Drain-blocking techniques on blanket peat: A framework for best practice

In recent years there has been a dramatic increase in artificial drain-blocking in world peatlands. The UK blanket peatlands have been severely drained over the past few decades but now drains are being blocked in an attempt to improve peatland environments. The drain-blocking has been a disparate process with limited knowledge transfer between organisations and within organisations operating in different geographic areas. Consequently, there has been no compilation of techniques used and their effectiveness. During this study thirty-two drain-blocked sites were surveyed and all the key stakeholders interviewed. Drain-blocking using peat turf was preferred by practitioners and was also the most cost-effective method. Peat turves were successful except on steep slopes, in areas of severe erosion, in very wet or very dry locations, or if the mineral substrate was exposed. A drain-blocking best practice guide is offered by this paper, providing information on the most suitable methods for blocking peatland drains under different circumstances. Additional considerations are provided for practitioners to ensure peatland drain-blocking is as successful as possible.

Mobile radiography at a music festival

Limb injuries are common at music festival sites and traditionally patients seen by on-site medical services require referral to hospital emergency departments for radiographic exclusion of bony injury. This takes clinical personnel off site, increases demand on local emergency departments and is inconvenient for revellers. This is an audit of the use of a portable digital radiography system at the Virgin music festival in Staffordshire over a 3-year period.

Differences in SMN1 allele frequencies among ethnic groups within North America

Background:

Spinal muscular atrophy (SMA) is the most common inherited lethal disease of children. Various genetic deletions involving the bi-allelic loss of SMN1 exon 7 are reported to account for 94% of affected individuals. Published literature places the carrier frequency for SMN1 mutations between 1 in 25 and 1 in 50 in the general population. Although SMA is considered to be a pan-ethnic disease, carrier frequencies for many ethnicities, including most ethnic groups in North America, are unknown.

Objectives and methods:

To provide an accurate assessment of SMN1 mutation carrier frequencies in African American, Ashkenazi Jewish, Asian, Caucasian, and Hispanic populations, more than 1000 specimens in each ethnic group were tested using a clinically validated, quantitative real-time polymerase chain reaction (PCR) assay that measures exon 7 copy number.

Results:

The observed one-copy genotype frequency was 1 in 37 (2.7%) in Caucasian, 1 in 46 (2.2%) in Ashkenazi Jew, 1 in 56 (1.8%) in Asian, 1 in 91 (1.1%) in African American, and 1 in 125 (0.8%) in Hispanic specimens. Additionally, an unusually high frequency of alleles with multiple copies of SMN1 was identified in the African American group (27% compared to 3.3–8.1%). This latter finding has clinical implications for providing accurate adjusted genetic risk assessments to the African American population.

Conclusions:

Differences in the frequency of SMA carriers were significant among several ethnic groups. This study provides an accurate assessment of allele frequencies and estimates of adjusted genetic risk that were previously unavailable to clinicians and patients considering testing.

Prospective randomised multi-centre trial comparing the clinical efficacy, safety and patient acceptability of circular stapled anopexy with closed diathermy haemorrhoidectomy

OBJECTIVE

Unlike excisional haemorrhoidectomy, stapled anopexy (SA), which does not involve radical excision, has theoretical advantages, thus offering potential patient benefits. We compared the clinical efficacy, safety and patient acceptability of SA, with closed haemorrhoidectomy (CH).

PATIENTS AND METHODS

182 patients with symptomatic haemorrhoids (grades II, III, IV) were randomly assigned to receive SA or CH and were followed for up to 1 year (6, 12, 24, 48 weeks) after operation. Postoperative pain, symptom control, complications, re-treatment rates, patient satisfaction, and quality of life were compared on an intention-to-treat basis.

RESULTS

Postoperative pain in the SA group (n = 91) was significantly lower (p = 0.004, Mann-Whitney U test). At 1 year there were no significant differences in the symptom load, symptom severity or the disease severity between the two groups. Overall complication rates were similar but faecal urgency was reported more frequently following SA (p = 0.093, Fisher's exact test). Despite a similar rate of residual symptoms, prolapse control was better with CH (p = 0.087, Fisher's exact test), and more patients in the SA group required re-treatment for residual prolapse at 1 year (p = 0.037, Fisher's exact test). However, more patients rated SA as an excellent operation at 6 and 12 weeks (p = 0.008 and 0.033, binary logistic regression) and were willing to undergo a repeat procedure if required (p = 0.018, Fisher's exact test).

CONCLUSION

Stapled anopexy offers a significantly less painful alternative to excisional haemorrhoidectomy and achieves a higher patient acceptability. Although the overall symptom control and safety are similar in the majority of the patients, the re-treatment rate for recurrent prolapse at 1 year is higher following SA when compared to CH.

