Galaxy growth in a massive halo in the first billion years of cosmic history

According to the current understanding of cosmic structure formation, the precursors of the most massive structures in the Universe began to form shortly after the Big Bang, in regions corresponding to the largest fluctuations in the cosmic density field. Observing these structures during their period of active growth and assembly-the first few hundred million years of the Universe-is challenging because it requires surveys that are sensitive enough to detect the distant galaxies that act as signposts for these structures and wide enough to capture the rarest objects. As a result, very few such objects have been detected so far. Here we report observations of a far-infrared-luminous object at redshift 6.900 (less than 800 million years after the Big Bang) that was discovered in a wide-field survey. High-resolution imaging shows it to be a pair of extremely massive star-forming galaxies. The larger is forming stars at a rate of 2,900 solar masses per year, contains 270 billion solar masses of gas and 2.5 billion solar masses of dust, and is more massive than any other known object at a redshift of more than 6. Its rapid star formation is probably triggered by its companion galaxy at a projected separation of 8 kiloparsecs. This merging companion hosts 35 billion solar masses of stars and has a star-formation rate of 540 solar masses per year, but has an order of magnitude less gas and dust than its neighbour and physical conditions akin to those observed in lower-metallicity galaxies in the nearby Universe. These objects suggest the presence of a dark-matter halo with a mass of more than 100 billion solar masses, making it among the rarest dark-matter haloes that should exist in the Universe at this epoch.

Understanding the structure and functioning of polar pelagic ecosystems to predict the impacts of change

The determinants of the structure, functioning and resilience of pelagic ecosystems across most of the polar regions are not well known. Improved understanding is essential for assessing the value of biodiversity and predicting the effects of change (including in biodiversity) on these ecosystems and the services they maintain. Here we focus on the trophic interactions that underpin ecosystem structure, developing comparative analyses of how polar pelagic food webs vary in relation to the environment. We highlight that there is not a singular, generic Arctic or Antarctic pelagic food web, and, although there are characteristic pathways of energy flow dominated by a small number of species, alternative routes are important for maintaining energy transfer and resilience. These more complex routes cannot, however, provide the same rate of energy flow to highest trophic-level species. Food-web structure may be similar in different regions, but the individual species that dominate mid-trophic levels vary across polar regions. The characteristics (traits) of these species are also different and these differences influence a range of food-web processes. Low functional redundancy at key trophic levels makes these ecosystems particularly sensitive to change. To develop models for projecting responses of polar ecosystems to future environmental change, we propose a conceptual framework that links the life histories of pelagic species and the structure of polar food webs.

Leukemia-cell proliferation and disease progression in patients with early stage chronic lymphocytic leukemia

The clinical course of patients with recently diagnosed early stage chronic lymphocytic leukemia (CLL) is highly variable. We examined the relationship between CLL-cell birth rate and treatment-free survival (TFS) in 97 patients with recently diagnosed, Rai stage 0-II CLL in a blinded, prospective study, using in vivo 2H2O labeling. Birth rates ranged from 0.07 to 1.31% new cells per day. With median follow-up of 4.0 years, 33 subjects (34%) required treatment by NCI criteria. High-birth rate was observed in 44% of subjects and was significantly associated with shorter TFS, unmutated IGHV status and expression of ZAP70 and of CD38. In multivariable modeling considering age, gender, Rai stage, expression of ZAP70 or CD38, IGHV mutation status and FISH cytogenetics, only CLL-cell birth rate and IGHV mutation status met criteria for inclusion. Hazard ratios were 3.51 (P=0.002) for high-birth rate and 4.93 (P<0.001) for unmutated IGHV. The association between elevated birth rate and shorter TFS was observed in subjects with either mutated or unmutated IGHVs, and the use of both markers was a better predictor of TFS than either parameter alone. Thus, an increased CLL birth rate in early stage disease is a strong predictor of disease progression and earlier treatment.

Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplantation in Patients Over Age 70 Years: A Case Report

Extracorporeal membrane oxygenation (ECMO) may be used safely as a bridge to lung transplantation in carefully selected elderly patients. We report the case of a 70-year-old patient bridged on ECMO before transplantation. A brief discussion on improving outcomes for the elderly and patients bridged on ECMO in general is presented.

UX007 for the treatment of long chain-fatty acid oxidation disorders: Safety and efficacy in children and adults following 24weeks of treatment

BACKGROUND

Long-chain fatty acid oxidation disorders (LC-FAOD) lead to accumulation of high concentrations of potentially toxic fatty acid intermediates. Newborn screening and early intervention have reduced mortality, but most patients continue to experience frequent hospitalizations and significant morbidity despite treatment. The deficient energy state can cause serious liver, muscle, and heart disease, and may be associated with an increased risk of sudden death. Triheptanoin is a medium odd-chain fatty acid. Anaplerotic metabolites of triheptanoin have the potential to replace deficient tricarboxylic acid (TCA) cycle intermediates, resulting in net glucose production as a novel energy source for the treatment of LC-FAOD.

STUDY DESIGN

A single-arm, open-label, multicenter Phase 2 safety and efficacy study evaluated patients with severe LC-FAOD evidenced by ongoing related musculoskeletal, cardiac, and/or hepatic events despite treatment. After a four-week run-in on current regimen, investigational triheptanoin (UX007) was titrated to a target dose of 25-35% of total daily caloric intake. Patients were evaluated on several age/condition-eligible endpoints, including submaximal exercise tests to assess muscle function/endurance (12-minute walk test; 12MWT) and exercise tolerance (cycle ergometry), and health related quality of life (HR-QoL). Results through 24weeks of treatment are presented; total study duration is 78weeks.

RESULTS

Twenty-nine patients (0.8 to 58years) were enrolled; most qualified based on severe musculoskeletal disease. Twenty-five patients (86%) completed the 24-week treatment period. At Week 18, eligible patients (n=8) demonstrated a 28% increase (LS mean=+181.9 meters; p=0.087) from baseline (673.4meters) in 12MWT distance. At Week 24, eligible patients (n=7) showed a 60% increase in watts generated (LS mean=+409.3W; p=0.149) over baseline (744.6W) for the exercise tolerance test. Improvements in exercise tests were supported by significant improvements from baseline in the adult (n=5) self-reported SF-12v2 physical component summary score (LS mean=+8.9; p<0.001). No difference from baseline was seen in pediatric parent-reported (n=5) scores (SF-10) at Week 24. Eighteen patients (62%) had treatment-related adverse events, predominantly gastrointestinal (55%), mild-to-moderate in severity, similar to that seen with prior treatment with medium chain triglyceride (MCT) oil. One patient experienced a treatment-related serious adverse event of gastroenteritis. One patient discontinued from study due to diarrhea of moderate severity; the majority of patients (25/29; 86%) elected to continue treatment in the extension period.

CONCLUSIONS

In patients with severe LC-FAOD, UX007 interim study results demonstrated improved exercise endurance and tolerance, and were associated with positive changes in self-reported HR-QoL.

Predictors of developmental surveillance completion at six months of age in south western Sydney

BACKGROUND

While developmental surveillance programs promote early identification of child developmental problems, evidence has indicated suboptimal uptake. This study aimed to identify predictors of developmental surveillance completion at 6 months postpartum.

METHODS

Questionnaires were administered to the parents of 510 infants who were born in south western Sydney, Australia over a 22-month period. Attendance for developmental screening and completion of the Parents' Evaluation of Developmental Status (PEDS) at 6 months postpartum were modelled separately using multivariable logistic regression.

RESULTS

Developmental surveillance attendance was predicted by higher levels of maternal education, annual income and being informed about checks. PEDS completion at 6 months of age was predicted by higher income and being informed, as well as being married, employed, speaking English at home, full-term birth and the professional status of the practitioner completing the check.

CONCLUSIONS

Barriers to developmental surveillance included low socioeconomic status, linguistic diversity and possible gaps in parental knowledge and professional education. Developmental surveillance rates may be increased by the addition of targeted parental and professional support within current universal frameworks.

