Comparison of a Radiant Patient Warming Device with Forced Air Warming during Laparoscopic Cholecystectomy

The importance of maintaining a patient's core body temperature during anaesthesia to reduce the incidence of postoperative complications has been well documented. The standard practice of this institution is the use of a forced air device for intraoperative warming. The purpose of this study was to compare this standard with an alternative warming device using a radiant heat source which only heated the face.

This prospective, randomized controlled trial compared the efficacy of two methods of intraoperative warming: the BairHugger™ (Augustine Medical, U.S.A.) forced air device and the SunTouch™ (Fisher & Paykel Healthcare, N.Z.) radiant warmer during laparoscopic cholecystectomy in 42 female patients. Oesophageal core temperatures were recorded automatically on to computer during operations using standardised anaesthesia, intravenous infusions and draping.

The study failed to show any statistical or clinical difference between the two patient groups in terms of mean core temperature both intraoperatively (P=0.42) and in the recovery period (P=0.54). Mean start to end core temperature differences were marginly lower in the radiant group (0.08°C) but not statistically or clinically significantly different.

Given some of the drawbacks with forced air systems, such as the expense of the single use blanket, this new radiant warming device offers an alternative method of active warming with advantages in terms of cost and possible application to a wide variety of surgical procedures.

Negative self-appraisal mediates the relationship between mindfulness and confidence among adolescent female provincial hockey players in South Africa

Background

Mounting evidence suggests that mindfulness is positively related to athletic performance and athlete wellbeing. However, few attempts have been made to explore the psychological processes by which mindfulness might impact performance.

Objective

To determine whether negative self-appraisal mediates the relationship between dispositional mindfulness and the confidence component of mental toughness among provincial adolescent female hockey players in South Africa.

Methods

Provincial adolescent female hockey players (n=486) completed measures of dispositional mindfulness, mental toughness-related confidence and negative self-appraisal. Correlation coefficients were calculated between all variables included in the study. An ordinary least-squares regression analysis was performed to test the indirect effect of negative self-appraisal on the relationship between dispositional mindfulness and confidence.

Results

Negative self-appraisal exhibited an indirect effect on the relationship between dispositional mindfulness and the confidence component of mental toughness ( β = .06, SE = .0, CI ₉₅ = .04, .09). A subsequent Soble test confirmed that negative self-appraisal served as a statistically significant mediator ( β = .06, SE = .01, Z = 5.76, p = .001) in the model. Furthermore, 78.3% of the variance in the effect of dispositional mindfulness on the confidence component of mental toughness was accounted for by negative self-appraisal.

Conclusion

The effect of dispositional mindfulness on the confidence component of mental toughness among adolescent athletes is mediated by negative self-appraisal. Based on the current findings, dispositional mindfulness may foster confidence by lessening the impact of rigid negative appraisals of one's performance and worth as an athlete.

Statins influence epithelial expression of the anti-microbial peptide LL-37/hCAP-18 independently of the mevalonate pathway

Anti-microbial resistance increases among bacterial pathogens and new therapeutic avenues needs to be explored. Boosting innate immune mechanisms could be one attractive alternative in the defence against infectious diseases. The cholesterol-lowering drugs, statins, have been demonstrated to also affect the immune system. Here we investigate the effect of statins on the expression of the human cathelicidin anti-microbial peptide (CAMP) LL-37/hCAP-18 [encoded by the CAMP gene] and explore the underlying mechanisms in four epithelial cell lines of different origin. Simvastatin induced CAMP expression in bladder epithelial cells telomerase-immortalized uroepithelial cells (TERT-NHUCs), intestinal cells HT-29 and keratinocytes HEKa, but not in airway epithelial cells A549. Gene induction in HEKa cells was reversible by mevalonate, while this effect was independent of the cholesterol biosynthesis pathway in TERT-NHUCs. Instead, inhibition of histone deacetylases by simvastatin seems to be involved. For HT-29 cells, both mechanisms may contribute. In addition, simvastatin increased transcription of the vitamin D-activating enzyme CYP27B1 which, in turn, may activate LL-37/hCAP-18 production. Taken together, simvastatin is able to promote the expression of LL-37/hCAP-18, but cell line-specific differences in efficacy and the involved signalling pathways exist.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Motivational characteristics and resistance training in older adults: A randomized controlled trial and 1-year follow-up