Cognitive behaviour therapy for violent men with antisocial personality disorder in the community: an exploratory randomized controlled trial

BACKGROUND

Little information exists on treatment effectiveness in antisocial personality disorder (ASPD). We investigated the feasibility and effectiveness of carrying out a randomized controlled trial of cognitive behaviour therapy (CBT) in men with ASPD who were aggressive.

METHOD

This was an exploratory two-centre, randomized controlled trial in a community setting. Fifty-two adult men with a diagnosis of ASPD, with acts of aggression in the 6 months prior to the study, were randomized to either treatment as usual (TAU) plus CBT, or usual treatment alone. Change over 12 months of follow-up was assessed in the occurrence of any act of aggression and also in terms of alcohol misuse, mental state, beliefs and social functioning.

RESULTS

The follow-up rate was 79%. At 12 months, both groups reported a decrease in the occurrence of any acts of verbal or physical aggression. Trends in the data, in favour of CBT, were noted for problematic drinking, social functioning and beliefs about others.

CONCLUSIONS

CBT did not improve outcomes more than usual treatment for men with ASPD who are aggressive and living in the community in this exploratory study. However, the data suggest that a larger study is required to fully assess the effectiveness of CBT in reducing aggression, alcohol misuse and improving social functioning and view of others. It is feasible to carry out a rigorous randomized controlled trial in this group.

Mechanism of ritonavir changes in methadone pharmacokinetics and pharmacodynamics: II. Ritonavir effects on CYP3A and P-glycoprotein activities

Ritonavir diminishes methadone plasma concentrations, an effect attributed to CYP3A induction, but the actual mechanisms are unknown. We determined short-term (2-day) and steady-state (2-week) ritonavir effects on intestinal and hepatic CYP3A4/5 (probed with intravenous (IV) and oral alfentanil (ALF) and with miosis) and P-glycoprotein (P-gp) (fexofenadine), and on methadone pharmacokinetics and pharmacodynamics in healthy volunteers. Acute ritonavir increased the area under the concentration-time curve (AUC)(0-infinity)/dose ratio (ritonavir/control) for oral ALF 25-fold. Steady-state ritonavir increased the AUC(0-Infinity)/dose ratio for IV and oral ALF 4- and 10-fold, respectively; reduced hepatic extraction (from 0.26 to 0.07) and intestinal extraction (from 0.51 to 0); and increased bioavailability (from 37 to 95%). Acute ritonavir inhibits first-pass CYP3A > 96%. Chronic ritonavir inhibits hepatic CYP3A (> 70%) and first-pass CYP3A (> 90%). Acute and steady-state ritonavir increased the fexofenadine AUC(0-infinity) 2.8- and 1.4-fold, respectively, suggesting P-gp inhibition. Steady-state compared with acute ritonavir caused mild apparent induction of P-gp and hepatic CYP3A, but net inhibition still predominated. Ritonavir inhibited both intestinal and hepatic CYP3A and drug transport. ALF miosis noninvasively determined CYP3A inhibition by ritonavir.

Mechanism of ritonavir changes in methadone pharmacokinetics and pharmacodynamics: I. Evidence against CYP3A mediation of methadone clearance

Ritonavir diminishes methadone plasma concentrations, an effect attributed to CYP3A induction, but the actual mechanisms are unknown. We determined ritonavir effects on stereoselective methadone pharmacokinetics and clinical effects (pupillary miosis) in healthy human immunodeficiency virus-negative volunteers. Subjects received intravenous plus oral (deuterium-labeled) racemic methadone after no ritonavir, short-term (3-day) ritonavir, and steady-state ritonavir. Acute and steady-state ritonavir, respectively, caused 1.5- and 2-fold induction of systemic and apparent oral R- and S-methadone clearances. Ritonavir increased renal clearance 40-50%, and stereoselectively (S > R) increased hepatic methadone N-demethylation 50-80%, extraction twofold, and clearance twofold. Bioavailability was unchanged despite significant inhibition of intestinal P-glycoprotein. Intestinal and hepatic CYP3A was inhibited > 70%. Ritonavir shifted methadone plasma concentration-miosis curves leftward and upward. Rapid ritonavir induction of methadone clearance results from increased renal clearance and induced hepatic metabolism. Induction of methadone metabolism occurred despite profound CYP3A inhibition, suggesting no role for CYP3A in clinical methadone metabolism and clearance. Ritonavir may alter methadone pharmacodynamics.

Repetitive task training for improving functional ability after stroke

BACKGROUND

The active practice of task-specific motor activities is a component of current approaches to stroke rehabilitation.

OBJECTIVES

To determine if repetitive task training after stroke improves global, upper or lower limb function, and if treatment effects are dependent on the amount, type or timing of practice.

SEARCH STRATEGY

We searched the Cochrane Stroke Trials Register (October 2006), The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, SportDiscus, Science Citation Index, Index to Theses, ZETOC, PEDro, and OT Seeker (to September 2006), and OT search (to March 2006). We also searched for unpublished/non-English language trials, conference proceedings, combed reference lists, requested information on bulletin boards, and contacted trial authors.

