Early Warning Symptoms Research Articles

Intraabdominal desmoplastic small round cell tumor: Report of a case and literature review

IntroductionDesmoplastic small round cell tumor is a rare malignancy with poor prognosis that predominantly affects young males. Its etiopathogenesis is still unknown and diagnosis can be achieved only by immunohistochemistry and cytogenetic studies. Due to our limited knowledge of the pathologic and clinical nature of this disease, there is no clear consensus regarding the optimal therapeutic procedures for treating this neoplasm. A high degree of care and improvements in diagnostic capabilities are required in order to identify this entity and avoid misdiagnosis. Case presentationWe report a new case of a 29-year-old male who proceeded to our Emergency Department complaining about non-specific abdominal pain. Physical examination revealed no abnormalities except for a palpable mass in the lower abdomen and a diffuse abdominal pain. Computed Tomography scan showed enlarged paraortic and mesenteric lymphadenopathy, thickness of the small bowel wall and dispersed masses intraperitoneally. He underwent an exploratory laparotomy and the resultant biopsy revealed desmoplastic small round cell tumor. DiscussionDiagnosis of desmoplastic small round cell tumor can easily be missed because it presents with few early warning symptoms and signs, while the routine blood tests are within normal limits. ConclusionA high degree of suspicion, a thorough physical examination, a full imaging check and an aggressive therapeutic approach are required in order to identify this disease and fight for a better quality of life for these patients. In addition we make a review of the literature in an effort to clarify the epidemiological, clinical and pathological aspects of this entity.

TCM and western psychiatry: An integrative proposal

The LVR Klinik Bedburg Hau cooperated with the Radboud University Nijmegen in an integrative medicine project that added weekly acupuncture treatments to the usual western psychiatric treatment in outpatients with chronic schizophrenia. Acupuncture treatment was performed in groups. The amount of dropout in the acupuncture group was significantly lower, compared to any other group-treatment conducted in the outpatient-clinic so far. Moreover, most patients asked for more acupuncture treatment after the project was over, something that is not often seen in this chronic group of often non-compliant patients. Psychological testing was conducted before and after the treatment period, results are being gathered currently, first results show positive effects in the area of sleep latency, awakenings per night, and concentration. In short, this project resulted in the proposal to implement acupuncture in the western psychiatric treatment that is usually given in this clinic. This may be done as in the project, namely in a group, thereby no patient is left alone during treatment and patients are able to support each other. Moreover, by providing weekly acupuncture treatments, more contact is provided between the clinic and the patient, allowing for more possibilities to recognise early warning symptoms and respond to them, without investing more than approximately 15 min (direct intensive contact) per patient per week (and about half an hour observational presence in the group, with needles inserted). This might result in less time per patient, if looked upon from the practitioners point of view (1 h per month during 4 contact moments, compared to the usual approximately 2 h per month in direct contact), but on the other hand it results in more control. These findings are in line with recent studies on health care economics, showing that integrative medicine costs less and results in healthier patients [1]. In this presentation, a full integrative treatment proposal for patients with schizophrenia will be presented, based on all results that were found in the conducted pilot study.

Fatal group A Streptococcus purpura fulminans in a child receiving TNF-α blocker

Inhibition of tumor necrosis factor alpha (TNF-α) is effective in the treatment of many pediatric autoimmune diseases and inflammatory conditions. Commonly available biologic agents blocking TNF-α are infliximab, etanercept, and adalimumab. These agents have changed the management of rheumatic diseases in the adult population and are being used more and more in pediatric patients as safety and efficacy have been demonstrated. Infections have been the most commonly reported adverse effects of TNF-α inhibition. Granulomatous infections such as tuberculosis are well-known complications, but serious bacterial infections are also reported. We describe a fatal case of purpura fulminans caused by group A Streptococcus in an 8-year-old child with systemic juvenile idiopathic arthritis treated with etanercept. This case highlights the clinical association of severe bacterial infection and TNF-α inhibition in children. Pediatricians should educate their patients who are treated with TNF-α blockers regarding early warning symptoms and should also have a lower threshold for initiating antibiotic therapy in case of fever.

