Introduction of an assessment toolkit associated with increased rate of DLB diagnosis

Background

Dementia with Lewy bodies (DLB) and dementia in Parkinson’s disease (PDD) are recognised to be under-recognised in clinical practice in the UK, with only one third to a half of expected cases diagnosed. We aimed to assess whether clinical diagnostic rates could be increased by the introduction of a structured assessment toolkit for clinicians.

Methods

We established baseline diagnostic rates for DLB and PDD in four memory clinics and three movement disorder/Parkinson’s disease (PD) clinics in two separate geographical regions in the UK. An assessment toolkit specifically developed to assist with the recognition and diagnosis of DLB and PDD was then introduced to the same clinical teams and diagnostic rates for DLB and PDD were reassessed.

For assessing DLB diagnosis, a total of 3820 case notes were reviewed before the introduction of the toolkit, and 2061 case notes reviewed after its introduction. For PDD diagnosis, a total of 1797 case notes were reviewed before the introduction of the toolkit and 3405 case notes after it. Mean values and proportions were analysed using Student’s t test for independent samples and χ² test, respectively.

Results

DLB was diagnosed in 4.6% of dementia cases prior to the introduction of the toolkit, and 6.2% of dementia cases afterwards, an absolute rise of 1.6%, equal to a 35% increase in the number of DLB cases diagnosed when using the toolkit (χ² = 4.2, P = 0.041).

The number of PD patients diagnosed with PDD was not found overall to be significantly different when using the toolkit: 9.6% of PD cases before and 8.2% of cases after its introduction (χ² = 1.8, P = 0.18), though the ages of PD patients assessed after the toolkit’s introduction were lower (73.9 years vs 80.0 years, t = 19.2, p < 0.001).

Conclusion

Introduction of the assessment toolkit was associated with a significant increase in the rate of DLB diagnosis, suggesting that a structured means of assessing symptoms and clinical features associated with DLB can assist clinicians in recognising cases. The assessment toolkit did not alter the overall rate of PDD diagnosis, suggesting that alternate means may be required to improve the rate of diagnosis of dementia in Parkinson’s disease.

Mild cognitive impairment with Lewy bodies: blood perfusion with arterial spin labelling

Objective

To use arterial spin labelling to investigate differences in perfusion in mild cognitive impairment with Lewy bodies (MCI-LB) compared to Alzheimer type MCI (MCI-AD) and healthy controls.

Methods

We obtained perfusion images on 32 MCI-LB, 30 MCI-AD and 28 healthy subjects of similar age. Perfusion relative to cerebellum was calculated, and we aimed to examine differences in relative perfusion between MCI-LB and the other groups. This included whole brain voxelwise comparisons, as well as using predefined region-of-interest ratios of medial occipital to medial temporal, and posterior cingulate to precuneus. Differences in occipital perfusion in eyes open vs eyes closed conditions were also examined.

Results

Compared to controls, the MCI-LB showed reduced perfusion in the precuneus, parietal, occipital and fusiform gyrus regions. In our predefined regions, the ratio of perfusion in occipital/medial temporal was significantly lower, and the posterior cingulate/precuneus ratio was significantly higher in MCI-LB compared to controls. Overall, the occipital perfusion was greater in the eyes open vs closed condition, but this did not differ between groups.

Conclusion

We found patterns of altered perfusion in MCI-LB which are similar to those seen in dementia with Lewy bodies, with reduction in posterior parietal and occipital regions, but relatively preserved posterior cingulate.

Early versus delayed surgery for paediatric supracondylar humeral fractures in the absence of vascular compromise: a systematic review and meta-analysis

AIMS

We set out to determine if there is a difference in perioperative outcomes between early and delayed surgery in paediatric supracondylar humeral fractures in the absence of vascular compromise through a systematic review and meta-analysis.

MATERIALS AND METHODS

A literature search was performed, with search outputs screened for studies meeting the inclusion criteria. The groups of early surgery (ES) and delayed surgery (DS) were classified by study authors. The primary outcome measure was open reduction requirement. Meta-analysis was performed in the presence of sufficient study homogeneity. Individual study risk of bias was assessed using the Risk of Bias in Non-Randomised Studies - of Interventions (ROBINS-I) criteria, with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria used to evaluate outcomes independently.

RESULTS

A total of 12 studies met the inclusion criteria (1735 fractures). Pooled mean time to surgery from injury was and 10.7 hours for ES and 91.8 hours for DS. On meta-analysis there was no significant difference between ES versus DS for the outcome of open reduction requirement. There was also no significant difference for the outcomes: Iatrogenic nerve injury, pin site infection, and re-operation. The quality of evidence for all the individual outcomes was low or very low.