SELECTION CRITERIA

Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal, and where the amount of practice could be quantified.

DATA COLLECTION AND ANALYSIS

Two authors independently screened abstracts, extracted data and appraised trials. Assessment of methodological quality was undertaken for allocation concealment, blinding, loss to follow up and equivalence of treatment. We contacted trial authors for additional information.

MAIN RESULTS

Fourteen trials with 17 intervention-control pairs and 659 participants were included.

PRIMARY OUTCOMES

results were statistically significant for walking distance (mean difference (MD) 54.6, 95% CI 17.5 to 91.7); walking speed (standardised mean difference (SMD) 0.29, 95% CI 0.04 to 0.53); sit-to-stand (standard effect estimate 0.35, 95% CI 0.13 to 0.56); and of borderline statistical significance for functional ambulation (SMD 0.25, 95% CI 0.00 to 0.51), and global motor function (SMD 0.32, 95% CI -0.01 to 0.66). There were no statistically significant differences for hand/arm function, or sitting balance/reach.

SECONDARY OUTCOMES

results were statistically significant for activities of daily living (SMD 0.29, 95% CI 0.07 to 0.51), but not for quality of life or impairment measures. There was no evidence of adverse effects. Follow-up measures were not significant for any outcome at six or twelve months. Treatment effects were not modified by intervention amount or timing, but were modified by intervention type for lower limbs.

AUTHORS' CONCLUSIONS

Repetitive task training resulted in modest improvement in lower limb function, but not upper limb function. Training may be sufficient to impact on daily living function. However, there is no evidence that improvements are sustained once training has ended. The review potentially investigates task specificity rather more than repetition. Further research should focus on the type and amount of training, and how to maintain functional gain.

Influence of socioeconomic status on clinical outcomes and quality of life after percutaneous coronary intervention

OBJECTIVES

To determine whether socioeconomic status (SES) influences clinical outcomes and quality of life after percutaneous coronary intervention (PCI).

DESIGN

Prospective observational study.

SETTING

Two interventional cardiac centres.

PARTICIPANTS

1346 consecutive patients undergoing PCI over a 12-month period.

OUTCOMES

Self reported health-related quality of life (HRQoL; EuroQol-5 Dimensions (EQ-5D); EuroQol Visual Analogue Scale (EQ-VAS)), repeat angiography, revascularisation, hospital admission, myocardial infarction and death within 12 months, by SES derived using postal address code.

MAIN RESULTS

No significant differences were found between patients with high and low SES in the occurrence of repeat angiography (p = 0.55), repeat revascularisation (PCI, p = 0.81, CAEG, p = 0.27), total cardiac hospitalisation (p = 0.10), myocardial infarction (p = 0.97) or death 12 months after PCI (p = 0.88). Non-procedure-related readmissions were higher in patients with low SES (18.6% v 13.7%; p = 0.025). After adjustment for confounding factors, patients with low SES had lower HRQoL scores at baseline (95% CI for difference 0.01 to 0.14; p = 0.003) and at 12 months (95% CI 0.07 to 0.17; p<0.001) compared with those with high SES.

CONCLUSIONS

Clinical outcomes were similar for patients in different SES groups. Patients with low SES had considerably more non-procedure-related readmissions and lower quality-of-life scores. Future studies on HRQoL after coronary revascularisation should take account of these important differences related to SES.

Families of patients with premature coronary heart disease: an obvious but neglected target for primary prevention

Risk of premature coronary heart disease is increased in the families of affected patients. C K Chow and colleagues argue that targeting relatives for primary prevention would be an effective policy

Phase I clinical and pharmacokinetic (PK) trial of the kinesin spindle protein (KSP) inhibitor MK-0731 in patients with solid tumors

