bluuebunny/crossref_metadata_2025 huggingface dataset:
Fcγ receptor transmembrane domains: role in cell surface expression, γ chain interaction, and phagocytosis
Authors: Kim Moo-Kyung , Huang Zhen-Yu , Hwang Pyoung-Han , Jones Brian A. , Sato Norihito , Hunter Sharon , Kim-Han Tai-Hee , Worth Randall G. , Indik Zena K. , Schreiber Alan D.
Published: May 2003

We constructed chimeric receptors to dissect the role of the transmembrane (TM) domain in cell surface expression of and phagocytosis by the γ chain–dependent Fcγ receptors FcγRIIIA and FcγRI. FcγR chimeras containing the TM and cytoplasmic (CY) domains of the γ chain were expressed on the cell surface and mediated an efficient phagocytic signal. In contrast, chimeras containing the FcγRIIIA TM were poorly expressed. Receptors containing the FcγRI TM and the γ chain CY but lacking the γ chain TM also were expressed efficiently and mediated phagocytosis, suggesting that a γ chain dimer induced by the γ chain TM is not required for efficient phagocytosis. Cotransfection of FcγRI or FcγRIIIA with the chimera CD8-γ-γ (EC-TM-CY) resulted in FcγR cell surface expression and phagocytosis, whereas CD8-CD8-γ, whose TM does not associate with FcγR, allowed cell surface expression of (but not phagocytosis by) FcγRI. CD8-CD8-γ also did not allow surface expression of FcγRIIIA. Exchanging FcγRI and CD8 TMs indicated that the C-terminal 11 amino acids of the FcγRI TM are essential for association of FcγRI with the γ chain and phagocytosis. The data indicate that specific sequences in the FcγRIIIA and FcγRI TMs govern their different interactions with the γ chain in cell surface expression and phagocytosis and that γ chain TM sequences are not required for γ chain–mediated phagocytosis. The data identify a specific region of the FcγRI TM and its asparagine as important for FcγRI cell surface expression in the absence of the γ chain and for distinguishing the FcγRI and FcγRIIIA phenotypes.
Translating research into practice: how are guidelines implemented?
Authors: Partridge M.R.
Published: May 2003

Numerous guidelines have now been produced both nationally and internationally for the management of respiratory and nonrespiratory disease. They should be regarded as useful tools designed to aid the busy clinician, but their method of production, their value and especially their applicability to primary care and to low income countries need to be assessed critically.

The production of guidelines needs to be carefully incorporated into a planned dissemination and implementation programme. This is likely to be most successful when use is made of interactive educational methods associated with intraconsultation prompting and use of reminders. Updating and life-long learning is necessary and guideline revisions need to be closely incorporated into continuing medical education programmes. National campaigns, the use of media and the “training” of patients to make them more effective partners in healthcare can all enhance a beneficial change in health professional behaviour.

Recent research has enhanced the knowledge of a wide range of respiratory conditions and very effective therapies now exist for many conditions. However, too little attention is often given to the ways in which care is organised and to the important aspects of management that are nonpharmacological. When dealing with long-term conditions, long-term supervision and the teaching of self-management skills are as important as the prescription.

In many parts of the world the ideals, as laid out in guidelines, remain dreams and will continue to be dreams until there is some global redistribution of wealth. Only then will research be translated into practice everywhere.
Early detection of lung cancer: role of biomarkers
Authors: Brambilla C. , Fievet F. , Jeanmart M. , de Fraipont F. , Lantuejoul S. , Frappat V. , Ferretti G. , Brichon P.Y. , Moro-Sibilot D.
Published: May 2003

Early detection of lung cancer requires none or few invasive techniques. Distal lung cancer (40% of the cases in most European countries) can be sensitively detected by spiral computed tomography. Theoretically, in 60% of cases, the proximal lesions (main to segmental bronchi, accessible by bronchoscopy) should be able to be detected by sputum cytology. Unfortunately, this very specific technique has a low sensitivity and is time consuming. Fluorescent bronchoscopy increases the detection rate of early or micro-invasive lesions and may be proposed in highly selected populations, but not as a screening test. Biomarkers in blood and sputum have not yet been clinically validated. However, the amount of data generated from studies first on resected tumours, then on early bronchial lesions and more recently on blood and sputum offer a wide field for investigation.

Lung carcinogenesis is a multistep process characterised by the accumulation of successive molecular genetic and epigenetic abnormalities, resulting in selection of clonal cells with uncontrolled growth capacities throughout the whole respiratory tract (field cancerisation). Molecular lesions far precede morphological transformation of preneoplastic bronchial lesions (dysplasia) or alveolar lesions (atypical alveolar hyperplasia). Genetic and epigenetic abnormalities in the genes involved in cell cycle, senescence, apoptosis, repair, differentiation and cell migration control may be detected on bronchial biopsies, on respiratory cells from the sputum and even in the circulating deoxyribonucleic acid (DNA). The key genes involved include those in the P53- retinoblastoma (Rb) pathways.