Early results of the LPS™ limb preservation system in the management of periprosthetic femoral fractures

INTRODUCTION

Achieving skeletal fixation in the presence of progressive bone loss is a surgical challenge, especially in cases of periprosthetic fracture (PPF). Unpredictable fracture patterns and preexisting bone loss frequently combine in this patient group. Megaprosthetic arthroplasty allows for immediate mobilisation and shorter periods of rehabilitation. We describe the clinical outcomes of a cohort of LPS™ megaprostheses performed for PPF by a single surgeon at our institution.

METHODS

Between July 2013 and November 2015, 23 patients underwent endoprosthetic femoral replacement of which 16 were performed for PPF or bone loss. Patient demographics, surgical indication, operative details, implant composition, blood loss, survival, and revision surgery details were recorded in a prospectively maintained database. Patients underwent serial clinical and X-ray evaluations at 6 weeks, 3 months and 6 months post surgery with yearly reviews thereafter.

RESULTS

The PPF cohort consisted of 9 males and 7 females with a mean age of 75 and a mean follow up of 19.2 months. The mean Oxford score prior to fracture was 41 (range 12-48), and 39 (range 13-48, p = 0.6) post megaprosthesis insertion. Postoperative dislocation of the megaprosthesis occurred in two patients (12.5%), with no postoperative infections recorded.

CONCLUSION

We report minimal postoperative changes in functional outcome scores. The results of revision arthroplasty with LPS™ proximal femur megaprosthesis were satisfactory in 15/16 patients at a mean follow-up of 19.2 months. We recommend the use of megaprostheses in patients with markedly deficient bone stock for whom other available reconstructive procedures are unavailable.

Arthrodesis of Little Finger Distal Interphalangeal Joint in Flexion to Regain Sporting Ability

BACKGROUND

Finger injuries are common in the sport of hurling. Injury to the little finger distal interphalangeal joint (DIPJ) often occurs when a high dropping ball impacts on the outstretched finger. The little finger contributes to approximately 15% of grip strength. Injury therefore results in reduced grip strength and may impair the ability of players to grip or catch a ball.

METHODS

Six elite hurlers with post-traumatic arthritis of their non-dominant little finger DIPJ underwent arthrodesis in 30 degrees of flexion. Kirchner wires were inserted for up to 8 weeks to achieve fusion of the joint. Patients were evaluated after recovery using a dynamometer to assess grip strength, the DASH questionnaire and a sport specific questionnaire.

RESULTS

All arthrodeses achieved bony union without complication. All patients reported a resolution of their pain and recovery in their ability to catch & retain a ball. Measurements of grip strengths were comparable between hands. DASH scores improved by up to 47 points. All scores were less than 5 at final follow-up.

CONCLUSIONS

Grip strength decreases when fingers are immobilized in full extension. In sports that require catching or gripping a ball or a bat, arthrodesis of the DIP joint in flexion can improve grip strength and hand function. Fusion in 30 degrees of flexion for hurlers results in restoration of function and resolution of pain. Little finger DIPJ arthrodesis is a valid method of treating posttraumatic arthritis in ball and bat sports.

Medium term review of the ASR implant system: A single surgeon series

INTRODUCTION

Both ASR hip resurfacings and stemmed ASR XL arthroplasties have failed at high rates in several published series. We assessed a single surgeon series of these arthroplasties looking to identify factors associated with their failure.

METHODS

All surgeries were performed by one surgeon. Patients were evaluated clinically, radiologically and with serial cobalt and chromium ion analysis.

RESULTS

274 implants were analysed - 152 ASR resurfacings and 122 ASR XL implants. Thirty revisions were performed.

CONCLUSION

The failure rate of the ASR implant in our series is unacceptably high - its use in routine hip arthroplasty cannot be supported.