2548

Background: KSP is essential for the separation of spindle poles during mitosis and inhibition results in mitotic arrest. MK- 0731 is a potent inhibitor of KSP, with an IC50 of 2.2 nM, and >20,000 fold selectivity against other kinesins. MK-0731 causes mitotic arrest with an EC50 in several tumor cell lines of 3–5 nM. Methods: Phase I study to determine the safety and tolerability, MTD, and PK of MK-0731 administered IV over 24 hrs every 21 days. In part 1, dosing started at 6 mg/m2/24 hr and was escalated until the MTD was reached. In part 2, pts with measurable taxane-resistant cancer were treated at the MTD established in Part 1 (target accrual =22 pts in part 2). Interim Results: 35 pts with solid tumors (M/F 23/12), median age 63 yrs (23 - 79), were treated at doses of 6 to 48 mg/ m2/24hrs (median cycles 3, range 1–10, total cycles=128). Frequent tumor types included prostate (8), ovarian (4), colon (3), bladder (2), neuroendocrine (2), lung (2), breast (2). Prolonged (>5 days) grade 4 neutropenia was observed in 2 pts at 48 mg/m2/24hrs (11 days duration) and 2 pts at 24 mg/m2/24hrs (7 days duration) leading to expansion of cohorts at lower dose levels. At the MTD of 17 mg/ m2/24, there were no DLTs. 14 patients have been enrolled at the MTD in part 2 of the study. Drug related grade 3/4 toxicities were anemia (1), AST (1), hyperglycemia (1), nausea/vomiting (1), neutropenia (7), syncope (1). PK results from the first 20 patients suggest that MK- 0731 concentrations appear to decline monoexponentially or biexponentially following the infusion with terminal t1/2 from ∼4 to 22 hrs. In some patients, steady-state concentrations may not be achieved by the end of the 24 hr infusion. Mean values at the 17 mg/m2/24hrs dose level were Cmax=599 nM, AUC8=14.56 μM·hr, and CL=119 mL/min. AUC, exposures, and end of infusion concentrations appear to increase proportionally with dose. Stable disease for = 4 cycles (range 4- 10) was seen in 16 patients. Conclusion: Treatment with MK-0731 at the MTD of 17 mg/m2/day every 21 days in patients with advanced solid tumors was well tolerated with consistent dose limiting toxicity of myelosuppression.

No significant financial relationships to disclose.

Influence of CYP3A5 genotype on the pharmacokinetics and pharmacodynamics of the cytochrome P4503A probes alfentanil and midazolam

The hepatic and first-pass cytochrome P4503A (CYP3A) probe alfentanil (ALF) is also metabolized in vitro by CYP3A5. Human hepatic microsomal ALF metabolism is higher in livers with at least one CYP3A5*1 allele and higher CYP3A5 protein content, compared with CYP3A5*3 homozygotes with little CYP3A5. The influence of CYP3A5 genotype on ALF pharmacokinetics and pharmacodynamics was studied, and compared to midazolam (MDZ), another CYP3A probe. Healthy volunteers (58 men, 41 women) were genotyped for CYP3A5 *1, *3, *6, and *7 alleles. They received intravenous MDZ then ALF, and oral MDZ and ALF the next day. Plasma MDZ and ALF concentrations were determined by mass spectrometry. Dark-adapted pupil diameters were determined coincident with blood sampling. In CYP3A5(*)3/(*)3 (n=62), (*)1/(*)3 (n=28), and (*)1/(*)1 (n=8) genotypes, systemic clearances of ALF were 4.6+/-1.8, 4.8+/-1.7, and 3.9+/-1.7 ml/kg/min and those of MDZ were 7.8+/-2.3, 7.7+/-2.3, and 6.0+/-1.4 ml/kg/min, respectively (not significant), and apparent oral clearances were 11.8+/-7.2, 13.3+/-6.1, and 12.6+/-8.2 ml/kg/min for ALF and 35.2+/-19.0, 36.4+/-15.7, and 29.4+/-9.3 ml/kg/min for MDZ (not significant). Clearances were not different between African Americans (n=25) and Whites (n=68), or between CYP3A5 genotypes within African Americans. ALF pharmacodynamics was not different between CYP3A5 genotypes. There was consistent concordance between ALF and MDZ, in clearances and extraction ratios. Thus, in a relatively large cohort of healthy subjects with constitutive CYP3A activity, CYP3A5 genotype had no effect on the systemic or apparent oral clearances, or pharmacodynamics, of the CYP3A probes ALF and MDZ, despite affecting their hepatic microsomal metabolism.

A systematic study of hcp crystal orientation and morphology effects in polycrystal deformation and fatigue

Elastically anisotropic, physically based, length-scale- and rate-dependent crystal plasticity finite element investigations of a model hcp polycrystal are presented and a systematic study was carried out on the effects of combinations of crystallographic orientations on local, grain-level stresses and accumulated slip in cycles containing cold dwell. It is shown that the most damaging combination is the one comprising a primary hard grain with c -axis near-parallel to the loading direction and an adjacent soft grain having c -axis near-normal to the load and a prismatic slip plane at approximately 70° to the normal to the load. We term such a combination a rogue grain combination. In passing, we compare results with the Stroh model and show that even under conditions of plasticity in the hcp polycrystal, the Stroh model qualitatively predicts some of the observed behaviours. It is shown that under very particular circumstances, a morphological – crystallographic interaction occurs which leads to particularly localized accumulated slip in the soft grain and the penetration of the slip into the adjacent hard grain. The interaction effect occurs only when the (morphological) orientation of the grain boundary in the rogue grain combination coincides (within approximately ±5°) with the (crystallographic) orientation of an active slip system in the soft grain. It is argued that the rogue grain combination and the morphological–crystallographic interaction are responsible for fatigue facet formation in Ti alloys with cold dwell, and a possible mechanism for facet formation is presented. The experimental observations of fatigue facet formation have been reviewed and they provide considerable support for the conclusions from the crystal plasticity modelling. In particular, faceting was found to occur at precisely those locations predicted by the model, i.e. at a rogue grain combination. Some experimental evidence for the need for a crystallographic–morphological interaction in faceting is also presented.