The balance between cyclin-dependent kinases and their inhibitors regulates the level of Rb phosphorylation and its function at G1-S transition; P53 plays at least two functions (cell cycle and apoptosis control). The balance of bax-bcl2 is important in the control of apoptosis as well as loss of fragile histidine triad expression. O(6)-methylguanine-DNA methyltransferase seems to be important in DNA repair control, the RARβ receptor in differentiation, and cadherin H and E and different metalloproteases genes in cell migration.

The demonstration of hyperexpression or silencing of these genes needs different validated techniques: immunohistochemistry on biopsies or cytological preparations, molecular biology techniques for mutations, loss of heterozygosity and aberrant methylation abnormalities. Automation and miniaturisation of these techniques will allow early detection and may be widely applied once clinically validated.
Detection of asthma and chronic obstructive pulmonary disease in primary care
Authors: van Schayck C.P. , Chavannes N.H.
Published: May 2003

Chronic obstructive pulmonary disease (COPD) and asthma are major health problems, the number of patients with these diseases is still rising and only 25–50% of these patients are known to their doctors.

Lung function gradually decreases in COPD and asthmatic patients during their lives. Due to adaptation of the patients or due to the doctor being unaware of the symptoms, COPD is often diagnosed late in its course and when finally diagnosed, lung function is often relatively poor. Underdiagnosis and consequently undertreatment might play an important role in the increase in morbidity and mortality as a result of COPD and asthma. Early detection and treatment might improve the long-term prognosis of these patients and this secondary prevention may also prevent irreversible loss of function.

The identification of patients is useless if no effective preventive measures are available. In asthma, inhaled corticosteroids have been shown to have distinct effects on the progression of the disease. However, in COPD inhaled corticosteroids have only been shown to have some effects and the long-term effects on lung function have been disappointing. At present, the most effective treatment available for COPD is the cessation of smoking. It appears that a smoker at risk of developing COPD is more motivated to stop smoking than someone who is not at risk and this may help a physician in encouraging an attempt to quit.

General practitioners appear to be already using this knowledge, as they seem more likely to advise smokers to quit smoking if they perceive their problems to be smoking related.
Surgery for nonsmall cell lung cancer: can improvements be made?
Authors: Spiro S.G.
Published: May 2003

Low-dose spiral computed tomography (CT) for the earlier detection of lung cancer is at the stage of producing hypothesis-generating studies. These studies have shown that more cancers are found at a favourable stage (IA) in prevalence screening but that the fewer numbers found in incidence screening tend to have a slightly worse stage. Randomised controlled trials will be necessary to resolve the place of spiral CT screening.

The role of neo-adjuvant chemotherapy before surgery in nonsmall cell lung cancer looks less promising than suggested by earlier studies and the place of adjuvant chemotherapy following surgery appears to be unhelpful, although results of some large, randomised international studies are still awaited.

Radical radiotherapy is a poor alternative to surgery in resectable patients who refuse or are unfit for surgery and postoperative radiotherapy is detrimental. Positron emission tomography scanning offers a genuine opportunity to identify occult disease and improve staging prior to surgery and therefore save futile thoracotomies in ∼20% of patients otherwise apparently suitable for resection.
Airway inflammation in COPD: physiological outcome measures and induced sputum
Authors: Crapo R.O. , Jensen R.L. , Hargreave F.E.
Published: May 2003

Chronic obstructive pulmonary disease (COPD) is a result of airway inflammation, and the best predictor of COPD is the early detection of airflow limitation by spirometry. The Global Initiative for Obstructive Lung Disease Workshop Report defines airflow limitation using simple spirometric indices. Available guidelines categorise the severity of COPD using forced expiratory volume in one second (FEV1) and forced vital capacity (FVC), with symptoms playing a minor role in the assessment.

Current standards define COPD by progressive loss of FEV1, and thus longitudinal decline in FEV1will be the primary outcome variable for intervention studies aimed at preventing or reducing the loss of pulmonary function. There is evidence, however, that the variable FEV1/FVC and FEV1are often not measured properly in all settings.

This article will discuss the roles of physiological measurements in diagnosing COPD and physiological outcome measures for COPD. It does not formally compare physiological measures with other outcome measures, such as symptoms or quality of life. Additionally, improved treatment of established disease requires a better understanding of the inflammatory process and its clinical effects and treatment.

