Associations between childhood deaths and adverse childhood experiences: An audit of data from a child death overview panel

BACKGROUND

Despite strong associations between adverse childhood experiences (ACEs) and poor health, few studies have examined the cumulative impact of ACEs on causes of childhood mortality.

METHODS

This study explored if data routinely collected by child death overview panels (CDOPs) could be used to measure ACE exposure and examined associations between ACEs and child death categories. Data covering four years (2012-2016) of cases from a CDOP in North West England were examined.

RESULTS

Of 489 cases, 20% were identified as having ≥4 ACEs. Deaths of children with ≥4 ACEs were 22.26 (5.72-86.59) times more likely (than those with 0 ACEs) to be classified as 'avoidable and non-natural' causes (e.g., injury, abuse, suicide; compared with 'genetic and medical conditions'). Such children were also 3.44 (1.75-6.73) times more likely to have their deaths classified as 'chronic and acute conditions'.

CONCLUSIONS

This study evidences that a history of ACEs can be compiled from CDOP records. Measurements of ACE prevalence in retrospective studies will miss individuals who died in childhood and may underestimate the impacts of ACEs on lifetime health. Strong associations between ACEs and deaths from 'chronic and acute conditions' suggest that ACEs may be important factors in child deaths in addition to those classified as 'avoidable and non-natural'. Results add to an already compelling case for ACE prevention in the general population and families affected by child health problems. Broader use of routinely collected child death records could play an important role in improving multi-agency awareness of ACEs and their negative health and mortality risks as well in the development of ACE informed responses.

Understanding the core principles of a 'modified ketogenic diet': a UK and Ireland perspective

BACKGROUND

Many centres across the UK and Ireland anecdotally report using a 'modified ketogenic diet' (MKD) as a treatment for refractory epilepsy. Although a MKD is within the spectrum of ketogenic diets (KDs), there is little literature reporting upon its definition, use or clinical effectiveness. We aimed to understand the core principles of MKD practice and to assess whether and how the MKD differs from other KD protocols.

METHODS

An online survey, designed by a consensus group of ketogenic dietitians, was circulated to 39 KD centres across the UK and Ireland. It consisted of 35 questions regarding dietetic practice when providing MKD.

RESULTS

Eighteen centres completed the questionnaire: 13 paediatric, three adult and two combined centres. All dietitians based MKD 'prescriptions' on estimated total energy requirements. The average macronutrient profile was 75% fat and 5% carbohydrate, with protein ad libitum. Carbohydrate and fat targets were implemented via weighed portions (carbohydrate lists n = 18; fat lists n = 13) and 'household measures' (carbohydrate lists n = 2; fat lists n = 3). Of the centres, 94% (n = 17) adjusted macronutrients over time; these decisions were based on ketone levels and seizures in most cases (83%; n = 14). Ketogenic nutritional products available on prescription were used by 10 centres (56%) when initiating and by all centres when 'fine-tuning' the MKD.

CONCLUSIONS

A modified ketogenic diet in the UK and Ireland is a hybrid KD, adopting principles from other established KD protocols and defining new elements unique to the MKD. Further research into the clinical and cost-effectiveness of MKD would be of benefit.

Abstract P5-10-01: Using whole genome sequencing and somatic mutation signatures to unravel insight into familial breast cancer aetiology

