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Clinical study of hearing instruments: a cross-sectional longitudinal audit based on consumer experiences.

The objective of the present audit was to document improvements/changes in hearing instrument (HI) benefit in terms of use and satisfaction throughout the 1990s and compare the benefit in consumers fitted with analogue (A), programmable (P), and digital signal processing (DSP) HIs. The audit data are based on a questionnaire mailed to subjects fitted with HIs 3 to 4 months after the fitting, including questions concerning satisfaction with the HI, use of the HI, ability to manage the HI, and satisfaction with the overall services in the department. Information was obtained from 32,694 subjects (i.e., 71.2 per cent of those fitted with HIs throughout the last decade), with a median age at fitting of 78 years (range, 18-102), with a preponderance of females. No significant differences in age, gender distribution, and hearing instrument distribution were found between the respondents and non-respondents. The audit shows that there are no significant differences in any of the benefit parameters throughout the decade, irrespective of the introduction of P-HIs in 1995 and of the DSP-HIs in 1998. Thus, from the consumers' perspective, no changes have appeared in the last decade. A comparative analysis of the A-HIs, P-HIs, and DSP-HIs shows that among those provided with P-HIs and DSP-HIs, only 69.6 per cent (CI 68.1-71.0) and 65.5 per cent (CI 60.2-78.8), respectively, were very satisfied/satisfied with the HI, which is significantly less than the 73.5 per cent (CI 72.4-74.5) in those fitted with A-HIs. The daily/weekly use of all three types of HIs was similar. However, the group fitted with DSP-HIs was significantly less satisfied with the general services compared with those fitted with A-HIs and P-HIs, respectively. Based on these audit data, it is concluded that, according to the consumers, the outcome from HIs has not changed over the last decade, and a comparison between the traditional A-HIs with both P-HIs and DSP-HIs is in favour of the traditional A-HIs.

Aged↗

Application of variable life adjusted display (VLAD) in early detection of deficiency in trauma care.

Early detection of deficient care is an increasingly important element of trauma audit. We aimed to assess the feasibility and demonstrate the use of a variable life adjusted display (VLAD) in trauma audit. Data from the Trauma Audit and Research Network database of Sheffield Teaching Hospitals NHS Trust were used to create a VLAD. A cumulative display of survival was plotted in which survivors were incorporated as a positive value equal to 1 minus the probability of survival, and deaths were incorporated as a negative value equal to the probability of survival. Downward deflections of the display thus indicated potentially deficient trauma care. Data from 191 consecutive patients over 1 year were plotted and displayed. The first 2 months of this period were characterised by a downward trend in the line, which may indicate suboptimum performance and provides an example of a trend that would prompt detailed review. The VLAD chart is a potentially useful "early warning" system for poor performance in trauma care. Further work should to be carried out to evaluate VLAD prospectively as an audit tool, perhaps involving comparison of VLAD charts from different institutions.

Adult↗

Cost effectiveness of drug eluting coronary artery stenting in a UK setting: cost-utility study.

OBJECTIVE: To assess the cost effectiveness of drug eluting stents (DES) compared with conventional stents for treatment of symptomatic coronary artery disease in the UK. DESIGN: Cost-utility analysis of audit based patient subgroups by means of a simple economic model. SETTING: Tertiary care. PARTICIPANTS: 12 month audit data for 2884 patients receiving percutaneous coronary intervention with stenting at the Cardiothoracic Centre Liverpool between January 2000 and December 2002. MAIN OUTCOME MEASURES: Risk of repeat revascularisation within 12 months of index procedure and reduction in risk from use of DES. Economic modelling was used to estimate the cost-utility ratio and threshold price premium. RESULTS: Four factors were identified for patients undergoing elective surgery (n = 1951) and two for non-elective surgery (n = 933) to predict risk of repeat revascularisation within 12 months. Most patients fell within the subgroup with lowest risk (57% of the elective surgery group with 5.6% risk and 91% of the non-elective surgery group with 9.9% risk). Modelled cost-utility ratios were acceptable for only one group of high risk patients undergoing non-elective surgery (only one patient in audit data). Restricting the number of DES for each patient improved results marginally: 4% of stents could then be drug eluting on economic grounds. The threshold price premium justifying 90% substitution of conventional stents was estimated to be 112 pound sterling (212 USD, 162 pound sterling) (sirolimus stents) or 89 pound sterling (167 USD, 130 pound sterling) (paclitaxel stents). CONCLUSIONS: At current UK prices, DES are not cost effective compared with conventional stents except for a small minority of patients. Although the technology is clearly effective, general substitution is not justified unless the price premium falls substantially.

Aged↗

Quality assurance and monitoring in the Hypertension Prevention Trial. Hypertension Prevention Trial Research Group.

The Hypertension Prevention Trial (HPT), was a randomized, controlled, multicenter (four clinics, four resource centers) trial designed to test the feasibility of achieving and sustaining dietary changes in the intake of calories, sodium, and potassium and to assess the effect of those changes on blood pressure in a normotensive population. The trial involved 841 men and women (plus a test cohort of 78) who, at the first baseline (BL) examination were in the age range of 25-49 years and had diastolic blood pressure (DBP) greater than or equal to 76 but less than 100 mm Hg (average of two readings), and at the examination prior to randomization (BL 2) had DBP greater than or equal to 78 but less than 90 mm Hg (also averaged). Participants were randomly assigned to a control treatment group (no dietary counseling) or to one of four dietary treatment groups involving counseling designed to reduce calorie intake, reduce sodium intake, reduce sodium and calorie intake, and reduce sodium and increase potassium intake. This chapter describes HPT procedures for training and certifying clinic staff, for data entry checks and data audits of its distributed data entry system, and for inspecting clinical equipment. Replicate analyses were performed regularly by the two arms of the Data Coordinating Center. The Food Coding Center and the Central Laboratory were evaluated by both internal and external monitoring techniques. The performance monitoring report, prepared semiannually for the governing committees of the HPT, reported on the effectiveness of quality assurance procedures and served to alert staff to developing problems.

Adult↗

Performance indicators from routine hospital data: death following aortic surgery as a potential measure of quality of care.