The inflammatory process, and how drugs affect it, can be studied noninvasively or relatively noninvasively by using refined methods of examining spontaneous or induced sputum. Enhanced understanding of the use of induced sputum will assist in predicting patients' responses to short- and long-term inhaled corticosteroid treatment, and the methods of sputum examination need to be simplified so that they can be applied more easily to clinical practice.
COPD exacerbations: definitions and classifications
Authors: Burge S. , Wedzicha J.A.
Published: May 2003

Chronic obstructive pulmonary disease (COPD) is defined independently of exacerbations, which are largely a feature of moderate-to-severe disease. This article is the result of a workshop that tried to define exacerbations of COPD for use in clinical, pharmacological and epidemiological studies. The conclusions represent the consensus of those present.

This review describes definitions, ascertainment, severity assessments, duration and frequency, using varying sources of data including direct patient interview, healthcare databases and symptom diaries kept by patients in studies.

The best general definition of a COPD exacerbation is the following: an exacerbation of COPD is a sustained worsening of the patient's condition, from the stable state and beyond normal day-to-day variations that is acute in onset and may warrant additional treatment in a patient with underlying COPD.

A more specific definition for studies where a bacteriological cause of exacerbation is being studied is included, as well as simpler definitions for retrospective identification from database sources. Prospective diary card assessments are best recorded as changes from an agreed baseline, rather than absolute symptom severities. Diary cards identify many unreported exacerbations, which on average have similar severities to reported exacerbations. A scale for exacerbation severity is proposed that incorporates in- and outpatient assessments. Exacerbation duration, which also relates to severity, is defined from diary card reports. Healthcare utilisation is not an adequate substitute for severity, depending on many unrelated social and comorbidity factors. It is an outcome in its own right.
The assessment of health status among patients with COPD
Authors: Curtis J.R. , Patrick D.L.
Published: May 2003

Survival and physiological measures alone do not represent the full experiences of patients with chronic obstructive pulmonary disease. Reducing the personal and social burden of disease by improving patients' symptoms, functional status and quality of life are also important goals.

There has been a substantial increase in the use of newly developed tools that measure health status and it is important for clinicians and researchers to understand these instruments' strengths and weaknesses in providing insight into a patient's condition and experience.

Relying only on mortality and physiological outcomes could blind a clinician to significant benefits patients may receive from a treatment. A growing body of research utilises end-points assessed directly by patients whose self-reported health status includes health-related quality of life and functional status.

This article reviews major concepts and methods in health-status assessments for patients with chronic obstructive pulmonary disease, which will have an important role in assessing the efficacy and effectiveness of new treatments.
The burden of illness and economic evaluation for COPD
Authors: Ramsey S.D. , Sullivan S.D.
Published: May 2003

In today's cost-conscious environment, understanding the economic implications associated with disease processes and their treatments is as important as understanding their clinical impact.

Medical expenditures for treating chronic obstructive pulmonary disease (COPD) and the indirect costs of morbidity can represent a substantial economic and social burden. Very little economic information concerning COPD is available, however, particularly outside of a few very well-developed Western nations.

This article will provide an approach for conducting high-quality studies aimed at estimating the economic burden of chronic obstructive pulmonary disease and for making economic evaluations of healthcare interventions aimed at preventing and treating this disease.
Similarities and differences between asthma and chronic obstructive pulmonary disease: treatment and early outcomes
Authors: Buist A.S.
Published: May 2003

There are now many guidelines that provide direction for the diagnosis and management of asthma and chronic obstructive pulmonary disease (COPD). However, both diseases are still underdiagnosed (or misdiagnosed) and undertreated.

There is considerable evidence that treatment with anti-inflammatory drugs reduces morbidity and mortality in asthma. The evidence is growing regarding their effect on slowing the remodelling that occurs in subsets of asthmatics. COPD is more challenging. There are no disease-modifying drugs available yet that will change the natural history of COPD.

However, there is overwhelming evidence that smoking cessation will slow the progression of disease. Until better drugs are available for the treatment of COPD, emphasis must be placed on primary and secondary prevention by reducing exposure to noxious agents (cigarette smoke in particular).

Inhaled corticosteroids appear to have a place in the management of severe chronic obstructive pulmonary disease, perhaps by decreasing the frequency of exacerbations.
Guidelines for the use of spiral computed tomography in screening for lung cancer
Authors: Henschke C.I. , Yankelevitz D.F. , McCauley D.I. , Libby D.M. , Pasmantier M.W. , Smith J.P.
Published: May 2003

Screening should be considered in lung cancer, more than any other cancer. Not only is the disease highly fatal, essentially incurable, when diagnosed on the prompting of symptoms and/or clinical signs, but its occurrence is also highly concentrated in identifiably high-risk persons.

The degree of usefulness of computed tomography (CT)-based screening for lung cancer must be thought of in reference to a particular, presumably optimal, regimen of pursuing early stage diagnosis. This is an algorithm that begins with the initial test (“screening CT”) and ends in either discontinuation of the diagnostic pursuit or in diagnosis of lung cancer.