Approximately 10-15% of breast cancers are associated with a strong family history of disease. Pathogenic variants in BRCA1, BRCA2 or other moderate to highly penetrant susceptibility genes (e.g. TP53, ATM, CHEK2, PALB2 and PTEN) account for a number of breast cancer families. However, for over 50% of families the underlying genetic contribution to their risk remains unknown (termed here as non-BRCA1/2). This has a profound impact for how individuals and their families are managed in the clinic. We applied whole genome sequencing (WGS) to determine whether somatic mutation analysis can reveal insight into the aetiology of familial breast cancer. The full repertoire of somatic mutations was evaluated in 26 BRCA1, 22 BRCA2 and 32 non-BRCA1/2 tumours; including SNPs, indels, copy number changes and structural rearrangements, and mutational signatures. Genomes were also analysed using the HRD Index and HRDetect, as predictors of homologous recombination deficiency. BRCA1, BRCA2 and non-BRCA1/2 tumours exhibited a different burden of mutations, a different spectrum of mutational signatures and different telomere length. Based on collective patterns of mutation signatures, tumours were classified as 'BRCA1-like', 'BRCA2-like' or 'non-BRCA1/2-like' with a 15% rate of tumour re-classification from their original clinical BRCA status. The results demonstrate the power of WGS to differentiate between BRCA1 and BRCA2 driven tumours; in the identification of double-pathogenic germline mutation carriers based on the resulting somatic mutation signature; and in the interpretation of BRCA unclassified variants. WGS of tumour genomes reveals fascinating insights into tumour aetiology and could compliment current genetic testing of breast cancer families.

Citation Format: Simpson P, Nones K, Johnson J, Newell F, Patch A-M, Thorne H, Kazakoff S, De Luca X, Parsons M, Ferguson K, Reid L, McCart Reed A, Srihari S, Lakis V, Davidson A, Mukhopadhyay P, Holmes O, Xu Q, Wood S, Leonard C, Beasley J, Degasperi A, Nik-Zainal S, Ragan M, Spurdle A, Khanna KK, Lakhani S, Pearson J, Chenevix-Trench G, Waddell N. Using whole genome sequencing and somatic mutation signatures to unravel insight into familial breast cancer aetiology [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-10-01.

Revealing Color Forces with Transverse Polarized Electron Scattering

The Spin Asymmetries of the Nucleon Experiment measured two double spin asymmetries using a polarized proton target and polarized electron beam at two beam energies, 4.7 and 5.9 GeV. A large-acceptance open-configuration detector package identified scattered electrons at 40° and covered a wide range in Bjorken x (0.3<x<0.8). Proportional to an average color Lorentz force, the twist-3 matrix element, d[over ˜]_{2}^{p}, was extracted from the measured asymmetries at Q^{2} values ranging from 2.0 to 6.0  GeV^{2}. The data display the opposite sign compared to most quark models, including the lattice QCD result, and an unexpected scale dependence. Furthermore, when combined with the neutron data in the same Q^{2} range the results suggest a flavor independent average color Lorentz force.

Does adult alcohol consumption combine with adverse childhood experiences to increase involvement in violence in men and women? A cross-sectional study in England and Wales

OBJECTIVES

To examine if, and to what extent, a history of adverse childhood experiences (ACEs) combines with adult alcohol consumption to predict recent violence perpetration and victimisation.

DESIGN

Representative face-to-face survey (n=12 669) delivered using computer-assisted personal interviewing and self-interviewing.

SETTING

Domiciles of individuals living in England and Wales.

PARTICIPANTS

Individuals aged 18-69 years resident within randomly selected locations. 12 669 surveys were completed with participants within our defined age range.

MAIN OUTCOME MEASURES

Alcohol consumption was measured using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) and childhood adversity using the short ACEs tool. Violence was measured using questions on perpetration and victimisation in the last 12 months.

RESULTS

Compliance was 55.7%. There were strong positive relationships between numbers of ACEs and recent violence perpetration and victimisation in both sexes. Recent violence was also strongly related to positive AUDIT-C (≥5) scores. In males, heavier drinking and ≥4ACEs had a strong multiplicative relationship with adjusted prevalence of recent violent perpetration rising from 1.3% (95% CIs 0.9% to 1.9%; 0 ACEs, negative AUDIT-C) to 3.6% (95% CIs 2.7% to 4.9%; 0 ACEs, positive AUDIT-C) and 8.5% (95% CI 5.6% to 12.7%; ≥4ACEs, negative AUDIT-C) to 28.3% (95% CI 22.5% to 34.8%; ≥4ACEs, positive AUDIT-C). In both sexes, violence perpetration and victimisation reduced with age independently of ACE count and AUDIT-C status. The combination of young age (18-29 years), ≥4ACEs and positive AUDIT-C resulted in the highest adjusted prevalence for both perpetration and victimisation in males (61.9%, 64.9%) and females (24.1%, 27.2%).