CONCLUSIONS

There is no evidence that delaying supracondylar fracture surgery negatively influences outcomes in the absence of vascular compromise. There are, however, notable limitations to the existing available literature.

Sex, size and isotopes: cryptic trophic ecology of an apex predator, the white shark Carcharodon carcharias

Demographic differences in resource use are key components of population and species ecology across the animal kingdom. White sharks (Carcharodon carcharias) are migratory, apex predators, which have undergone significant population declines across their range. Understanding their ecology is key to ensuring that management strategies are effective. Here, we carry out the first stable isotope analyses of free-swimming white sharks in South Africa. Biopsies were collected in Gansbaai (34.5805°S, 19.3518°E) between February and July 2015. We used Stable Isotope Bayesian Ellipsis in R and traditional statistical analyses to quantify and compare isotopic niches of male and female sharks of two size classes, and analyse relationships between isotopic values and shark length. Our results reveal cryptic trophic differences between the sexes and life stages. Males, but not females, were inferred to feed in more offshore or westerly habitats as they grow larger, and only males exhibited evidence of an ontogenetic niche shift. Lack of relationship between δ13C, δ15N and female shark length may be caused by females exhibiting multiple migration and foraging strategies, and a greater propensity to travel further north. Sharks < 3 m had much wider, and more diverse niches than sharks > 3 m, drivers of which may include individual dietary specialisation and temporal factors. The differences in migratory and foraging behaviour between sexes, life stages, and individuals will affect their exposure to anthropogenic threats, and should be considered in management strategies.

The Effect of Hemodialysis on Whole Blood, Plasma and Erythrocyte Viscosity

The effect of hemodialysis (HD) on blood viscosity has not been adequately investigated. We studied blood viscosity during HD employing coneplate viscometry. Ten patients with end-stage renal disease were studied before and immediately after HD. To dissect the possible effects of HD on plasma and red blood cell (RBC) determinants, we measured whole blood, plasma, and reconstituted erythrocyte viscosities. The latter consisted of RBC's suspended in a buffered saline solution (pH = 7.4 units). In addition, serum, electrolytes and hematocrit (HCT) were measured. The results revealed a significant rise in whole blood viscosity after dialysis. Likewise, plasma viscosity rose considerably with dialysis. However, when the RBC's were reconstituted to a constant HCT, no significant difference was noted before and after HD. As expected, body weight, blood urea nitrogen (BUN) and creatinine concentrations fell while HCT and protein concentration rose with HD. A significant correlation was found between the observed rise in HCT, and dialysis-induced rise in whole blood viscosity. Likewise, the observed rises in plasma viscosity after dialysis significantly correlated with the rise in protein concentration. In addition, the change in whole blood and plasma viscosity values correlated with the degree of ultrafiltration (weight loss). In conclusion, whole blood and plasma viscosity rises with hemodialysis. The observed rise in viscosity is primarily due to hemoconcentration.

Tracing of particulate organic C sources across the terrestrial-aquatic continuum, a case study at the catchment scale (Carminowe Creek, southwest England)

Soils deliver crucial ecosystem services, such as climate regulation through carbon (C) storage and food security, both of which are threatened by climate and land use change. While soils are important stores of terrestrial C, anthropogenic impact on the lateral fluxes of C from land to water remains poorly quantified and not well represented in Earth system models. In this study, we tested a novel framework for tracing and quantifying lateral C fluxes from the terrestrial to the aquatic environment at a catchment scale. The combined use of conservative plant-derived geochemical biomarkers n-alkanes and bulk stable δ¹³C and δ¹⁵N isotopes of soils and sediments allowed us to distinguish between particulate organic C sources from different land uses (i.e. arable and temporary grassland vs. permanent grassland vs. riparian woodland vs. river bed sediments) (p<0.001), showing an enhanced ability to distinguish between land use sources as compared to using just n-alkanes alone. The terrestrial-aquatic proxy (TAR) ratio derived from n-alkane signatures indicated an increased input of terrestrial-derived organic matter (OM) to lake sediments over the past 60years, with an increasing contribution of woody vegetation shown by the C₂₇/C₃₁ ratio. This may be related to agricultural intensification, leading to enhanced soil erosion, but also an increase in riparian woodland that may disconnect OM inputs from arable land uses in the upper parts of the study catchment. Spatial variability of geochemical proxies showed a close coupling between OM provenance and riparian land use, supporting the new conceptualization of river corridors (active river channel and riparian zone) as critical zones linking the terrestrial and aquatic C fluxes. Further testing of this novel tracing technique shows promise in terms of quantification of lateral C fluxes as well as targeting of effective land management measures to reduce soil erosion and promote OM conservation in river catchments.