A carefully developed, extensively pilot tested and critically reviewed, updated protocol for CT-based screening for lung cancer is presented here. Its implementation is addressed, together with quality assurance. Finally, the associated curability rate for lung cancer is addressed in the light of what is known or can be surmised from evidence already available. However, recommendation for or against screening requires further information. Principally, the patients risk for lung cancer (in the near future) and the patients life expectancy (when spared of death from lung cancer). These two factors influence when, if ever, to begin screening, and if it is initiated, when to discontinue it. Finally, cost-effectiveness of the screening program should also be considered.
New techniques for early detection of lung cancer
Authors: Sutedja G.
Published: May 2003

The resurgence of interest in lung cancer screening and the application of new techniques for the management of early cancer have raised various issues regarding this global epidemic. In previous randomised clinical trials, the use of conventional chest radiographs and sputum cytology examinations for screening have been shown not to reduce lung cancer mortality.

The use of biomolecular markers, autofluorescence bronchoscopy, low-dose spiral and high-resolution computed tomography, endobronchial ultrasonography, optical coherence tomography, confocal micro-endoscopy, positron emission tomography in combination with video-assisted thoracic surgery and intraluminal bronchoscopic treatments may provide new modalities with which to manage lung cancer at the earliest stage possible.

New hopes arise that the combined use of more accurate and minimally invasive diagnostic and treatment techniques may justify screening and reduce mortality. More individuals may also benefit, as many in the target population already suffer from poor cardiovascular and pulmonary health due to their smoking history and are considered at risk for surgical intervention. The cost-effectiveness of lung cancer screening will strongly depend on the proper selection of the target population and the optimal application of these new techniques.

Despite epidemiological controversy regarding lung cancer screening, the feasibility to define more precisely who are at risk and the use of less invasive techniques may preserve quality of life and improve the survival of many lung cancer patients.
Screening
Authors: Boyle P.
Published: May 2003

Screening for cancer is currently entering a very promising period as new technologies become available for assessment. However, this great opportunity also presents significant problems, starting with how do you select the likeliest method for evaluation? How do you do trials where the technology will be out-moded by the time the result is known? Indeed, how can all promising technologies be evaluated?

There is a need for a renewal of methodological thinking on this topic at present. Randomised trials, which currently rely on death as the primary outcome, are very long and very complicated to undertake and run. There is an urgent need for biological markers, which are true surrogate end-points, to help reduce sample size and make trials more feasible, so that more trials can be done.

For those screening modalities of demonstrated effectiveness, the key issue at present is how to maximise the outcome in population screening when the technology is transferred from the research setting to the public health setting. It is essential to remember that screening, per se, has never prevented a cancer nor prevented a cancer death. It is impossible to separate the issues of screening with those of adequate treatment: the best results in a screening programme will come when treatment is excellent.

Screening is the first, and sometimes key, stage in a global management programme for the cancer in question. As the aim at present is to strive to maximise the effectiveness of population-based programmes, this aspect should be foremost in all thought processes.
Differences in supporting families of dementia patients and cancer patients: a palliative perspective
Authors: Albinsson Lars , Strang Peter
Published: May 2003

Objectives: To investigate what staff working in close contact with patients perceive as good support of families in dementia care as compared with support of families in palliative cancer care. Design and subjects: During four national courses on dementia care and one national course on palliative cancer care, 316 and 121 participants, respectively, responded to an open-ended question: In your experience, what are the two most important measures for supporting families of dementia patients/severely ill cancer patients? Sixty-one items were coded and allocated into 10 main categories and analysed with both a qualitative and quantitative approach. Results: The dominant items for both staff groups were to listen to the family member and to give information, although listening was significantly more often stressed in the palliative group (PB = 0.001). The staff in dementia care stressed significantly more the importance to form support groups for families (PB = 0.001), to offer respite care (PB = 0.001), to educate families (PB = 0.001) and to try to relieve the family's feeling of guilt (PB = 0.001). In the palliative staff group, the importance of being available (PB = 0.05), creating a sense of security (PB = 0.001) and supporting the family after the patients death (PB = 0.01) were significantly more focused on. Discussion: The respondents from the dementia staff group and from the palliative cancer group stressed the importance of supporting family members. However, the type of support needed partly differs because of the different trajectories in dementia compared with severe cancer phases.
Effect of a palliative home care team on hospital admissions among patients with advanced cancer
Authors: Costantini Massimo , Higginson Irene J , Boni Luca , Orengo Maria Antonietta , Garrone Elsa , Henriquet Franco , Bruzzi Paolo
Published: May 2003