CONCLUSIONS

Those suffering multiple adverse experiences in childhood are also more likely to be heavier alcohol users. Especially for males, this combination results in substantially increased risks of violence. Addressing ACEs and heavy drinking together is rarely a feature of public health policy, but a combined approach may help reduce the vast costs associated with both.

Adverse childhood experiences and sources of childhood resilience: a retrospective study of their combined relationships with child health and educational attendance

BACKGROUND

Adverse childhood experiences (ACEs) including maltreatment and exposure to household stressors can impact the health of children. Community factors that provide support, friendship and opportunities for development may build children's resilience and protect them against some harmful impacts of ACEs. We examine if a history of ACEs is associated with poor childhood health and school attendance and the extent to which such outcomes are counteracted by community resilience assets.

METHODS

A national (Wales) cross-sectional retrospective survey (n = 2452) using a stratified random probability sampling methodology and including a boost sample (n = 471) of Welsh speakers. Data collection used face-to-face interviews at participants' places of residence. Outcome measures were self-reported poor childhood health, specific conditions (asthma, allergies, headaches, digestive disorders) and school absenteeism.

RESULTS

Prevalence of each common childhood condition, poor childhood health and school absenteeism increased with number of ACEs reported. Childhood community resilience assets (being treated fairly, supportive childhood friends, being given opportunities to use your abilities, access to a trusted adult and having someone to look up to) were independently linked to better outcomes. In those with ≥4 ACEs the presence of all significant resilience assets (vs none) reduced adjusted prevalence of poor childhood health from 59.8 to 21.3%.

CONCLUSIONS

Better prevention of ACEs through the combined actions of public services may reduce levels of common childhood conditions, improve school attendance and help alleviate pressures on public services. Whilst the eradication of ACEs remains unlikely, actions to strengthen community resilience assets may partially offset their immediate harms.

Case Report: Spontaneous Hemorrhage of a Rare Renal Tumor in the Native Kidney of a Renal Transplant Recipient

Renal cancers are some of the most common solid organ malignancies found during follow-up of patients who have undergone renal transplantation (RT). In this case report, we describe a life-threatening spontaneous hemorrhage of a rare subtype of renal cell carcinoma in the native kidney of a 27-year-old man, 4 years after RT. After fluid resuscitation and stabilization, the patient underwent emergent open radical nephrectomy with the final histopathology reporting T1bN0Mx mucinous tubular and spindle cell (MTSC) carcinoma. This case report highlights the need to consider an underlying malignancy in patients who presents with spontaneous hemorrhage of native kidneys after RT.

Long-Term Parenteral Nutrition: Problems with Venous Access

Long-term parenteral nutrition requires central venous access, often difficult in patients who have had several central venous catheterizations. Therapy may be complicated by thrombosis and sepsis which may further compromise central access. We report five cases illustrating such difficulties and suggest that these patients be referred early to specialist centres where experienced catheter insertion and management results in a greatly reduced incidence of complications.

Intrapartum glycaemic control and neonatal hypoglycaemia in pregnancies complicated by diabetes: a systematic review

AIMS

To examine whether, in neonates of mothers with Type 1, Type 2 and gestational diabetes, in-target intrapartum glycaemic control was associated with a lower risk of neonatal hypoglycaemia compared with out-of-target glycaemic control.

METHODS

We searched PubMed and EMBASE for all available publications, regardless of year, based on a published protocol (PROSPERO CRD42016052439). Studies were excluded if they did not report original data or were animal studies. Data were extracted from published reports in duplicate using a prespecified data extraction form. The main outcome of interest was the association between in-target intrapartum glycaemic control and neonatal hypoglycaemia.

RESULTS

We screened 2846 records for potential study inclusion; 23 studies, including approximately 2835 women with diabetes, were included in the systematic review. Only two of those studies specifically examined in-target vs out-of-target intrapartum glycaemic control. Of the studies included, six showed a relationship between intrapartum glucose and neonatal hypoglycaemia, five others showed a relationship in at least one of the analyses performed and 12 did not find a significant relationship. Only one study was identified as having a low risk of bias.

