4.44 s (range = 0.97-9.87 s); the fastest pattern change as well as contrast change within a fixed pattern occurred within 1 s. Aside from apparent defensive camouflage, E. striatus used camouflage offensively to approach crustacean or fish prey, and three successful predation events were recorded. Although animal camouflage is a widespread tactic, dynamic camouflage is relatively uncommon and has been studied rarely in marine teleosts under natural conditions. The rapid changes observed in E. striatus suggest direct neural control of some skin colouration elements, and comparative studies of functional morphology and behaviour of colour change in other coral-reef teleosts are likely to reveal new mechanisms and adaptations of dynamic colouration.

Altered speech following adenoidectomy: a 20 year experience.

Altered speech related to velopharyngeal insufficiency is a rare but well-recognised complication of adenoidectomy. Over a 20 year period, 42 patients were referred to the Edinburgh cleft team for investigation of altered speech persisting for more than 12 months after adenoidectomy. We studied the cases to ascertain the incidence, clinical features and causes of altered speech in these patients and to assess the efficacy of a selective treatment policy. All data were prospectively collected when the patients were assessed in a multidisciplinary clinic and investigated by videofluoroscopy. Nasopharyngoscopy was also possible in half of the patients. Overall, 27 patients were male and 15 were female, and their mean age was 6.5 years. The incidence was one in 1200 adenoidectomies. Diagnoses included five submucous cleft palates, six occult submucous cleft palates, 22 cases of velopharyngeal disproportion, seven developmental or neurological causes, one iatrogenic palatal injury and one case that defied diagnosis. In six patients treatment was not required, 13 responded to speech therapy and 23 required surgical intervention. The choice of operation was based on the findings at investigation. Ten patients were treated by a superiorly based pharyngeal flap, 10 underwent a sphincteric pharyngoplasty and three had an intravelar veloplasty. Speech outcome was assessed in 36 cases. Treatment resulted in significantly improved speech in all but one patient and normal speech in 16 patients. Persistently altered speech is a rare complication of adenoidectomy. Preoperative screening by clinical examination will prevent some but not all of such problems. When patients present they should undergo multidisciplinary assessment and multi-modality investigation. A good outcome can be anticipated in most patients.

Measurement of twitch transdiaphragmatic, esophageal, and endotracheal tube pressure with bilateral anterolateral magnetic phrenic nerve stimulation in patients in the intensive care unit.

OBJECTIVE: In the critically ill, respiratory muscle strength usually has been assessed by measuring maximum inspiratory pressure. The maneuver is volitional, and results can be unreliable. The nonvolitional technique of bilateral anterolateral magnetic stimulation of the phrenic nerves, producing twitch transdiaphragmatic pressure, has been successful in normal subjects and ambulatory patients. In this study we used the technique in the intensive care unit and explored the measurement of twitch endotracheal tube pressure as a less invasive technique to assess diaphragmatic contractility. DESIGN: Clinical study to quantify diaphragm strength in the intensive care unit. SETTING: Patients from three London teaching hospital intensive care units and high-dependency units. PATIENTS: Forty-one intensive care patients were recruited. Of these, 33 (20 men, 13 women) were studied. INTERVENTIONS: Esophageal and gastric balloon catheters were passed through the anaesthetized nose, and an endotracheal tube occlusion device was placed in the ventilation circuit, next to the endotracheal tube. Two 43-mm magnetic coils were placed anteriorly on the patient's neck, and the phrenic nerves were stimulated magnetically. MEASUREMENTS AND MAIN RESULTS: On phrenic nerve stimulation, twitch gastric pressure, twitch esophageal pressure, twitch transdiaphragmatic pressure, and twitch endotracheal tube pressure were measured. Forty-one consecutive patients consented to take part in the study, and twitch pressure data were obtained in 33 of these. Mean transdiaphragmatic pressure was 10.7 cm H2O, mean twitch esophageal pressure was 6.7 cm H2O, and mean twitch endotracheal tube pressure was 6.7 cm H2O. The mean difference between twitch esophageal pressure and twitch endotracheal tube pressure was 0.02 cm H2O. Correlation of the means of twitch endotracheal tube pressure to twitch esophageal pressure was 0.93, and that for twitch endotracheal tube pressure to transdiaphragmatic pressure was 0.78. CONCLUSIONS: Transdiaphragmatic pressure can be measured in the critically ill to give a nonvolitional assessment of diaphragm contractility, but not all patients can be studied. At present, the relationship of twitch endotracheal tube pressure to transdiaphragmatic pressure is too variable to reliably represent a less invasive measure of diaphragm strength.

