Screening for latent tuberculosis in UK health care workers

Background

Active tuberculosis (TB) infection was diagnosed in two health care workers (HCWs) originally from high-incidence countries at a National Health Service (NHS) hospital trust in Northern England. In response, the trust screened current clinical employees from countries with a high TB prevalence for active and latent TB infection (LTBI).

Aims

To identify the number of HCWs, within the organization, who are at risk of TB infection.

Methods

Clinical employees from countries with a high TB prevalence (those described by the World Health Organization as having an incidence of >40 cases per 100000 populations) were reviewed. Employees were identified via human resource systems and occupational health records, from which nationality or country of birth was identified. A letter was sent to identified employees advising of the rationale for a reviewed screening process and inviting them to attend for an interferon-gamma release assay (IGRA) blood test.

Results

A total of 587 clinical staff were identified as fitting the criteria of clinical HCWs from high-incidence countries. Of 469 HCWs screened, 27% screened positive using IGRA. This represented 4% of the total clinical workforce for the organization.

Conclusions

A considerable proportion of the workforce at this NHS hospital trust had previously undiagnosed LTBI, carrying a risk of conversion to active disease. Further action, such as treatment of LTBI or increased workforce awareness of symptoms of active disease, could help to reduce the risk of transmission of TB to patients and the need for associated 'look-back' exercises.

Investigating Socioeconomic Position in Dental Caries and Traumatic Dental Injury among Children in Quebec

OBJECTIVES

Socioeconomic position (SEP) is inversely associated with most oral health outcomes, but the patterns of association may vary depending on the specific outcome. We estimated associations between SEP and two oral health outcomes, dental caries and traumatic dental injuries (TDI), in Quebec children.

METHODS

We used data from the baseline visit of the QUALITY (QUebec Adipose and Lifestyle Investigation in Youth) Cohort, an ongoing study in Montreal and Quebec, Canada. The analytical sample included 590 children aged 8-10 years. Data on parents' SEP (household income, education) and children's health behaviours and involvement in sports were obtained through questionnaires and interviews. Oral health outcomes (dental caries and TDI in permanent teeth) were assessed by clinical oral exam. Negative binomial regression was used to model dental caries (DMFS index) and number of teeth with TDI adjusting for selected covariates.

RESULTS

The mean (SD) DMFS and number of TDI were 0.61 (1.43) and 0.12 (0.43), respectively. Compared to the upper quartile of income, children in the lower quartile had a DMFS approximately 3 times higher (PRR=2.68, 95% CI: 1.43, 5.04). Adjusting for oral health and nutritional behaviours had no effect. Conversely, children in the highest income quartile had a 3 times higher number of teeth with TDI compared to the lowest quartile (PRR=3.14, 95% CI: 1.22, 8.08). Physical activity did not explain this relationship. Parents' education was not associated with dental caries or TDI.

CONCLUSION

SEP seems to play a different role in the cause of dental caries and TDI.

Psychological Services in Hospices in the UK and Republic of Ireland

OBJECTIVE

To evaluate the level of psychological services available to patients and staff in hospices.

DESIGN

Questionnaire analysis.

SETTING

Hospices in the UK and Republic of Ireland.

PARTICIPANTS

224 hospices.

MAIN OUTCOME MEASURES

The availability of professional psychological support for those with advanced disease.

RESULTS

Responses were received from 166 hospices (74%). Only 50 hospices (30%) have access to a psychiatrist, whilst 68 (41%) have access to a clinical psychologist and 92 (45%) have neither. Only 21 hospices (12%) have service level agreements with local mental health trusts. Counsellors, complementary therapists and spiritual advisors such as chaplains were more plentiful.

CONCLUSIONS

Delivery of the NICE guidelines, especially tier four, may be compromised by limited availability of specialist services. This has implications for the psychological assessment of applicants for voluntary euthanasia under an Assisted Dying Act.

Association between metabolic syndrome and gingival inflammation in obese children

BACKGROUND AND OBJECTIVE

Our previous work showed a positive association between metabolic syndrome (MetS) and gingival crevicular fluid (GCF) tumour necrosis factor-alpha (TNF-α) in a sample of obese and non-obese children. However, whether this association persists among obese children is unknown. We aim to investigate the extent to which MetS is associated with GCF TNF-α level among obese children.

METHODOLOGY

We performed a cross-sectional analysis using data from visit 1 of the QUebec Adipose and Lifestyle InvesTigation in Youth cohort. A total of 219 obese children aged 8-10 years, for whom data were available for both MetS and TNF-α, were included in our analysis. The independent variable, MetS, was defined according to the International Diabetes Federation recommendations. GCF samples were collected from the gingival sulcus using a paper strip, and the concentration of TNF-α was determined by enzyme-linked immunosorbent assay. Analyses included descriptive statistics and sex-specific linear regression analyses adjusting for potential confounders.

RESULTS

In this sample comprising only obese children, 24 (10.9%) had MetS. Among obese boys, those with MetS had 44.9% higher GCF TNF-α (95% confidence interval: 16.5%-73.3%) compared to those without MetS. No such association was detected in obese girls.