The aim of this study was to investigate the effects of a 9-month supervised resistance training intervention on motivational and volitional characteristics related to exercise, and whether the absolute level and/or intervention-induced change in these characteristics predict self-directed continuation of resistance training 1 year after the intervention. Community dwelling older adults aged 65-75, who did not fulfill physical activity recommendations, were randomized into resistance training intervention groups: training once- (n = 26), twice- (n = 27), three-times-a-week (n = 28) or non-training control group (n = 25). Training groups participated in supervised resistance training for 9 months: during months 1-3 all groups trained twice-a-week and then with allocated frequencies during months 4-9. Exercise-related motivation, self-efficacy, and planning were measured with questionnaires at baseline, month-3 and month-9. The continuance of resistance training was determined by interviews 6 and 12 months after the end of the intervention. The intervention improved action and coping planning as well as intrinsic motivation (group × time P < .05). During 1-year follow-up, 54% of participants did not continue self-directed regular resistance training, 22% continued regular resistance training once-a-week, and 24% twice-a-week. Increases in exercise self-efficacy and intrinsic motivation related to training during the intervention predicted continuation of resistance training twice-a-week. Resistance training improved exercise-related motivational and volitional characteristics in older adults. These improvements were linked to continuing resistance training 1 year after the supervised intervention. The role of these characteristics should be taken into account when promoting long-term resistance training participation among older adults.

Pleuroparenchymal sarcoidosis - A recognised but rare manifestation of disease

Pleural involvement is rare in sarcoidosis. The presence of a large symptomatic effusion in a patient with sarcoidosis should therefore prompt further investigation for an alternate aetiology. Here we present a case of confirmed pleuro-parenchymal sarcoidosis. We discuss the important differential diagnoses and review the current literature.

In the grip of worry: cerebral blood flow changes during worry induction and reappraisal in late-life generalized anxiety disorder

Severe worry includes a complex blend of maladaptive affective and cognitive processes. Contrary to other forms of anxiety, there is no consensus in the field regarding the neural basis of worry. To date, no study has looked at neural patterns associated specifically with in-scanner induction and reappraisal of worry. In this study, we attempt to describe distinct components of the 'neural phenomenology' of worry: induction, maintenance, severity and reappraisal, by using a personalized, in-scanner worry script. Twenty older, non-anxious participants and twenty late-life generalized anxiety disorder (GAD) participants were included. Whole-brain axial pseudo-continuous arterial spin-labeling scans were collected. We used a voxel-wise two-way ANOVA to test the group-by-block interaction. Worry induction was associated with greater cerebral blood flow (CBF) in the visual cortex, thalamus, caudate and medial frontal cortex compared with the rest. Reappraisal was associated with greater CBF in similar regions, whereas the orbital frontal gyrus showed lower CBF relative to rest. Relative to non-anxious participants, GAD had greater CBF in multiple regions during worry induction (visual and parietal cortex, middle and superior frontal) and lower CBF during reappraisal in the supplemental motor area, middle cingulate gyrus, insula and putamen. Except for the thalamus, there was no change in CBF throughout the five blocks of worry induction and reappraisal. Severe worry is distinctly associated with increased CBF in several neocortical regulatory regions. We present new data supporting the view of worry as a complex process, engaging multiple regions in the initiation, maintenance and reappraisal of worry.

Cost-effectiveness analysis of new generation coronary CT scanners for difficult-to-image patients

AIMS

New generation dual-source coronary CT (NGCCT) scanners with more than 64 slices were evaluated for patients with (known) or suspected of coronary artery disease (CAD) who are difficult to image: obese, coronary calcium score > 400, arrhythmias, previous revascularization, heart rate > 65 beats per minute, and intolerance of betablocker. A cost-effectiveness analysis of NGCCT compared with invasive coronary angiography (ICA) was performed for these difficult-to-image patients for England and Wales.

METHODS AND RESULTS

Five models (diagnostic decision model, four Markov models for CAD progression, stroke, radiation and general population) were integrated to estimate the cost-effectiveness of NGCCT for both suspected and known CAD populations. The lifetime costs and effects from the National Health Service perspective were estimated for three strategies: (1) patients diagnosed using ICA, (2) using NGCCT, and (3) patients diagnosed using a combination of NGCCT and, if positive, followed by ICA. In the suspected population, the strategy where patients only undergo a NGCCT is a cost-effective option at accepted cost-effectiveness thresholds. The strategy of using NGCCT in combination with ICA is the most favourable strategy for patients with known CAD. The most influential factors behind these results are the percentage of patients being misclassified (a function of both diagnostic accuracy and the prior likelihood), the complication rates of the procedures, and the cost price of a NGCCT scan.

