What are dental non-attenders' preferences for anxiety management techniques? A cross-sectional study based at a dental access centre

OBJECTIVE

Dental anxiety is a barrier to attendance. Dental non-attenders may seek emergency care and may prefer to receive anxiety management measures for treatment required. Little is known about the preferences of these dental non-attenders for different anxiety management techniques. Understanding such preferences may inform management pathways, improve experiences, alleviate anxieties and encourage a more regular attendance pattern. As such, the aim of this study was to gain a greater understanding of the dental anxiety of patients attending a dental access centre for emergency dental treatment and to ascertain preferences for different anxiety management techniques.

DESIGN

Cross-sectional study involving self-completed questionnaires and clinical observation.

SETTING

NHS Dental Access Centre, York, UK.

SUBJECTS AND METHODS

Two hundred participants not registered with a general dental practitioner, aged 18 years or over, experiencing pain and self-referred were recruited on a consecutive sampling basis. Participants completed a questionnaire eliciting demographic and dental history details, dental anxiety and preferences for dental anxiety management options.

MAIN OUTCOME MEASURES

Correlation of the modified dental anxiety scale with preference for different dental anxiety management techniques.

RESULTS

No significant predictive factors were found that explained preferring local anaesthetic to sedation, or general anaesthesia for restorations or extractions. Those highly anxious were less likely to consider tell-show-do techniques (p=0.001) or watching explanatory videos (p=0.004) to be helpful for overcoming their anxieties than the low or moderate anxiety groups.

CONCLUSIONS

People attending access centres may represent a group who are unwilling to explore non-pharmacological methods to overcome their anxieties. This supports the need for sedation to provide treatment. Future work may include exploring in more depth the thoughts and opinions of this group of patients to improve understanding of their complex dental attitudes. From this, more effective strategies may be developed to encourage regular dental attendance.

Older inpatients' room preference: single versus shared accommodation

INTRODUCTION

The Royal Victoria Hospital, a geriatric medicine assessment and rehabilitation hospital in Edinburgh, was re-provided into a new 130 bed purpose-built unit on the Western General Hospital site in June 2012. All patient rooms in the new unit are single occupancy with en-suite facilities.

METHODS

We surveyed inpatients on their room preference in 2008 and repeated the survey with inpatients in the new unit in 2013. Patients were asked whether they would prefer to be in a shared room or a single room and to explain the reason behind their choice. They were also asked whether they would prefer to eat their meals in a day/dining room or by their bed. The patients in the 2013 survey were also questioned as to whether they felt lonely in their single room. Forty-three inpatients agreed to participate in the 2008 survey and 46 in the 2013 survey. All had an abbreviated mental test score≥8/10. In 2008, those surveyed had a mean age of 78. In 2013, the mean age was 83.

RESULTS

In 2008, 37.2% of patients expressed a preference for single room accommodation, whereas in 2013, 84.8% said that they preferred a single room. The majority of patients, 60.5% in 2008 and 76.1% in 2013, preferred to eat their meal at their bedside. Only 8.7% of patients in 2013 would consider eating in a day/dining room compared with 34.9% in 2008. In the 2013 survey, 60.9% of patients reported that they never felt lonely in a single room.

DISCUSSION

The benefits of single room versus multi-occupancy room hospital accommodation has been recently debated. The results from our survey indicate a marked difference in the preference for a single room between 2008 and 2013. The introduction of open visiting and care rounding has reduced the risk of isolation in single rooms. Our survey introduces new discussion about social isolation, privacy, noise levels and patient well-being and recovery.

Body condition constrains immune function in field populations of female Australian plague locust Chortoicetes terminifera

The insect innate immune system comprises both humoral and cellular defence responses. In the laboratory, the insect immune system is well characterized. In the field, however, little is known about the role of constitutive insect immune function and how it varies within and between populations. Laboratory studies suggest that host nutrition has significant impact upon insect immune function. Thus, the rationale for this study was to sample natural populations of the Australian Plague Locust Chortoicetes terminifera to establish whether locust body condition (as determined by protein and lipid content) impacted their constitutive immune system and, as a result, has the potential to impact on their capacity to respond to a pathogenic challenge. We found that body condition varied greatly between individual female locusts within sites and that haemolymph protein levels, but not body lipid content, varied between sites. Moreover, our measures of immune function were correlated with the haemolymph levels of protein (in the case of haemocyte density), lipid (prophenoloxidase activity) or both (lysozyme-like antimicrobial activity). We discuss the implications of these findings for the role of biological pesticides in the control of locust populations.

Nonmedically indicated induction vs expectant treatment in term nulliparous women

OBJECTIVE

The purpose of this study was to compare maternal and neonatal outcomes in nulliparous women with nonmedically indicated inductions at term vs those expectantly treated.