Ayahuasca enhances creative divergent thinking while decreasing conventional convergent thinking

INTRODUCTION

Ayahuasca is a South American psychotropic plant tea traditionally used in Amazonian shamanism. The tea contains the psychedelic 5-HT2A receptor agonist N,N-dimethyltryptamine (DMT), plus β-carboline alkaloids with monoamine oxidase-inhibiting properties. Increasing evidence from anecdotal reports and open-label studies indicates that ayahuasca may have therapeutic effects in treatment of substance use disorders and depression. A recent study on the psychological effects of ayahuasca found that the tea reduces judgmental processing and inner reactivity, classic goals of mindfulness psychotherapy. Another psychological facet that could potentially be targeted by ayahuasca is creative divergent thinking. This mode of thinking can enhance and strengthen psychological flexibility by allowing individuals to generate new and effective cognitive, emotional, and behavioral strategies. The present study aimed to assess the potential effects of ayahuasca on creative thinking.

METHODS

We visited two spiritual ayahuasca workshops and invited participants to conduct creativity tests before and during the acute effects of ayahuasca. In total, 26 participants consented. Creativity tests included the "pattern/line meanings test" (PLMT) and the "picture concept test" (PCT), both assessing divergent thinking and the latter also assessing convergent thinking.

RESULTS

While no significant effects were found for the PLMT, ayahuasca intake significantly modified divergent and convergent thinking as measured by the PCT. While convergent thinking decreased after intake, divergent thinking increased.

CONCLUSIONS

The present data indicate that ayahuasca enhances creative divergent thinking. They suggest that ayahuasca increases psychological flexibility, which may facilitate psychotherapeutic interventions and support clinical trial initiatives.

Audit of Pulse Oximetry Screening for Critical Congenital Heart Disease (Cchd) in Newborns

BACKGROUND: UK data suggests that 25% of infants with CCHD are not diagnosed with heart disease until after discharge from the nursery (0.6 per 1000). In general SpO2 ≤ to 95% or a difference of upper and lower SpO2 of more than 3% in a newborn greater than 24 hours of age is considered significant. In March 2014 the Maternal Child Newborn Screening Committee of the Provincial Council for Maternal Child Health (PCMCH) recommended screening for critical congenital heart disease in Ontario.

OBJECTIVES: To assess the efficacy and cost related parameters of a new screening protocol for CCHD.

DESIGN/METHODS: An audit of consecutive healthy normal newborn patients over a one-year period was undertaken.

RESULTS: The cost of screening estimated for our center was approximately $7.20 per patient. The median age of screening was 25 hours (6-80 hours). Four patients were screened positive and were seen by a paediatrician in consultation. No Echocardiograms were ordered. No child in this screening survey had CCHD (specificity 99.4%). The screening compliance was 94.7%. One patient from our regional catchment area was delivered at an alternate secondary level center where there is no CCHD protocol in effect. The infant was discharged home and returned to the primary level center two days later in shock. The ultimate diagnosis was Hypoplastic Left Heart Syndrome. The estimated cost of the resuscitation was $1000. The emergency transport (direct) cost for this unstable newborn by helicopter is estimated to be $5000.00.

Conclusion: Cost analysis: The total direct costs of the CCHD screening program for a year is approximately $5200. The costs for the four patients who were falsely identified as having CCHD is estimated at $200. The total direct cost to the system of the one patient in our region who was not screened and was subsequently identified as having CCHD was estimated to be $6000. Assessment issues: In contrast to the US references, none of the false positive cases had an echocardiogram ordered. The cases were dealt with by utilizing a consultation with a paediatrician. Compliance with routine newborn orders: The screening compliance rate of 94.7%.

CONCLUSIONS: A simple screening test for Critical Congenital Heart Disease was successfully undertaken in a secondary level center over a one-year period. The test was cost effective, with high specificity (99.4%) and good compliance (94.7%).