CONCLUSION

The use of NGCCT might be considered cost-effective in both populations since it is cost-saving compared to ICA and generates similar effects.

Cost-effectiveness of computerized cognitive-behavioural therapy for the treatment of depression in primary care: findings from the Randomised Evaluation of the Effectiveness and Acceptability of Computerised Therapy (REEACT) trial

BACKGROUND

Computerized cognitive-behavioural therapy (cCBT) forms a core component of stepped psychological care for depression. Existing evidence for cCBT has been informed by developer-led trials. This is the first study based on a large independent pragmatic trial to assess the cost-effectiveness of cCBT as an adjunct to usual general practitioner (GP) care compared with usual GP care alone and to establish the differential cost-effectiveness of a free-to-use cCBT programme (MoodGYM) in comparison with a commercial programme (Beating the Blues) in primary care.

METHOD

Costs were estimated from a healthcare perspective and outcomes measured using quality-adjusted life years (QALYs) over 2 years. The incremental cost-effectiveness of each cCBT programme was compared with usual GP care. Uncertainty was estimated using probabilistic sensitivity analysis and scenario analyses were performed to assess the robustness of results.

RESULTS

Neither cCBT programme was found to be cost-effective compared with usual GP care alone. At a £20 000 per QALY threshold, usual GP care alone had the highest probability of being cost-effective (0.55) followed by MoodGYM (0.42) and Beating the Blues (0.04). Usual GP care alone was also the cost-effective intervention in the majority of scenario analyses. However, the magnitude of the differences in costs and QALYs between all groups appeared minor (and non-significant).

CONCLUSIONS

Technically supported cCBT programmes do not appear any more cost-effective than usual GP care alone. No cost-effective advantage of the commercially developed cCBT programme was evident compared with the free-to-use cCBT programme. Current UK practice recommendations for cCBT may need to be reconsidered in the light of the results.

Risk of cervical cancer in symptomatic women aged ≥40 in primary care: A case-control study using electronic records

There are approximately 3,000 new UK diagnoses of cervical cancer annually, with many women presenting symptomatically. We aimed to identify and quantify features of cervical cancer in primary care in a case-control study in the UK. Putative features of cervical cancer were identified, and odd ratios and positive predictive values (PPVs) were calculated. About 1,006 women aged ≥40 years diagnosed with cervical cancer and 4,992 age-, sex- and practice-matched controls were selected from the Clinical Practice Research Datalink. Median age at diagnosis was 61 years (interquartile range 51-75). Seven symptoms and two abnormal investigations were associated with cervical cancer: post-menopausal bleeding, odds ratio 43 (95% confidence interval 25, 75); vaginal discharge or vaginitis 8.8 (5.2, 15), intermenstrual bleeding 4.7 (1.6, 14); haematuria 4.6 (2.1, 10); irregular menstruation 3.8 (1.6, 9.0); urinary tract infection 1.9 (1.3, 2.8); abdominal pain 1.8 (1.4, 2.5); high white cell count 5.1 (2.9, 8.8) and low haemoglobin 2.6 (1.8, 3.8): all p < .005. The PPV of cervical cancer in women aged ≥55 with post-menopausal bleeding was 4.6% (2.5, 8.3). Other than for post-menopausal bleeding no symptom is high risk. Some symptoms, particularly haematuria, may be helpful. The primary care clinician must consider the unlikely diagnosis when the likely diagnosis does not settle with treatment.

CNTN6 mutations are risk factors for abnormal auditory sensory perception in autism spectrum disorders

Contactin genes CNTN5 and CNTN6 code for neuronal cell adhesion molecules that promote neurite outgrowth in sensory-motor neuronal pathways. Mutations of CNTN5 and CNTN6 have previously been reported in individuals with autism spectrum disorders (ASDs), but very little is known on their prevalence and clinical impact. In this study, we identified CNTN5 and CNTN6 deleterious variants in individuals with ASD. Among the carriers, a girl with ASD and attention-deficit/hyperactivity disorder was carrying five copies of CNTN5. For CNTN6, both deletions (6/1534 ASD vs 1/8936 controls; P=0.00006) and private coding sequence variants (18/501 ASD vs 535/33480 controls; P=0.0005) were enriched in individuals with ASD. Among the rare CNTN6 variants, two deletions were transmitted by fathers diagnosed with ASD, one stop mutation CNTN6W923X was transmitted by a mother to her two sons with ASD and one variant CNTN6P770L was found de novo in a boy with ASD. Clinical investigations of the patients carrying CNTN5 or CNTN6 variants showed that they were hypersensitive to sounds (a condition called hyperacusis) and displayed changes in wave latency within the auditory pathway. These results reinforce the hypothesis of abnormal neuronal connectivity in the pathophysiology of ASD and shed new light on the genes that increase risk for abnormal sensory perception in ASD.