Reducing risks of Transfusion-transmitted infections in a resource-limited hospital-based blood bank: the case of the Yaoundé University Teaching Hospital, Cameroon

BACKGROUND AND OBJECTIVES

Although interest in assessing risk of TTIs, very few trends in blood safety epidemiological data from resource-limited blood services are reported in the literature. This analysis aims at reporting trends in seroprevalences of TTIs in blood donations in the Yaoundé University Teaching Hospital (UTH) from 2011 to 2015 and to describe reasons for these changes.

MATERIALS AND METHODS

All donations of 2015 were tested for HIV 1&2 antibodies and the P24 antigen, HBsAg, HCV antibody and the Treponema pallidum antibody. Screening for HIV uses a national algorithm based on the systematic use of two assays of different principles: a rapid determination testing assay and an EIA HIV 1 & 2 Ab-Ag. The tests used for HBsAg and HCVAb screening were all based on EIA techniques. Treponema pallidum antibody screening was based on Treponema Pallidum hemagglutination assay (TPHA) and rapid immunochromatographic test (RIT). Screening techniques and results from 2015 were compared to retrospective data from 2011, 2012, 2013 and 2014.

RESULTS

In 2015, 13·4% (n = 214) of 1,596 blood donations were seropositive for at least one screened TTIs. The most frequent serological marker was HBsAg with 123 (7·7%) blood units contaminated. Nineteen (1·2%) and 18 (1·1%) blood units was positive for HIV and syphilis, respectively. There was a significant decrease in the total number of blood donations (P < 10^-4) and HIV, HBsAg and syphilis seroprevalences and an increase in the proportion of voluntary non-remunerated blood donor (P < 0·05). HCVAb seroprevalence was 3·8% in 2015 and has not decreased significantly over the years (P = 0·09).

CONCLUSION

Significant progress is noted in reduction in seroprevalences of HIV, HBV, HCV and syphilis since the beginning of a regular registration of data in 1990.

Astrocyte arachidonate and palmitate uptake and metabolism is differentially modulated by dibutyryl-cAMP treatment

Astrocytes play a vital role in brain lipid metabolism; however the impact of the phenotypic shift in astrocytes to a reactive state on arachidonic acid metabolism is unknown. Therefore, we determined the impact of dibutyryl-cAMP (dBcAMP) treatment on radiolabeled arachidonic acid ([1-(14)C]20:4n-6) and palmitic acid ([1-(14)C]16:0) uptake and metabolism in primary cultured murine cortical astrocytes. In dBcAMP treated astrocytes, total [1-(14)C]20:4n-6 uptake was increased 1.9-fold compared to control, while total [1-(14)C]16:0 uptake was unaffected. Gene expression of long-chain acyl-CoA synthetases (Acsl), acyl-CoA hydrolase (Acot7), fatty acid binding protein(s) (Fabp) and alpha-synuclein (Snca) were determined using qRT-PCR. dBcAMP treatment increased expression of Acsl3 (4.8-fold) and Acsl4 (1.3-fold), which preferentially use [1-(14)C]20:4n-6 and are highly expressed in astrocytes, consistent with the increase in [1-(14)C]20:4n-6 uptake. However, expression of Fabp5 and Fabp7 were significantly reduced by 25% and 45%, respectively. Acot7 (20%) was also reduced, suggesting dBcAMP treatment favors acyl-CoA formation. dBcAMP treatment enhanced [1-(14)C]20:4n-6 (2.2-fold) and [1-(14)C]16:0 (1.6-fold) esterification into total phospholipids, but the greater esterification of [1-(14)C]20:4n-6 is consistent with the observed uptake through increased Acsl, but not Fabp expression. Although total [1-(14)C]16:0 uptake was not affected, there was a dramatic decrease in [1-(14)C]16:0 in the free fatty acid pool as esterification into the phospholipid pool was increased, which is consistent with the increase in Acsl3 and Acsl4 expression. In summary, our data demonstrates that dBcAMP treatment increases [1-(14)C]20:4n-6 uptake in astrocytes and this increase appears to be due to increased expression of Acsl3 and Acsl4 coupled with a reduction in Acot7 expression.

