Bowel cleansing for colonoscopy: prospective randomized assessment of efficacy and of induced mucosal abnormality with three preparation agents

BACKGROUND AND STUDY AIMS

Bowel-cleansing studies are frequently underpowered, poorly designed, and use subjective bowel cleansing assessments. Consensus on efficacy, tolerability, and preparation-induced mucosal abnormalities is lacking. This study aimed to clarify the differences in efficacy and preparation-induced mucosal inflammation of sodium phosphate (NaP), colonLYTLEY (PEG), and Picoprep (Pico).

PATIENTS AND METHODS

This was a prospective randomized single-blinded trial of ambulatory patients to assess the efficacy of bowel preparation and preparation-induced mucosal inflammation. Proceduralists who were blinded to the preparation taken, assessed both bowel cleansing by using the Ottawa bowel preparation assessment tool and preparation-induced mucosal inflammation.

RESULTS

Of the 634 patients, 98 % ingested more than 75 % of the bowel preparation and data were complete for colonic preparation scoring in 99 %. The preparation used, time of procedure, and patient sex all independently impacted on bowel cleansing. NaP was less efficacious than PEG ( P < 0.001) and Pico ( P < 0.001) for morning procedures whereas all bowel preparations were equally efficacious for afternoon procedures. Preparation-induced mucosal inflammation was 10-fold greater with NaP ( P = 0.03) and Pico ( P = 0.03) compared with PEG.

CONCLUSIONS

This is the largest published prospective randomized blinded study on this topic and the first to evaluate the three major classes of preparation with a validated tool. The bowel preparation used, time of procedure, and patient sex all independently impacted on bowel cleansing. NaP gave the worst preparation for morning procedures whereas all preparations were equally effective for afternoon procedures. NaP and Pico induced mucosal inflammation 10-fold more frequently than PEG, a finding that requires further investigation.

Absorptive capacity as a guiding concept for effective public sector management and conservation of freshwater ecosystems

The ability of an organisation to recognise the value of new external information, acquire it, assimilate it, transform, and exploit it, namely its absorptive capacity (AC), has been much researched in the context of commercial organisations and even applied to national innovation. This paper considers four key AC-related concepts and their relevance to public sector organisations with mandates to manage and conserve freshwater ecosystems for the common good. The concepts are the importance of in-house prior related knowledge, the importance of informal knowledge transfer, the need for motivation and intensity of effort, and the importance of gatekeepers. These concepts are used to synthesise guidance for a way forward in respect of such freshwater management and conservation, using the imminent release of a specific scientific conservation planning and management tool in South Africa as a case study. The tool comprises a comprehensive series of maps that depict national freshwater ecosystem priority areas for South Africa. Insights for implementing agencies relate to maintaining an internal science, rather than research capacity; making unpublished and especially tacit knowledge available through informal knowledge transfer; not underestimating the importance of intensity of effort required to create AC, driven by focussed motivation; and the potential use of a gatekeeper at national level (external to the implementing organisations), possibly playing a more general 'bridging' role, and multiple internal (organisational) gatekeepers playing the more limited role of 'knowledge translators'. The role of AC as a unifying framework is also proposed.

Late Cortical Disinhibition in Human Motor Cortex: A Triple-Pulse Transcranial Magnetic Stimulation Study

In human motor cortex transcranial magnetic stimulation (TMS) has been used to identify short-interval intracortical inhibition (SICI) corresponding to γ-aminobutyric acid type A (GABAA) effects and long-interval intracortical inhibition (LICI) and the cortical silent period (SP) corresponding to postsynaptic GABAB effects. Presynaptic GABAB effects, corresponding to disinhibition, can also be identified with TMS and have been shown to be acting during LICI by measuring SICI after a suprathreshold priming stimulus (PS). The duration of disinhibition is not certain and, guided by studies in experimental preparations, we hypothesized that it may be longer-lasting than postsynaptic inhibition, leading to a period of late cortical disinhibition and consequently a net increase in corticospinal excitability. We tested this first by measuring the motor-evoked potential (MEP) to a test stimulus (TS), delivered after a PS at interpulse intervals (IPIs) ≤300 ms that encompassed the period of PS-induced LICI and its aftermath. MEP amplitude was initially decreased, but then increased at IPIs of 190–210 ms, reaching 160 ± 17% of baseline 200 ms after PS ( P < 0.05). SP duration was 181 ± 5 ms. A second experiment established that the onset of the later period of increased excitability correlated with PS intensity ( r2 = 0.99) and with the duration of the SP ( r2 = 0.99). The third and main experiment demonstrated that SICI was significantly reduced in strength at all IPIs ≤220 ms after PS. We conclude that TMS-induced LICI is associated with a period of disinhibition that is at first masked by LICI, but that outlasts LICI and gives rise to a period during which disinhibition predominates and net excitability is raised. Identification of this late period of disinhibition in human motor cortex may provide an opportunity to explore or modulate the behavior of excitatory networks at a time when inhibitory effects are restrained.