The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement

The 2016 Warwick Agreement on femoroacetabular impingement (FAI) syndrome was convened to build an international, multidisciplinary consensus on the diagnosis and management of patients with FAI syndrome. 22 panel members and 1 patient from 9 countries and 5 different specialties participated in a 1-day consensus meeting on 29 June 2016. Prior to the meeting, 6 questions were agreed on, and recent relevant systematic reviews and seminal literature were circulated. Panel members gave presentations on the topics of the agreed questions at Sports Hip 2016, an open meeting held in the UK on 27-29 June. Presentations were followed by open discussion. At the 1-day consensus meeting, panel members developed statements in response to each question through open discussion; members then scored their level of agreement with each response on a scale of 0-10. Substantial agreement (range 9.5-10) was reached for each of the 6 consensus questions, and the associated terminology was agreed on. The term 'femoroacetabular impingement syndrome' was introduced to reflect the central role of patients' symptoms in the disorder. To reach a diagnosis, patients should have appropriate symptoms, positive clinical signs and imaging findings. Suitable treatments are conservative care, rehabilitation, and arthroscopic or open surgery. Current understanding of prognosis and topics for future research were discussed. The 2016 Warwick Agreement on FAI syndrome is an international multidisciplinary agreement on the diagnosis, treatment principles and key terminology relating to FAI syndrome.Author note The Warwick Agreement on femoroacetabular impingement syndrome has been endorsed by the following 25 clinical societies: American Medical Society for Sports Medicine (AMSSM), Association of Chartered Physiotherapists in Sports and Exercise Medicine (ACPSEM), Australasian College of Sports and Exercise Physicians (ACSEP), Austian Sports Physiotherapists, British Association of Sports and Exercise Medicine (BASEM), British Association of Sport Rehabilitators and Trainers (BASRaT), Canadian Academy of Sport and Exercise Medicine (CASEM), Danish Society of Sports Physical Therapy (DSSF), European College of Sports and Exercise Physicians (ECOSEP), European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA), Finnish Sports Physiotherapist Association (SUFT), German-Austrian-Swiss Society for Orthopaedic Traumatologic Sports Medicine (GOTS), International Federation of Sports Physical Therapy (IFSPT), International Society for Hip Arthroscopy (ISHA), Groupo di Interesse Specialistico dell'A.I.F.I., Norwegian Association of Sports Medicine and Physical Activity (NIMF), Norwegian Sports Physiotherapy Association (FFI), Society of Sports Therapists (SST), South African Sports Medicine Association (SASMA), Sports Medicine Australia (SMA), Sports Doctors Australia (SDrA), Sports Physiotherapy New Zealand (SPNZ), Swedish Society of Exercise and Sports Medicine (SFAIM), Swiss Society of Sports Medicine (SGMS/SGSM), Swiss Sports Physiotherapy Association (SSPA).

Compound heterozygous mutations in the IFT140 gene cause Opitz trigonocephaly C syndrome in a patient with typical features of a ciliopathy

〈 We report on an infant with Opitz trigonocephaly C syndrome (OTCS), who also had manifestations of ciliopathy, including short ribs (non-asphyxiating), trident acetabular roofs, postaxial polydactyly cone-shaped epiphyses, and dysplasia of the renal, hepatic and pancreatic tissues. To investigate the molecular cause, we used an exome sequencing strategy followed by Sanger sequencing. Two rare variants, both predicted to result in loss of functional protein, were identified in the IFT140 gene; a substitution at the splice donor site of exon 24 (c.723 + 1 G > T) and a 17 bp deletion, impacting the first coding exon (c.-11_6del). The variants were confirmed as being biallelic using Sanger sequencing, showing that the splice variant was inherited from the propositus mother and the deletion from the father. To date, Mainzer-Saldino syndrome, Jeune syndrome, and a form of nonsyndromic retinal dystrophy, have been identified as ciliopathies caused by IFT140 mutations. We provide the first description of an OTCS phenotype that appears to result from IFT140 mutations. The presentation of this patient is consistent with previous reports showing that OTCS already exhibited skeleletal and nonskeletal features of a ciliopathy.