BACKGROUND: There is increasing pressure to monitor surgical performance. In the UK, the Department of Health has produced clinical indicators based on routine data to monitor performance. This study analysed whether such data could measure performance in aortic surgery. METHODS: Routine hospital data on postoperative mortality were collected for 1995-1997 in the Trent region. Procedural and diagnostic codes, modes of admission, districts of residence, treatment and specialty data were compared with audit data and the Operating Theatre Information System. RESULTS: Inaccuracies in the Health Resource Group (HRG) codes meant that 21.4 per cent of elective aortic cases (HRG Q02) were probably emergencies and 26 per cent of probable ruptured aneurysms were not coded as a vascular emergency. Case mix and patient selection introduced a bias, apparent between tertiary and district general hospitals. For patients aged over 80 years, two district hospitals undertook no elective aortic surgery; the rate for emergency aortic surgery varied between 16 and 25 per cent in the district hospitals, and was 77 per cent in the tertiary centre. CONCLUSION: Crude mortality rates used as an indicator of performance are subject to bias and distortion owing to the collection of incorrect information, variation in patient selection between hospitals and case-mix differences. There was a considerable variation in selection and outcomes of patients undergoing aortic surgery in this study.

Aortic Aneurysm, Abdominal↗

Effectiveness of darbepoetin alfa versus epoetin alfa in patients with chemotherapy-induced anemia treated in clinical practice.

PRIMARY PURPOSE: The objective of this retrospective observational cohort study was to compare the effectiveness of darbepoetin alfa with that of epoetin alfa in patients with chemotherapy-induced anemia using data from noncontemporaneous chart audits conducted at a community-based oncology practice. MATERIALS AND METHODS: For the first chart audit, data were collected from consecutive patients with nonmyeloid malignancies with diagnoses of chemotherapy-induced anemia and hemoglobin levels < or = 10.5 g/dl who were receiving concurrent chemotherapy and had at least 5 weeks of visits from July-September 2000. After therapeutic substitution of darbepoetin alfa for epoetin alfa for all patients with chemotherapy-induced anemia, data were collected from consecutive darbepoetin alfa-treated patients with diagnoses of chemotherapy-induced anemia and at least 8 weeks of visits from June-October 2002 (darbepoetin alfa was approved in July 2002). RESULTS: Most (86%) of the 212 epoetin alfa-treated patients had received an initial dose of 40,000 U once weekly, and most (85%) of the 196 darbepoetin alfa-treated patients had received a fixed dose of either 100 microg once weekly (49%) or 200 microg every 2 weeks (36%). At 8 weeks, the mean change in hemoglobin level was 1.1 g/dl for the darbepoetin alfa patient group and 1.0 g/dl for the epoetin alfa patient group. DISCUSSION: Utilization, dose escalation rates, and clinical outcomes were considered comparable for the darbepoetin alfa and epoetin alfa patient groups. CONCLUSIONS: Darbepoetin alfa, 100 microg once weekly or 200 microg every 2 weeks, appears to be as effective as epoetin alfa, 40,000 U once weekly, for the treatment of chemotherapy-induced anemia in the clinical practice setting.

Adult↗

NTP Toxicology and Carcinogenesis Studies of 1,2-Epoxybutane (CAS No. 106-88-7) in F344/N Rats and B6C3F1 Mice (Inhalation Studies).

1,2-Epoxybutane was selected for study because it is a short-chain epoxide that had been shown to be mutagenic and because no carcinogenicity data were available. Approximately 8 million pounds of 1,2-epoxybutane are produced annually in the United States. The chemical is used primarily as a stabilizer in chlorinated hydrocarbon solvents. Single-Exposure, Fourteen-Day, and Thirteen-Week Studies: Single-exposure, 14-day, 13-week, and 2-year studies were conducted in F344/N rats and B6C3F1 mice. The chemical was greater than 99% pure and was administered as a vapor by the inhalation route to mimic worker exposure; room air was used as the control exposure during these studies. Exposures were 6 hours per day (5 days per week), except in the single-exposure studies (4 hours). Additional studies were performed to evaluate the potential for genetic damage in bacteria and in mammalian cells. In the single-exposure studies, the chemical was administered at exposure concentrations of 400-6,550 ppm in rats and 400-2,050 ppm in mice. In the 14-day studies, rats and mice were exposed at 400-6,400 ppm, and in the 13-week studies, rats and mice were exposed at 50-800 ppm. All rats in the single-exposure studies at 6,550 ppm died; compound-related deaths were not seen in other dosed groups. All mice at 2,050 ppm and 4/5 mice of each sex at 1,420 ppm died; compound-related mortality was not seen in other dosed groups. In the 14-day studies, all rats at 3,200 and 6,400 ppm and 2/5 female rats at 1,600 ppm died; all mice at 1,600, 3,200, and 6,400 and 1/5 male mice at 800 ppm died. Final mean body weights of surviving rats exposed at 800 or 1,600 ppm were 12%-33% lower than those of the controls; final mean body weights of surviving mice at 800 ppm were 10%-12% lower than those of the controls. Compound-related lesions included pulmonary hemorrhage and rhinitis in rats at 1,600 ppm and nephrosis in mice at 800 and 1,600 ppm. In the 13-week studies, no compound-related mortality was observed in rats; all mice exposed at 800 ppm died. No compound-related clinical signs were seen in rats or in surviving mice. The final mean body weight of rats exposed at 800 ppm was 23% lower than that of controls for males and 16% lower for females. Final body weights