Individualism and insulin pump therapy

To the Editor: Nowadays, so-called ‘smart’ insulin pumps invariably have built-in features that are perceived to add benefit for users. These include: dosage calculators that manage the complexarithmetic associated with pump use; an ‘insulin-on-board’ feature that considers the amount of insulin still ‘active’ in a patient prior to recommending an insulin dosage; and the ability to programme alternative basal insulin delivery rates for corresponding times of the day and night and for different types of bolus infusion according to variations in types of foods and meal content. Other features include programmable reminders and alerts, carbohydrate databases, and so on. The increasing complexity of pumps is partly an attempt to give manufacturers a ‘market edge’ against their competitors. However, the evidence base (i.e. randomised controlled clinical trials) for including such features is generally lacking. In Bournemouth, UK, we provide a dedicated 2 day group education programme for commencement of insulin pump therapy. The programme is run by trained nurse educators and dietitians. It uses a structured curriculum approach and covers all aspects of pump therapy, including the ‘smart’ features. Consistent with published data, we have found that the use of insulin pump therapy is associated with sustained improvements in HbA1c levels, fewer hypoglycaemic episodes, enhanced early warning symptoms of impending low blood glucose levels and an improved quality of life [1–4]. Recently we have incorporated insulin pump download software into our routine clinical practice. This has the potential to provide greater insights into an individual’s use of these complex technological features. Despite identical training, pump-users seem to prefer a simple and individual

Sex Differences in Congenital Heart Disease

Sex differences in the clinical presentation, diagnosis, and treatment outcomes of cardiac disease have long been recognized. Since the mid-1980s, the total number of deaths from cardiovascular disease has been higher for women than for men. A greater proportion of women (52%) than men (42%) with myocardial infarction die of sudden cardiac death before reaching the hospital, perhaps in part because women tend to have nonspecific prodromal symptoms rather than chest pain and these symptoms are not recognized as being cardiac in origin.1 Even after acute myocardial infarction, women are 46% less likely to undergo coronary angiography than men, despite accounting for confounders.2 Two-thirds of women who suffer a myocardial infarction never completely recover,3,4 and those who do survive have a 2-fold recurrence of myocardial infarction and mortality during the first year compared with their male counterparts.5 Article p 26 Women with stable angina have higher in-hospital mortality rates6 and worse outcomes after coronary interventions, both percutaneous and surgical. Following percutaneous coronary interventions women have higher rates of short- and long-term mortality, cardiac events, and the need for emergency coronary artery bypass grafting. This may relate to the comparatively smaller coronary artery size of women,7 although this is unproven.8 Higher mortality and complication rates of coronary artery bypass grafting also occur, with women obtaining less functional relief, more frequent hospital readmissions, and lower functional gains than their male counterparts.9 Whether some of these sex disparities relate to an autoimmune precursor for atherosclerotic disease remains speculative. Sex-specific differences in C-reactive protein, as an inflammatory marker, are consistent with the 10-fold increased frequency of inflammatory-mediated autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus, and thyroiditis in women compared with men.4,10 Recent studies report atherosclerotic plaque in both the carotid and coronary arteries …

Schizophrenia: is therapy involving early warning symptoms and antipsychotics successful?

In spite of advances in neuroleptic treatment, relapse of positive symptoms continues to punctuate the course of schizophrenia. In this paper the conceptual and empirical basis for early intervention in the process of psychotic relapse as a preventative manoeuvre is evaluated. The predictive efficacy of early, ‘prodromal’ signs, their nature, and the utility of early detection and intervention strategies are reviewed. There is strong evidence that relapse is preceded by early signs, but the classical (medical) concept of prodrome is inadequate to explain the findings. The early detection and treatment of early signs appears to confer protection from relapse, but the active ingredients of the pharmacological and psychological based treatment studies are as yet unclear and suggest important avenues for future research.