Eosinophilic glomerulonephritis in children in Southwestern Uganda

Acute renal disease is common in sub-Saharan Africa, with high mortality. Its etiology is poorly understood; quartan malaria owing to Plasmodium malariae was implicated in previous series. Few previous studies have included histological data; furthermore, much of the literature pre-dates the human immunodeficiency virus (HIV) epidemic. We report prospective analysis of acute proteinuric renal disease in children in rural Uganda. Clinical and laboratory data are presented on 65 patients (aged 2-14 years, mean 8.4; 35 male, 30 female) in 41 of whom histological diagnosis was obtained by renal biopsy. The most frequent histological finding was endocapillary proliferative glomerulonephritis (GN) in 27/41 cases, in 20 of which eosinophils were very prominent. No cases showed features of HIV nephropathy. Malarial films were positive in 11 cases: all owing to Plasmodium falciparum. Patients were treated with diuretics, antihypertensives, and supportive measures. Corticosteroids were rarely used, being reserved for patients with minimal changes on renal biopsy. Clinical outcomes were fair: 91% of patients survived to discharge. We conclude that acute GN is common in children in Uganda, that an unusual eosinophilic proliferative GN is the most frequent histological finding, that HIV is not implicated as an important factor in this age group, and that good outcomes can be achieved using simple clinical and laboratory diagnostic methods. Renal biopsy in selected cases is feasible and helpful, especially in allowing rational use of corticosteroids and other potentially toxic treatments. Symptomatic treatments and careful supportive care will allow the majority of children to recover.

Production of indole diterpenes by Aspergillus alliaceus

Production of two related indole diterpenes (differing by a dimethyl leucine side chain) by Aspergillus alliaceus was improved through several pilot scale fermentations. Media were optimized through focus primarily on initial increases, as well as mid-cycle additions, of carbon and nitrogen sources. Fermentation conditions were improved by varying ventilation conditions using various combinations of air flowrate and back-pressure set points. Production improvements were quantified based on total indole diterpene concentration as well as the ratio of the major-to-minor by-product components. Those changes with a positive substantial impact primarily on total indole diterpene concentration included early cycle glycerol shots and enhanced ventilation conditions (high air flowrate, low back-pressure). Those changes with a significant impact primarily on ratio included higher initial cerelose, soybean oil, monosodium glutamate, tryptophan, or ammonium sulfate concentrations, higher broth pH, and enhanced ventilation conditions. A few changes (higher initial glycerol and monosodium glutamate concentrations) resulted in less notable and desirable titer or ratio changes when implemented individually, but they were adopted to more fully realize the impact of other improvements or to simplify processing. Overall, total indole diterpene titers were improved at the 600 L pilot scale from 125-175 mg/L with a ratio of about 2.1 to 200-260 mg/L with a ratio of about 3.3-4.5. Thus, the ability to optimize total indole diterpene titer and/or ratio readily exists for secondary metabolite production using Aspergillus cultures.

Evaluation of a diabetes referral pathway for the management of hypoglycaemia following emergency contact with the ambulance service to a diabetes specialist nurse team

OBJECTIVES

To evaluate the effectiveness of ambulance crew referral of patients treated for acute hypoglycaemia, to a diabetes specialist nurse (DSN) team. Patients were assessed by the ambulance service and did not attend an emergency department.

METHODS

For a 3 month period patients were referred from two areas of West Yorkshire by the ambulance service to specialist diabetes teams. The DSNs contacted the patients within 7 days by telephone and arranged further review if necessary. Satisfaction questionnaires were sent to patients.

RESULTS

Thirty eight patients were referred and all were reviewed by telephone; 30 (79%) also required a clinic review appointment. Warning signs of hypoglycaemia were identified by 21 (55%) patients, but 14 (37%) had none (three had incomplete data). Twelve patients had had a self-treated episode in the previous 6 months; nine patients had had three or more. Fifteen (39%) patients had called an emergency ambulance for similar reasons in the previous 6 months (27 "999" calls). Twenty patients (53%) had their drug treatment altered at a clinic appointment and 14 (37%) required ongoing review. Twenty six patients returned the satisfaction questionnaire; of these 88% agreed or strongly agreed that they had improved their understanding of hypoglycaemia and 73% felt more able to treat a hypoglycaemic episode in the future. Patient satisfaction with this care pathway was high.

CONCLUSIONS

The ambulance service can coordinate successful referral of patients with episodes of acute hypoglycaemia to a DSN-led service. Patients often required treatment review. They valued this service and felt more confident managing their diabetes.