ARIA 2016: Care pathways implementing emerging technologies for predictive medicine in rhinitis and asthma across the life cycle

The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative commenced during a World Health Organization workshop in 1999. The initial goals were (1) to propose a new allergic rhinitis classification, (2) to promote the concept of multi-morbidity in asthma and rhinitis and (3) to develop guidelines with all stakeholders that could be used globally for all countries and populations. ARIA—disseminated and implemented in over 70 countries globally—is now focusing on the implementation of emerging technologies for individualized and predictive medicine. MASK [MACVIA (Contre les Maladies Chroniques pour un Vieillissement Actif)-ARIA Sentinel NetworK] uses mobile technology to develop care pathways for the management of rhinitis and asthma by a multi-disciplinary group and by patients themselves. An app (Android and iOS) is available in 20 countries and 15 languages. It uses a visual analogue scale to assess symptom control and work productivity as well as a clinical decision support system. It is associated with an inter-operable tablet for physicians and other health care professionals. The scaling up strategy uses the recommendations of the European Innovation Partnership on Active and Healthy Ageing. The aim of the novel ARIA approach is to provide an active and healthy life to rhinitis sufferers, whatever their age, sex or socio-economic status, in order to reduce health and social inequalities incurred by the disease.

Mindfulness and mental toughness among provincial adolescent female hockey players

Introduction: Mental toughness is highly valued within competitive sport. However, scant attention has been paid to the psychological processes that underpin mental toughness.Objectives: To explore the relationship between mindfulness and mental toughness among provincial adolescent female hockey players.Methods: Provincial adolescent female hockey players (N=484) completed measures of mindfulness and mental toughness. Correlation coefficients were calculated with respect to mindfulness and mental toughness. A one-way between-groups analysis of variance (ANOVA) was conducted to determine whether athletes assigned to four levels of mindfulness (high, moderate, medium and low) differed significantly with regard to mental toughness.Results: Mindfulness exhibited significant positive correlations with confidence, constancy and control, as well as with total mental toughness. The results of the ANOVA and the relevant post hoc analyses indicated that athletes in the high mindfulness group reported significantly higher levels of control and general mental toughness than those in the other three groups. The high mindfulness participants also reported significantly higher levels of constancy than those in the medium and low mindfulness groups. Conclusion: Mindfulness was positively correlated with all aspects of mental toughness investigated in this study. In addition, individuals with high levels of mindfulness reported higher control, constancy and general mental toughness than those with lower levels of mindfulness. Based on the current findings, the role of mindfulness in the development and maintenance of mental toughness among adolescent athletes warrants further investigation.

Clinical psychologists' attitudes towards the biology and 'new genetics' of intellectual and developmental disabilities: a pilot study using Q-methodology

BACKGROUND

The current study investigated how ideas and models from the 'New Genetics' and associated fields of developmental neuroscience and behavioural phenotypes are perceived by clinical psychologists working with people with intellectual and developmental disabilities (IDD). As well as examining the take-up and influence of such ideas, it also examines barriers, both personal and institutional, to the widespread adoption of such concepts and research findings in services for people with IDD.

METHODS

A Q-methodology study was undertaken with 31 qualified and 16 trainee clinical psychologists in the North West of England using a specifically developed 81-item Q set.

RESULTS

Three factors were identified and labelled Integration of social and medical models, Social model of disability is more helpful and Genetic advances in conflict with recognising the value of people with IDD.

CONCLUSION

There was a lack of consensus in clinical psychologists working with people with IDD, with amount and type of professional experience affecting the factor loadings, which may need to be considered in developing clinical applications of genetic IDD research.

Scaling up strategies of the chronic respiratory disease programme of the European Innovation Partnership on Active and Healthy Ageing (Action Plan B3: Area 5)

Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) focuses on the integrated care of chronic diseases. Area 5 (Care Pathways) was initiated using chronic respiratory diseases as a model. The chronic respiratory disease action plan includes (1) AIRWAYS integrated care pathways (ICPs), (2) the joint initiative between the Reference site MACVIA-LR (Contre les MAladies Chroniques pour un VIeillissement Actif) and ARIA (Allergic Rhinitis and its Impact on Asthma), (3) Commitments for Action to the European Innovation Partnership on Active and Healthy Ageing and the AIRWAYS ICPs network. It is deployed in collaboration with the World Health Organization Global Alliance against Chronic Respiratory Diseases (GARD). The European Innovation Partnership on Active and Healthy Ageing has proposed a 5-step framework for developing an individual scaling up strategy: (1) what to scale up: (1-a) databases of good practices, (1-b) assessment of viability of the scaling up of good practices, (1-c) classification of good practices for local replication and (2) how to scale up: (2-a) facilitating partnerships for scaling up, (2-b) implementation of key success factors and lessons learnt, including emerging technologies for individualised and predictive medicine. This strategy has already been applied to the chronic respiratory disease action plan of the European Innovation Partnership on Active and Healthy Ageing.

