Relative ratios of collagen composition of periarticular tissue of joints of the upper limb

We investigated the relative ratios of collagen composition of periarticular tissue of the elbow, wrist, metacarpophalangeal, proximal and distal interphalangeal joints. Periarticulat tissue, which we defined as the ligaments, palmar plate and capsule, was harvested from ten fresh-frozen cadaveric upper limbs, yielding 50 samples. The mean paired differences (95% confidence interval) of the relative ratios of collagen between the five different joints were estimated using mRNA expression of collagen in the periarticular tissue. We found that the relative collagen composition of the elbow was not significantly different to that of the proximal interphalangeal joint, nor between the proximal interphalangeal joint and distal interphalangeal joint, whereas the differences in collagen composition between all the other paired comparisons of the joints had confidence intervals that did not include zero.

Comparison of sequencing the D2 region of the large subunit ribosomal RNA gene (MicroSEQ®) versus the internal transcribed spacer (ITS) regions using two public databases for identification of common and uncommon clinically relevant fungal species

CONTEXT

Fungal infections cause considerable morbidity and mortality in immunocompromised patients. Rapid and accurate identification of fungi is essential to guide accurately targeted antifungal therapy. With the advent of molecular methods, clinical laboratories can use new technologies to supplement traditional phenotypic identification of fungi.

OBJECTIVE

The aims of the study were to evaluate the sole commercially available MicroSEQ® D2 LSU rDNA Fungal Identification Kit compared to the in-house developed internal transcribed spacer (ITS) regions assay in identifying moulds, using two well-known online public databases to analyze sequenced data.

DESIGN

85 common and uncommon clinically relevant fungi isolated from clinical specimens were sequenced for the D2 region of the large subunit (LSU) of ribosomal RNA (rRNA) gene with the MicroSEQ® Kit and the ITS regions with the in house developed assay. The generated sequenced data were analyzed with the online GenBank and MycoBank public databases.

RESULTS

The D2 region of the LSU rRNA gene identified 89.4% or 92.9% of the 85 isolates to the genus level and the full ITS region (f-ITS) 96.5% or 100%, using GenBank or MycoBank, respectively, when compared to the consensus ID. When comparing species-level designations to the consensus ID, D2 region of the LSU rRNA gene aligned with 44.7% (38/85) or 52.9% (45/85) of these isolates in GenBank or MycoBank, respectively. By comparison, f-ITS possessed greater specificity, followed by ITS1, then ITS2 regions using GenBank or MycoBank. Using GenBank or MycoBank, D2 region of the LSU rRNA gene outperformed phenotypic based ID at the genus level. Comparing rates of ID between D2 region of the LSU rRNA gene and the ITS regions in GenBank or MycoBank at the species level against the consensus ID, f-ITS and ITS2 exceeded performance of the D2 region of the LSU rRNA gene, but ITS1 had similar performance to the D2 region of the LSU rRNA gene using MycoBank.

CONCLUSION

Our results indicated that the MicroSEQ® D2 LSU rDNA Fungal Identification Kit was equivalent to the in-house developed ITS regions assay to identify fungi at the genus level. The MycoBank database gave a better curated database and thus allowed a better genus and species identification for both D2 region of the LSU rRNA gene and ITS regions.

Brief intervention, physical exercise and cognitive behavioural group therapy for patients with chronic low back pain (The CINS trial)

BACKGROUND AND OBJECTIVE

Cognitive-behavioural treatments (CBT) and physical group exercise (PE) have both shown promising effects in reducing disability and increasing work participation among chronic low back pain (CLBP) patients. A brief cognitive intervention (BI) has previously been demonstrated to reduce work disability in CLBP. The aim of this study was to test if the effect of BI could be further increased by adding either group CBT or group PE.