Early recognition of meningitis and septicaemia: the ‘red flag’ symptoms

Meningitis and septicaemia can be deceptive in the diversity of their presentation in children. Added to this difficulty, most health professionals see few cases in their professional lifetimes. The meningococcus is the leading cause of bacterial meningitis in the UK, and it can kill within 24?hours of symptom onset. Many child survivors just starting out in life face debilitating and sometimes permanent disabilities including neurological damage, sensory deficits, limb amputations, and often damage to tissue, skin and organs. There may be further impact on quality of life even for those who appear to recover well. Group B meningococcus accounts for the great majority of meningococcal cases, however a vaccine that protects against it remains elusive. Consequently, given the severity of the disease, its ability to develop at an alarming rate, and the absence of universally protective vaccines against meningitis and septicaemia, it is crucial to be able to recognize the signs and symptoms. ‘Red flag’ symptoms have been recently identified as early warning symptoms of the disease. They manifest some 5 hours earlier than the well-known ‘classic’ symptoms. Knowledge of these earlier symptoms could speed up diagnosis and treatment thereby reducing morbidity and mortality. The purpose of this paper is to draw attention to this deadly disease and highlight the early ‘red-flag’ symptoms.

Interventions for helping people recognise early signs of recurrence in bipolar disorder.

Recurrence rates for bipolar disorder are high despite effective treatments with mood stabiliser drugs. Self-help treatments and psychological treatments that teach patients to recognise and manage early warning symptoms and signs (EWS) of impending manic or depressive episodes are popular with patients. The main aim of such interventions is to intervene early and prevent bipolar episodes, thereby increasing the time to the next recurrence and preventing hospitalisation. To compare the effectiveness of an EWS intervention plus treatment as usual (TAU ) versus TAU (involving and not involving a psychological therapy) on time to manic, depressive and all bipolar episodes (the primary outcome), hospitalisation, functioning, depressive and manic symptoms. Relevant studies identified by searching Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (CCDANCTR-Studies and CCDANCTR-References - searched on 20/10/2005), supplemented with hand searching the journal Bipolar Disorders, searching the UK National Research Register, checking reference lists of included studies and contacting authors. Only randomised controlled trials (RCTs) were included. Participants were adults with a diagnosis of bipolar disorder based on standardised psychiatric criteria. Two reviewers independently rated trials for inclusion. Data were extracted from included trials by reviewers using a data extraction sheet. Authors of all the included studies were contacted for any additional information required. Time to recurrence data was summarised as log hazard ratios, dichotomous data as relative risk and continuous data as weighted mean difference, using random effects models to calculate effect size only when there was heterogeneity in the data. Eleven RCTs were identified, but only six provided primary outcome data. All six RCTs were of high quality. Time to first recurrence of any type (RE, hazards ratio 0.57, 95% CI 0.39 to 0.82), time to manic/hypomanic episode, time to depressive episode, and percentage of people hospitalised and functioning favoured the intervention group. Neither depressive nor hypomanic symptoms differed between intervention and control groups. This review shows a beneficial effect of EWS in time to recurrence, percentage of people hospitalised and functioning in people with bipolar disorder. However, the absence of data on the primary outcome measure in so many included studies is a source of concern and a potential source of bias. Mental health services should consider routinely providing EWS interventions to adults with bipolar disorder, as they appear to reduce hospitalisation and therefore may be cost-effective.

New approaches to the treatment and prevention of neurally mediated reflex (neurocardiogenic) syncope.