of surviving mice were unaffected by exposure. Inflammation of the nasal turbinates was seen in rats at 800 ppm but not at lower exposure concentrations. Renal tubular necrosis was seen in mice at 800 ppm but not at lowerconcentrations. Inflammation of the nasal turbinates was observed in female mice at 100, 200, 400, and 800 ppm and in male mice at 200, 400, and 800 ppm. The highest exposure concentration selected for the 2-year studies in rats was 400 ppm because of body weight effects and nasal lesions observed at 800 ppm. The highest concentration selected for the 2-year studies in mice was 100 ppm because the nasal lesions seen at 200 and 400 ppm were considered to be potentially life threatening. Two-Year Studies: The 2-year toxicology and carcinogenesis studies of 1,2-epoxybutane were conducted by exposing groups of 50 animals per species and sex to the chemical by inhalation, 6 hours per day 5 days per week. Rats were exposed at concentrations of 0, 200, or 400 ppm for 103 weeks and mice at 0, 50, or 100 ppm for 102 weeks. Body Weight and Survival in the Two-Year Studies: The survival of all groups of dosed rats was at least 50% until week 98, but final survival was reduced in the dosed groups (final survival-- male: control, 30/50; low dose, 18/50; high dose, 23/50; female: 32/50; 21/50; 22/50). Mean body weights of control and exposed male rats were similar until week 86; thereafter, mean body weights of high dose male rats were 4%-8% lower than those of controls. Mean body weights of high dose female rats were 5%-10% lower than those of controls after week 22. Survival in male mice was comparable among groups (final survival: 41/50; 45/50; 33/50). Survival in female mice was greater than 50% in all groups at week 86 and then was reduced in high dose females toward the end of the stin all groups at week 86 and then was reduced in high dose females toward the end of the study (final survival: 29/50; 25/50; 9/50). This decreased survival was associated with suppurative inflammation of the ovary and uterus. Klebsiella oxytoca was isolated from these ovarian/uterine lesions. Mean body weights of high dose male mice were 10&percnt;-14&percnt; lower than those of the controls after week 69; mean body weights of low dose male mice were 4&percnt;-8&percnt; lower than those of the controls after week 86. Mean body weights of high dose female mice were 13&percnt;-23&percnt; lower than those of the controls after week 60, and mean body weights of low dose female mice were 12&percnt;-16&percnt; lower than those of the controls after week 73. Nonneoplastic and Neoplastic Effects in the Two-Year Studies: Dosed rats had nonneoplastic lesions of the nasal cavity including inflammation, epithelial hyperplasia, squamous metaplasia, hyperostosis of the nasal turbinate bone, and atrophy of the olfactory epithelium. Seven papillary adenomas of the nasal cavity were seen in highdose male rats and two in high dose female rats. The historical incidences of nasal cavity adenomas in untreated male and untreated female F344/N rats are less than 0.1&percnt;. The incidences of alveolar/bronchiolar carcinomas (0/50; 1/50; 4/49) and adenomas or carcinomas (combined) (0/50; 2/50; 5/49) were increased in high dose male rats; no increased incidences of these tumors were observed in dosed female rats. Dosed mice had increased incidences of nonneoplastic lesions of the nasal cavity but no significant increase in the incidence of neoplastic lesions of the nasal cavity. The nonneoplastic lesions included suppurative inflammation (empyema), epithelial hyperplasia, erosion, regeneration, and squamous metaplasia in the nasal cavity; atrophy of the olfactory sensory epithelium; hyperplasia of the nasal gland (Bowman's glands); and inflammation and hyperplasia of the nasolacrimal duct. A single squamous cell papilloma was seen in the incisive duct of one high dose male mouse. Genetic Toxicology: 1,2-Epoxybutane was mutagenic in Salmonella typhimurium strains TA100 and TA1535 when tested with a preincubational protocol with or without rat liver S9, indicating that it is a direct-acting mutagen capable of inducing base-pair substitutions in prokaryotes; it did not cause gene reversion in strains TA1537 or TA98. 1,2-Epoxybutane induced forward mutations at the TK locus of cultured mouse L5178Y lymphoma cells with and without metabolic activation. Both chromosomal aberrations andsister chromatid exchanges were induced in cultured Chinese hamster ovary cells after exposure to 1,2-epoxybutane in the presence and absence of metabolic activation. 1,2-Epoxybutane, when fed to male Drosophila, caused significant increases in the number of sex-linked recessive lethal mutations and reciprocal translocations in the germ cells. Data Audit: An audit of the experimental data was conducted for the 2-year studies of 1,2-epoxybutane. No data discrepancies were found that influenced the final interpretations. Conclusions: Under the conditions of these 2-year inhalation studies, there was clear evidence of carcinogenic activity of 1,2-epoxybutane for male F344/N rats, as shown by an increased incidence of papillary adenomas of the nasal cavity, alveolar/bronchiolar carcinomas, and alveolar/bronchiolar adenomas and carcinomas (combined). There was equivocal evidence of carcinogenic activity for female F344/N rats, as shown by the presence of papillary adenomas of the nasal cavity. There was no evidence of carcinogenic activity for male or female B6C3F1 mice exposed at 50 or 100 ppm. 1,2-Epoxybutane exposure was associated with adenomatous hyperplasia and inflammatory lesions of the nasal cavity in rats and inflammatory lesions of the nasal cavity in mice. Synonyms: 1-butene oxide; 1,2-butene oxide; butylene oxide; 1,2-butylene oxide; ethyl ethylene oxide; ethyl oxirane