STUDY DESIGN

Data were obtained from maternal and neonatal charts for all deliveries on randomly selected days across 25 US hospitals over a 3-year period. A low-risk subset of nulliparous women with vertex nonanomalous singleton gestations who delivered 38 0/7 to 41 6/7 weeks were selected. Maternal and neonatal outcomes for nonmedically indicated induction within each week were compared with women who did not undergo nonmedically indicated induction during that week. Multivariable analysis was used to adjust for hospital, maternal age, race/ethnicity, body mass index, cigarette use, and insurance status.

RESULTS

We found 31,169 women who met our criteria. Neonatal complications were either less frequent with nonmedically indicated induction or no different between groups. Nonmedically indicated induction was associated with less frequent peripartum infections (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.16-0.98) at 38 weeks of gestation and less frequent third- and fourth-degree lacerations (OR, 0.60; 95% CI, 0.42-0.86) and less frequent peripartum infections (OR, 0.66; 95% CI, 0.49-0.90) at 39 weeks of gestation. Nonmedically indicated induction was associated with a longer admission-to-delivery time by approximately 3-4 hours and increased odds of cesarean delivery at 38 (OR, 1.50; 95% CI, 1.08-2.08) and 40 weeks (OR, 1.30; 95% CI, 1.15-1.46) of gestation.

CONCLUSION

At 39 weeks of gestation, nonmedically indicated induction is associated with lower maternal and neonatal morbidity than women who are expectantly treated.

Impact of preprocedural mitral regurgitation upon mortality after transcatheter aortic valve implantation (TAVI) for severe aortic stenosis

Objective

To identify the effects of preprocedural significant mitral regurgitation (MR) and change in MR severity upon mortality after transcatheter aortic valve implantation (TAVI) using the Edwards SAPIEN system.

Methods

A retrospective analysis of 316 consecutive patients undergoing TAVI for aortic stenosis at a single centre in the UK between March 2008 and January 2013. Patients were stratified into two groups according to severity of MR: ≥grade 3 were classed as significant and ≤grade 2 were non-significant. Change in MR severity was assessed by comparison of baseline and 30-day echocardiograms.

Results

60 patients had significant MR prior to TAVI (19.0%). These patients were of higher perioperative risk (logistic EuroScore 28.7±16.6% vs 20.3±10.7%, p=0.004) and were more dyspnoeic (New York Heart Association class IV 20.0% vs 7.4%, p=0.014). Patients with significant preprocedural MR displayed greater 12-month and cumulative mortality (28.3% vs 20.2%, log-rank p=0.024). Significant MR was independently associated with mortality (HR 4.94 (95% CI 2.07 to 11.8), p<0.001). Of the 60 patients with significant MR only 47.1% had grade 3–4 MR at 30 days (p<0.001). Patients in whom MR improved had lower mortality than those in whom it deteriorated (log-rank p=0.05).

Conclusions

Significant MR is frequently seen in patients undergoing TAVI and is independently associated with increased all-cause mortality. Yet almost half also exhibit significant improvements in MR severity. Those who improve have better outcomes, and future work could focus upon identifying factors independently associated with such an improvement.

Fetal death and preterm birth associated with maternal influenza vaccination: systematic review

BACKGROUND

Before 2012, few studies had addressed pregnancy outcomes following maternal influenza vaccination; however, the number of publications on this topic has increased recently.

OBJECTIVES

To review comparative studies evaluating fetal death or preterm birth associated with influenza vaccination during pregnancy.

SEARCH STRATEGY

We searched bibliographic databases from inception to April 2014.

SELECTION CRITERIA

Experimental or observational studies assessing the relationship between influenza vaccination during pregnancy and fetal death or preterm birth.

DATA COLLECTION AND ANALYSIS

Two reviewers independently abstracted data from studies meeting the inclusion criteria.

MAIN RESULTS

We included one randomised clinical trial and 26 observational studies. Meta-analyses were not considered appropriate because of high clinical and statistical heterogeneity. Three studies of fetal death at any gestational age reported adjusted effect estimates in the range 0.56-0.79, and four of five studies of fetal death at <20 weeks reported adjusted estimates between 0.89 and 1.23, all with confidence intervals including 1.0. Adjusted effect estimates for four of five studies of fetal death at ≥20 weeks ranged from 0.44 to 0.77 (two with confidence intervals not crossing 1.0), whereas a fifth reported a non-significant effect in the opposite direction. Among 19 studies of preterm birth, there was no strong evidence suggesting any increased risk, and meta-regression did not explain the moderate between-study heterogeneity (I(2) = 57%).