CONCLUSIONS

There is a paucity of high-quality data supporting the association of glucose during labour and delivery with neonatal hypoglycaemia in pregnancies complicated by diabetes. Further studies are required to examine the impact of tight glycaemic targets in labour.

Auditory verbal hallucinations in first episode psychosis – an fMRI symptom capture study

Introduction

Neurobiological models of auditory verbal hallucination (AVH) have been advanced by symptom capture functional magnetic resonance imaging (fMRI), where participants self-report hallucinations during scanning. To date, regions implicated are those involved with language, memory and emotion. However, previous studies focus on chronic schizophrenia, thus are limited by factors, such as medication use and illness duration. Studies also lack detailed phenomenological descriptions of AVHs. This study investigated the neural correlates of AVHs in patients with first episode psychosis (FEP) using symptom capture fMRI with a rich description of AVHs. We hypothesised that intrusive AVHs would be associated with dysfunctional salience network activity.

Methods

Sixteen FEP patients with frequent AVH completed four psychometrically validated tools to provide an objective measure of the nature of their AVHs. They then underwent fMRI symptom capture, utilising general linear models analysis to compare activity during AVH to the resting brain.

Results

Symptom capture of AVH was achieved in nine patients who reported intrusive, malevolent and uncontrollable AVHs. Significant activity in the right insula and superior temporal gyrus (cluster size 141 mm3), and the left parahippocampal and lingual gyri (cluster size 121 mm3), P < 0.05 FDR corrected, were recorded during the experience of AVHs.

Conclusions

These results suggest salience network dysfunction (in the right insula) together with memory and language processing area activation in intrusive, malevolent AVHs in FEP. This finding concurs with others from chronic schizophrenia, suggesting these processes are intrinsic to psychosis itself and not related to length of illness or prolonged exposure to antipsychotic medication.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Sex steroid hormones in relation to Barrett's esophagus: an analysis of the FINBAR Study

Previously, we observed strong positive associations between circulating concentrations of free testosterone and free dihydrotestosterone (DHT) in relation to Barrett's esophagus in a US male military population. To replicate these findings, we conducted a second study of sex steroid hormones and Barrett's esophagus in the Factors Influencing the Barrett/Adenocarcinoma Relationship (FINBAR) Study based in Northern Ireland and Ireland. We used mass spectrometry to quantitate EDTA plasma concentrations of nine sex steroid hormones and ELISA to quantitate sex hormone-binding globulin in 177 male Barrett's esophagus cases and 185 male general population controls within the FINBAR Study. Free testosterone, free DHT, and free estradiol were estimated using standard formulas. Multivariable logistic regression estimated odds ratios (OR) and 95% confidence intervals (95%CI) of associations between exposures and Barrett's esophagus. While plasma hormone and sex hormone-binding globulin concentrations were not associated with all cases of Barrett's esophagus, we did observe positive associations with estrogens in younger men (e.g. estrone + estradiol OR_{continuous per ½IQR}  = 2.92, 95%CI:1.08, 7.89), and free androgens in men with higher waist-to-hip ratios (e.g. free testosterone OR_{continuous per ½IQR}  = 2.71, 95%CI:1.06, 6.92). Stratification by body mass index, antireflux medications, and geographic location did not materially affect the results. This study found evidence for associations between circulating sex steroid hormones and Barrett's esophagus in younger men and men with higher waist-to-hip ratios. Further studies are necessary to elucidate whether sex steroid hormones are consistently associated with esophageal adenocarcinogenesis.

Abstract P3-14-07: Neoadjuvant radiotherapy in mastectomy and immediate autologous free flap reconstruction. Findings from the primary radiotherapy and DIEP flap (PRADA) pilot study

Background:

The need for post mastectomy radiotherapy (PMRT), may preclude reconstructive surgeons from offering patients immediate, autologous reconstruction. This is due to historical evidence suggesting high rates of short- and long-term complications as well as poorer aesthetic outcomes. As the indications for PMRT broaden this practice denies an ever-increasing number of women the benefit of an immediate reconstruction.