Predicting Outcome in Patients with Acute Coronary Syndrome: Evaluation of B-Type Natriuretic Peptide and the Global Registry of Acute Coronary Events (GRACE) Risk Score

Background

Accurate risk stratification soon after admission for patients with acute coronary syndromes (ACS) is vital in guiding management. Clinical risk scores and B-type natriuretic peptide (BNP) can predict mortality and re-infarction in ACS, but it is unknown whether BNP provides prognostic information over and above that of the clinical risk scores.

Methods

142 unselected patients with ACS were prospectively studied. BNP was measured and patients were stratified according to BNP and Global Registry of Acute Coronary Events (GRACE) score. In-hospital and 30-day events were characterised.

Results

20.4% of ACS subjects had ST-elevation myocardial infarction (MI), 14.1%, non-ST elevation MI and 65.5% unstable angina. Elevated BNP predicted inhospital and 30-day heart failure (p<0.01), and the risk of in-hospital recurrent ACS (p<0.05). Increasing GRACE score predicted in-hospital recurrent ACS (p<0.05), heart failure (p<0.001), arrhythmias (p<0.05) and angioplasty (p<0.05). GRACE score also predicted 30-day heart failure (p<0.05). In contrast, the predictive accuracy of troponin elevation was less robust.

Conclusion

BNP and the GRACE score predict complementary outcomes from ACS, but both predicted heart failure. BNP is a powerful indicator of heart failure in patients with ACS and provides prognostic information above and beyond conventional biomarkers and risk scores.

Extension of the Q Orbitrap intrascan dynamic range by using a dedicated customized scan

RATIONALE

The intrascan dynamic range of modern Orbitrap instrumentation is specified to reach 1:5000, while the interscan dynamic range is significantly larger due to the utilization of the automatic gain control feature. There are some applications (e.g. residue analysis in complex matrices, metabolomics or structural elucidation) where a wider intrascan dynamic range is desirable.

METHODS

The Application Programming Interface (API) of the Q Exactive Orbitrap mass spectrometer has been used to program a customized scan in order to cover a larger intrascan dynamic range. Different approaches were used, which were all based on the variation of the isolation time of low-abundance versus high-abundance mass range segments. The differently attenuated mass range segments isolated by the quadrupole were sequentially forwarded to the C-trap. Finally, the accumulated mass segments were measured within the Orbitrap analyzer.

RESULTS

The spectra obtained by the customized scans show an enlarged dynamic range. This has been demonstrated by monitoring the higher isotope mass peaks (first and second isotope) of a low intensity analyte. Furthermore, a practical application (veterinary drugs in bovine kidney) has been investigated with the proposed customized scan. Analytes eluting within the retention time region of very intense matrix peaks (e.g. peptides) showed improved detectability when utilizing the customized scan.

CONCLUSIONS

The extension of the intrascan dynamic range by a customized scan is helpful when analyzing residues which happen to elute together with a dominating matrix peak or within a high ion abundance region (e.g. dead volume). Furthermore, this feature helps in the process of determining the elemental composition of compounds by permitting the investigation of low-abundance ions (e.g. belonging to the isotopic fine structure of the investigated compound).

Product ion isotopologue pattern: A tool to improve the reliability of elemental composition elucidations of unknown compounds in complex matrices

RATIONALE

Elucidation of the elemental compositions of unknown compounds (e.g., in metabolomics) generally relies on the availability of accurate masses and isotopic ratios. This study focuses on the information provided by the abundance ratio within a product ion pair (monoisotopic versus the first isotopic peak) when isolating and fragmenting the first isotopic ion (first isotopic mass spectrum) of the precursor.

METHODS

This process relies on the capability of the quadrupole within the Q Orbitrap instrument to isolate a very narrow mass window. Selecting only the first isotopic peak (first isotopic mass spectrum) leads to the observation of a unique product ion pair. The lighter ion within such an isotopologue pair is monoisotopic, while the heavier ion contains a single carbon isotope. The observed abundance ratio is governed by the percentage of carbon atoms lost during the fragmentation and can be described by a hypergeometric distribution.