This was a quasi-experimental study designed to determine whether, in patients with advanced cancer, a palliative home care team (PHCT) modified hospital utilization in the last six months before death. Of 2503 cancer deaths in the municipality of Genoa, Italy, in 1991, 189 (7.5%) received care from a PHCT. Three hundred and seventy-eight controls matched for primary tumour were selected. The groups were similar in terms of age, gender and most other demographic variables, except that educational level was lower, and times to death, from first diagnosis and from diagnosis of advanced or metastatic cancer, were longer among PHCT patients compared with the controls. Before referral to a PHCT, or a matched time in controls, both groups spent about 15% of days in hospital. After admission to a PHCT, the percentages of days in hospital increased in both groups as death approached, but it was much higher in the control group (30.3%; 95% confidence interval (CI): 26–34) than in the PHCT group (19.0%; 95% CI: 15–23). The difference between groups was most marked in the last month of life, and disappeared among those patients who were in care for more than 120 days (throughout the course of their illness). We conclude that a PHCT appears to reduce days in hospital and allows patients to spend more time at home. Differences in time in care between groups requires further investigations.
A qualitative study of clinical nurse specialists' views on depression in palliative care patients
Authors: Williams Mari Lloyd , Payne Sheila
Published: May 2003

Depression is the most common psychiatric illness in patients with terminal cancer. Depression not only lowers the quality of life for the patients and their families, but patients who are depressed may also have physical symptoms that are difficult to palliate and that improve as their depression is appropriately treated. However, up to 80% of the psychological and psychiatric morbidity that develops in cancer patients goes unrecognized and untreated and patients are often reluctant to spontaneously discuss symptoms with medical and nursing staff. In the UK, palliative care clinical nurse specialists have a key role in the assessment of symptoms and advising on management in patients with advanced metastatic cancer. A qualitative study was carried out to determine how specialist palliative care nurses, working both in the community and within a hospital, perceive, assess and manage depression in their patients. Seventeen nurses were interviewed. Nurses found it difficult to discuss depression with their patients and tended to focus on physical symptoms. The lack of training in identifying psychological and psychiatric symptoms was a source of concern to nurses as was the difficulties they encountered in trying to persuade medical staff that patients required further assessment or antidepressant medication. Nurses also felt that psychiatric expertise was not utilized as fully as it could be. The findings of this study have implications for the training and support of nurse specialists in the psychological and psychiatric assessment and management of palliative care patients.
The development and implementation of a standardized policy for the management of dysphagia in motor neurone disease
Authors: Kirker F J , Oliver D J
Published: May 2003

Following an audit to determine the standards of the assessment and management of dysphagia within the Wisdom Hospice, a standardized, multidisciplinary dysphagia policy was established, incorporating a dysphagia trained nurse (DTN) scheme. The standards of care of dysphagic patients were audited after its introduction and the results indicate that the resourcing and quality of care difficulties identified have been improved by the implementation of the policy. The service development implications for the management of dysphagia in palliative care settings are discussed.
Breaking bad news: a Chinese perspective
Authors: Tse C Y , Chong Alice , Fok S Y
Published: May 2003

The amount of information received by terminal cancer patients about their illness varies across different countries. Many Chinese families object to telling the truth to the patient and doctors often follow the wish of the families. However, a population study in Hong Kong has shown that the majority wanted the information. To address this difference in attitudes, the ethical principles for and against disclosure are analysed, considering the views in Chinese philosophy, sociological studies and traditional Chinese medicine. It is argued that the Chinese views on autonomy and nonmaleficence do not justify nondisclosure of the truth. It is recommended that truth telling should depend on what the patient wants to know and is prepared to know, and not on what the family wants to disclose. The standard palliative care approach to breaking bad news should be adopted, but with modifications to address the ‘family determination’ and ‘death as taboo’ issues.
The effectiveness of palliative care education delivered by videoconferencing compared with face-to-face delivery
Authors: van Boxel Patris , Anderson Keith , Regnard Claud
Published: May 2003

As part of a four-year study into the use of videoconferencing in palliative care, the delivery of workshops on palliative care to community nurses was evaluated by the Open University. Twenty nurses were randomly allocated to alternating videoconferencing and face-to-face modes of presentation. The quantitative study measured the amount of learning that occurred in each workshop with pre-tests and post-tests, and the mode of presentation. Forty-nine workshop attendances were analysed. The qualitative study used observation and analysis of videorecordings to assess the activity and attention spans in interactive communication during workshops, while a combination of interviews and questionnaires was used to assess the participants' level of satisfaction with presentation. The results showed that the nurses' level of satisfaction with the instructional presentation was high in both modes of presentation. Despite difficulties at the start of the project in the videoconferencing presentation, there was little difference between the modes of presentation in achievement scores or the gain in achievement scores. Although the learners preferred face-to-face workshops, they learnt as much from a videoconferenced workshop. Videoconferencing was less suitable for psychological or emotional discussions, but this may have been due to the time constraints on the workshops. Some features of videoconferencing suggest it could be used effectively in helping learners discuss sensitive issues. The Current Learning in Palliative Care (CLiP) worksheets were found to be an effective means of delivering learning.
Burden of care in amyotrophic lateral sclerosis
Authors: Hecht Martin J , Graesel Elmar , Tigges Sebastian , Hillemacher Thomas , Winterholler Martin , Hilz Max-Josef , Heuss Dieter , Neundörfer Bernhard
Published: May 2003