Neurally mediated reflex syncope (sometimes referred to as neurocardiogenic syncope), encompasses a group of disorders of which the best known and most frequently occurring forms are the vasovagal (or common) faint, and carotid sinus syndrome. Postmicturition syncope, defecation syncope, cough syncope, and other situational reflex faints are also included among these conditions. With the exception of carotid sinus syndrome in which cardiac pacing is effective, treatment of most neurally mediated reflex faints is shifting from reliance on various drugs to greater emphasis on education and nonpharmacologic therapy. Initial management should include counseling of patients regarding recognition of early warning symptoms, and avoidance of precipitating factors. Volume expansion with salt tablets or electrolyte-containing beverages and patient education on how to perform isometric arm contractions and/or leg crossing in order to abort impending syncope are also important. Thereafter, tilt-training has demonstrated benefit in several clinical studies. When symptoms remain despite the above-noted interventions, pharmacologic therapy with midodrine or a nonselective b-blocker can be considered. In the case of most neurally mediated reflex faints, permanent cardiac pacing should be reserved only for those older patients with significant bradycardia or asystole at time of syncope when all other interventions have failed.

Women's early warning symptoms of acute myocardial infarction.

Data remain sparse on women's prodromal symptoms before acute myocardial infarction (AMI). This study describes prodromal and AMI symptoms in women. Participants were 515 women diagnosed with AMI from 5 sites. Using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey, we surveyed them 4 to 6 months after discharge, asking about symptoms, comorbidities, and demographic characteristics. Women were predominantly white (93%), high school educated (54.8%), and older (mean age, 66+/-12), with 95% (n=489) reporting prodromal symptoms. The most frequent prodromal symptoms experienced more than 1 month before AMI were unusual fatigue (70.7%), sleep disturbance (47.8%), and shortness of breath (42.1%). Only 29.7% reported chest discomfort, a hallmark symptom in men. The most frequent acute symptoms were shortness of breath (57.9%), weakness (54.8%), and fatigue (42.9%). Acute chest pain was absent in 43%. Women had more acute (mean, 7.3+/-4.8; range, 0 to 29) than prodromal (mean, 5.71+/-4.36; range, 0 to 25) symptoms. The average prodromal score, symptom weighted by frequency and intensity, was 58.5+/-52.7, whereas the average acute score, symptom weighted by intensity, was 16.5+/-12.1. These 2 scores were correlated (r=0.61, P<0.001). Women with more prodromal symptoms experienced more acute symptoms. After controlling for risk factors, prodromal scores accounted for 33.2% of acute symptomatology. Most women have prodromal symptoms before AMI. It remains unknown whether prodromal symptoms are predictive of future events.

Diagnosis and treatment of neurally mediated syncope.

Syncope is caused by a severe but reversible reduction in blood flow to the brain stem neurons responsible for supporting consciousness (reticular activating system). Neurally mediated syncope, also referred to as vasovagal or reflex syncope, is the most frequent cause of loss of consciousness in apparently normal subjects. Neurally mediated syncope is believed to be a reflex response with afferent, central, and efferent pathways. Characteristic autonomic changes in neurally mediated syncope are an increase in parasympathetic efferent activity causing bradycardia and a reduction in sympathetic vasoconstrictor outflow causing vasodilatation. Premonitory symptoms, such as nausea, diaphoresis, abdominal discomfort, and blurred vision, are caused by autonomic activation and are distinguishing features of neurally mediated syncope. Neurally mediated syncope frequently has a characteristic trigger, although this may not be apparent. Testing orthostatic tolerance during passive head-up tilt is the best available diagnostic procedure to evaluate patients with syncope in whom a cardiac cause has been excluded. In many cases, once the diagnosis of neurally mediated syncope is confirmed, it may suffice to reassure the patient and teach him to avoid known triggers and to recognize and act upon early warning symptoms. Because subjects with neurally mediated syncope may potentially be sodium depleted, increasing salt intake can be beneficial in improving their orthostatic intolerance. Neurally mediated syncope is the most common form of syncope in healthy adults. The best diagnostic tools are the clinical history and passive head-up tilt. The best treatment strategies are the avoidance of triggering factors as well as intravascular volume expansion.