RESULTS

The observed carbon isotopologue abundance ratio (product ion isotopologue pattern) gives reliable information regarding the percentage of carbon atoms lost in the fragmentation process. It therefore facilitates the elucidation of the involved precursor and product ions. Unlike conventional isotopic abundances, the product ion isotopologue pattern is hardly affected by isobaric interferences. Furthermore, the appearance of these pairs greatly aids in cleaning up a 'matrix-contaminated' product ion spectrum.

CONCLUSIONS

The product ion isotopologue pattern is a valuable tool for structural elucidation. It increases confidence in results and permits structural elucidations for heavier ions. This tool is also very useful in elucidating the elemental composition of product ions. Such information is highly valued in the field of multi-residue analysis, where the accurate mass of product ions is required for the confirmation process. Copyright © 2016 John Wiley & Sons, Ltd.

Concussion knowledge and return-to-play attitudes among subelite rugby union players

Background. Concussion is a significant health issue in rugby union. However, little is known about players’ levels of concussion knowledgeor return-to-play (RTP) attitudes.Objectives. To determine the concussion knowledge and concussion-related RTP attitudes of subelite rugby union players in South Africa.Methods. Subelite rugby union players (n=127; mean age 24.1 years) completed a measure of concussion knowledge and a concussionrelatedRTP attitude scale. Frequencies were calculated with regard to concussion knowledge and RTP attitudes for the total sample, aswell as separately for previously concussed and non-concussed participants. Pearson’s χ2 tests and t-tests for independent groups wereemployed to determine significant differences in concussion knowledge and RTP attitudes between previously concussed and nonconcussedparticipants.Results. Participants displayed varying, yet generally less than optimal levels of concussion knowledge. Knowledge of concussion-relatedRTP protocols (20 - 23%) and the efficacy of safety equipment (20 - 25%) was particularly poor. The subelite rugby players included in thesample did not hold notably conservative RTP attitudes, with the majority expressing a willingness to participate in practice (74%) andcompetition (47 - 56%) without having fully recovered from a concussion. No significant differences were apparent with regard to the RTPattitudes and concussion knowledge of the previously concussed and non-concussed players.Conclusion. The general level of concussion knowledge among subelite rugby union players appears less than optimal. Moreover, themajority of these players expressed an intention to RTP before they had fully recovered from concussion.

Cost-effectiveness of integrated collaborative care for comorbid major depression in patients with cancer

OBJECTIVES

Comorbid major depression is associated with reduced quality of life and greater use of healthcare resources. A recent randomised trial (SMaRT, Symptom Management Research Trials, Oncology-2) found that a collaborative care treatment programme (Depression Care for People with Cancer, DCPC) was highly effective in treating depression in patients with cancer. This study aims to estimate the cost-effectiveness of DCPC compared with usual care from a health service perspective.

METHODS

Costs were estimated using UK national unit cost estimates and health outcomes measured using quality-adjusted life-years (QALYs). Incremental cost-effectiveness of DCPC compared with usual care was calculated and scenario analyses performed to test alternative assumptions on costs and missing data. Uncertainty was characterised using cost-effectiveness acceptability curves. The probability of DCPC being cost-effective was determined using the UK National Institute for Health and Care Excellence's (NICE) cost-effectiveness threshold range of £ 20,000 to £ 30,000 per QALY gained.

RESULTS

DCPC cost on average £ 631 more than usual care per patient, and resulted in a mean gain of 0.066 QALYs, yielding an incremental cost-effectiveness ratio of £ 9549 per QALY. The probability of DCPC being cost-effective was 0.9 or greater at cost-effectiveness thresholds above £ 20,000 per QALY for the base case and scenario analyses.

CONCLUSIONS

Compared with usual care, DCPC is likely to be cost-effective at the current thresholds used by NICE. This study adds to the weight of evidence that collaborative care treatment models are cost-effective for depression, and provides new evidence regarding their use in specialist medical settings.

Reported consent processes and demographics: a substudy of the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial

OBJECTIVES

Efforts are needed to improve informed consent of participants in research. The Strategic Timing of AntiRetroviral Therapy (START) study provides a unique opportunity to study the effect of length and complexity of informed consent documents on understanding and satisfaction among geographically diverse participants.

METHODS

Interested START sites were randomized to use either the standard consent form or the concise consent form for all of the site's participants.