Journal Article↗

NTP Toxicology and Carcinogenesis Studies of Methyl Carbamate (CAS No. 598-55-0) in F344/N Rats and B6C3F1 Mice (Gavage Studies).

Methyl carbamate is used as a chemical intermediate by the textile industry for the manufacture of dimethylol methyl carbamate-based resins that are applied on polyester/cotton blend fabrics as durable-press finishes. Experimental Design: Toxicology and carcinogenesis studies of methylyl carbamate (98% pure) were conducted by exposing groups of F344/N rats and B6C3F1 mice by gavage in water in a single dose and by repeated administration for 16 days, 13 weeks, 6 months, 12 months, 18 months, and 2 years. In addition, short-term mutagenicity studies in bacteria, mammalian cells, and Drosophila and of unscheduled DNA synthesis in rat liver cells were conducted. Single-Administration Studies: In the single-administration studies, 5/5 male and 5/5 female rats that received 8,000 mg/kg methyl carbamate and 2/5 male and 5/5 female that received 4,000 mg/kg died before the end of the 15-day observational period. Five of five male and 5/5 female mice that received 8,000 mg/kg and 1/5 females that received 4,000 mg/kg died before the end of the 15-day observational period. No compound-related morphologic effects were observed in rats or mice that received 2,000 mg/kg. Sixteen-Day Studies: In the 16-day studies, all rats dosed at 2,000 or 4,000 mg/kg died, and 3/5 male rats that received 1,000 mg/kg died. Male mice that received 2,000 or 4,000 mg/kg, female mice that received 4,000 mg/kg, and 1/5 female mice that received 2,000 mg/kg died. No compound-related gross pathologic or histopathologic effects were seen in male or female rats (groups of five each) that received 500 mg/kg or in mice that received 1,000 mg/kg. Thirteen-Week Studies: In the 13-week studies, groups of 10 male and 10 female rats and mice received up to 800 mg/kg (male rats), 1,000 mg/kg (female rats), 1,500 mg/kg (male mice), or 2,000 mg/kg (female mice). Four of 10 male rats that received 800 mg/kg and 1/10 female rats that received 1,000 mg/kg died of compound-related causes before the end of the studies. Toxic hepatitis, splenic pigmentation, bone marrow atrophy, and testicular atrophy were observed in the two highest dose groups of rats. One of the female mice that received 2,000 mg/kg died. The dosed female mice had significantly greater liver weights than did the vehicle controls. Experimental Design of Six-, Twelve-, and Eighteen-Month and Two-Year Studies: Based on the findings in the short-term studies, 2-year studies of methyl carbamate were conducted by administering 0, 100, or 200 mg/kg methyl carbamate in distilled water by gavage, 5 days per week for 103 weeks, to groups of 50 F344/N rats of each sex for 103 weeks. Groups of 50 B6C3F1 mice of each sex were administered 0, 500, or 1,000 mg/kg methyl carbamate on the same schedule. Additional groups of 30 rats of each sex were administered 0 or 400 mg/kg methyl carbamate, and additional groups of 30 mice of each sex were administered 0 or 1,000 mg/kg methyl carbamate in distilled water by gavage, 5 days per week. Ten animals from each group were killed at 6, 12, or 18 months so that the progression of lesions could be followed. Results of the Six-, Twelve-, and Eighteen-Month and Two-Year Studies: In the 6-month studies, all vehicle control and dosed (400 mg/kg) rats survived. Cytologic alterations and atypical proliferative changes were observed in the liver of all dosed male and female rats, and neoplastic nodules of the liver were observed in 6/10 dosed male and 5/10 dosed female rats. In the 12-month studies, all vehicle control male and female rats and dosed female rats survived. One of 10 dosed male rats died. Neoplastic nodules of the liver were observed in 7/10 dosed male and 9/10 dosed female rats, and hepatocellular carcinomas were observed in 8/10 dosed male and 6/10 dosed female rats. In the 18-month studies, 1/10 dosed male and 8/10 dosed female and all vehicle control rats survived. Hepatocellular carcinomas were observed in 9/10 dosed male and 8/10 dosed female rats. Compound-related neoplastic changes were not observed in mice in the 6-, 12-, or 18-month studies. In the 2-year studar studies, mean body weights of high dose (200 mg/kg) male rats were generally 5&percnt;-9&percnt; lower than those of the vehicle controls after week 20. Mean body weights of high dose female rats were 5&percnt;-8&percnt; lower than those of the vehicle controls after week 56. Survival of dosed and vehicle control rats was similar (male: vehicle control, 19/50; low dose, 26/50; high dose, 29/50; female: 29/50; 36/50; 35/50). The mean body weights of high dose (1,000 mg/kg) male mice were about 8&percnt;-18&percnt; lower than those of the vehicle controls after week 24. The mean body weights of high dose (1,000 mg/kg) female mice were about 16&percnt; lower than those of the vehicle controls after week 16 and 30&percnt; lower after week 64. Survival of dosed and vehicle control mice was similar (male: 28/50; 35/50; 28/50; female: 38/50; 36/50; 32/50). Chronic focal inflammation and cytologic alteration of the liver were observed at increased incidences in high dose rats of each sex. Hyperplasia of hepatocytes was observed atincreased incidences in dosed male and high dose female rats. Neoplastic nodules or hepatocellular carcinomas (combined) in female rats occurred with a significant positive trend (0/50; 0/50; 6/49; P<0.01); the incidence of neoplastic nodules or hepatocellular carcinomas (combined) in high dose female rats was greater (P<0.03) than that in the vehicle controls. Incidences of liver neoplasms in dosed male rats were not significantly increased (4/50; 0/50; 7/49). Inflammation of the harderian gland was observed at increased incidences in dosed rats (male: 4/50; 11/50; 16/50; female: 7/50; 16/50; 30/50). The lesions were considered to be chemically related. In the 2-year studies in rats, significant decreases in tumor incidences included the following: leukemia (both sexes), pituitary gland (male), adrenal gland (male), and mammary gland (female). In the 2-year mouse studies, multinucleate giant cells in the liver were observed at increased incidences in dosed male mice (14/50; 31/50; 31/49). Adenomatous hyperplasia and histiocytosis of the lung were observed at increased incidences in high dose mice (adenomatous hyperplasia--male: 13/50; 19/50; 24/49; female: 7/49; 10/50; 18/50; histiocytosis--male: 11/50; 7/50; 21/49; female: 9/49; 10/50; 21/50). Genetic Toxicology: Methyl carbamate was not mutagenic in Salmonella typhimurium strains TA97, TA98, TA100, or TA1535 when tested with or without metabolic activation in a preincubation protocol at doses up to 10 mg/plate. Methyl carbamate did not induce forward mutations in the mouse L5178Y/TK&plusmn; lymphoma assay with or without metabolicactivation at doses up to 5 mg/ml. Unscheduled DNA synthesis was not detected in rat hepatocytes after in vitro treatment with methyl carbamate at concentrations of 1.0-1,000 ug/ml. When tested in Drosophila at doses of 25,000-50,000 ppm, methyl carbamate did not induce sex-linked recessive lethal mutations. Results of tests for induction of chromosomal aberrations and sister chromatid exchanges by methyl carbamate in cultured Chinese hamster ovary cells were also negative at doses up to 5 mg/ml. Data Audit: An audit of the experimental data was conducted for the 6-, 12-, and 18-month and 2-year studies of methyl carbamate. No data discrepancies were found that influenced the final interpretation. Conclusions: Under the conditions of these 6-, 12-, and 18-month and 2-year gavage studies, there was clear evidence of carcinogenic activity for male and female F344/N rats given methyl carbamate as indicated by increased incidences of hepatocellular neoplastic nodules and hepatocellular carcinomas. There was no evidence of carcinogenic activity for male and female B6C3F1 mice given methyl carbamate at doses of 500 or 1,000 mg/kg. Methyl carbamate also induced inflammation of the harderian gland in male and female rats and adenomatous hyperplasia and histiocytosis of the lung in male and female mice. Synonyms: carbamic acid, methyl ester; methylurethan; methylurethane; urethylane

Journal Article↗

NTP Toxicology and Carcinogenesis Studies of Ethylene Oxide (CAS No. 75-21-8) in B6C3F1 Mice (Inhalation Studies).