Aim:

This pilot study evaluates the safety of offering radiotherapy prior to mastectomy and immediate DIEP flap reconstruction.

Methods:

Women planned for neoadjuvant chemotherapy (NAcT), mastectomy (following unsuccessful breast conservation surgery (BCS) or upfront selection) and PMRT were offered a change in sequencing of RT at two academic breast surgery units in London, UK. Data was prospectively captured on 19 women, including: patient demographics, treatment details, tumour characteristics, oncological and post-operative outcomes. Operative parameters included unplanned return to theatre [RTT] &lt;30 days, mastectomy skin flap necrosis, and evidence of wound infection at 5 days, 4 and 12 weeks post-operatively. All mastectomies, were performed by one of 3 breast surgeons (DH, FAM, DRL) using a circumareolar incisions with one patient undergoing a vertical pattern incision for skin reduction.

Results:

The cohort demonstrated a broad range of age, body mass index (BMI) and mastectomy weight [mean (range): age=46 years (28-72); BMI = 28.4 kg/m2 (23-37.6) and specimen weight=678gm (257-1040)]. The mean time from completion of NAcT to neoadjuvant radiotherapy (NART) was 31.1 days (9-49 days), and time from completion of NART to mastectomy and DIEP was 17.8 days (13-24 days). There was one unplanned RTT at 72 hours for an evacuation of haematoma, 1 revision of micro-vascular anastomosis, 1 clinical fat necrosis requiring formal excision and 1 wound debridement and primary closure for poor wound healing (vertical pattern skin reduction). There were no flap failures and no mastectomy envelope necrosis. With a mean follow-up of 16.2 months, there were no loco-regional recurrences, 5 distant relapses with mean presentation at 13.7 months and 2 breast-cancer related deaths at 13.9 and 22.2months respectively.

Conclusion:

This pilot study suggests that mastectomy and DIEP reconstruction is surgically feasible within 4 weeks of completing NART. In this small cohort of oncologically high-risk women with altered sequencing of RT we did not observe flap failure or post-mastectomy skin flap necrosis. A larger multicentre study with aesthetic assessment, PROMS and translational aspects is planned.

Citation Format: Thiruchelvam P, Hadjiminas D, Cleator S, Wood S, Leff D, Jallali N, James S, MacNeill F. Neoadjuvant radiotherapy in mastectomy and immediate autologous free flap reconstruction. Findings from the primary radiotherapy and DIEP flap (PRADA) pilot study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-14-07.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Distinct subclonal tumour responses to therapy revealed by circulating cell-free DNA

BACKGROUND

The application of precision medicine in oncology requires in-depth characterisation of a patient's tumours and the dynamics of their responses to treatment.

PATIENTS AND METHODS

We used next-generation sequencing of circulating cell-free DNA (cfDNA) to monitor the response of a KIT p.L576P-mutant metastatic vaginal mucosal melanoma to sequential targeted, immuno- and chemotherapy.

RESULTS

Despite a KIT mutation, the response to imatinib was mixed. Unfortunately, tumours were not accessible for molecular analysis. To study the mechanism underlying the mixed clinical response, we carried out whole-exome sequencing and targeted longitudinal analysis of cfDNA. This revealed two tumour subclones; one with a KIT mutation that responded to imatinib and a second KIT-wild-type subclone that did not respond to imatinib. Notably, the subclones also responded differently to immunotherapy. However, both subclones responded to carboplatin/paclitaxel, and although the KIT-wild-type subclone progressed after chemotherapy, it responded to subsequent re-administration of paclitaxel.

CONCLUSION

We show that cfDNA can reveal tumour evolution and subclonal responses to therapy even when biopsies are not available.

