The financial burden for the surgical management of osteoradionecrosis

Osteoradionecrosis (ORN) remains a difficult clinical problem. In large refractory cases surgery appears to be the only option but it does not guarantee a cure and is expensive. Cost analysis of 31 patients who had resection with or without reconstruction of their mandible was £892,357. The largest cost was in-patient stay, which accounted for 62% of the total. This article explores in detail the expenditure associated with major ORN surgery and its subsequent implications.

Recombinant β-defensin 126 promotes bull sperm binding to bovine oviductal epithelia

Primate β-defensin 126 regulates the ability of spermatozoa to bind to oviductal epithelial cells in vitro. Bovine β-defensin 126 (BBD126) exhibits preferential expression in the cauda epididymis of the bull, but there have been few studies on its functional role in cattle. The aim of the present study was to examine the role of BBD126 in bull sperm binding to bovine oviductal epithelial cell (BOEC) explants. BBD126 has been shown to be highly resistant to the standard methods of dissociation used in other species and, as a result, corpus epididymal spermatozoa, which have not been exposed to the protein, were used to study the functional role of BBD126. Corpus epididymal spermatozoa were incubated with recombinant (r) BBD126 in the absence or presence of anti-BBD126 antibody. Addition of rBBD126 significantly enhanced the ability of epididymal spermatozoa to bind to BOEC explants (P < 0.05). Anti-BBD126 antibody blocked the BBD126-mediated increase in sperm binding capacity. Ejaculated spermatozoa, which are coated with native BBD126 protein but also a large number of seminal plasma proteins in vivo, were incubated with rBBD126 in the absence or presence of the anti-BBD126 antibody. Addition of rBBD126 significantly enhanced the ability of ejaculated spermatozoa to bind to BOEC explants (P < 0.05), whereas rBBD126 also reduced corpus sperm agglutination (P < 0.05). These results suggest that, similar to the role of its analogue in the macaque, spermatozoa with more BBD126 in their acrosome may represent spermatozoa with more oviduct binding capacity.

Postnatal depression: Can visual media and dramatisation of a young woman's experiences, enable student health care professionals develop knowledge to enhance clinical practice skills?

Introduction

Since the presentation of the symptoms of postnatal depression (PND) can vary; healthcare professionals must receive the appropriate level of training to develop the knowledge required for the effective assessment and referral of women. Yet, healthcare professionals may have limited knowledge in perinatal mental health and students may lack practice opportunities to develop the knowledge and clinical skills. For these reasons, the use of alternative learning resources within perinatal mental health education is vital.

Objectives

To explore the use of visual media in perinatal mental health education.

Aims

Against the background of increasing concerns about the ability of professionals to assess women with PND, this paper will consider how using dramatisation as a teaching approach can enable students to develop their knowledge and guide clinical skill development.

Methods

Three separate groups of senior student midwives and health visitors were asked to evaluate a dramatisation developed from women's lived experience of PND. Pre and post verbal evaluation of the drama were undertaken with the use of focus groups guided by semi-structured questions. Ethical approval was granted by the university.

Results

Following thematic analysis three issues were identified:

–the role of the healthcare professional;

–improvements needed in care;

–issues of education and training.

Conclusions

Against the background of limited placement experience and opportunity for assessment of PND, the use of visual media can improve student healthcare professionals’ learning; with the use of structured facilitation, there is a great potential for multidisciplinary learning.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

In vitro addition of docosahexaenoic acid improves the quality of cooled but not frozen-thawed stallion semen

The aim of the present study was to assess the effect of the addition of docosahexaenoic acid (DHA) on the in vitro quality of cooled and frozen-thawed stallion semen. In Experiment 1, semen from 10 stallions was collected (three ejaculates per stallion). Semen was diluted to 100×10⁶ spermatozoa mL^-1 with 0.02mM vitamin E (VE) and 0, 1, 10 or 20ng mL^-1 DHA and frozen. Semen was thawed and total motility (TM), rapid progressive motility (PM), acrosome integrity, membrane fluidity and morphology were assessed. In Experiment 2, semen from three stallions was collected (three ejaculates per stallion) and frozen as in Experiment 1, but VE and DHA were added after thawing. TM and PM were assessed at 30, 60 and 120min and viability, acrosome integrity and membrane fluidity were evaluated at 30min. In Experiment 3, semen from five stallions was collected (one to three ejaculates per stallion), diluted to 20×10⁶ spermatozoa mL^-1 and stored at 4°C. After 1, 24, 48 and 72h, TM, PM, viability, membrane fluidity and lipid peroxidation were assessed. The addition of DHA had no effect on frozen semen (Experiments 1 and 2) but improved TM, PM and membrane fluidity in cooled stallion semen.