Objectives: Amyotrophic lateral sclerosis (ALS) is a fatal disease with unique demands on patients and carers. Patients and methods: The total burden of care and burden components in 37 ALS carers were measured using validated questionnaires. Furthermore, influencing factors (functional impairment of the patient, additional carers, participation in support groups) were assessed. Results: The mean total burden of care for ALS was low compared with dementia, mixed neuropsychiatric and internal diseases, but was correlated with functional impairment ( P = 0.003). The main burden components were 'personal and social restrictionsfland ’physical and emotional problems‘. Problem behaviour of the patients was low in general, but was higher in carers participating in support groups ( P = 0.002). Carers supported by additional carers had higher strain. Conclusion: The low burden of ALS carers may be caused by the low incidence of problem behaviour in ALS patients. However, if problem behaviour exists, carers participate more often in support groups, indicating the need for assistance. The burden of care increases with the functional impairment. Support for the carers has to start sooner.
Clinical guidelines
Authors: Keeley Paul W
Published: May 2003

Clinical guidelines are likely to be an important part of medical practice for the foreseeable future. Guidelines at their best are tools for consistency and effectiveness in patient care. Guideline methodology has evolved such that there are internationally agreed standards with which to develop and assess guidelines. Guideline development groups should ideally be multidisciplinary in composition and if possible have patient representation. Key to the process is the rigour of the systematic review in order to assess the best evidence on which to base recommendations. Guideline recommendations should be explicitly linked to the evidence. In order to safeguard trust, guideline development groups must have editorial independence of government, industry and special interest groups, while at the same time having regard to the implications of their recommendations. Implementation of guidelines by passive dissemination is largely ineffective; effective dissemination requires an imaginative approach tailored to the intended audience.
Brief report on user involvement at St Christopher's Hospice
Authors: Kraus Frances , Levy Jean , Oliviere David
Published: May 2003

As part of their Clinical Governance agenda, St Christopher's Hospice in southeast London has established a system for gaining patient and carersflviews, in order to ensure these are given adequate consideration in planning and providing services. A users forum has been set up, and this article discusses some of the issues that had to be addressed in organizing the forum. Items such as who to invite, who should facilitate the meetings, venue, timetable, and boundaries all needed to be agreed. Evaluation of the usefulness of the forum is still required, with many questions still to be answered, but so far staff, patients and carers have enthusiastically embraced the forum. This report identifies some of the challenges in developing a person-centred user involvement scheme in a voluntary hospice.
Symptoms in 400 patients referred to palliative care services: prevalence and patterns
Authors: Potter Jean , Hami Faeqa , Bryan Tamsin , Quigley Columba
Published: May 2003

The demographics and prevalence of symptoms in patients at first referral to the different components of palliative care services were identified by a retrospective case note study of 400 patients referred to three palliative care centres in London, UK: Michael Sobell House, Mount Vernon Hospital; The North London Hospice; St Bartholomew's and the Royal London Hospitals. One hundred consecutive referrals to each of the following service components were analysed: a hospice inpatient service; a community team; an NHS hospital support team and an outpatient service. A standardized proforma was used to collect the data. Ninety five per cent (380/400) of patients referred had a cancer diagnosis. The five most prevalent symptoms overall were pain (64%), anorexia (34%), constipation (32%), weakness (32%) and dyspnoea (31%), which is similar to other published reports. However, the commonest symptoms and their prevalence varied depending on the service component to which the patient was referred. Patients referred to hospice and community services had the highest symptom burden (mean number of symptoms per patient 7.21 and 7.13, respectively). This study suggests that different patient subgroups may have different needs in terms of symptoms, which will be relevant for the planning and rationalization of palliative care services.
Learning the hard way! Setting up an RCT of aromatherapy massage for patients with advanced cancer
Authors: Westcombe A M , Gambles M A , Wilkinson S M , Barnes K , Fellowes D , Maher E J , Young T , Love S B , Lucey R A , Cubbin S , Ramirez A J
Published: May 2003

Aromatherapy massage is used in cancer palliative care to improve quality of life but there is little evidence for its effectiveness. A large pragmatic multicentre randomized controlled trial was set up to examine the effectiveness of aromatherapy in improving psychological distress and quality of life in patients with cancer. This paper examines the challenges encountered in the design and execution of the study. The original design, i) focused on palliative care patients with advanced disease; ii) had both a no-intervention and a treatment control group (relaxation therapy); and iii) adopted 90% power for sample size calculations. A varied measurement strategy was employed. Recruitment proved difficult, referrers were ‘gate-keeping’, patients were often too ill to approach and others declined. The trial was modified to ensure viability. Eligibility was extended to all patients with cancer irrespective of stage, the relaxation group was removed and the power reduced to 80%. Although it is not generally good practice to change a study design once recruitment has started, the changes were consistent with the original basic study aims and design principles. The data collection phase was successfully completed in July 2002.
Poststructuralist ethics: subjectivity, responsibility and the space of community
Authors: Popke E. Jeffrey
Published: May 2003