医薬品市販後に追加される重大な副作用の現状

When a novel additional adverse effect is reported for a marketed medicine, the medical information leaflet has to be revised to inform physicians and pharmacists of this. Pharmacists are responsible for informing patients of early warning symptoms to avoid the subsequent appearance of severe adverse effects. However, at present, patients may suffer from severe adverse events because such symptoms may remain unrecognized until the medicine is on the market. As a result, investigations to predict and prevent novel additional adverse effects of medicines are required. In this study, we investigated a novel additional adverse effect classified as a pharmacological effect based on the drug safety update (DSU). As a result, skin disorders including toxic epidermal necrolysis and Stevens Johnson syndrome, and pseudomembranous colitis have become evident as additional adverse effects of antibiotics, with a high incidence. In addition, neuroleptic malignant syndrome and aplastic anemia have also been reported as adverse effects of central nervous system agents.Therefore, it is important to provide patients with information about the early warning symptoms related to such adverse effects, even though such adverse effects are not contained in the patient information leaflet.

Current diagnosis and treatment modalities for ovarian cancer.

Ovarian cancer is the major pelvic cancer health hazard for women. In 2000, the American Cancer Society estimates that 23,100 new ovarian cancer cases will be diagnosed and 14,000 women will have died of ovarian cancer (1). It is the fifth most common cancer in American women but the fourth most common cause of cancer death (1). The high mortality rate is due in part to a lack of obvious early warning symptoms, unavailability of sensitive early detection techniques and therapy of limited effectiveness. Despite improvements in management of women with epithelial ovarian cancer, the overall survival for this disease has been unchanged for at least the last 20 years (2). This chapter will concentrate on advances in the diagnosis and management of epithelial ovarian cancers, the form of ovarian cancer that represents at least 90% of all ovarian malignancies.

The role of early warning symptoms in the detection and prevention of relapse in schizophrenia.

The capacity of most clinical programs to detect early signs of relapse in schizophrenia and to implement strategies to prevent clinical progression remains unevaluated. The aim of this paper is to review the literature on the detection of relapse in schizophrenia and to draw conclusions that may be of use in the implementation of clinical programs. The relevant literature identified by standard search methods is explored and analysed. Few studies have the capacity to directly address the question as to whether it is possible to predict relapse with a high degree of predictive power. Recently, the implementation of a multifactorial approach to relapse prediction appears to have offered substantial benefits. The prediction of episodes of psychotic relapse is a realistic goal. Evidence indicates that interventions based upon programs of early detection can reduce rates of illness relapse. Prediction of relapse is most successful when implemented in a multifactorial way that involves specific and non-specific symptoms, structured ratings, clinical judgement, families, patients and clinicians.

Ethnicity and childhood mortality in The Netherlands

Background: This paper describes the rates and the causes of differences in childhood mortality between Turkish, Moroccan and native Dutch children in The Netherlands. Methods: Retrospective analysis of all routinely collected death certificates of 0-15 year old children who died between 1979 and 1993. In total 20,211 death certificates of which 1,764 of Turkish and Moroccan children were analysed. Childhood mortality was divided into four age periods, analysed according to ICD-9 codes and measured over three five-year periods. Results: Compared to native Dutch children, the relative mortality risk (RR) for Turkish and Moroccan infants and children is twice as high. It did diminish from 3.2 in the first five- year period (1979-1983) to 2.2 in the second (1984-1988). After 1988 no further decline In relative mortality risk was noticed (RR: 2.1). Minor differences were found between the Turkish and Moroccan groups in the four different age categories. The relative risk for Turkish and Moroccan children to die from different diagnostic categories is as follows: Infectious diseases: RR 2.2 (95% Cl: 1.83-2.68), hereditary (metabolic) disorders: RR 2.0 (Cl: 1.78-2.20), accidents and drowning RR 1.9 (Cl: 1.64-2.21). There was a decline In all cause specific mortality ratios over time except for hereditary disorders and (traffic) accidents and drowning. One quarter of the Turkish and Moroccan children died while on holiday in their country of origin. The only significant difference between the Turkish and Moroccan group was found in Sudden Infant Death Syndrome. While the actual number of SIDS cases declined drastically over the last five year period, the SIDS rate for Turkish infants remained twice as high as for Dutch Infants and four times higher than for Moroccan infants. Conclusion: Differences in mortality between Turkish, Moroccan and Dutch children are significant and have hardly changed during the last 10 years. Apart from apparent socio-economic differences, socio-cultural and life-style factors may play an important role as well. Preventive measures such as health and safety education concerning the (yearly) holiday trip to the country of origin, genetic counselling in consanguinity, better knowledge of early warning symptoms of serious infectious diseases, road safety education and early swimming-lessons are possible. The high SIDS differences have to be investigated further.