Source-based subjective responses to sleep disturbance from transportation noise

There is increasing evidence to suggest that the use of subjective responses to questions concerning night-time environmental noise exposure is a robust method of assessing sleep disturbance from road traffic noise. However, there have only been a few studies exploring this issue in a real world context beyond controlled laboratory settings. This paper presents results from such a study. It utilises 208 household questionnaire surveys to assess subjective responses to levels of night-time sleep disturbance and annoyance from four different residential sites. Each residential site is characterised by a dominant noise source - road, light rail, and aircraft - and these sites are compared to a control site that is relatively free from transportation noise. The results demonstrate the inadequacy of continuous equivalent noise level measures as indicators of night-time disturbance. Furthermore, they suggest that the use of these measures alone is likely to result in inaccurate appraisals of night-time sleep disturbance from transportation noise. Ultimately, the research implies that measurement data should be used in conjunction with subjective response data to accurately gauge the level of night-time disturbance from transportation noise.

Financial impact of allogeneic hematopoietic cell transplantation on patients and families over 2 years: results from a multicenter pilot study

Hematopoietic cell transplantation (HCT) is a procedure that can significantly influence the socioeconomic wellbeing of patients, caregivers and their families. Among 30 allogeneic HCT recipients and their caregivers enrolled on a pilot study evaluating the feasibility of studying financial impact of HCT, 16 agreed to participate in the long-term phase, completed a baseline questionnaire and received phone interviews at 6, 12, 18 and 24 months post-HCT. Analyses showed that by 2-years post-HCT, 54% of patients who previously contributed to household earnings had not returned to work and 80% of patients/caregivers reported transplant as having moderate to great impact on household income. However, patients’ level of confidence in their ability to meet household financial obligations increased from baseline to 2-years. A relatively large proportion of patients reported inability to pay for medical care through this time period. Case studies demonstrated patient individual perception of financial impact of HCT varies considerably, regardless of actual income. We demonstrate the feasibility of conducting a study to evaluate financial impact of allogeneic HCT through 2-years post-transplantation. Some patients/caregivers continue to experience significant long-term financial burden after this procedure. Our study lays the foundation for a larger evaluation of patient/caregiver financial burden associated with HCT.

Significant improvements in quality of life following paediatric tonsillectomy: a prospective cohort study

BACKGROUND

The clinical efficacy of adenotonsillectomy is under debate with falling tonsillectomy rates in the UK and Ireland. In 2010, an NHS commissioned randomised controlled trial recommended medical management, leading to some Primary Care Trusts refusing to commission any tonsillectomies at all. With the HSE cutting Hospital Spending by €200 million euro in 2014, data supporting the benefit of adenotonsillectomy in the Irish population are sorely lacking.

AIMS

We aimed to evaluate the symptomatic benefit reported by parents of children undergoing adenotonsillectomy/tonsillectomy in the Irish population.

METHODS

We utilised the T14 Paediatric Throat disorders Outcome Test, a disease-specific, validated questionnaire which assesses patient reported outcome measures (PROMs). We administered pre and post-operative questionnaires to parents of children ages 3-16 years undergoing tonsillectomy. Symptomatic children on our tonsillectomy waiting list were also simultaneously recruited.

RESULT

Eighty-six children were recruited. A total of 55 parents of children undergoing tonsillectomy filled questionnaires. These were well matched in age and gender with 31 children on the waiting list. An independent samples t test was conducted to compare the improvement scores for tonsillectomy and control groups. There was a significant difference in scores for the tonsillectomy group, with pre-operative scores of (M = 39.8, SD = 9.7) and at post-operative follow-up of (M = 1.6, SD = 7.3) t (61) = -18, p ≤ 0.0001 (two tailed). This correlated with a significant difference in the mean between the two periods (mean difference = 38.3, 95 % CI: 42.3-34.1).

CONCLUSION

This study provides clear evidence that tonsillectomy provides significant improvement in PROMs vs. watchful waiting. We consider tonsillectomy to be a procedure of considerable clinical benefit and a worthwhile allocation of HSE expenditure.