PALEOCEANOGRAPHY. A warm and poorly ventilated deep Arctic Mediterranean during the last glacial period

Changes in the formation of dense water in the Arctic Ocean and Nordic Seas [the "Arctic Mediterranean" (AM)] probably contributed to the altered climate of the last glacial period. We examined past changes in AM circulation by reconstructing radiocarbon ventilation ages of the deep Nordic Seas over the past 30,000 years. Our results show that the glacial deep AM was extremely poorly ventilated (ventilation ages of up to 10,000 years). Subsequent episodic overflow of aged water into the mid-depth North Atlantic occurred during deglaciation. Proxy data also suggest that the deep glacial AM was ~2° to 3°C warmer than modern temperatures; deglacial mixing of the deep AM with the upper ocean thus potentially contributed to the melting of sea ice, icebergs, and terminal ice-sheet margins.

Impact of the Diabetes Inpatient Care and Education (DICE) project and the DICE Care Pathway on patient outcomes and trainee doctor's knowledge and confidence

AIM

To evaluate the impact of the Diabetes Inpatient Care and Education project and a comprehensive diabetes care pathway, the Diabetes Inpatient Care and Education Care Pathway, on patient outcomes and on the knowledge and confidence of trainee doctors.

METHODS

The effect on patient outcomes was evaluated by comparing the National Diabetes Inpatient Audit data before (2012) and after (2013) implementing the Diabetes Inpatient Care and Education project. The impact on trainee doctors was evaluated using the Modified Kirkpatrick model. Just before the project began and again 3 months later, trainee doctors were surveyed to assess their knowledge and confidence in inpatient diabetes care.

RESULTS

Patient harm was found to have been reduced significantly when National Diabetes Inpatient Audit data for 2012 and 2013 were compared. Severe hypoglycaemia decreased from 15.4 to 9.7%, medication errors from 56.9 to 21.1% and insulin errors from 31 to 7%. Across the 96 trainee doctors surveyed, the mean (sd) knowledge and confidence scores increased significantly (P < 0.001 for both) from 57.1 (16.8) and 61.8 (14.9) to 68.4 (13.3) and 74.3 (11.7), respectively.

CONCLUSION

The Diabetes Inpatient Care and Education project and the Diabetes Inpatient Care and Education Care Pathway improved patient outcomes and the knowledge and confidence of trainee doctors in this hospital. The impact of a similar project in other hospitals needs to be evaluated.

3D culture model of fibroblast-mediated collagen creep to identify abnormal cell behaviour

Native collagen gels are important biomimetic cell support scaffolds, and a plastic compression process can now be used to rapidly remove fluid to any required collagen density, producing strong 3D tissue-like models. This study aimed to measure the mechanical creep properties of such scaffolds and to quantify any enhanced creep occurring in the presence of cells (cell-mediated creep). The test rig developed applies constant creep tension during culture and measures real-time extension due to cell action. This was used to model extracellular matrix creep, implicated in the transversalis fascia (TF) in inguinal hernia. Experiments showed that at an applied tension equivalent to 15% break strength, cell-mediated creep over 24-h culture periods was identified at creep rates of 0.46 and 0.38%/h for normal TF and human dermal fibroblasts, respectively. However, hernia TF fibroblasts produced negligible cell-mediated creep levels under the same conditions. Raising the cell culture temperature from 4 to 37 °C was used to demonstrate live cell dependence of this creep. This represents the first in vitro demonstration of TF cell-mediated collagen creep and to our knowledge the first demonstration of a functional, hernia-related cell abnormality.

Femoral vein injury from a trochanteric hip fracture

A case of a comminuted trochanteric fracture where the lesser trochanteric fragment had displaced significantly injuring and becoming lodged within the common femoral vein.

PainDETECT: a suitable screening tool for neuropathic pain in patients with painful post-traumatic trigeminal nerve injuries?

The PainDETECT questionnaire (PD-Q), originally developed and validated in a multicentre study of neuropathic pain (NeP) patients with back pain, is increasingly being applied to other pain conditions. The present study assessed whether the PD-Q would be a suitable screening tool for detecting NeP in patients with post-traumatic inferior alveolar nerve injury (IANI) and lingual nerve injury (LNI). A prospective cohort of patients with clinically diagnosed neuropathy was given the PD-Q at their clinic appointment, or it was sent to them after their consultation. Eighty-nine patients (IANI = 56, LNI = 33) were included in the study, 75 of whom suffered from painful neuropathy. Of the patients who completed the questionnaire fully (n = 56), allowing a summary score to be calculated, 34% were classified as having 'likely NeP' according to the PD-Q; 41% of patients scored in the uncertain classification range and the remaining quarter in the 'likely nociceptive' classification. There was a significant association between PD-Q scores and pain intensity levels across the sample, with those classified as likely NeP reporting high levels of pain. The results suggest that the PD-Q in its current format is not a suitable screening tool for NeP associated with IANI or LNI.