The theoretical tenets of poststructuralism pose significant challenges to traditional ethical thinking, suggesting the need for an ethics sensitive to openness and difference. Drawing upon the work of Levinas, Derrida and Nancy, I discuss three dimensions of such an ethics: a theory of subjectivity based in a responsibility to the other; a politics of deconstruction within which this responsibility is foregrounded; and a theory of spatiality articulated in the sharing of community. This points toward an ethics of hospitality, in which the space of community is offered as a gift, and in the context of an irrecusable responsibility toward others.
Submarine slides on volcanic islands - a source for mega-tsunamis in the Quaternary
Authors: Whelan Franziska , Kelletat Dieter
Published: May 2003

Slope instability and mass movements on volcanic islands may generate large magnitude tsunamis. During the Quaternary, tsunamis originating from volcanic islands have significantly impacted the world’s coastlines. However, research has only recently begun to analyse the effects of tsunamis in coastal environments. This paper overviews the distribution, magnitude, recurrence interval, and age of large submarine slides on volcanic islands and their potential for the generation of mega-tsunamis during the Quaternary.
Climatic, environmental and human consequences of the largest known historic eruption: Tambora volcano (Indonesia) 1815
Authors: Oppenheimer Clive
Published: May 2003

The 1815 eruption of Tambora volcano (Sumbawa island, Indonesia) expelled around 140 gt of magma (equivalent to ≈50 km3 of dense rock), making it the largest known historic eruption. More than 95% by mass of the ejecta was erupted as pyroclastic flows, but 40% by mass of the material in these flows ended up as ash fallout from the ‘phoenix’ clouds that lofted above the flows during their emplacement. Although they made only a minor contribution to the total magnitude of the eruption, the short-lived plinian explosions that preceded the climactic eruption and caldera collapse were powerful, propelling plumes up to 43 km altitude. Over 71 000 people died during, or in the aftermath of, the eruption, on Sumbawa and the neigh-bouring island of Lombok. The eruption injected ≈60 mt of sulfur into the stratosphere, six times more than was released by the 1991 Pinatubo eruption. This formed a global sulfate aerosol veil in the stratosphere, which resulted in pronounced climate perturbations. Anomalously cold weather hit the northeastern USA, maritime provinces of Canada, and Europe the following year. 1816 came to be known as the ‘Year without a summer’ in these regions. Crop failures were widespread and the eruption has been implicated in accelerated emigration from New England, and widespread outbreaks of epidemic typhus. These events provide important insights into the volcanic forcing of climate, and the global risk of future eruptions on this scale.
Hormesis and risk communication
Authors: Renn Ortwin
Published: May 2003

Hormesis has been defined as a dose-response relationship in which there is a stimulatory response at low doses, but an inhibiting response at high doses, resulting in a U or inverted U-shaped dose response. Toxic agents that are detrimental to human health above certain threshold levels may induce positive effects at a dose that is significantly lower than the NOAEL level. In spite of the evidence for hormesis effects, the topic is still a matter of high controversy among toxicologists. Facing this ambiguity, the article raises the question: how should risk communication be arranged in a situation of high ambiguity, lack of empirical certainty about the effects, major policy dilemmas and significant equity problems? The article summarizes the main results of risk communication research and applies these results to the question of hormesis. First, it explains the main context variables that impact on the success or failure of any risk communication program. These refer to i) the levels of the risk debate, ii) the socio-political style of regulation, iii) different types of audiences, and iv) subcultural prototypes. Secondly, the paper addresses the major functions of risk communication: i) dealing with public perception; ii) gaining trust and credibility; iii) involving stakeholders in the communication process. The last section draws some conclusions for improving risk communication on issues of hormesis.
Comments on Ortwin Renn's article ‘Hormesis and risk communication’: considerations about uncertainity, ignorance and governance
Authors: De Marchi Bruna
Published: May 2003

After acknowledging Renn's careful investigation and valuable insights, this paper expands on some issues that have been somewhat neglected in his account. It addresses the relationship between risk, uncertainity and ignorance in risk assessment, focusing in particular on the need to recognize that framing assumptions condition all subsequent steps. Subsequently, it discusses the implications for risk communication in the case of hormesis. The author maintains that problems of risk are strictly and irremediably intertwined with problems of governance. Therefore, she is doubtful that regulatory agencies would promote, and the public would welcome, modifications in current regimes on the basis of still limited and debated evidence of good.
Commentary on hormesis and public risk communication: is there a basis for public discussions?
Authors: Flynn James , MacGregor Donald
Published: May 2003