Adductor pollicis twitch tension assessed by magnetic stimulation of the ulnar nerve.

Many critically ill patients develop significant skeletal muscle weakness in the Intensive Care Unit (ICU), which ultimately may cause difficulties in weaning from mechanical ventilation and a protracted, expensive ICU stay. Reliable monitoring of muscle strength in this environment is difficult. The purpose of this study was to develop a reproducible, nonvolitional method of measuring adductor pollicis (AP) muscle function by magnetic stimulation of the ulnar nerve (MSUN) that could be applied to patients in the ICU and operating theater (OT). Fifty subjects (32 healthy control subjects [12 of whom were elderly], 12 ICU patients with critical illness [mean APACHE II score 20], and six otherwise healthy patients requiring minor surgery in the OT) received MSUN. In 12 of the normal subjects electrical stimulation of the ulnar nerve (ESUN) and MSUN were compared and AP twitch tension (Tw AP) and surface electromyogram (EMG) were measured. Close agreement was found between supramaximal Tw AP (median [95% CI] for MSUN 6.3 N [5-7.2 N] and ESUN 6.9 N [5.2-7.8 N] [p = NS]). Median (95% CI) values with MSUN for the 20 young and 12 elderly control subjects were 6.9 N (5. 3-7.4 N) and 7.1 N (4.4-9.8 N). Median (95% CI) Tw AP for the ICU group was 4.2 (2.2-6.7 N) and for the OT group was 5.8 (4-9.1 N). Tw AP was significantly reduced in ICU patients compared with age-matched controls (p = 0.01). MSUN can be used to measure neuromuscular function in both the laboratory and clinical settings including the ICU.

Anaesthetic management of patients undergoing lung volume reduction surgery for treatment of severe emphysema.

Lung volume reduction surgery can improve lung function in patients with emphysema. We report our anaesthetic experience, problems and the physiological data of eight patients. Our aims were prevention of air trapping and air leaks, good analgesia and early recovery and mobilization. We were able to achieve these aims using pressure limited ventilation, lumbar epidural diamorphine, propofol infusions and intensive physiotherapy. Hypoxia during one-lung ventilation was the main intraoperative problem. Air leaks, infection and pulmonary hypertension were the main postoperative problems.

Social interaction skills and theory of mind in young children.

Two studies explored relations between peer social skills and theory of mind in young children. In Study 1, a global teacher rating of social skills with peers, performance on a traditional false-belief task, a standardized assessment of auditory language comprehension, and a time sampling of amount of speech with peers were obtained. Positive, but moderate, zero-order correlations were observed between the false-belief measure and social skills, and false belief accounted for a significant amount of additional variance in social skills after covarying age and the 2 measures of language. Study 2 replicated the findings of Study 1 by using a larger sample and a standardized teacher questionnaire. The results are discussed with regard to the critical role of a mentalistic theory of behavior for human social interactions.

Silicone gel-filled breast implants and connective tissue diseases.

Recent worldwide press and media speculation that silicone implants may be linked to an increased incidence of breast cancer, other cancers, and connective tissue diseases-particularly systemic sclerosis-is a current cause for concern to the medical profession and public alike. We conducted a cross-sectional study of the prevalence of connective tissue diseases, as well as signs and symptoms associated with these conditions, in women who had received a silicone gel-filled breast implant for either breast augmentation or breast reconstruction following mastectomy for breast cancer compared with women without implants in South East Scotland. We compared 317 patients who had had a silicone gel-filled breast implant inserted with matched controls. We found no increased incidence of antinuclear antibodies or rheumatoid factor in the study groups. We detected one case of rheumatoid arthritis in the reconstruction group and one in matched controls, but no cases of any other connective tissue disease. No cases were found among the augmentation patients or their controls. No differences were found in symptoms or physical signs of connective tissue diseases between the study patients and their controls. This study has failed to find any case for a link between silicone gel-filled breast implants and connective tissue diseases.

Outcome analysis of a modified Tajima procedure.