RESULTS

A total of 4473 HIV-positive participants at 154 sites world-wide took part in the Informed Consent Substudy, with consent given in 11 primary languages. Most sites sent written information to potential participants in advance of clinic visits, usually including the consent form. At about half the sites, staff reported spending less than an hour per participant in the consent process. The vast majority of sites assessed participant understanding using informal nonspecific questions or clinical judgment.

CONCLUSIONS

These data reflect the interest of START research staff in evaluating the consent process and improving informed consent. The START Informed Consent Substudy is by far the largest study of informed consent intervention ever conducted. Its results have the potential to impact how consent forms are written around the world.

Transcriptional regulators of GntR family in Streptomyces coelicolor A3(2): analysis in silico and in vivo of YtrA subfamily

Transcriptional factors of the GntR family regulate numerous physiological and morphological processes in response to the nutrient state of bacterial cells. The number of GntR transcriptional factors in genomes of soil-dwelling actinomycetes is one of the highest among bacteria, reflecting both the large size of their chromosomes and the complex ecological niche that they occupy. However, very little is known about the roles of GntRs in actinomycete biology. Here, we analyzed the genome of model actinomycete, Streptomyces coelicolor A3(2), in an attempt to gain new insights into the function of GntR family. All 56 GntR proteins of M145 strain were classified into FadR, HutC, MocR, YtrA, and DevA subfamilies according to their secondary structure. We then checked for the presence of GntR orthologs in six other sequenced Streptomyces and one Kitasatospora genomes, revealing that 12 GntRs were conserved in all analyzed strains. Genomic analysis of the less studied YtrA type regulators revealed 160 sequences present in 88 members of Coriobacteridae, Rubrobacteridae, and Actinobacteridae subclasses. These proteins form seven dense clusters on the consensus phylogenetic tree and their genes are usually co-located with the genes for transport proteins. Probable operator sites were identified for orthologous groups of Sco0823 and Sco3812 proteins. All S. coelicolor YtrA-like regulatory genes (SCO0823, SCO1728, SCO3812) were analyzed at transcriptional level, knocked out, and introduced on moderate copy number plasmid in M145 strain. Also, gene SCO0824, a part of putative SCO0823 operon, was studied. Results of these experiments are discussed here.

The same but different: discussing the literature regarding mental health nurses' difficulty in meeting the physical health needs of service users, regardless of differing education programmes

In the Western world, there is increasing concern regarding the ability of health care professionals to meet the physical health care needs of those diagnosed with mental illness. This discussion paper seeks to explore some of the issues facing mental health nurses in delivering care to those who have both mental and physical illness. Criticism of the National Health Service for failing to meet the physical health needs of people with serious mental illness has generated a number of political strategies aimed at addressing inequalities between mental and physical health care, a consequence being a change in pre-registration nurse education. It is envisaged that such changes will enable all nurses to deliver safe, effective care to service users, with adult and mental health nurses being more adept at meeting both the mental and physical health needs of those in their care. The impact of three key areas identified within the literature will be considered: the impact of co-existing physical and mental illness; the role of mental health nurses and perceptions of service users re physical health care; and education, training and learning from others in the Western world. In conclusion, the complexities of delivering such care will be addressed.

MACVIA-ARIA Sentinel NetworK for allergic rhinitis (MASK-rhinitis): the new generation guideline implementation

Several unmet needs have been identified in allergic rhinitis: identification of the time of onset of the pollen season, optimal control of rhinitis and comorbidities, patient stratification, multidisciplinary team for integrated care pathways, innovation in clinical trials and, above all, patient empowerment. MASK-rhinitis (MACVIA-ARIA Sentinel NetworK for allergic rhinitis) is a simple system centred around the patient which was devised to fill many of these gaps using Information and Communications Technology (ICT) tools and a clinical decision support system (CDSS) based on the most widely used guideline in allergic rhinitis and its asthma comorbidity (ARIA 2015 revision). It is one of the implementation systems of Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA). Three tools are used for the electronic monitoring of allergic diseases: a cell phone-based daily visual analogue scale (VAS) assessment of disease control, CARAT (Control of Allergic Rhinitis and Asthma Test) and e-Allergy screening (premedical system of early diagnosis of allergy and asthma based on online tools). These tools are combined with a clinical decision support system (CDSS) and are available in many languages. An e-CRF and an e-learning tool complete MASK. MASK is flexible and other tools can be added. It appears to be an advanced, global and integrated ICT answer for many unmet needs in allergic diseases which will improve policies and standards.