Preference of sheep among annual legumes is more closely related to plant nutritive characteristics as plants mature

We hypothesised that the preference of sheep among a wide range of annual legumes at successive stages of plant phenology would be related to laboratory measurements of the chemical composition of the forage. We tested this by examining the relative preferences of sheep among 20 genotypes of annual plants at three phenological stages of plant growth using the Chesson–Manly selection index. Plant material was collected for laboratory analyses at each phenological stage and samples were analysed for nitrogen, sulfur, neutral detergent fibre, acid detergent fibre, in vitro digestibility and water soluble carbohydrates. Sheep differed in relative preference among the plant genotypes within and between each of the three phenological stages. Vegetative characteristics that were correlated with relative preference also differed with plant phenology. Measured characteristics of the plant material explained an increasing proportion of the variance in relative preference with successive phenological stages (4.8, 51.1 and 60.9% at the vegetative, reproductive and senesced stages; P < 0.001). The relative preference of the sheep depended on the overall quality of the vegetation. When the quality of the vegetation was high, relative preference did not correlate well with measured nutritive characteristics. However, when the vegetation was of low quality, sheep selected plants with characteristics associated with higher nutritive value. We conclude that sheep adopt different foraging strategies in response to changing vegetation characteristics and increase their preference for plants that increase their intake of digestible dry matter as the sward matures.

Alloy powders for medical applications

The use of gas atomised alloy powders for the fabrication of medical devices offers a number of cost saving benefits and is therefore gaining in popularity. Their use in established and emerging manufacturing processes for products including hip and knee implants is described.

Hypotonic activation of volume-sensitive outwardly rectifying anion channels (VSOACs) requires coordinated remodeling of subcortical and perinuclear actin filaments

Cell volume regulation requires activation of volume-sensitive outwardly rectifying anion channels (VSOACs). The actin cytoskeleton may participate in the activation of VSOACs but the roles of the two major actin pools remain undefined. We hypothesized that structural reorganization of both subcortical and perinuclear actin filaments (F-actin) contributes to the hypotonic activation of VSOACs. Hypotonic stress of pulmonary artery smooth muscle cells (PASMCs) was associated with reorganization of both peripheral and perinuclear F-actin, and with activation of VSOACs. Preincubation with cytochalasin D caused prominent dissociation of perinuclear, but not of subcortical F-actin. Cytochalasin D failed to induce isotonic activation and delayed the hypotonic activation of VSOACs. F-actin stabilization by phalloidin delayed both the hypotonic stress-induced dissociation of membrane-associated actin filaments and the activation kinetics of VSOACs. PKCepsilon, which was proposed to phosphorylate and inhibit VSOACs, colocalized primarily with F-actin and the net kinase activity remained unchanged during hypotonic cell swelling. In conclusion, normal hypotonic activation of VSOACs requires disruption of peripheral F-actin but intact perinuclear F-actin; interference with this pattern of actin reorganization delays the activation kinetics of VSOACs. The cell swelling-induced peripheral actin dissociation may underlie the observed translocation of PKCepsilon, which leads to a net decrease of PKCepsilon inhibitory activity in submembranous sites. Thus, reorganization of actin and PKCepsilon may establish conditions for mechano- and/or signal transduction-mediated activation of VSOACs.

The impact of computer display height and desk design on 3D posture during information technology work by young adults

Computer display height and desk design to allow forearm support are two critical design features of workstations for information technology tasks. However there is currently no 3D description of head and neck posture with different computer display heights and no direct comparison to paper based information technology tasks. There is also inconsistent evidence on the effect of forearm support on posture and no evidence on whether these features interact. This study compared the 3D head, neck and upper limb postures of 18 male and 18 female young adults whilst working with different display and desk design conditions. There was no substantial interaction between display height and desk design. Lower display heights increased head and neck flexion with more spinal asymmetry when working with paper. The curved desk, designed to provide forearm support, increased scapula elevation/protraction and shoulder flexion/abduction.