Secondary nasal correction of cleft patients is acknowledged to be a difficult problem. There are many different operations but few objective assessments of their results. We have evaluated the results of a modified Tajima operation by use of the Bristol computer technique. Eighteen patients were followed up for a mean of 33 months (range 10-56). Measures of asymmetry were obtained for different photographic views, preoperatively and at later postoperative visits. In all views there was a significant improvement in shape in the early postoperative photos. This same improvement was also seen when comparing preoperative to late postoperative results i.e. this initial improvement is maintained over time. There was no significant difference between the early and late postoperative views. In this small series the modified Tajima technique has given statistically significant lasting improvement. However, few other operations have been objectively assessed and hence comparison is difficult. We advocate the use of the computer technique for other procedures to allow meaningful comparisons between them.

Patient satisfaction following insertion of silicone breast implants.

Because of allegations linking silicone implants with cancer and connective tissue diseases and mounting media coverage, women with silicone breast implants are extremely concerned, despite the lack of evidence showing a link between silicone gel-filled breast implants and connective tissue diseases or cancer. To assess whether or not this group of women were satisfied with their operations, we sent all women who had silicone breast implants inserted in the south-east of Scotland between 1982 and 1991 a quality of life questionnaire. One hundred and two breast augmentation and 212 breast reconstruction patients replied. Not everyone answered every question. The majority of women in our study, 84% (79/94) and 91.8% (192/209) of augmented and reconstructed patients, respectively, stated that they were satisfied with their operations, although only about half were very satisfied. Although 91.2% (270/296) of all the women were aware of the allegations with 29.7% (88/296) concerned, only 3% (9/296) of all the women felt that there was cause for concern. It would appear that, although most women with silicone breast implants are aware of the accusations regarding silicone and systemic illnesses, the adverse publicity has only given a small number of them a cause for concern and the majority are satisfied with the outcome of their operation and perceive the benefits to outweigh the risks.

The effect of sphincter pharyngoplasty on the range of velar movement.

The aim of this study was to assess the mobility of the soft palate following sphincter pharyngoplasty in patients with velopharyngeal incompetence of variable aetiology. Pre- and postoperative videotape recordings of lateral view videofluoroscopy of 24 patients were retrospectively studied and compared with regard to the range of velar movement. Tracings of the velopharyngeal port were made on acetate paper directly from the television monitor and absolute angle measurements were taken. Analysis of the results showed a highly significant increase in the range of palatal movement postoperatively. There was no evidence of correlation between the magnitude of the increase and the postoperative improvement in speech. The findings and their implications are discussed.

The detection of breast implant rupture using ultrasound.

Because little or no information exists about the life span of silicone implants, there is a need for a non-invasive and sensitive diagnostic tool for assessing their integrity. It is extremely difficult to diagnose rupture of these implants clinically. The aims of this study were to assess how many of our patients--in particular asymptomatic women--had ruptured implants and whether or not ultrasound was an effective tool in excluding rupture and reassuring anxious patients. All patients in the south east of Scotland who had a silicone gel-filled breast implant inserted between the years 1982-1991 were invited to take part in an investigation into morbidity due to silicone implants. We screened 307 asymptomatic patients with 385 implants and only found one patient with a ruptured silicone implant. One other patient had a ruptured saline implant and one implant was found to have leaked. We found ultrasound to be a quick, reliable, cheap and safe method of screening for implant rupture which can be used to reassure an anxious patient that her implants are intact.

Cutaneous malignant melanoma. Publicity, screening clinics and survival--the Edinburgh experience 1982-90.

The incidence of cutaneous malignant melanoma has increased considerably in south-east Scotland over recent years. In 1987 the Cancer Research Campaign launched a project to aid the early detection, diagnosis and treatment of malignant melanoma. Edinburgh, chosen as one of seven centres in the U.K. to participate in the study, was provided with funding for a direct access pigmented lesion clinic from 1987 to 1989. The changes in the pattern of cutaneous malignant melanoma before, during and after the publicity campaign have been examined; between 1982 and 1990. The incidence of malignant melanoma doubled from 5.7 to 11.4/100,000 per annum. The percentage of thin tumours (Breslow thickness < or = 1.5 mm) increased steadily and significantly (from 43% in 1982 to 68% in 1990), but the number of thick tumours (Breslow thickness > 3.0 mm) remained constant over the same period (22 +/- 3.8). The influence of publicity was assessed using a questionnaire. Those who were influenced by publicity were significantly younger and had more thin tumours (Breslow < or = 1.5 mm) than those who were uninfluenced by publicity. Five-year survival has significantly increased from 70% in the 1982-84 cohort to 84% in the 1987-89 cohort. The effect of the publicity campaign has been beneficial, but the impact on mortality cannot yet be assessed.