Six-year follow-up of the SPHERE RCT: secondary prevention of heart disease in general practice

OBJECTIVE

To determine the long-term effectiveness of a complex intervention in primary care aimed at improving outcomes for patients with coronary heart disease.

DESIGN

A 6-year follow-up of a cluster randomised controlled trial, which found after 18 months that both total and cardiovascular hospital admissions were significantly reduced in intervention practices (8% absolute reduction).

SETTING

48 general practices in the Republic of Ireland and Northern Ireland.

PARTICIPANTS

903 patients with established coronary heart disease at baseline in the original trial.

INTERVENTION

The original intervention consisted of tailored practice and patient plans; training sessions for practitioners in medication prescribing and behavioural change; and regular patient recall system. Control practices provided usual care. Following the intervention period, all supports from the research team to intervention practices ceased.

PRIMARY OUTCOME

hospital admissions, all cause and cardiovascular; secondary outcomes: mortality; blood pressure and cholesterol control.

RESULTS

At 6-year follow-up, data were collected from practice records of 696 patients (77%). For those who had died, we censored their data at the point of death and cause of death was established. There were no significant differences between the intervention and control practices in either total (OR 0.83 (95% CI 0.54 to 1.28)) or cardiovascular hospital admissions (OR 0.91 (95% CI 0.49 to 1.65)). We confirmed mortality status of 886 of the original 903 patients (98%). There were no significant differences in mortality (15% in intervention and 16% in control) or in the proportions of patients above target control for systolic blood pressure or total cholesterol.

CONCLUSIONS

Initial significant differences in the numbers of total and cardiovascular hospital admissions were not maintained at 6 years and no differences were found in mortality or blood pressure and cholesterol control. Policymakers need to continue to assess the effectiveness of previously efficacious programmes.

TRIAL REGISTRATION NUMBER

Current Controlled Trials ISRCTN24081411.

Major cost savings associated with biologic dose reduction in patients with inflammatory arthritis

The purpose of this study was to explore whether patients with Inflammatory Arthritis (IA) (Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) or Ankylosing Spondylitis (AS)) would remain in remission following a reduction in biologic dosing frequency and to calculate the cost savings associated with dose reduction. This prospective non-blinded non-randomised study commenced in 2010. Patients with Inflammatory Arthritis being treated with a biologic agent were screened for disease activity. A cohort of those in remission according to standardized disease activity indices (DAS28 < 2.6, BASDAI < 4) was offered a reduction in dosing frequency of two commonly used biologic therapies (etanercept 50 mg once per fortnight instead of weekly, adalimumab 40 mg once per month instead of fortnightly). Patients were assessed for disease activity at 3, 6, 12, 18 and 24 months following reduction in dosing frequency. Cost saving was calculated. 79 patients with inflammatory arthritis in remission were recruited. 57% had rheumatoid arthritis (n = 45), 13% psoriatic arthritis (n = 10) and 30% ankylosing spondylitis (n = 24). 57% (n = 45) were taking etanercept and 43% (n = 34) adalimumab. The percentage of patients in remission at 24 months was 56% (n = 44). This resulted in an actual saving to the state of approximately 600,000 euro over two years. This study demonstrates the reduction in biologic dosing frequency is feasible in Inflammatory Arthritis. There was a considerable cost saving at two years. The potential for major cost savings in biologic usage should be pursued further.

Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial

PURPOSE

Cognitive impairment after critical illness is common and debilitating. We developed a cognitive therapy program for critically ill patients and assessed the feasibility and safety of administering combined cognitive and physical therapy early during a critical illness.

METHODS

We randomized 87 medical and surgical ICU patients with respiratory failure and/or shock in a 1:1:2 manner to three groups: usual care, early once-daily physical therapy, or early once-daily physical therapy plus a novel, progressive, twice-daily cognitive therapy protocol. Cognitive therapy included orientation, memory, attention, and problem-solving exercises, and other activities. We assessed feasibility outcomes of the early cognitive plus physical therapy intervention. At 3 months, we also assessed cognitive, functional, and health-related quality of life outcomes. Data are presented as median (interquartile range) or frequency (%).