CONCLUSION

MetS was positively associated with GCF TNF-α concentration in obese boys. These results suggest that obese boys with MetS may have a worse gingival health profile compared to their obese counterpart without MetS.

A case series of anal melanoma including the results of treatment with imatinib in selected patients

AIM

Anal melanoma is a rare malignancy with a poor prognosis.

METHOD

All patients with a diagnosis of anal melanoma treated at a single institution between 2000 and 2012 were identified and their treatment and outcome were evaluated.

RESULTS

Sixteen patients had a median survival of 2.9 years. Fourteen had Stage I or II disease with a median survival of 4.0 years and progression-free survival of 1.5 years. When used for disease staging, whole body positron emission tomography/CT identified an additional three sites of metastasis in five patients compared with CT of the chest, abdomen and pelvis. Surgery involved wide local excision or abdominoperineal excision with respective local recurrence rates of 50% and 66%. Eleven patients underwent testing for c-Kit mutations, of whom five were positive. Four of these were treated with the tyrosine kinase inhibitor imatinib, and showed rapid response of metastases outside the central nervous system.

CONCLUSION

The outcome of this malignancy remains poor. PET is the modality of choice for disease staging. Testing tumours for c-Kit mutations may allow selected patients to participate in trials of tyrosine kinase inhibitors.

Pulmonary Hilar Stereotactic Body Radiation Therapy in the Rat

Stereotactic Body Radiation therapy (SBRT) is an emerging modality of treatment for early stage non-small cell lung carcinoma. Concerns have arisen related to increased toxicities for medial tumors. We have developed a model of high dose, hypofractionated radiotherapy to the pulmonary hilum using the Leksell Gamma-Knife™. Sprague-Dawley rats received hypofractionated SBRT to the unilateral lung hilum using a custom immobilization device on the Gamma Knife. Each animal was individually scanned, treatment planned, and treated with either two 4 mm or one 8 mm collimated shots at escalating doses of 20, 40, and 80 Gy to the 50% isodose volume, encompassing the right mainstem bronchus. All animals were carefully followed post-treatment and imaged by plain film and CT. In addition, histopathological analysis of all rats was performed at selected time points. Animals treated with 4 mm collimated shots demonstrated no appreciable changes on plain films or sequential, follow-up CT scans, or histopathologically. Animals irradiated with the 8 mm collimator were less active, gained weight at a reduced rate, and demonstrated histopathological changes in 7/34 animals six months post-irradiation. Cellular atypia and interstitial pneumonitis were found, three of the seven of the animals showed clear bronchial damage and two showed vascular damage. Significant volume and time effects were found. Utilizing a novel Gamma Knife based animal model to study SBRT toxicity, it was found that the bronchus will tolerate small volumes of very high dose radiotherapy. It was postulated that radiation of the surrounding support stroma and normal tissue are important in the etiology of bronchial or hilar damage.

Assessing Children's Time-Use in Relation to Physical Fitness and Risks of Obesity and Diabetes: Development of a New Physical Activity Self-Report Instrument

BACKGROUND

This study introduces a novel self-report instrument to measure children's time-use in physical and sedentary activities and examines the relationships between children's time-use and physical fitness and risks of obesity and diabetes.

METHODS

The new instrument utilizes a series of timelines, each representing an activity type. 188 children (53% girls) aged 10 to 14 year-old participated in the study. Their time-use data for two weekdays and one weekend day were collected. Anthropometrics and cardiovascular fitness were measured and children's BMI z-score and PACER z-score were computed. One-time blood draw for fasting glucose and insulin were used to calculate insulin resistance using homeostasis model assessment for insulin resistance (HOMAIR).

RESULTS

The reliability assessment of this instrument indicated a moderately reproducible procedure (ICC > 0.6) for six activity types. The validity correlation for motorized travel time was high (r = 0.226, P < 0.05) between self-report instrument and GPS tracks. PACER z-score was positively correlated with time-uses of play (r = 0.159, P < 0.05), and organized sports (r = 0.198, P < 0.05); and was highly inversely correlated with BMI z-score (r = -0.441, P < 0.0001) and HOMAIR (r = -0.472, P < 0.0001). Overall, only 14% of the children had physical activity for more than 60 minutes daily over three observation days.

CONCLUSIONS

This instrument is particularly useful in assessing children's activity patterns, especially for specific physical activities. The new instrument provides a reproducible measure of children's perception of their activities. Our results emphasize the temporal context which is critical to formulating effective interventions targeting physical activity increase in children. Further efforts are needed to understand the differences between activity time obtained by the new self-report instrument and GPS tracks.