METHODS

A total of 214 patients, all sick listed 2-10 months due to CLBP, were randomized to BI (n = 99), BI + group CBT (n = 55) or BI + group PE (n = 60). Primary outcome was increased work participation at 12 months, whereas secondary outcomes included pain-related disability, subjective health complaints, anxiety, depression, coping and fear avoidance.

RESULTS

There were no significant differences between the groups in work participation at 12 months follow-up (χ²  = 1.15, p = 0.56). No significant differences were found on the secondary outcomes either, except for a statistically significant reduction (time by group) in pseudoneurology one domain of subjective health complaints (sleep problems, tiredness, dizziness, anxiety, depression, palpitation, heat flushes) (F_2,136  = 3.109, p = 0.048) and anxiety (F_2,143  = 4.899, p = 0.009) for the groups BI + group CBT and BI + group PE, compared to BI alone. However, these differences were not significant in post hoc analyses (Scheffé adjusted).

CONCLUSION

There was no support for an effect of the added group CBT or group PE treatments to a brief cognitive intervention in this study of patients on sick leave due to low back pain.

SIGNIFICANCE

Our study demonstrates that treatments that previously were found to be effective and are included in most treatment guidelines, such as group cognitive-behavior therapy and exercise, were not effective in this given context compared to a brief, cognitive intervention. This implies that an optimized brief intervention is difficult to outperform in patients on sick leave due to low back pain.

Extended spectrum beta lactamase (ESBL) producing bacteria urinary tract infections and complex pediatric urology

AIM OF THE STUDY

Extended spectrum beta lactamase (ESBL) producing bacteria are resistant to most beta-lactam antibiotics including third-generation cephalosporins, quinolones and aminoglycosides. This resistance is plasmid-borne and can spread between species. Management of ESBL is challenging in children with recurrent urinary tract infections (UTIs) and complex urological abnormalities. We aim to quantify the risk in children and specifically in urological patients.

METHODS

Retrospective review of a microbiology database (April 2014 to November 2015). This identified urine isolates, pyuria, ESBL growth and patient demographics. Data analysis was by Chi square, Mann-Whitney U-test and ANOVA. A P value of <0.05 was taken as significant.

MAIN RESULTS

Analysis of 9418 urine samples showed 2619 with pure isolates, of which 1577 had pyuria (>10×10⁶ WC/L). 136 urine cultures (n=79 patients) grew purely ESBL. Overall, 5.2% of urine isolates were ESBL and 9.5% isolates with pyuria (>100×10⁶ WC/L) had ESBL, whereas only 22/1032 (2.1%) with no pyuria, (P<0.0001). Urology patients had 86/136 (63%) ESBL positive cultures. These represented 86/315 (27%) of all positive cultures for urology patients vs. 50/2267 (2.2%) for all other specialties (P<0.0001). Potential ESBL transmission between organisms occurred in 3 (all on prophylactic antibiotics). Over the study period, there was no significant rise of the monthly incidence between 2014 and 2015 (ANOVA P=0.1).

CONCLUSION

This study is the first to document the incidence of ESBL in children (5%), and estimate the frequency of possible plasmid transmission between bacterial species in children. This quantifies the risk of ESBL, especially to urology patients, and mandates better antibiotic stewardship.

LEVEL OF EVIDENCE

Level IIc.

Medical education of attention: A qualitative study of learning to listen to sound

INTRODUCTION

There has been little qualitative research examining how physical examination skills are learned, particularly the sensory and subjective aspects of learning. The authors set out to study how medical students are taught and learn the skills of listening to sound.

METHODS

As part of an ethnographic study in Melbourne, 15 semi-structured in-depth interviews were conducted with students and teachers as a way to reflect explicitly on their learning and teaching.

RESULTS

From these interviews, we found that learning the skills of listening to lung sounds was frequently difficult for students, with many experiencing awkwardness, uncertainty, pressure, and intimidation. However not everyone found this process difficult. Often those who had studied music reported finding it easier to be attentive to the frequency and rhythm of body sounds and find ways to describe them.