Conocimientos, creencias y actitudes de la población femenina de Mallorca respecto al cáncer

BACKGROUND: To analyze the knowledge of the facts on the part of the female population of Mallorca with regard to the causes of cancer, the beliefs regarding diagnosis and treatment and their attitude toward prevention. METHODS: A descriptive cross-section study of a random population sample (n=124) of women within the 40-69 age range. The questionnaire includes socio-demographic variables, risk factors, early warning symptoms and beliefs regarding diagnosis and treatment and attitudes toward prevention. RESULTS: Cigarette smoking (92.7%;CI:88.1-97.3) and drinking alcoholic (85.7%; CI:79.4-92.0) are the most well-identified causes. Also the presence of a lump in the breast (92.6%;CI:87.9-97.2) and changes in a mole or wart on the skin (89.7% ; CI:84.2-95.2%). The underestimate the role of the diet (44.4%; CI:35.1-53.8) and overestimate the environmental factors. The knowledge and use of self-examination procedures on the breast are associated directly with the degree of education (p<0.05). Most believe that early diagnosis improves the prognosis (98.4%; CI:94.2-99.5) and that treatment is beneficial (85.2%; CI:78.5-91.9). They consider surgery to be the most highly effective method, and in the event of any doubt they would first see their primary care physician (41.9%; CI:33.2-50.6). It is mainly older women having a low level of completed schooling who get their information regarding cancer above all from the television (43.5%; CI:34.8-52.3). Worthy of special mention is the very small impact of health care personal as a source of information (6.5%; CI:2.1-10.8). CONCLUSIONS: A major knowledge of the facts exists regarding the causes and warning signs, although some misconceptions do exist. In view of future prevention campaigns, educational measures addressed mainly to older women having a low level of completed schooling should be carried out.

Trauma and pregnancy.