Evaluation of focussed assessment with sonography in trauma (FAST) by UK emergency physicians

OBJECTIVES

To evaluate the introduction of a focussed assessment with sonography in trauma (FAST) scan into the early assessment of trauma patients in the UK.

METHODS

The setting was an inner city teaching hospital emergency department (annual attendance 100,000). All patients aged 16 or over admitted to the resuscitation room after blunt trauma were included in a prospective observational study. Patients had a FAST scan performed at the end of the primary survey. Results were compared to results of other investigations, laparotomy, postmortem examination, or observation.

RESULTS

153 patients were entered into the study. The sensitivity of the FAST scan was 78% and specificity was 99%.

CONCLUSION

FAST is a highly specific "rule in" technique and is useful in the initial assessment of trauma patients. Emergency physicians can perform FAST after a brief training period.

Effects of changing clinical practice on costs and outcomes of percutaneous coronary intervention between 1998 and 2002

AIM

To assess the effect of changing clinical practice on the costs and outcomes of percutaneous coronary intervention (PCI) between 1998 and 2002.

SETTING

Two tertiary interventional centres.

PATIENTS

Consecutive patients undergoing PCI over a 12-month period between 1998 and 2002.

DESIGN

Comparative observational study of costs and 12-month clinical outcomes of consecutive PCI procedures in 1998 (n = 1047) and 2002 (n = 1346). Clinical data were recorded in the Scottish PCI register. Repeat PCI, coronary artery bypass graft and mortality were obtained by record linkage. Costs of equipment were calculated using a computerised bar-code system and standard National Health Service reference costs.

RESULTS

Between 1998 and 2002, the use of bare metal stents increased from 44% to 81%, and the use of glycoprotein IIB/IIIA inhibitors increased from 0% to 14% of cases. During this time, a significant reduction was observed in repeat target-vessel PCI (from 8.4% to 5.1%, p = 0.001), any repeat PCI (from 11.7% to 9.2%, p = 0.05) and any repeat revascularisation (from 15.1% to 11.3%, p = 0.009) within 12 months. Significantly higher cost per case in 2002 compared with 1998 (mean (standard deviation) 2311 pounds (1158) v 1785 pounds (907), p<0.001) was mainly due to increased contribution from bed-day costs in 2002 (45.0% (16.3%) v 26.2% (12.6%), p = 0.01) associated with non-elective cases spending significantly longer in hospital (6.22 (4.3) v 4.6 (4.3) days, p = 0.01).

CONCLUSIONS

Greater use of stents and glycoprotein IIb/IIIa inhibitors between 1998 and 2002 has been accompanied by a marked reduction in the need for repeat revascularisation. Longer duration of hospital stay for non-elective cases is mainly responsible for increasing costs. Strategies to reduce the length of stay could considerably reduce the costs of PCI.

Patient compliance in hypertension: role of illness perceptions and treatment beliefs

Despite many years of study, questions remain about why patients do or do not take medicines and what can be done to change their behaviour. Hypertension is poorly controlled in the UK and poor compliance is one possible reason for this. Recent questionnaires based on the self-regulatory model have been successfully used to assess illness perceptions and beliefs about medicines. This study was designed to describe hypertensive patients' beliefs about their illness and medication using the self-regulatory model and investigate whether these beliefs influence compliance with antihypertensive medication. We recruited 514 patients from our secondary care population. These patients were asked to complete a questionnaire that included the Beliefs about Medicines and Illness Perception Questionnaires. A case note review was also undertaken. Analysis shows that patients who believe in the necessity of medication are more likely to be compliant (odds ratio (OR)) 3.06 (95% CI 1.74-5.38), P<0.001). Other important predictive factors in this population are age (OR 4.82 (2.85-8.15), P<0.001), emotional response to illness (OR 0.65 (0.47-0.90), P=0.01) and belief in personal ability to control illness (OR 0.59 (0.40-0.89), P=0.01). Beliefs about illness and about medicines are interconnected; aspects that are not directly related to compliance influence it indirectly. The self-regulatory model is useful in assessing patients health beliefs. Beliefs about specific medications and about hypertension are predictive of compliance. Information about health beliefs is important in achieving concordance and may be a target for intervention to improve compliance.