The use of a negative pressure wound management system in perineal wound closure after extralevator abdominoperineal excision (ELAPE) for low rectal cancer

BACKGROUND

Perineal wound healing is a significant challenge after extralevator abdominoperineal excision (ELAPE) due to a high rate of wound breakdown. Negative pressure therapy has proven benefits in open wounds, and recently a negative pressure system has been developed for use on closed wounds at high risk of breakdown, such as apronectomy and hysterectomy. The aim of the present study was to determine whether negative pressure therapy applied to closed perineal wounds after ELAPE improved wound healing and compare outcomes to the published literature and outcomes from a historical cohort of patients who had undergone 'standard' abdominoperineal resection (APR) and primary closure of the perineal wounds.

METHODS

Prospective data on consecutive patients having ELAPE in the period from November 2012 to April 2015 were collected. The pelvic floor defect was reconstructed with biologic mesh. The adipose tissue layer was closed with vicryl sutures, a suction drain was left in the deep layer, the subcuticular layer and skin were closed, and the negative pressure system was applied. Any wound breakdown within the first 30 days postoperatively was recorded.

RESULTS

Of the 32 consecutive ELAPE patients whose perineal wounds were closed within 30 days with the use of the negative pressure system, there was 1 patient with major perineal wound breakdown and 2 patients with a 1 cm superficial wound defect, which needed no further treatment. In the remaining 29 (90 %) patients, the perineal wounds healed fully without complications. Twenty-five patients underwent standard APR in 2010-2011 with primary closure of their perineal wounds. Ten out of 25(40 %) of patients who had undergone standard APR and primary closure of perineal wounds had major wound complications (p = 0.01).

CONCLUSIONS

Our results suggest that after ELAPE the application of a negative pressure system to the perineal wound closed with biologic mesh may reduce perineal wound complications and may reduce the need for major perineal reconstruction.

Use of antiretroviral treatment among people living with HIV in Australia between 1997 and 2012

Current international targets aim for 90% of people diagnosed with HIV to be on antiretroviral treatment (ART). This paper aims to identify sociodemographic and attitudinal factors associated with ART non-use over time in three samples of Australian people living with HIV (PLHIV). Data for this paper were derived from an Australian cross-sectional survey of PLHIV that was repeated at three different time points: 1997, 2003, and 2012. There were approximately 1000 respondents to each survey (n = 3042 in total). The survey included approximately 250 items related broadly to health and well-being, ART use, and attitudes towards ART use. Univariate and multivariate logistic regression analyses were used. While the proportion of participants using ART increased between 1997 and 2012 (78.8-87.6%, p < .001), there was a decrease between 1997 and 2003 to 70.6% (p < .001). Factors linked to ART non-use remained steady over those 15 years. In all cohorts, people less likely to be using ART were younger and had a more recent diagnosis of HIV. In 2003 and 2012, people in full-time employment were less likely to be using ART, while those whose main source of income was a pension or social security were more likely to be using ART. Multivariate models showed that, at each time point, a belief in the health benefits of delayed ART uptake was associated with non-use. These findings suggest that there may be barriers to ART uptake that have persisted over time despite changes to clinical guidelines that now encourage early uptake.

Postnatal MRI Brain in Infants Treated for Twin-Twin Transfusion Syndrome

Untreated twin-twin transfusion syndrome (TTTS) is associated with significant mortality and neurological impairment. Fetoscopic laser surgery (FLS) is the treatment of choice. We sought to assess intracranial abnormalities in TTTS twins following treatment. In this prospective, blinded study MRI scans were performed on 3 groups; (1) monochorionic diamniotic (MCDA) twins with TTTS who had undergone FLS (n = 10), (2) MCDA twins without TTTS (n = 8) and (3) dichorionic twins (n = 8). Scans were scored as either normal or abnormal. The primary outcome was a composite of abnormal MRI brain or intrauterine fetal demise. The primary outcome occurred in 6/10 (60%) of the TTTS group versus 3/8 (37.5%) in the MCDA group. The primary outcome was significantly different across all study groups [p = 0.029; X2 = 7.112]. We found that twins treated for TTTS are more likely to have abnormalities on MRI brain at term than other twin groups. This group merits term-corrected MRI as part of their postnatal assessment.