Trauma and/or accidental injury complicates 6-7% of all pregnancies. The management protocols for trauma in pregnancy are based largely on case reports and small series. The purposes of this study were to: describe the demographics of pregnant trauma patients at a tertiary care center and a large community hospital; identify variables predictive of fetal outcome including an examination of Kleihauer-Betke and nonstress testing; and recommend an evaluation and management protocol after trauma based on empirical data rather than anecdotal reports. Data from pregnancies complicated by trauma from July 1987 through October 1993 were retrospectively reviewed. Statistical analysis included Chi-square and Kruskall-Wallis testing. There were 476 medical records available for review. Of the trauma cases, 54.6% were motor vehicle accidents, 22.3% were domestic abuse and assaults, 21.8% were associated with falls, and 1.3% were secondary to burns, puncture wounds, or animal bites. Mean maternal age was 24 years, 49.9% were Caucasian, and 43% were primigravid. Mean gestational age at occurrence of trauma was 25.9 weeks and mean gestational age of delivery was 37.9 weeks. Domestic abuse occurred most frequently before 18 weeks, falls between 20-30 weeks' gestation, and motor vehicle accidents occurred with equal frequency throughout gestation. Uterine contractions occurred in 39.8% of patients and as often as every 1 to 5 min in 18% of patients. Preterm labor occurred in 11.4%, preterm delivery in 25%, and abruptions in 1.58% of the trauma population. Fetal heart rate monitoring was abnormal in 3% of cases. Twenty-seven perinatal deaths were noted and in 14 pregnancies the deaths were related to trauma. Eight of these perinatal deaths were associated with motor vehicle accidents, four with domestic violence, and two with falls. The only preventable perinatal deaths were a twin pregnancy transferred with nonreassuring fetal heart tones. Early warning symptoms of vaginal bleeding, uterine contractions, and/or abdominal and/or uterine tenderness were not predictive of either preterm delivery or adverse pregnancy outcome, sensitivity 52%, specificity 48%. Abnormal monitoring and positive Kleihauer-Betke tests were also not predictive of adverse pregnancy outcome. However, there were no adverse outcomes directly related to trauma when monitoring was normal and early warning symptoms were absent (negative predictive value 100%). Two hundred eighty-nine Kleihauer-Betke tests were performed and only one affected management. Repetitive monitoring over several days did not uncover any patients whose heart rate tracings evolved from normal to abnormal monitoring. Given our findings that prolonged monitoring was not helpful in management of pregnant trauma patients, we support the recommendation that initial external fetal monitoring be performed for 4 hr, and, if reassuring, the patient may be sent home with precautions. We also recommend an Rh-immunoglobulin work-up for all Rh-negative pregnant trauma patients, but do not recommend Kleihauer-Betke testing for Rh-positive women. Given the frequency with which trauma affects pregnancy and the difficulty encountered with identifying variables predictive of pregnancy outcome, there may be great benefits of incorporating trauma prevention into routine prenatal care.

Biology of pulmonary preneoplastic lesions

In industrialized countries, lung cancer is the leading cause of death from cancer, and this high mortality is mainly due to late diagnosis (I). The disease usually develops insidiously, without early warning symptoms, reaching a tumour load that is often too large to be amenable to curative surgical therapy at the time of diagnosis. Pulmonary preneoplastic lesions are a heterogeneous group of morphological epithelial changes that can eventually progress to invasive cancer. Interest in these pre-invasive lesions is based on the assumption that their better characterization might lead to earlier diagnosis of lung tumours and so to new therapeutic approaches. In order to review the current knowledge on pulmonary preneoplastic lesions, the authors performed a database search. This included Cancerlit’, Medline@, and Healthstar’ for the period from January 1989 to December 1996 with the following key words: lung, precancerous condition, preneoplasia(s), preneoplastic, metaplasia(s) and dysplasia(s). Papers on chemoprevention approaches and bronchogenic dysplasias in infants were not considered. In addition, information collected in symposia, namelythetwo IASLC (International Association for Lung Cancer Study) Workshops hold in Elsinore (Prevention and early detection of lung cancer, 22-25 June 1996) and in Nancy (Biological basis of lung cancer prevention, 20-22 October 1996) have been summarized. This review will first discuss current concepts on the carcinogenesis of lung cancer, and will then review, in detail, recent advances in the pathophysiology and molecular biology of pulmonary preneoplastic lesions.

Spousal abuse/homicide. A current issue in health risk management.