Ethylene oxide is a major industrial chemical used primarily as an intermediate in the manufacture of other chemicals; e.g., ethylene glycol, a major component of automotive and other antifreeze products. Exposure to ethylene oxide is greatest in the health care industry, where an estimated 75,000 workers are potentially exposed. Ethylene oxide was nominated for toxicology and carcinogenesis studies in B6C3F1 mice because of its extensive production; the potential for human exposure in the workplace, from medical devices, or from food; the positive results of genetic toxicology assays; and the previous use of only F344/N rats in inhalation carcinogenicity studies. Two inhalation studies reported in 1984 by Snellings et al. and by Lynch et al. demonstrated carcinogenic responses in F344/N rats. Results were similar in both studies and consisted of increased incidences of mononuclear cell leukemia, peritoneal mesotheliomas, and primary brain tumors. Experimental Design: Toxicology and carcinogenesis studies of ethylene oxide (greater than 99% pure) were conducted by exposing groups of 50 B6C3F1 mice of each sex to air containing 0, 50, or 100 ppm ethylene oxide, 6 hours per day, 5 days per week for 102 weeks. These doses were selected because, in 14-week studies, all mice exposed at 600 ppm died within 1 week, and all mice exposed at 400 ppm died by week 4. Rhinitis was observed in both sexes exposed at 200, 400, and 600 ppm as was renal tubular degeneration in both sexes at 100, 200, and 400 ppm. The latter effects observed at 100 ppm were slight and deemed not to be life threatening in 2-year studies. Two-Year Studies: Survival of exposed and control mice was comparable in the 2-year studies (male: control, 28/50; low dose, 31/50; high dose, 34/50; female: 25/50; 24/50;31/50). Final mean body weights in exposed mice were 95%-102% of those of the controls. No compound-related clinical signs were observed. Those neoplastic lesions that occurred at elevated incidences in mice exposed to ethylene oxide are reported in the following table (see page 6 of the Technical Report). In male mice, alveolar/bronchiolar carcinomas, alveolar/bronchiolar adenomas, and papillary cystadenomas of the harderian gland occurred with positive trends. In female mice, alveolar/bronchiolar adenomas, alveolar/bronchiolar carcinomas, papillary cystadenomas of the harderian gland, malignant lymphomas, and uterine adenocarcinomas occurred with positive trends. Mammary gland tumors also were increased in exposed female mice. Data Audit: An audit of the experimental data was conducted for the 2-year studies of ethylene oxide. No data discrepancies were found that influenced the final interpretations. Conclusions: Under the conditions of these 2-year inhalation studies, there was clear evidence of carcinogenic activity for B6C3F1 mice as indicated by dose-related increased incidences of benign or malignant neoplasms of the lung and benign neoplasms of the harderian gland in both male and female B6C3F1 mice following exposure to ethylene oxide vapors at 50 and 100 ppm. In female mice, ethylene oxide caused additional malignant neoplasms of the uterus, mammary gland, and hematopoietic system (lymphoma). Synonyms: oxirane; EO; ETO; dihydrooxirene; dimethylene oxide; 1,2-epoxyethane; oxane; a,beta-oxidoethane

Journal Article↗

NTP Toxicology and Carcinogenesis Studies of Dimethyl Methylphosphonate (CAS No. 756-79-6) in F344/N Rats and B6C3F1 Mice (Gavage Studies).

Dimethyl methylphosphonate (98% pure) is one of four chemicals nominated by the U.S. Army for toxicology and carcinogenesis studies because it was being considered for use to simulate the physical and spectroscopic (but not the biologic) properties of anticholinesterase (nerve) agents. Dimethyl methylphosphonate is also used as a flame retardant, a preignition additive for gasoline, an antifoam agent, a plasticizer and stabilizer, a textile conditioner and antistatic agent, and an additive for solvents and low-temperature hydraulic fluids. The United States produces 0.2-2 million pounds (91,000-910,000 kg) of per year. Gavage was chosen as the route of administration for all four candidate "simulants" to mimic potential exposure. Experimental Design: Dimethyl methylphosphonate was administered in corn oil by gavage to male and female F344/N rats and B6C3F1 mice in single-administration, 15-day, and 13-week studies to obtain toxicity data, to establish dose levels for the 2-year studies, and to identify target tissues. Additional studies were also performed to determine toxicity to the reproductive system of male F344/N rats and B6C3F1 mice and to study the potential for genetic damage in bacteria, mammalian cells, and Drosophila. Single-Administration Studies: In the single-administration studies, dimethyl methylphosphonate was given to rats and mice at doses up to 6,810 mg/kg body weight. No compound-related deaths were seen in male or female rats or male mice; two high dose female mice died. Rats exhibited inactivity, unsteady gait, and prostration after dosing; mice were inactive after dosing. Fifteen-Day Studies: Rats and mice received doses of 0, 1,250, 2,500, 5,000, 10,000, or 15,000 mg/kg dimethyl methylphosphonate per day. Compound-related deaths occurred in the three highest dose groups of rats and the two highest dose groups of mice. Rats receiving doses of 2,500 mg/kg or higher were inactive and at 5,000 or 10,000 mg/kg had an unsteady gait after dosing; mice exhibited inactivity, shallow breathing, and prostration at doses of 10,000 mg/kg or higher. No lesions were reported in rats. Nonneoplastic lesions of the stomach were seen in some male mice at doses of 1,250 mg/kg and higher and in some female mice at doses of 5,000 mg/kg and higher. Thirteen-Week Studies: Dimethyl methylphosphonate was given at doses up to 8,000 mg/kg per day. Compound-related deaths occurred at 2,000, 4,000, and 8,000 mg/kg in rats and at 4,000 and 8,000 mg/kg in mice. Mean body weights of rats at 1,000 mg/kg and mice at 2,000 mg/kg were similar to those of the vehicle controls; decreased weight gain was seen at higher doses. No compound-related clinical signs were reported. Minimal to mild renal and testicular lesions were seen at all doses in male rats, but the severity of these lesions