Phase I clinical and pharmacokinetic (PK) trial of the kinesin spindle protein (KSP) inhibitor MK-0731 in cancer patients

2001

Background: KSP is essential for the separation of spindle poles during mitosis and inhibition results in mitotic arrest. Function is thought to be limited to mitosis and inhibitors should not cause the peripheral neuropathy seen with other mitotic-inhibitors. MK-0731 is a potent inhibitor of KSP, with an IC50 of 2.2 nM, and >20,000 fold selectivity against other kinesins. MK-0731 causes mitotic arrest with an EC50 in several tumor cell lines of 3−5 nM. Methods: Phase I study to determine the safety and tolerability, MTD, and PK of MK-0731 administered IV over 24 hrs every 21 (Q21) ds. Results: Eight pts with solid tumors (M/F 6/2), median age 55 yrs (45–72 yrs), were treated at doses of 6 to 48 mg/m2/24hrs. Prolonged (≥5 ds) Grade 4 neutropenia was observed in 2 pts at 48 mg/m2/24 hrs leading to expansion of cohorts at lower dose levels. Other drug related toxicities include diarrhea, alopecia, nail changes, nausea/vomiting, mucositis, abdominal pain, anorexia, phlebitis. PK results suggest that steady-state concentrations may not be achieved by the end of the 24 hr infusion and MK-0731 concentrations appear to decline monoexponentially or biexponentially following the infusion with terminal t1/2 from ∼4 to 11 hrs. Median values at the 48 mg/m2/24 hrs dose level were Cmax = 1223 nM, AUC∞ = 26.585 μM · hr, and CL=122 mL/min. AUC, exposures, and end of infusion concentrations appear to increase proportionally with dose. Conclusions: This is the first study of MK-0731. The MTD was exceeded at 48 mg/m2/24 hrs Q21. Further evaluation will continue at lower doses.

[Table: see text]

Use of a forensic technique to identify blood contamination of emergency department and ambulance trauma equipment

Using a Kastle-Meyer (KM) technique, the following equipment from the emergency departments of six UK hospitals (four trusts) and three regional ambulance services was tested for blood contamination: extrication ("spinal") boards, cervical collars, straps, box splints, head blocks, and headboards. Only equipment ready for patient use was tested. Over half of trauma equipment (57%) tested positive for blood, including 15% of equipment that was visibly stained with blood. There have been no recorded cases of infection from contaminated trauma equipment but our study has identified the potential risk. Disposable covers for boards, disposable straps, and disposable radiolucent head blocks which are currently available provide a solution but have resource implications.

Economic evaluation of the impact of nicorandil in angina (IONA) trial

OBJECTIVE

To estimate the net cost of adding nicorandil to usual treatment for patients with angina and to compare this with indicators of health benefit.

DESIGN

Cost effectiveness analysis.

SETTING

Based on results of the IONA (impact of nicorandil on angina) trial.

PATIENTS

Patients with angina fulfilling the entry criteria for the IONA trial.

INTERVENTIONS

In one arm of the trial nicorandil was added to existing antianginal treatment and compared with existing treatment alone.

MAIN OUTCOME MEASURES

Costs were for use of hospital resources (for cardiovascular, cerebrovascular, and gastrointestinal reasons), nicorandil, and care after hospital discharge. Benefits were assessed in three ways: (1) IONA trial primary outcome (coronary heart disease (CHD) death, non-fatal myocardial infarction, or hospital admission for cardiac chest pain); (2) acute coronary syndrome (CHD death, non-fatal myocardial infarction, or unstable angina); and (3) event-free survivors at the end of the trial.

RESULTS

The net cost for each additional IONA trial end point averted was -5 pounds sterling (-7 euros). The net cost for each case of acute coronary syndrome averted was -8 pounds sterling (-12 euros). The net cost for each event-free survivor was -5 pounds sterling (-7 euros). These figures are based on gastrointestinal events that were judged definitely or probably related to nicorandil. When all gastrointestinal events were included these three ratios rose to 567 pounds sterling (835 euros), 886 pounds sterling (1305 euros), and 516 pounds sterling (760 euros), respectively.

CONCLUSIONS

A substantial amount of the additional cost of nicorandil is offset by reduced use of hospital services. The limited comparisons possible with other CHD interventions suggest that nicorandil compares favourably.

Variations in clinical decision-making between cardiologists and cardiac surgeons; a case for management by multidisciplinary teams?

Objective

To assess variations in decisions to revascularise patients with coronary heart disease between general cardiologists, interventional cardiologists and cardiac surgeons

Design

Six cases of coronary heart disease were presented at an open meeting in a standard format including clinical details which might influence the decision to revascularise. Clinicians (n = 53) were then asked to vote using an anonymous electronic system for one of 5 treatment options: medical, surgical (CABG), percutaneous coronary intervention (PCI) or initially medical proceeding to revascularisation if symptoms dictated. Each case was then discussed in an open forum following which clinicians were asked to revote. Differences in treatment preference were compared by chi squared test and agreement between groups and between voting rounds compared using Kappa.

Results

Surgeons were more likely to choose surgery as a form of treatment (p = 0.034) while interventional cardiologists were more likely to choose PCI (p = 0.056). There were no significant differences between non-interventional and interventional cardiologists (p = 0.13) in their choice of treatment. There was poor agreement between all clinicians in the first round of voting (Kappa 0.26) but this improved to a moderate level of agreement after open discussion for the second vote (Kappa 0.44). The level of agreement among surgeons (0.15) was less than that for cardiologists (0.34) in Round 1, but was similar in Round 2 (0.45 and 0.45 respectively)

Conclusion

In this case series, there was poor agreement between cardiac clinical specialists in the choice of treatment offered to patients. Open discussion appeared to improve agreement. These results would support the need for decisions to revascularise to be made by a multidisciplinary panel.