Evaluation of dengue virus strains for human challenge studies

Discordance between the measured levels of dengue virus neutralizing antibody and clinical outcomes in the first-ever efficacy study of a dengue tetravalent vaccine (Lancet, Nov 2012) suggests a need to re-evaluate the process of pre-screening dengue vaccine candidates to better predict clinical benefit prior to large-scale vaccine trials. In the absence of a reliable animal model and established correlates of protection for dengue, a human dengue virus challenge model may provide an approach to down-select vaccine candidates based on their ability to reduce risk of illness following dengue virus challenge. We report here the challenge of flavivirus-naïve adults with cell culture-passaged dengue viruses (DENV) in a controlled setting that resulted in uncomplicated dengue fever (DF). This sets the stage for proof-of-concept efficacy studies that allow the evaluation of dengue vaccine candidates in healthy adult volunteers using qualified DENV challenge strains well before they reach field efficacy trials involving children. Fifteen flavivirus-naïve adult volunteers received 1 of 7 DENV challenge strains (n=12) or placebo (n=3). Of the twelve volunteers who received challenge strains, five (two DENV-1 45AZ5 and three DENV-3 CH53489 cl24/28 recipients) developed DF, prospectively defined as ≥2 typical symptoms, ≥48h of sustained fever (>100.4°F) and concurrent viremia. Based on our study and historical data, we conclude that the DENV-1 and DENV-3 strains can be advanced as human challenge strains. Both of the DENV-2 strains and one DENV-4 strain failed to meet the protocol case definition of DF. The other two DENV-4 strains require additional testing as the illness approximated but did not satisfy the case definition of DF. Three volunteers exhibited effusions (1 pleural/ascites, 2 pericardial) and 1 volunteer exhibited features of dengue (rash, lymphadenopathy, neutropenia and thrombocytopenia), though in the absence of fever and symptoms. The occurrence of effusions in milder DENV infections counters the long-held belief that plasma leakage syndromes are restricted to dengue hemorrhagic fever/dengue shock syndromes (DHF/DSS). Hence, the human dengue challenge model may be useful not only for predicting the efficacy of vaccine and therapeutic candidates in small adult cohorts, but also for contributing to our further understanding of the mechanisms behind protection and virulence.

The utility of molecular diagnostics to predict recurrence of head and neck carcinoma

BACKGROUND

Locoregional recurrence is the major cause of treatment failure after surgery for oral squamous cell carcinoma. Molecular diagnostics have the potential to improve on clinicopathological parameters to predict this recurrence and plan adjuvant treatment. The test most frequently applied is based on detecting TP53 mutations, but alternative methodology is required for cases that harbour the wild-type gene.

METHODS

One hundred and two cases with tumour-adjacent margins, considered to be clear margins by microscopy, were examined using carefully optimised molecular diagnostics based on detection of the TP53 and Ly-6D markers. The markers were also combined to provide a dual approach.

RESULTS

The dual molecular diagnostic identified cases with a significant increase in the probablility of developing locoregional recurrence when tumour-adjacent positive and clear margins were compared (P=0.0001). These tests were most useful when the clearance at the resection margins was 5 mm or less. The TP53-based diagnostic was a better predictor of locoregional recurrence than established clinicopathological parameters.

CONCLUSION

The optimised TP53-based diagnostic rapidly identifies an important subgroup of cases with close margins that will benefit from new treatment modalities to reduce the risk of recurrence.

A human challenge model for dengue infection reveals a possible protective role for sustained interferon gamma levels during the acute phase of illness

Dengue has recently been defined by the World Health Organization as a major international public health concern. Although several vaccine candidates are in various stages of development, there is no licensed vaccine available to assist in controlling the further spread of this mosquito borne disease. The need for a reliable animal model for dengue disease increases the risk to vaccine developers as they move their vaccine candidates into large-scale phase III testing. In this paper we describe the cellular immune responses observed in a human challenge model for dengue infection; a model that has the potential to provide efficacy data for potential vaccine candidates in a controlled setting. Serum levels of sIL-2Rα and sTNF-RII were increased in volunteers who developed illness. Supernatants from in vitro stimulated PBMC were tested for cytokines associated with a T(H)1 or T(H)2 T-cell response (IL-2, TNF-α, IFN-γ, IL-4, IL-10, IL-5) and only IFN-γ was associated with protection against fever and/or viremia. Interestingly, IFN-γ levels drop to 0 pg/mL for volunteers who develop illness after challenge suggesting that some mechanism of immunosuppression may play a role in dengue illness. The human challenge model provides an opportunity to test potential vaccine candidates for efficacy prior to large-scale phase III testing, and hints at a possible mechanism for immune suppression by dengue.