did not increase with increasing dose of the chemical. No apparent target tissues were identified in female rats or male and female mice. Doses selected for the 2-year studies were based on body weight effects and mortality seen in the 13-week studies; the lesions seen in the kidney of male rats at the end of the 13-week studies were judged not to be life threatening. In the 2-year studies, dimethyl methylphosphonate was administered in corn oil by gavage at doses of 0, 500, or 1,000 mg/kg per day to groups of 50 F344/N rats of each sex and at 0, 1,000, or 2,000 mg/kg per day to groups of 50 B6C3F1 mice of each sex. All animals were dosed 5 days per week for 103 weeks. Body Weight and Survival in the Two-Year Studies: Mean body weights of high dose male rats were 5%-10% lower than those of the vehicle controls between weeks 28 and 76 and were 10%-24% lower between weeks 80 and 104. Mean body weights of high dose female rats were 8%-12% lower than those of the vehicle controls after week 80. Survival of male rats was greater than 50% in all groups until week 80, and after this time, survival decreased in both groups, with the survival at the end of the study being 27/50 in vehicle control, 17/50 in low dose, and 4/50 in high dose groups. Survival of in low dose, and 4/50 in high dose groups. Survival of low dose female rats was comparable to that of the vehicle controls, but the final survival of high dose female rats was decreased (vehicle control, 30/50; low dose, 33/50; high dose, 23/50). No other compound-related clinical signs were observed. Mean body weights of high dose male mice were 7&percnt;-16&percnt; lower than those of the vehicle control males between weeks 36 and 76, and those of high dose female mice were 6&percnt;-12&percnt; lower between weeks 88 and 103. Decreased survival between weeks 23 and 45 in high dose male mice was associated with fighting. Seventeen high dose male and 22 high dose female mice died during week 45; these deaths were associated with the accidental administration of a dose mixture that had a concentration 34&percnt; greater than the targeted amount. Eleven low dose male mice died on the same day during week 77. By the end of the study, 29/50 vehicle control, 12/50 low dose, and 0/50 high dose male mice were alive; 41/50, 30/50, and 2/50 female mice survived to the end of the study. Renal Effects in the Two-Year Studies: Administration of dimethyl methylphosphonate to male rats increased the average severity of nephropathy and caused mineralization (calcification) of the collecting tubules in the renal papilla (12/50; 41/50; 36/49), hyperplasia of the transitional epithelium lining the renal pelvis and overlying the renal papilla (0/50; 23/50; 21/49), and focal hyperplasia of the renal tubular epithelium (0/50; 8/50; 9/49). Administration of dimethyl methylphosphonate to male rats was also associated with the occurrence of rare renal tubular cell adenocarcinomas (0/50; 2/50; 3/49) and papillomas of the transitional epithelium lining of the renal pelvis (0/50; 2/50; 3/49); a transitional cell carcinoma occurred in a low dose male rat. There were no tubular cell or transitional cell neoplasms of the kidney in female rats. Hematopoietic System Effects in the Two-Year Studies: The incidence of mononuclear cell leukemia was increased in high dose male rats (10/50; 11/50; 17/50). Genetic Toxicity: Dimethyl methylphosphonate was not mutagenic when tested in the Salmonella typhimurium/microsome assay by the preincubational protocol with strains TA98, TA100, TA1535, or TA1537 with or without metabolic activation. The chemical did induce forward mutations in the mouse lymphoma L5178Y/TK&plusmn; assay system in the absence of metabolic activation. Treatment of cultured Chinese hamster ovary cells with dimethyl methylphosphonate did not induce chromosomal aberrations; however, sister chromatid exchanges were induced after exposure to this chemical in both the presence and absence of metabolic activation. When fed to Drosophila, dimethyl methylphosphonate induced a significant increase in the frequency of sex-linked recessive lethal mutations but did not induce reciprocal translocations. Dimethyl methylphosphonate caused a dominant lethal effect in male rats and mice. Studies of Reproductive Effects: Dimethyl methylphosphonate caused a dose-related increase in the number of fetal resorptions in undosed female rats and mice mated with males that received the chemical by gavage in water 5 days per week for 13 weeks at doses of 0-2,000 mg/kg per day. After the 13-week dosing period, histopathologic changes were seen in the kidney and testis of male rats but not in male mice; dosed male rats sired fewer litters and fewer pups per litter. Dose-related decreases in sperm count and sperm motility occurred in male rats but not in male mice. Toxic effects to the reproductive system of male rats and mice were reversible after a 13-to 14-week recovery period. Data Audit: An audit of the experimental data was conducted for the 2-year studies on dimethyl methylphosphonate. No data discrepancies were found that influenced the final interpretations. Conclusions: Under the conditions of these 2-year gavage studies, there was some evidence of carcinogenic activity of dimethyl methylphosphonate for male F344/N rats as shown by increased incidences of tubular cell hyperplasia, tubular cell adenocarcinomas, hyperplasia of the transitional cell epithelium, and transitional cell papillomas of the kidney. There was an increased incidence of mononuclear cell leukemia in male rats at 1,000 mg/kg. Renal toxicity and decreased survival occurred in dosed male rats. There was no evidence of carcinogenic activity of dimethyl methylphosphonate for female F344/N rats given doses of 500 or 1,000 mg/kg. The study in male B6C3F1 mice was an inadequate study of carcinogenic activity because of decreased survival in both dosed groups. There was no evidence of carcinogenic activity for female B6C3F1 mice receiving dimethyl methylphosphonate at 1,000 mg/kg; decreased survival of female mice at 2,000 mg/kg made this group inadequate for determination of carcinogenic activity. Synonyms: fyrol DMMP; methyl phosphonic acid, dimethyl ester; DMMP; methanephosphonic acid dimethyl ester; dimethyl methanephosphonate