Declining incidence of paediatric burns in Scotland: a review of 1114 children with burns treated as inpatients and outpatients in a regional centre.

This retrospective study of paediatric burns in the Lothian region involved a review of 1114 case notes of children up to the age of 12 years, treated for burns as inpatients and outpatients, during a 3-year period between 1988 and 1990. There were more boys than girls and 79 per cent were below 5 years of age. 71.5 per cent were treated as outpatients only, whereas 28.5 per cent were admitted. The Lothian region had the highest incidence of burns of children in Scotland. There has been a statistically significant downward linear trend in burn rates and admissions in Scotland during the 20 years but in this hospital burns admissions have significantly diminished only since 1987. The number of flame burns has declined and a high proportion of the victims were scalded. Efforts need to be made to reduce the large number of scalds by educational and legislative measures.

A study of thin (< 1.5 mm) malignant melanomas with poor prognosis.

555 cases of malignant melanoma less than 1.5 mm in depth were studied. 30 recurred locally or metastasised during follow-up. The width and depth of excision was similar in those with and without recurrence. There were no local recurrences in tumours < 1.0 mm which had been completely excised, irrespective of the width of excision. Other variables, the size of the primary tumour (p < 0.03), the depth of uninvolved dermis deep to the lesion (p < 0.01), the Clark level (p < 0.03) and the presence of lesional regression (p < 0.001), identify a sub-group of thin melanomas which have a poor prognosis irrespective of local treatment.

The role of the psychosocial oncology CNS in a rural cancer outreach program.

The high cancer mortality rates in rural areas of Virginia are discussed, and cancer risk factors particular to the rural population are delineated. Rural health beliefs and their relationship to delay in seeking cancer care in rural areas are examined. A rural cancer outreach program and the role of the oncology clinical nurse specialist (CNS) in the program are described in terms of Psychosocial Oncology CNS subroles, i.e., clinician, consultant-liaison, networker/linker, coach, educator, change agent, researcher, and supervisor/supervisee. Effectiveness of the role in the program is analyzed. An innovative urban-rural nurse oncology program is delineated, and recommendations for research in rural nursing cancer care and actions for fostering CNS role development are suggested.

Silicone gel breast implants, breast cancer and connective tissue disorders.

Recent worldwide media speculation that silicone gel-filled breast implants may be linked to an increased incidence of breast and other cancers, and connective tissue disease (particularly systemic sclerosis) has caused concern to the medical profession and public alike. Until carefully controlled studies have been performed to prove the safety of these implants, the US Food and Drug Administration has restricted their use to research and breast reconstruction. Research has so far failed to prove a causative relationship between silicone implants and cancer or connective tissue disorders.

Excision biopsy of malignant melanoma by general practitioners in south east Scotland 1982-91.

OBJECTIVE: To examine the management of patients who had a malignant melanoma excised initially by general practitioners in south east Scotland over the past 10 years and to assess the impact of the April 1990 contract on this. DESIGN: A retrospective case-control study. SETTING: South east Scotland. SUBJECTS: All patients in south east Scotland who had malignant melanomas excised by general practitioners in 1982-91. OUTCOME MEASURES: Demographic details of patients; Breslow thickness, clearance of excision. RESULTS: 42 patients had malignant melanomas excised by general practitioners in 1982-91: 15 in 1982-9 and 27 in 1990-1. These patients were significantly younger than those who had their tumours excised initially in hospital. Although the longest diameter of melanomas excised by general practitioners was significantly less than of those excised in hospital, the Breslow thicknesses were similar. Completeness of initial excision was doubtful or incomplete in nine (23%) general practitioner excisions compared with 4% of hospital excisions, but the time interval between excision biopsy and wide excision was similar. Pathology requests accompanying excision biopsies mentioned melanoma as a possible diagnosis in 15% (6/40) of general practitioner cases compared with 79% of hospital cases. Thirty nine general practitioners responded to a questionnaire and only 12 had considered melanoma in the differential diagnosis. CONCLUSIONS: General practitioners need to think more often of malignant melanoma when they excise pigmented lesions and when they consider this tumour a possibility should perform an excision biopsy with a lateral clearance of at least 2 mm.