El Niño and coral larval dispersal across the eastern Pacific marine barrier

More than 5,000 km separates the frequently disturbed coral reefs of the Eastern Tropical Pacific (ETP) from western sources of population replenishment. It has been hypothesized that El Niño events facilitate eastward dispersal across this East Pacific Barrier (EPB). Here we present a biophysical coral larval dispersal model driven by 14.5 years of high-resolution surface ocean current data including the extreme 1997–1998 El Niño. We find no eastward cross-EPB connections over this period, which implies that ETP coral populations decimated by the 1998 bleaching event can only have recovered from eastern Pacific sources, in congruence with genetic data. Instead, rare connections between eastern and central Pacific reefs are simulated in a westward direction. Significant complexity and variability in the surface flows transporting larvae mean that generalized upper-ocean circulation patterns are poor descriptors of inter-regional connectivity, complicating the assessment of how climate change will impact coral gene flow Pacific wide.

Over 5,000 km of open ocean separate central and eastern Pacific coral reefs. Here, the authors combine a biophysical dispersal model with genetic data to show that eastern Pacific coral populations have been isolated from western sources of larval recruitment since the 1997-98 El Niño-induced bleaching event.

Caustic ingestion injury of the upper aerodigestive tract in adults

Adult ingestion of caustic substances is an unusual but serious surgical problem, with injuries likely to be more extensive than those in the corresponding paediatric population. After initial stabilisation and airway management, clinicians are presented with a complex multisystemic problem, frequently requiring a multidisciplinary approach involving several surgical disciplines and associated therapies. A new multidisciplinary team was convened to discuss complex ingestion injury in adults and established techniques were used to bring forward a proposed treatment algorithm. An algorithm may potentially improve clinical efficacy and risk in the management of these complex patients.

Polarization Transfer in Wide-Angle Compton Scattering and Single-Pion Photoproduction from the Proton

Wide-angle exclusive Compton scattering and single-pion photoproduction from the proton have been investigated via measurement of the polarization transfer from a circularly polarized photon beam to the recoil proton. The wide-angle Compton scattering polarization transfer was analyzed at an incident photon energy of 3.7 GeV at a proton scattering angle of θ_{cm}^{p}=70°. The longitudinal transfer K_{LL}, measured to be 0.645±0.059±0.048, where the first error is statistical and the second is systematic, has the same sign as predicted for the reaction mechanism in which the photon interacts with a single quark carrying the spin of the proton. However, the observed value is ~3 times larger than predicted by the generalized-parton-distribution-based calculations, which indicates a significant unknown contribution to the scattering amplitude.

Dynamic characteristics of otolith ocular response during counter rotation about dual yaw axes in mice

The central vestibular system plays an important role in higher neural functions such as self-motion perception and spatial orientation. Its ability to store head angular velocity is called velocity storage mechanism (VSM), which has been thoroughly investigated across a wide range of species. However, little is known about the mouse VSM, because the mouse lacks typical ocular responses such as optokinetic after nystagmus or a dominant time constant of vestibulo-ocular reflex for which the VSM is critical. Experiments were conducted to examine the otolith-driven eye movements related to the VSM and verify its characteristics in mice. We used a novel approach to generate a similar rotating vector as a traditional off-vertical axis rotation (OVAR) but with a larger resultant gravito-inertial force (>1g) by using counter rotation centrifugation. Similar to results previously described in other animals during OVAR, two components of eye movements were induced, i.e. a sinusoidal modulatory eye movement (modulation component) on which a unidirectional nystagmus (bias component) was superimposed. Each response is considered to derive from different mechanisms; modulations arise predominantly through linear vestibulo-ocular reflex, whereas for the bias, the VSM is responsible. Data indicate that the mouse also has a well-developed vestibular system through otoliths inputs, showing its highly conserved nature across mammalian species. On the other hand, to reach a plateau state of bias, a higher frequency rotation or a larger gravito-inertial force was considered to be necessary than other larger animals. Compared with modulation, the bias had a more variable profile, suggesting an inherent complexity of higher-order neural processes in the brain. Our data provide the basis for further study of the central vestibular system in mice, however, the underlying individual variability should be taken into consideration.