RESULTS

Early cognitive therapy was a delivered to 41/43 (95%) of cognitive plus physical therapy patients on 100% (92-100%) of study days beginning 1.0 (1.0-1.0) day following enrollment. Physical therapy was received by 17/22 (77%) of usual care patients, by 21/22 (95%) of physical therapy only patients, and 42/43 (98%) of cognitive plus physical therapy patients on 17% (10-26%), 67% (46-87%), and 75% (59-88%) of study days, respectively. Cognitive, functional, and health-related quality of life outcomes did not differ between groups at 3-month follow-up.

CONCLUSIONS

This pilot study demonstrates that early rehabilitation can be extended beyond physical therapy to include cognitive therapy. Future work to determine optimal patient selection, intensity of treatment, and benefits of cognitive therapy in the critically ill is needed.

Employment in adults with cystic fibrosis

BACKGROUND

Chronic ill-health may significantly impact on an individual's ability to work. This not only relates to disease severity but also to psychosocial factors such as illness perception and coping strategies.

AIMS

To explore the factors associated with employment status in adults with cystic fibrosis (CF).

METHODS

Subjects recruited from adult CF clinics in Aberdeen, Birmingham and Newcastle completed questionnaires assessing health-related quality of life (HRQoL), workplace productivity (presenteeism) and employment. Clinical data indicative of disease severity were also recorded.

RESULTS

A total of 254 subjects were recruited, 41 from Aberdeen, 63 from Birmingham and 150 from Newcastle. Sixty-five per cent of subjects were in employment or education. If employed/self-employed, median hours worked was 37.3h/week. Forty per cent reported stopping a job due to CF; 47% felt CF had affected career choice and 24% changed duties because of CF. Ten per cent had taken a pay cut and 23% reported workplace discrimination due to CF. Multivariate modelling demonstrated that employment status was independently associated with educational attainment, centre and the HRQoL domains of role and health perception and is independent of clinical parameters of disease severity.

CONCLUSIONS

Adults with CF reported that CF impacted on their ability to work. Employment appeared to be most strongly associated with educational attainment, locality and HRQoL domains and not clinical parameters of severity. Specific guidance is needed for both adults with CF and potential employers, with appropriate targeted interventions aimed at improving health perceptions and coping strategies.

Dietary practices in pyridoxine non-responsive homocystinuria: a European survey

BACKGROUND

Within Europe, the management of pyridoxine (B6) non-responsive homocystinuria (HCU) may vary but there is limited knowledge about treatment practice.

AIM

A comparison of dietetic management practices of patients with B6 non-responsive HCU in European centres.

METHODS

A cross-sectional audit by questionnaire was completed by 29 inherited metabolic disorder (IMD) centres: (14 UK, 5 Germany, 3 Netherlands, 2 Switzerland, 2 Portugal, 1 France, 1 Norway, 1 Belgium).

RESULTS

181 patients (73% >16 years of age) with HCU were identified. The majority (66%; n=119) were on dietary treatment (1-10 years, 90%; 11-16 years, 82%; and >16 years, 58%) with or without betaine and 34% (n=62) were on betaine alone. The median natural protein intake (g/day) on diet only was, by age: 1-10 years, 12 g; 11-16 years, 11 g; and >16 years, 45 g. With diet and betaine, median natural protein intake (g/day) by age was: 1-10 years, 13 g; 11-16 years, 20 g; and >16 years, 38 g. Fifty-two percent (n=15) of centres allocated natural protein by calculating methionine rather than a protein exchange system. A methionine-free l-amino acid supplement was prescribed for 86% of diet treated patients. Fifty-two percent of centres recommended cystine supplements for low plasma concentrations. Target treatment concentrations for homocystine/homocysteine (free/total) and frequency of biochemical monitoring varied.

CONCLUSION

In B6 non-responsive HCU the prescription of dietary restriction by IMD centres declined with age, potentially associated with poor adherence in older patients. Inconsistencies in biochemical monitoring and treatment indicate the need for international consensus guidelines.