Journal Article↗

NTP Toxicology and Carcinogenesis Studies of Bromodichloromethane (CAS No. 75-27-4) in F344/N Rats and B6C3F1 Mice (Gavage Studies).

Bromodichloromethane (99% pure), one of several trihalomethanes commonly formed after chlorination of water, was selected for study because no carcinogenicity data were available for this compound and because chloroform, a related trihalomethane, had been found to cause tumors in rodents. The general population might be exposed to bromodichloromethane in drinking water supplies, in swimming pools, and in a variety of food substances. Single-administration, 14-day, 13-week, and 2-year studies were conducted in F344/N rats and B6C3F1 mice. The chemical was administered by gavage in corn oil because human exposure is primarily oral. Additional studies were performed to evaluate the potential for genetic damage in bacteria and mammalian cells. Results of the Short-Term Studies: In the single-administration studies, the chemical was administered at doses of 150-2,500 mg/kg per day. All rats and female mice at 1,250 and 2,500 mg/kg and all male mice at 600, 1,250, and 2,500 mg/kg died; 2/5 male rats, 1/5 female rats, and 2/5 female mice at 600 mg/kg died; all animals at lower dose levels survived. In the 14-day studies, rats received doses of 38-600 mg/kg, and mice received doses of 19-300 mg/kg per day. One female rat at 38 mg/kg and one female rat at 600 mg/kg died. Weight loss or decreased weight gain was seen at 300 and 600 mg/kg in male and female rats. All male mice at 150 and 300 mg/kg died, and one female mouse at 300 mg/kg died; no weight effects were observed in surviving mice. Dose-related necropsy findings included reddened renal medullae in male rats at 600 mg/kg and in male mice at 150 and 300 mg/kg. Clinical signs seen in high dose groups after dosing were hyperactivity in rats and lethargy in mice. In the 13-week studies, male and female rats received doses of 19-300 mg/kg per day, male mice received doses of 6.25-100 mg/kg per day, and female mice received doses of 25-400 mg/kg per day. Five of 10 male rats and 2/10 female rats at 300 mg/kg died. None of the mice died. Final body weights of male and female rats at 150 and 300 mg/kg were lower than those of vehicle controls (45%-88% of vehicle control weights); final body weights of male mice at 100 mg/kg and female mice at 400 mg/kg were 92% and 94% of those of the vehicle controls. Centrilobular degeneration in the liver and degeneration and necrosis of the kidney were seen in male rats at 300 mg/kg; centrilobular degeneration was seen in female rats at 300 mg/kg; degeneration andnecrosis of the kidney were seen in male mice at 100 mg/kg, and centrilobular degeneration of the liver was seen in female mice at 200 and 400 mg/kg. Experimental Design of the Two-Year Studies: The 2-year toxicology and carcinogenesis studies of bromodichloromethane were conducted by administering the chemical in corn oil by gavage, 5 days per week for 102 weeks, to groups of 50 male and female rats at doses of 0, 50, or 100 mg/kg per day; to groups of 50 male mice at doses of 0, 25, or 50 mg/kg per day; and to groups of 50 female mice at doses of 0, 75, or 150 mg/kg per day. The study in male rats was restarted because at 10.5 months into the original study, a temperature elevation killed 45/50 vehicle control male rats. Survival and Body Weight in the Two-Year Studies: Final survival of dosed rats was comparable to that of vehicle controls (male: vehicle control, 28/50; low dose, 36/50; high dose, 28/50; female: 34/50; 27/50; 41/50). Mean body weights of high dose male and female rats were decreased during the last 1.5 years of the study; final mean body weights of high dose male and female rats were 88% and 79% of the vehicle control mean weights. Final mean body weights of low dose male and female rats were comparable to those of the vehicle controls. Final survival of dosed male mice was comparable to that of the vehicle controls (34/50; 32/50; 42/50). At week 84, survival of female mice was greater than 50% in all dose groups. After week 84, survival of dosed and vehicle control female mice was reduced (final survival: 26/50; 13/50; 15/50), and this decreased survival was ass6/50; 13/50; 15/50), and this decreased survival was associated with ovarian abscesses (8/50; 19/47; 18/49). The final mean body weight of high dose male mice was 95&percnt; that of the vehicle controls; the final mean body weight of low dose male mice was comparable to that of the vehicle controls. Mean body weights of the high dose female mice were decreased during the last 1.5 years of the study; the final mean body weight was 75&percnt; that of the vehicle controls. The final mean body weight of the low dose female mice was 91&percnt; that of the vehicle controls. Nonneoplastic Effects in the Two-Year Studies: Compound-related nonneoplastic lesions included cytomegaly and tubular cell hyperplasia of the kidney and necrosis and fatty metamorphosis of the liver in male rats; eosinophilic cytoplasmic change, clear cell change, focal cellular change, and fatty metamorphosis of the liver and tubular cell hyperplasia of the kidney in female rats; fatty metamorphosisof the liver, renal cytomegaly, and follicular cell hyperplasia of the thyroid gland in male mice; and follicular cell hyperplasia of the thyroid gland in female mice. Neoplastic Effects in the Two-Year Studies: Bromodichloromethane caused compound-related increases in the incidences of neoplasms of the large intestine and kidney in male and female rats, the kidney in male mice, and the liver in female mice, as shown in the table (see page 5 of the Technical Report). The neoplasms of the large intestine and kidney are uncommon tumors in F344/N rats and B6C3F1 mice. Administration of bromodichloromethane was also associated with a decrease in the tumors of the adrenal glands in male rats, the pituitary and mammary glands in female rats, and the pituitary gland in female mice. Genetic Toxicology: Bromodichloromethane was not mutagenic in Salmonella typhimurium strains TA98, TA100, TA1535, or TA1537 when tested by the preincubational protocol at concentrations up to 1,000 ug/plate with or without metabolic activation. The compound was not mutagenic in the mouse lymphoma L5178Y/TK&plusmn; assay in the presence of S9 but did induce forward mutations in the system in the presence of metabolic activation from rat liver S9. Cytogenetic tests with Chinese hamster ovary cells demonstrated no induction of chromosomal aberrations orsister chromatid exchanges following treatment with bromodichloromethane in either the presence or absence of metabolic activation. Data Audit: An audit of the experimental data was conducted for the 2-year toxicology and carcinogenesis studies of bromodichloromethane. No discrepancies were found that influenced the final interpretations of the results of these studies. Conclusions: Under the conditions of these 2-year gavage studies, there was clear evidence of carcinogenic activity for male and female F344/N rats and B6C3F1 mice as shown by increased incidences of tubular cell adenomas and adenocarcinomas in the kidney and adenocarcinomas and adenomatous polyps in the large intestine in male and female rats, increased incidences of tubular cell adenomas and adenocarcinomas in the kidney of male mice, and increased incidences of hepatocellular adenomas and carcinomas in female mice. Synonym: dichlorobromoethane

Journal Article↗

NTP Toxicology and Carcinogenesis Studies of Rotenone (CAS No. 83-79-4) in F344/N Rats and B6C3F1 Mice (Feed Studies).