Infrared thermometry for lesion monitoring in cattle lameness

Infrared thermometry is a non-invasive tool shown to be useful in detecting claw abnormalities in cattle at an individual and herd level. This study used the technology to monitor foot temperature and investigate the association with lesion presence over time. A 990 cow dairy herd was enrolled and followed for six months, with data collection fortnightly, lesions were identified by examination of any cow with a mobility score >2, using the 0-3 scale. Two level, multilevel analysis of the association between ambient temperature and foot temperature found that the former was a significant predictor of the latter (coefficient estimate (se)=0.277 (0.02)). Actual foot temperatures were calculated by adjusting for this covariate to allow monitoring over time. Presence of a lesion was also found to be a significant predictor of foot temperature (coefficient estimate (se)=0.623 (0.19)), when added to the model, furthermore some lesion types, claw horn and multiple lesions, were found to be associated with differential foot temperatures. When monitoring lesions over time, the mean adjusted foot temperature was highest at the point of lesion identification. A marked drop in temperature then followed after the lesion was trimmed, with the lowest mean temperature recorded six weeks after treatment, significantly different from the point of lesion identification (P=0.003). This temperature was also lower than the six weeks prior to diagnosis of the lesion, suggesting inflammation was present for at least six weeks prior to the behavioural sign of lameness was seen.

Effectiveness of progestogens to improve perinatal outcome in twin pregnancies: an individual participant data meta-analysis

BACKGROUND

In twin pregnancies, the rates of adverse perinatal outcome and subsequent long-term morbidity are substantial, and mainly result from preterm birth (PTB).

OBJECTIVES

To assess the effectiveness of progestogen treatment in the prevention of neonatal morbidity or PTB in twin pregnancies using individual participant data meta-analysis (IPDMA).

SEARCH STRATEGY

We searched international scientific databases, trial registration websites, and references of identified articles.

SELECTION CRITERIA

Randomised clinical trials (RCTs) of 17-hydroxyprogesterone caproate (17Pc) or vaginally administered natural progesterone, compared with placebo or no treatment.

DATA COLLECTION AND ANALYSIS

Investigators of identified RCTs were asked to share their IPD. The primary outcome was a composite of perinatal mortality and severe neonatal morbidity. Prespecified subgroup analyses were performed for chorionicity, cervical length, and prior spontaneous PTB.

MAIN RESULTS

Thirteen trials included 3768 women and their 7536 babies. Neither 17Pc nor vaginal progesterone reduced the incidence of adverse perinatal outcome (17Pc relative risk, RR 1.1; 95% confidence interval, 95% CI 0.97-1.4, vaginal progesterone RR 0.97; 95% CI 0.77-1.2). In a subgroup of women with a cervical length of ≤25 mm, vaginal progesterone reduced adverse perinatal outcome when cervical length was measured at randomisation (15/56 versus 22/60; RR 0.57; 95% CI 0.47-0.70) or before 24 weeks of gestation (14/52 versus 21/56; RR 0.56; 95% CI 0.42-0.75).

AUTHOR'S CONCLUSIONS

In unselected women with an uncomplicated twin gestation, treatment with progestogens (intramuscular 17Pc or vaginal natural progesterone) does not improve perinatal outcome. Vaginal progesterone may be effective in the reduction of adverse perinatal outcome in women with a cervical length of ≤25 mm; however, further research is warranted to confirm this finding.

Who uses emergency departments inappropriately and when - a national cross-sectional study using a monitoring data system

BACKGROUND

Increasing pressures on emergency departments (ED) are straining services and creating inefficiencies in service delivery worldwide. A potentially avoidable pressure is inappropriate attendances (IA); typically low urgency, self-referred patients better managed by other services. This study examines demographics and temporal trends associated with IA to help inform measures to address them.

METHODS

Using a national ED dataset, a cross-sectional examination of ED attendances in England from April 2011 to March 2012 (n = 15,056,095) was conducted. IA were defined as patients who were self-referred; were not attending a follow-up; received no investigation and either no treatment or 'guidance/advice only'; and were discharged with either no follow-up or follow-up with primary care. Small, nationally representative areas were used to assign each attendance to a residential measure of deprivation. Multivariate analysis was used to predict relationships between IA, demographics (age, gender, deprivation) and temporal factors (day, month, hour, bank holiday, Christmas period).