CD4-veCD8-ve CD30+ve T cells are detectable in human lung transplant patients and their proportion of the lymphocyte population after in vitro stimulation with donor spleen cells correlates with preservation of lung physiology

INTRODUCTION

Survival following lung transplantation is less than 50% at 5 years, mainly due to immune-mediated chronic rejection. Recently a novel subset of T cells, CD4-veCD8-ve CD30+ve, so-called double negative (DN) CD30+ve T cells, has been described and shown to be responsible for tolerance in an animal model of skin transplantation.

METHODS

We investigated 18 lung transplant recipients for the presence of DN CD30+ve T cells in resting peripheral blood and also following in vitro stimulation of recipient peripheral blood mononuclear cells (PBMCs) with donor spleen cells.

RESULTS

Small percentages (0.2% to 6%) of DN T cells are detectable in resting PBMCs of human transplant patients (n = 18), but these did not correlate with allograft function, acute rejection episodes, HLA mismatch, or CMV status. On repeated stimulation of recipient PBMCs (two exposures) in vitro by donor spleen cells (2:1 ratio stimulators to responders) the percentage of DN CD30+ve T cells within the lymphocyte pool correlated with preservation of allograft lung function (both for FEV(1), P = .009, and FEF(25-75), P = .036) and was inversely correlated with grade of chronic rejection. On repeated exposure of recipient PBMCs to donor spleen cells with a 1:1 ratio the percentage of DN CD30+ve T cells correlated with the number of acute rejection episodes of grade 2 or greater. The total number of HLA mismatches correlated with the percentage DN CD30+ve T cells present after primary stimulation of recipient PBMCs with donor spleen cells (1:1 ratio). The number of mismatches at the B locus inversely correlated with the percentage of DN CD30+ve T cells after primary stimulation of recipient PBMCs with donor spleen cells (1:1 ratio; P = .031, n = 18).

CONCLUSION

Percentages of DN CD30+ve T cells present following repeated stimulation of recipient PBMCs by donor spleen cells correlated with preservation of graft function following lung transplantation.

Caring for patients with cancer in non-specialist wards: the nurse experience

This study aims to describe the experiences of nurses caring for cancer patients in non-specialist wards. The study was conducted in a large (420 beds) and small (32 beds) hospital in an area health service with urban and rural populations in the west of Sydney. A qualitative descriptive approach was utilized to collect data from the nurses. Data were collected using a survey and in-depth interviews of nurses working in non-specialist cancer wards. Transcribed data were managed with Nudist Vivo software and analysed for common themes using process of constant comparison and contrast. Twenty-five surveys were returned and five nurses volunteered to be interviewed. The six major themes that emerged from analysis of data were: emotional nature of care, lack of time, lack of knowledge of cancer treatment, family support, environment not conducive to proper care and dealing with patient's non-acceptance of cancer diagnosis. The nurses in this study wished to provide quality supportive care for cancer patients and their families but the inconducive environment and inadequate relevant training hindered the nurses' efforts. This then presents further need of relevant training for nurses in cancer care and time management, to meet up with these challenges.

What are the beliefs and attitudes of paramedics to prehospital thrombolysis? A questionnaire study

BACKGROUND

The Ambulance Services have a critical role in the management of acute myocardial infarction (AMI). Paramedic delivered prehospital thrombolysis (PHT) has been proposed. To the authors' knowledge there has been no research carried out to ascertain the views of paramedics.

METHODS

The authors conducted a postal questionnaire study of 250 paramedics in the West Yorkshire Metropolitan Ambulance Service (WYMAS). This included the knowledge of risks and benefits of AMI treatments, and their views on possible paramedic delivered PHT.

RESULTS

193 paramedics replied (77%); of these 83% felt paramedics could deliver PHT, 67% felt thrombolysis was safe, and only 12% felt that paramedics should not carry out PHT. There was a similar preference towards autonomous PHT (42%) and telemetry with physician directed PHT (46%). 96% wanted a nationally recognised certificate. There were concerns regarding the risks of AMI treatment, with underestimates of the benefits of aspirin, and overestimates of the benefits of thrombolysis. They also greatly overestimated the risks of thrombolysis in terms of extra deaths (71%), and bleeding (90%).

CONCLUSION

The majority of paramedics in WYMAS responding to the questionnaire supported the principle of PHT. Concerns included the risks of thrombolytic treatment, training, and the medico-legal implications for them as individual paramedics. Models for paramedic thrombolysis for each ambulance service should include the views of paramedics.