Toxicology and carcinogenesis studies of rotenone (more than 98% pure), a pesticide, were conducted in B6C3F1 mice and F344/N rats for 14 days, 13 weeks, and 2 years. Results of the Fourteen-Day Studies: In the 14-day studies (dietary rotenone concentrations of 0-600 ppm in the first 14-day studies and 0-4,800 ppm in the second 14-day studies), rough hair coats and dose-related decreases in mean body weight gain were observed in rats. Rats fed diets containing rotenone at concentrations of 1,200 ppm or higher lost weight. No compound-related toxic effects were observed in mice. Results of the Thirteen-Week Studies: In the 13-week studies (concentrations of 0-1,200 ppm rotenone in feed for rats and 0-50,000 ppm for mice), compound-related effects included lower body weight gain in rats at 150 ppm or more; and bone marrow atrophy and inflammation and hyperplasia of the forestomach in male rats at 300 ppm or more and in female rats at 150 ppm or more. These findings were used to establish the dietary concentrations of rotenone for the 2-year studies. Experimental Design for the Two-Year Studies: Two-year studies of rotenone were conducted by administering diets containing 0, 38, or 75 ppm rotenone to groups of 50 F344/N rats of each sex for 103 weeks. Groups of 50 B6C3F1 mice of each sex were administered diets containing 0, 600, or 1,200 ppm rotenone on the same schedule. The estimated average amount of rotenone consumed per day was 1.7 mg/kg or 3.5 mg/kg for low dose or high dose rats and 115 mg/kg or 250 mg/kg for low dose and high dose mice. Survival and Mean Body Weight in the Two-Year Studies: Survival of control and dosed rats was similar (male: control, 22/50; low dose. 31/50; high dose, 30/50; female: control, 27/50; low dose, 32/50; high dose, 31/50). Mean body weights of dosed and control male rats were comparable. Mean body weights of high dose female rats were 5%-9% lower than those of the controls between weeks 58 and 88. Survival of high dose male mice was significantly greater than that of the controls (male: 29/50; 36/50; 47/50; female: 37/50; 42/50; 45/50). Final mean body weights of dosed mice were lower than those of the controls by 8%-13% for males and 17%-24% for females. Neoplastic Effects in the Two-Year Studies: Parathyroid gland adenomas were observed in 1/41 control, 0/44 low dose, and 4/44 high dose male rats. The historicalincidence of this uncommon tumor in untreated control male rats in NTP studies is 4/1,314 (0.3%). Because these tumors are rare and because the highest incidence ever seen in a control group is 1/50, the increase in these tumors may have been related to rotenone administration. The incidence of subcutaneous tissue fibromas, fibrosarcomas, sarcomas, myxosarcomas, or neurofibrosarcomas (combined) in low dose female rats was greater (P<0.05) than that in the controls (0/50; 5/50; 3/50). These tumors were combined because of their possible common histiogenic origin from fibroblasts or undifferentiated mesenchymal cells. The incidence of those tumors in the low dose females was greater than the historical rats at this laboratory (9/337, 3% +/- 1%) and throughout the Program (50/2,021, 2% +/- 2%). Because of the lack of a significant dose-related trend and because statistical significance was attained only by combining tumors of differing morphology, the subcutaneous tissue tumors in female rats were not considered to be chemically related. The incidences of these tumors in dosed male rats were not significantly different from that in the controls. Hepatocellular adenomas or carcinomas (combined) occurred in male mice with a negative (P<0.02) trend, and the incidence in the high dose group was lower than that in the controls (12/47; 12/49; 1/50). Because this low rate of combined liver tumors is unusual, this decrease may have been related to rotenone administration. Subcutaneous tissue fibromas, sarcomas, fibrosarcomas, or neurofibrosarcomas (combined) in male mice occurred with a significant (P<0.05) negative trend (8/49; 4/50; 2/50). The incidence in the high dose group was signignificant (P<0.05) negative trend (8/49; 4/50; 2/50). The incidence in the high dose group was significantly lower than that in the controls by the life table test (P=0.01). Genotoxicity: Rotenone was not mutagenic when tested according to a preincubational protocol with Salmonella typhimurium strains TA100, TA1535, TA1537, and TA98 with or without metabolic activation by rat or hamster liver S9. Rotenone induced forward mutations in the mouse L5178Y/TK&plusmn; lymphoma assay without activation; it was not tested in the presence of S9. Results of tests with rotenone in Chinese hamster ovary cells were negative for induction of sister chromatid exchanges (SCEs) in the absence of exogenous metabolic activation (at concentrations at which the chemical was very toxic), equivocal for SCEs in the presence of rat liver S9 (due to a nonrepeatable positive response when tests were conducted up to toxic concentrations), and negative for chromosomal aberrationsin both the presence and absence of metabolic activation. Data Audit: An audit of the experimental data was conducted for the 2-year studies of rotenone. No data discrepancies were found that influenced the final interpretations. Conclusions: Under the conditions of these 2-year feed studies, there was equivocal evidence of carcinogenic activity of rotenone for male F344/N rats, as indicated by an increased incidence of parathyroid gland adenomas (uncommon tumors). There was no evidence of carcinogenic activity in female F344/N rats fed diets containing 38 or 75 ppm rotenone. There was no evidence of carcinogenic activity for male or female B6C3F1 mice fed diets containing 600 or 1,200 ppm rotenone for 2 years. The decreased incidence of liver neoplasms in male mice may have been related to the administration of rotenone. Synonym: 1,2,12,12a-tetrahydro-8,9-dimethoxy-2-1-methylethenyl)-[1]benzopyrano[3,4-b]furo2,3-h][1]benzopyran-6(6H)-one Trade Names of Formulations: Derrin; Derris; Tubatoxin; Nicouline; Prentox; Noxfish; Rotocide; Barbasco; Cube Root; Haiari; Dactinol

Journal Article↗

The Cardiology Audit and Registration Data Standards (CARDS), European data standards for clinical cardiology practice.

AIMS: Systematic registration of data from clinical practice is important for clinical care, local, national and international registries, and audit. Data to be collected for these different purposes should be harmonized. Therefore, during Ireland's Presidency of the European Union (EU) (January to June 2004), the Department of Health and Children worked with the European Society of Cardiology, the Irish Cardiac Society, and the European Commission to develop data standards for clinical cardiology. The Cardiology Audit and Registration Data Standards (CARDS) Project aimed to agree standards for three modules of cardiovascular health information systems: acute coronary syndromes (ACS), percutaneous coronary interventions (PCI), and clinical electrophysiology (pacemakers, implantable cardioverter defibrillators, and ablation procedures). METHODS AND RESULTS: Data items from existing registries and surveys were reviewed to derive draft data standards (variables, coding, and definitions). Variables common to the three modules include demographics, risk factors, medication, and discharge and follow-up data. Modules about a procedure contain variables on the lesion, the device, and medication during the procedure. The ACS module includes presenting symptoms, reperfusion and acute treatments, and procedures in hospital and at follow-up. CONCLUSIONS: The data standards were discussed and adopted at a conference involving EU member states in Cork, Ireland, in May 2004. After a pilot study, the standards will be disseminated to stakeholders throughout Europe.

Cardiology↗

Cardiovascular risk factor control and treatment patterns in primary care.

Previous research has shown that controlling hypertension and other cardiovascular (CV) risk factors reduces the number of CV events and racial/ethnic health disparities. The objectives of this study were to assess CV risk factor treatment, control, and disparities among patients with hypertension using data from retrospective medical record audits. Data were obtained from 63 primary care sites with 201 providers. In 49% of 35,940 patients with hypertension, the last blood pressure reading was less than 140/90 mm Hg. In 62% of 18,627 patients who also had dyslipidemia, low-density lipoprotein cholesterol was less than 130 mg/dL. In 49% of 6,616 patients with hypertension and diabetes, glycosylated hemoglobin levels were less than 7%. Multiple risk factor control was rare, especially among women and African Americans. It appears that programs to improve CV risk factor control using audit and feedback in primary care are feasible and instructive.

Black or African American↗

A care package for managing female sexual assault in genitourinary medicine.

This paper describes the development of a designated in-house service for the management of adult female victims of sexual assault within the Department of Genitourinary Medicine (GUM) at St Mary's Hospital, London. This was set up in 1994 as a need was identified by medical, nursing, psychological and health advising staff for an appropriate streamlined service which would provide comprehensive sexual health screening, psychological support and therapy and adequate medico-legal documentation within the limitations of a busy GUM clinic. A structured package of care consisting of medical and psychological protocols with training for relevant staff and a specialist in-house referral clinic was introduced. Fifty-four patients were seen during the first 17 months of the service, the notes of 48 of these were examined and relevant epidemiological and audit data are presented here. By auditing the quality of documentation before and after the introduction of the protocols specifically looking at the appropriateness and comprehensiveness of the sexually transmitted diseases screen and the medico-legal documentation it was clear that the quality of care to these patients was improved. We present here the development of these protocols, a detailed description of the protocols themselves and the method of their implementation.

Adaptation, Psychological↗