RESULTS

Overall, 11.7% of attendances were categorized as inappropriate. IA peaked in early childhood (adjusted odds ratio (AOR) = 1.53 for both one and two year olds), and was elevated throughout late-teens and young adulthood, with odds reducing steadily from age 27 (reference category, age 40). Both IA and appropriate attendances (AA) were most frequent in the most deprived populations. However, relative to AA, those living in the least deprived areas had the highest odds of IA (AOR = 0.89 in most deprived quintile). Odds of IA were also higher for males (AOR = 0.95 in females). Both AA and IA were highest on Mondays, whilst weekends, bank holidays and the period between 8 am and 4 pm saw more IA relative to AA.

CONCLUSIONS

Prevention of IA would be best targeted at parents of young children and at older youths/young adults, and during weekends and bank holidays. Service provision focusing on access to primary care and EDs serving the most deprived communities would have the most benefit. Improvements in coverage and data quality of the national ED dataset, and the addition of an appropriateness field, would make this dataset an effective monitoring tool to evaluate interventions addressing this issue.

A randomized, double-blind, placebo-controlled clinical trial to investigate the effect of Cynatine(®) HNS on skin characteristics

OBJECTIVE

A new, novel product, Cynatine(®) HNS was evaluated for its effects as a supplement for improving various aspects of skin in a randomized, double-blind, placebo-controlled clinical trial.

METHODS

A total of 50 females were included and randomized into two groups. The active group (n = 25) received two capsules totalling of Cynatine(®) HNS, comprised of Cynatine(®) brand keratin (500 mg) plus vitamins and minerals, per day, and the placebo group (n = 25) received two identical capsules of maltodextrin per day for 90 days. End points for skin moisture, skin elasticity, wrinkle reduction, skin compactness and skin appearance were measured.

RESULTS

The results show that subjects taking Cynatine(®) HNS showed statistically significant improvements in their skin when compared with placebo.

CONCLUSION

Cynatine(®) HNS is an effective supplement for improving skin in 90 days or less.

Does induction of labour increase the risk of caesarean section? A systematic review and meta-analysis of trials in women with intact membranes

BACKGROUND

Recent literature on the effect of induction of labour (compared with expectant management) has provided conflicting results. Reviews of observational studies generally report an increase in the rate of caesarean section, whereas reviews of post-dates and term prelabour rupture of membrane (PROM trials suggest either no difference or a reduction in risk.

OBJECTIVE

To evaluate with a systematic review and meta-analysis of randomised controlled trials (RCTs) whether or not the induction of labour increases the risk of caesarean section in women with intact membranes.

SEARCH STRATEGY

Literature search using electronic databases: MEDLINE, EMBASE, and the Cochrane Database of Clinical Trials.

SELECTION CRITERIA

RCTs comparing a policy of induction of labour with expectant management in women with intact membranes.

DATA COLLECTION AND ANALYSIS

A total of 37 trials were identified and reviewed. Quantitative analyses with fixed- and random-effects models were performed with revman 5.1.

MAIN RESULTS

Of the 37 RCTs, 27 were trials of uncomplicated pregnancies at 37-42 weeks of gestation. The remaining ten evaluated induction versus expectant management in pregnancies with suspected macrosomia (two), diabetes in pregnancy (one), oligohydramnios (one), twins (two), intrauterine growth restriction (IUGR) (two), mild pregnancy-induced hypertension (PIH) (one), and women with a high-risk score for caesarean section (one). Meta-analysis of 31 trials determined that a policy of induction was associated with a reduction in the risk of caesarean section compared with expectant management (OR 0.83, 95% CI 0.76-0.92).

AUTHOR'S CONCLUSIONS

Induction of labour in women with intact membranes reduces the risk of caesarean section. Review of the trials suggests that this effect may arise from non-treatment effects, and that additional trials are needed.