Research on radiation exposure is now focusing on microbiology and the impact of low dose exposures on cells and cell components. Eventually, this research may provide evidence to support changes in the models used to regulate human and environmental exposures. Currently, three models using older research results are subjects of interest and comparison. The linear no threshold model, the most restrictive on behalf of public health values, dominates regulatory decision making. Alternative models (i.e., the threshold model and the hormesis model) could reduce costs of radiation management, depending upon new research results and public acceptance. Enacting a new public exposure model is a daunting task for risk communication given existing public risk perceptions and the established public decision-making processes. Each of the three prominent models must answer the question, ‘what social good requires the use of this model in contrast to the others?’
Hormesis and risk communication: a comment to Ortwin Renn
Authors: Löfstedt Ragnar
Published: May 2003

Professor Ortwin Renn should be congratulated for authoring the definitive piece on risk communication with regard to hormesis.1 Most of his conclusions I agree with, specifically the importance of labelling hormesis as a possible natural effect, thereby reducing the stigmatization associated with a technical/chemical label. Rather than discussing all the points that Renn raises, in this comment I will focus on the issue of trust, a topic that Renn does examine but which I feel does not get adequate attention and which I do not completely agree with. In so doing, in my conclusions I am more optimistic than Renn is in preparing risk communication strategies regarding hormesis and other new paradigms to target audiences (defined in most instances as the general public and stakeholders).
Hormesis: public health policy, organizational safety and risk communication
Authors: Poumadére Marc
Published: May 2003

Thirty years of research suggests low doses of toxic substances may have positive health effects. If confirmed, hormesis will imply radical changes in risk assessment and management of existing industrial toxic sources (chemical and nuclear). Renn analyses risk communication issues and positions hormesis–largely unknown to the public today–as a hypothetical risk object in society. Our comments stress the necessity to consider hormesis first as a public health issue (versus an industrial regulatory issue), to consider the impact of managerial changes upon organizational safety culture, and to assess effects on public health from the ‘bad news’ of toxic exposure.
Benign paroxysmal positioning vertigo in multiple sclerosis: diagnosis, pathophysiology and therapeutic techniques
Authors: Frohman E M , Kramer P D , Dewey R B , Kramer L , Frohman T C
Published: May 2003

Objective: To report on the most common causes of vertigo in patients with multiple sclerosis (MS) and emphasize appro priate diagnostic techniques and treatment interventions. Background: True vertigo is estimated to occur in about 20% of MS patients. Lesions within the vestibular nuclei and in the root entry zone of cranial nerve VIII represent the most common locations where demyelinating activity can provoke vertigo in patients with MS. However, other causes of vertigo should be explored in MS patients in order to avoid unnecessar y treatment with corticosteroids and vestibular suppressants. Recently, we reviewed our four-year experience with new onset vertigo in our university-based MS population and found that benign paroxysmal positioning vertigo (BPPV) to be the most common cause. A ll patients diagnosed with BPPV were treated successfully with particle repositioning maneuvers. The remaining patients were treated with conventional therapies appro priate for the specific diagnosis. Conclusions: Empiric treatments with corticosteroids and/or vestibular suppressants should not be employed until all MS patients undergo a careful bedside examination, which includes diagnostic positional and, if indicated, particle repositioning maneuvers. Here we emphasize the pathophysiology of BPPV and illustrate the proper techniques for the diagnostic and therapeutic maneuvers.
Patient and community preferences for treatments and health states in multiple sclerosis
Authors: Prosser Lisa A , Kuntz Karen M , Bar-Or Amit , Weinstein Milton C
Published: May 2003

Objective: To examine preferences for treatments and health states for patients with relapsing-remitting MS and members of the community. Methods: A survey was developed to evaluate health-related quality-of-life measures (utilities) for three treatments and six MS health states using a utility-elicitatio n software package, U-Titer II. Sixty-two MS patients at two large teaching hospitals in Boston, MA, and 67 members of the general community in San Diego, C A, completed the health-related quality-of-life survey using a computer. Results: A ssessment of quality of life decreased as disability level of MS health states increased for both respondent groups. Respondents rated less-disabled health states relatively highly (>0.94 for patients and >0.89 for community respondents). Q uality-of-life measures for treatments in mean utilities ranged from 0.80 to 0.96. Patients assigned higher utilities for both MS health states and treatment states than community respondents; the ratings became more disparate as health states worsened. Conclusions: O n average, respondents assigned utilities to currently available treatments for MS that are comparable to those of mild to moderate stages of the disease itself. These results underscore the importance of including preferences for health states and treatment alternatives in the decision to initiate treatment for individual patients or in the evaluation of effectiveness or cost-effectiveness of these treatments in patients with MS.