Domestic homicides shocked Calgary in 1995. As the year drew to a close, statistics revealed that 5 of the city's 18 murders were at the hands of an abusive spouse, former spouse, or boyfriend. This prompted women across the city to campaign for more protection for women. Press conferences were held in which Calgary's most prominent women's groups called for tougher action against violent offenders. With 1996 over the halfway mark, one case of spousal homicide has occurred. Although statistics are down from this time last year, it is an event that should not have occurred. Although public awareness and pressure led to more women's shelters and programs, these results were tertiary measures. This level of prevention deals with "after the crisis response" to the event and is reactive in its approach. Proactive or primary measures which reduce the risk of the problem starting are now being called for. Throughout history, health care professionals have been called upon to assist the legal system in the prosecution of cases where patient care overlaps with the law, or where the law and physiological realities collide. However not until recently have nurses had the opportunity to study within the field in a formal, organized manner (Lynch, 1995). The shift toward community-based rather than institutional care brings health care professionals in direct contact with cases of abuse and neglect in their natural settings. Early warning signs and symptoms of interpersonal violence will go unreported until nurses are taught to include these in their observations. Nursing programs now prepare nurses for this new specialty practice. Although calls for changes to the restraining orders and greater police protection for women in volatile situations are perfectly understandable, no one pretends they are the answer. The solution begins with spreading the very basic understanding throughout society that women are not property to be exploited or targets for venting anger. To effect change, spousal abuse must be viewed as a primary health care issue that affects us all, as well as being a social and human rights issue. It would benefit our society to become as incensed over spousal abuse as we are over drunk driving. Spousal abuse is a criminal offense and should be treated as such. Ending spousal abuse will require a significant reevaluation of human relationships, a much decreased public tolerance of violence and its depiction, and economic and political conditions that promote equality and a greater ability to control one's own life, but not others (MacLeod, 1994). This analysis of Calgary's response to the domestic homicides of 1995 is a risk-management approach of how the city dealt with this critical problem. With a greater focus on risk management strategies, along with public education and a greater interface with law enforcement agencies, forensic nurses will help reduce the sequelae of human violence; specifically, the fatalities of spousal abuse.

Reduced awareness of hypoglycemia in adults with IDDM. A prospective study of hypoglycemic frequency and associated symptoms.

To prospectively evaluate the frequency and severity of hypoglycemic episodes in IDDM subjects who declare themselves to have reduced awareness of hypoglycemia, to validate their self-designations in their natural environment, and to determine objectively the presence or absence of autonomic and neuroglycopenic symptoms associated with their low blood glucose (BG) levels. A total of 78 insulin-dependent diabetes mellitus (IDDM) subjects (mean age 38.3 +/- 9.2 years; duration of diabetes 19.3 +/- 10.4 years) completed two sets of assessments separated by 6 months. The assessments included reports of frequency and severity of low BG, symptoms associated with low BG, and a BG symptom/estimation trial using a hand-held computer (HHC). Diaries of hypoglycemic episodes were kept for the intervening 6 months. HbA1 levels were determined at each assessment. Of the subjects, 39 declared themselves as having reduced awareness of hypoglycemia (reduced-awareness subjects). There were no differences between these reduced-awareness subjects and aware subjects with regard to age, sex, disease duration, insulin dose, or HbA1. During the HHC trials, reduced-awareness subjects were significantly less accurate in detecting BG < 3.9 mmol/l (33.2 +/- 47 vs. 47.6 +/- 50% detection, P = 0.001) and had significantly fewer autonomic (0.41 +/- 0.82 vs. 1.08 +/- 1.22, P = 0.006, reduced-awareness vs. aware) and neuroglycopenic (0.44 +/- 0.85 vs. 1.18 +/- 1.32, P = 0.004, reduced-awareness vs. aware) symptoms per subject. Prospective diary records revealed that reduced-awareness subjects experienced more moderate (351 vs. 238, P = 0.026) and severe (50 vs. 17, P = 0.0062) hypoglycemic events. The second assessment results were similar to the first and verified the reliability of the data. IDDM subjects who believe they have reduced awareness of hypoglycemia are generally correct. They have a history of more moderate and severe hypoglycemia, are less accurate at detecting BG < 3.9 mmol/l, and prospectively experience more moderate and severe hypoglycemia than do aware subjects. Neither disease duration nor level of glucose control explains their reduced awareness of hypoglycemia. Reduced-awareness individuals may benefit from interventions designed to teach them to recognize all of their potential early warning symptoms.