CONCLUSIONS

By incorporating, distinctively in medical education, theoretical insights into "attentiveness" from anthropology and science and technology studies, the article suggests that musical education provides medical students with skills in sensory awareness. Training the senses is a critical aspect of diagnosis that needs to be better addressed in medical education. Practical approaches for improving students' education of attention are proposed.

Treatment of hemophilia: A qualitative study of mothers' perspectives

BACKGROUND

In Norway, boys with hemophilia usually begin treatment after their first bleeding episode. Boys with severe hemophilia usually start prophylactic treatment around 18-24 months. Health professionals administer factor concentrate initially, but when boys are around 4 years old most parents start treating their children at home. There is a lack of research on how parents, and especially how carrier mothers, experience the medical treatment for their sons' hemophilia. Our aim was to investigate how carrier mothers experience this treatment in the hospital setting and at home.

METHODS

In this qualitative study, we interviewed 16 mothers of boys or men with hemophilia A or B. Data were collected via semistructured interviews and analyzed using an inductive thematic analytical approach.

RESULTS

Mothers experienced both practical and emotional challenges in relation to their sons' treatment, and repeated venipuncture was especially difficult emotionally. Parents preferred home treatment to hospital treatment because it was less time-consuming, less disruptive to family life, and provided a greater sense of control. Encountering healthcare professionals who were unfamiliar with hemophilia was a second major stress factor, especially when parents felt that health professionals lacked competence and were unwilling to seek advice.

CONCLUSION

While home treatment for hemophilia enables freedom, flexibility, and autonomy for the boys as well as for the family, mothers may experience treatment of hemophilia as a burden. Health professionals should provide tailored practical and emotional support to parents by probing into their experiences with treating their sons' hemophilia.

Improving physical and mental health in frontline mental health care providers: Yoga-based stress management versus cognitive behavioral stress management

The need for brief, low-cost, easily disseminable and effective interventions to promote healthy lifestyles is high. This is especially true for mental health providers. We developed two studies to compare the impacts of Cognitive Behavioral Stress Management (CBSM) and Yoga Based Stress Management (YBSM) interventions for healthcare professionals. Study 1 offered an 8-week YBSM intervention to 37 mental healthcare participants and collected health data pre and post. Study 2 offered YBSM and CBSM classes to 40 randomly assigned mental healthcare providers and collected mental and physical health data at four time points. In Study 1, using t-tests, the YBSM intervention affected a number of mental and physical wellbeing indices pre to post. In Study 2, using linear mixed modeling, both YBSM and CBSM groups improved significantly (p <.05) in fruit and vegetable intake, heart rate, alcohol consumption, relaxation and awareness, professional quality of life, compassion satisfaction, burnout, depression, and stress levels. There was a group by time effect for coping confidence (CBSM increased more, p<.05, F = 4.34), physical activity (YBSM increased more, p<.05, F = 3.47), overall mental health (YBSM increased more, p<.10, F =5.32), and secondary traumatic stress (YBSM decreased more, p<.10, F = 4.89). YBSM and CBSM appear to be useful for healthcare professionals' mental and physical health. YBSM demonstrates some benefit above and beyond the extremely well-studied and empirically supported CBSM, including increased physical activity, overall mental health, and decreased secondary traumatic stress benefits.

A giant testicular mixed germ cell tumour

We present a case that we believe to be the largest mixed germ cell testicular tumour reported in the United Kingdom. A 23-year-old male was admitted to our urology department with a large scrotal swelling. The patient was found to have a giant left testicular tumour and a solitary lung metastasis at presentation. He underwent an emergency radical orchidectomy and subsequently received four cycles of bleomycin, etoposide and cisplatin chemotherapy. Four months after starting treatment, the tumour markers had normalised and a repeat staging computed tomography showed no active disease. The tumour reached that size because of the patient's failure to seek medical attention due to fear and embarrassment.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.