Sporadic Creutzfeldt-Jakob disease in two adolescents

BACKGROUND

Sporadic Creutzfeldt-Jakob disease (CJD) is a condition predominantly affecting older age groups, with cases aged less than 45 years rare and an age at onset or death of less than 20 years exceptional.

METHODS

Data from the systematic study of sporadic CJD in the UK are available from 1970 onwards. Clinical and pathological data are reviewed in order to identify atypical cases, including those at the extremes of the age range of sporadic CJD. Detailed analysis of atypical cases is undertaken, and in selected cases laboratory transmission studies are carried out in order to provide information on the characteristics of the infectious agent.

RESULTS

In the UK, two cases of sporadic CJD in adolescents have been identified, dying at ages 16 and 20 years. The first case predated the epidemic of bovine spongiform encephalopathy and the characteristics of the second case, including laboratory transmission studies, are consistent with a diagnosis of sporadic rather than variant CJD.

CONCLUSION

The cases in this report indicate that sporadic CJD can develop at a very young age, that variant CJD is not the only form of CJD occurring in this age group and that neuropathological examination is essential for accurate diagnosis of human prion disease.

Factors influencing women's views on the acceptability and experience of being opportunistically screened for Chlamydia trachomatis in hospital settings

A subsample of 681 women participating in a two-centred, three-setting larger (2817) prevalence study were approached and, with consent, administered a questionnaire by post or in person. The questionnaire asked about their views of opportunistic screening for Chlamydia trachomatis (CT). The study response rate was 71%. In all, 94% women reported screening should be offered and most, on a regular basis. About 91% thought men should be screened but only 47% thought they would attend. Most (89%) knew the term 'chlamydia' but fewer, (63%) knew they could catch CT more than once. This is one of the very few UK studies which has explored women's views towards the acceptability of CT screening. Results suggest the majority of women report that screening for the condition is acceptable but not all have in-depth knowledge of CT. If a screening programme is to be established more education regarding the condition is required.

Serotonin facilitates a persistent calcium current in motoneurons of rats with and without chronic spinal cord injury

In the months after spinal cord transection, motoneurons in the rat spinal cord develop large persistent inward currents (PICs) that are responsible for muscle spasticity. These PICs are mediated by low-threshold TTX-sensitive sodium currents (Na PIC) and L-type calcium currents (Ca PIC). Recently, the Na PIC was shown to become supersensitive to serotonin (5-HT) after chronic injury. In the present paper, a similar change in the sensitivity of the Ca PIC to 5-HT was investigated after injury. The whole sacrocaudal spinal cord from acute spinal rats and spastic chronic spinal rats (S2 level transection 2 mo previously) was studied in vitro. Intracellular recordings were made from motoneurons and slow voltages ramps were applied to measure PICs. TTX was used to block the Na PIC. For motoneurons of chronic spinal rats, a low dose of 5-HT (1 microM) significantly lowered the threshold of the Ca PIC from -56.7 +/- 6.0 to -63.1 +/- 7.1 mV and increased the amplitude of the Ca PIC from 2.4 +/- 1.0 to 3.0 +/- 0.73 nA. Higher doses of 5-HT acted similarly. For motoneurons of acute spinal rats, low doses of 5-HT had no significant effects, whereas a high dose (about 30 microM) significantly lowered the threshold of the L-Ca PIC from -58.5 +/- 14.8 to -62.5 +/- 3.6 mV and increased the amplitude of the Ca PIC from 0.69 +/- 1.05 to 1.27 +/- 1.1 nA. Thus Ca PICs in motoneurons are about 30-fold supersensitive to 5-HT in chronic spinal rats. The 5-HT-induced facilitation of the Ca PIC was blocked by nimodipine, not by the I(h) current blocker Cs(+) (3 mM) or the SK current blocker apamin (0.15 microM), and it lasted for hours after the removal of 5-HT from the nCSF, even increasing initially after removing 5-HT. The effects of 5-HT make motoneurons more excitable and ultimately lead to larger, more easily activated plateaus and self-sustained firing. The supersensitivity to 5-HT suggests the small amounts of endogenous 5-HT below the injury in a chronic spinal rat may act on supersensitive receptors to produce large Ca PICs and ultimately enable muscle spasms.