An in vitro evaluation of gaseous microemboli handling by contemporary venous reservoirs and oxygenator systems using EDAC

Gaseous microemboli (GME) generated during cardiopulmonary bypass (CPB) can present a significant risk to patient outcomes, specifically if they are delivered to the cerebral vasculature. A number of GME sources have been identified, leading to improved clinical practice and equipment design to ameliorate the presence and intensity of GME during CPB. Recently, a number of new venous reservoir/oxygenator systems have entered the market, including the Sorin Inspire6 and Inspire8, the Terumo FX15 and FX25 and the Maquet Quadrox-i. The goal of the current study was to evaluate the GME-handling capacity of these contemporary venous reservoirs, oxygenators and complete systems, as well as our currently used Sorin Synthesis, using the EDAC system. The venous reservoir of the Quadrox-i was the most effective in removing all sizes of GME and total GME load, while the Synthesis was the least effective. The FX15 and FX25 were least effective removing small GME, while the FX15 and Quadrox-i were the least effective at removing medium GME. The Quadrox-i was least effective at removing large GME. In terms of complete venous reservoir/oxygenator systems, the Synthesis permitted the greatest amount of GME to pass, while the other systems appeared largely equivalent.

Active and passive smoking in relation to lung cancer incidence in the Women's Health Initiative Observational Study prospective cohort

BACKGROUND

Lung cancer is the leading cause of worldwide cancer deaths. While smoking is its leading risk factor, few prospective cohort studies have reported on the association of lung cancer with both active and passive smoking. This study aimed to determine the relationship between lung cancer incidence with both active and passive smoking (childhood, adult at home, and at work).

PATIENTS AND METHODS

The Women's Health Initiative Observational Study (WHI-OS) was a prospective cohort study conducted at 40 US centers that enrolled postmenopausal women from 1993 to 1999. Among 93 676 multiethnic participants aged 50-79, 76 304 women with complete smoking and covariate data comprised the analytic cohort. Lung cancer incidence was calculated by Cox proportional hazards models, stratified by smoking status.

RESULTS

Over 10.5 mean follow-up years, 901 lung cancer cases were identified. Compared with never smokers (NS), lung cancer incidence was much higher in current [hazard ratio (HR) 13.44, 95% confidence interval (CI) 10.80-16.75] and former smokers (FS; HR 4.20, 95% CI 3.48-5.08) in a dose-dependent manner. Current and FS had significantly increased risk for all lung cancer subtypes, particularly small-cell and squamous cell carcinoma. Among NS, any passive smoking exposure did not significantly increase lung cancer risk (HR 0.88, 95% CI 0.52-1.49). However, risk tended to be increased in NS with adult home passive smoking exposure ≥30 years, compared with NS with no adult home exposure (HR 1.61, 95% CI 1.00-2.58).

CONCLUSIONS

In this prospective cohort of postmenopausal women, active smoking significantly increased risk of all lung cancer subtypes; current smokers had significantly increased risk compared with FS. Among NS, prolonged passive adult home exposure tended to increase lung cancer risk. These data support continued need for smoking prevention and cessation interventions, passive smoking research, and further study of lung cancer risk factors in addition to smoking. CLINICALTRIALS.GOV: NCT00000611.

Insulin secretion and its association with physical activity, fitness and screen time in children

OBJECTIVES

To determine the independent associations of moderate to vigorous physical activity (MVPA), fitness, screen time, and adiposity with insulin secretion in children.

DESIGN AND METHODS

Caucasian youth (n = 423/630), 8-10 years old, with at least one obese biological parent, were studied (QUALITY cohort). Insulin secretion was measured using HOMA2-%B, area under the curve (AUC) of insulin to glucose over the first 30 minutes (AUC I/G(t30min)) of the OGTT and AUC I/G(t120min) over 2 hours. Fitness was measured by VO₂peak ; percent fat mass (PFM) by DXA; 7-day MVPA by accelerometry; self-reported screen time included television, video game, or computer use. Models were adjusted for age, sex, season, puberty, PFM, and insulin sensitivity [IS] (HOMA2-IS, Matsuda-ISI).

RESULTS

PFM was strongly associated with insulin secretion, even after adjustment for IS: for every 1% increase in PFM, insulin secretion increased from 0.3% to 0.8% across indices. MVPA was negatively associated with HOMA2-%B (P < 0.05), but not with OGTT-derived measures. Fitness was negatively associated with AUC I/G(t120min) (P < 0.05). Screen time showed a trend toward higher HOMA2-%B in girls (P = 0.060).

CONCLUSIONS

In children with an obese parent, lower insulin secretion is associated with lower adiposity, higher MVPA, better fitness, and possibly reduced screen time.

Prophylactic fibrinogen administration during complex congenital cardiac surgery leading to thrombosis of a patient's brachial artery and the cardiopulmonary bypass circuit: a case report

Cardiac surgery represents one of the largest consumers of blood products due to the level of blood loss in these patients. As such, there is considerable interest in hemostatic therapies for this patient population. A hemostatic agent that has recently garnered interest is fibrinogen. The conversion of fibrinogen to fibrin by activated thrombin results in clot formation, leading to hemostasis. Currently, a number of studies are underway to evaluate the efficacy of fibrinogen concentrate in cardiac surgery patients. While potentially beneficial in hemostasis for cardiac patients, the current case report provides evidence of the importance of timing in the administration of this product.