Determinants of diagnostic investigation sensitivities across the clinical spectrum of sporadic Creutzfeldt-Jakob disease

To validate the provisional findings of a number of smaller studies and explore additional determinants of characteristic diagnostic investigation results across the entire clinical spectrum of sporadic Creutzfeldt-Jakob disease (CJD), an international collaborative study was undertaken comprising 2451 pathologically confirmed (definite) patients. We assessed the influence of age at disease onset, illness duration, prion protein gene (PRNP) codon 129 polymorphism (either methionine or valine) and molecular sub-type on the diagnostic sensitivity of EEG, cerebral MRI and the CSF 14-3-3 immunoassay. For EEG and CSF 14-3-3 protein detection, we also assessed the influence of the time point in a patient's illness at which the investigation was performed on the likelihood of a typical or positive result. Analysis included a large subset of patients (n = 743) in whom molecular sub-typing had been performed using a combination of the PRNP codon 129 polymorphism and the form of protease resistant prion protein [type 1 or 2 according to Parchi et al. (Parchi P, Giese A, Capellari S, Brown P, Schulz-Schaeffer W, Windl O, Zerr I, Budka H, Kopp N, Piccardo P, Poser S, Rojiani A, Streichemberger N, Julien J, Vital C, Ghetti B, Gambetti P, Kretzschmar H. Classification of sporadic Creutzfeldt-Jakob disease based on molecular and phenotypic analysis of 300 subjects. Ann Neurol 1999; 46: 224-233.)] present in the brain. Findings for the whole group paralleled the subset with molecular sub-typing data available, showing that age at disease onset and disease duration were independent determinants of typical changes on EEG, while illness duration significantly influenced positive CSF 14-3-3 protein detection; changes on brain MRI were not influenced by either of these clinical parameters, but overall, imaging data were less complete and consequently conclusions are more tentative. In addition to age at disease onset and illness duration, molecular sub-type was re-affirmed as an important independent determinant of investigation results. In multivariate analyses that included molecular sub-type, time point of the investigation during a patient's illness was found not to influence the occurrence of a typical or positive EEG or CSF 14-3-3 protein result. A typical EEG was most often seen in MM1 patients and was significantly less likely in the MV1, MV2 and VV2 sub-types, whereas VV2 patients had an increased likelihood of a typical brain MRI. Overall, the CSF 14-3-3 immunoassay was the most frequently positive investigation (88.1%) but performed significantly less well in the very uncommon MV2 and MM2 sub-types. Our findings confirm a number of determinants of principal investigation results in sporadic CJD and underscore the importance of recognizing these pre-test limitations before accepting the diagnosis excluded or confirmed. Combinations of investigations offer the best chance of detection, especially for the less common molecular sub-types such as MV2 and MM2.

Experiences and expectations of refugee doctors: Qualitative study

BACKGROUND

Refugee doctors constitute a potentially valuable resource for reducing the recruitment crisis in psychiatry. However, various hurdles make their route into the National Health Service (NHS) difficult.

AIMS

To explore the perceptions and experiences of refugee doctors trying to practise psychiatry in the UK.

METHOD

Thirty-one refugee doctors participated in qualitative interviews designed to elicit their experiences in trying to practise as doctors in the UK. Twenty were re-interviewed about 6 months later.

RESULTS

Doctors identified a range of practical problems that made it difficult for them to take the required steps towards practising in the UK. These included lack of appropriate information, lack of a clear route through the system and feelings of isolation. The English language examination was seen as a particular bottleneck, as were finding clinical attachments. The psychological impact of the experience was profound.

CONCLUSIONS

These findings have important implications for how refugee doctors are introduced to the practice of psychiatry in the NHS.

Risk factors for encephalitis and death from West Nile virus infection

We conducted a nested case-control study to determine potential risk factors for developing encephalitis from West Nile virus (WNV) infection. Retrospective medical chart reviews were completed for 172 confirmed WNV cases hospitalized in Houston between 2002 and 2004. Of these cases, 113 had encephalitis, including 17 deaths, 47 had meningitis, and 12 were fever cases; 67% were male. Homeless patients were more likely to be hospitalized from WNV compared to the general population. A multiple logistic regression model identified age [odds ratio (OR) 1.1, P<0.001], history of hypertension, including those cases taking hypertension-inducing drugs (OR 2.9, P=0.012), and history of cardiovascular disease (OR 3.5, P=0.061) as independent risk factors for developing encephalitis from WNV infection. After adjusting for age, race/ethnicity (being black) (OR 12.0, P<0.001), chronic renal disease (OR 10.6, P<0.001), hepatitis C virus (OR 23.1, P=0.0013), and immunosuppression (OR 3.9, P=0.033) were identified as risk factors for death from WNV infection.