AUTHORS' CONCLUSIONS

Most studies reported no association between fetal death or preterm birth and influenza vaccination during pregnancy. Although several reported risk reductions, results may be biased by methodological shortcomings of observational studies of influenza vaccine effectiveness.

The impact of continuous haemofiltration with high-volume fluid exchange during cardiopulmonary bypass surgery on the recovery of patients with impaired renal function: a pilot randomised trial

BACKGROUND

There is widespread variability in clinical practice within cardiac surgery units worldwide on the use of haemofiltration. The clinical impact and safety of this modality is, however, unknown.

OBJECTIVES

The primary pilot trial objectives were as follows: to assess the feasibility of randomising 60 patients with impaired kidney function undergoing on-pump coronary artery bypass graft (CABG) surgery within 6 months; to assess the suitability and reliability of our chosen outcome measures; to explore issues that may impact on recruitment into a definitive trial; and to undertake an exploratory economic evaluation.

DESIGN

A pilot, single-centre, open-label randomised trial.

SETTING

Liverpool Heart and Chest Hospital NHS Foundation Trust between November 2010 and March 2012.

PARTICIPANTS

Men and women, aged > 18 years of age, undergoing on-pump CABG surgery, who had pre-operative impaired kidney function indicated by an estimated glomerular filtration rate (eGFR) of < 60 ml/minute adjusted for 1.73 m(2) of body surface area.

INTERVENTIONS

Group 1: patients who received haemofiltration during bypass (experimental group). Group 2: patients who did not receive haemofiltration during bypass (control group).

MAIN OUTCOME MEASURES

(1) Feasibility outcome measures: barriers to recruitment to a larger trial were documented as observations made during the recruitment period of the trial. Reliability of data collection methods was monitored using a 13-point case record form validation check for data entry against the patient clinical notes and the trial database. (2) The main clinical outcomes were frequency of intensive care unit (ICU) stay of duration > 3 days and the length of ICU stay days. (3) Other clinical outcomes were the need for postoperative haemofiltration in the ICU, mechanical ventilation time, hospital stay, composite of outcome of unfavourable perioperative events and eGFR values at 6 weeks' follow-up. (4) Secondary health economic feasibility outcomes.

RESULTS

Recruitment into the pilot trial was from 21 November 2010 to 30 March 2012. Thirty-seven eligible patients were consented and successfully randomised into the trial arms (30%). The main issues impacting on recruitment were the high volume of off-pump CABG surgery within the centre; recruitment being restricted to research nurses' working hours of the week; issues arising associated with the screening process for identifying prospective eligible patients based on eGFR values; protocol deviations/treatment crossovers; and unexpected outbreaks of pandemic influenza and other infectious conditions. The data collection process was sufficiently robust, with few errors detected. The length of ICU stay days was deemed a suitable primary outcome. There was an overall trend towards reduction in the length of ICU stay for patients who were given intraoperative haemofiltration, more so for those with diabetes. The economic evaluation estimated that the incremental costs per person were £1744 lower for the intraoperative haemofiltration group, while the incremental benefits per person increased by 0.11.

CONCLUSION

Given sufficient resources and broadening of the inclusion criteria, the recruitment into a larger multicentre trial is feasible and may demonstrate potential clinical and cost benefits of using intraoperative haemofiltration in this group of patients. However, owing to the small sample size in this pilot trial, no firm conclusions can be drawn from the findings at this stage. The outcomes of this pilot study are very encouraging and suggest that it is feasible to design a continuous superiority trial with the length of ICU stay days or time to tracheal extubation as the primary outcome measure, provided that guidelines for avoiding bias are implemented. An alternative primary outcome measure that avoids bias is mortality. The inclusion criteria should also be widened to include all cardiac surgery patients with impaired renal function.

TRIAL REGISTRATION

ISRCTN49513454.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 49. See the HTA programme website for further project information.

A novel patient-controlled bidirectional palatal lift appliance

OBJECTIVE

Palatal lift appliances have a role in management of velopharyngeal dysfunction for immobile palates of adequate length where surgery is contraindicated. Conventional appliances involve acrylic/wire work adjustment over successive appointments until they can be tolerated without gagging. A novel appliance has been developed where the lifting plate is incrementally distalized by the patient and vertically adjusted to optimize soft palate positioning.

METHOD

The design, construction, and utility of the appliance, which was developed in Dundee Dental Hospital, are described.

PARTICIPANTS

The subject was a 12-year-old boy with a variant of Moebius syndrome and velopharyngeal dysfunction. Previous pharyngoplasty had been carried out and further surgery was contraindicated.

INTERVENTIONS

The appliance is constructed and fitted and the flexible spring arm is vertically adjusted to lift the soft palate. The screw is turned incrementally at home, extending the lifting plate posteriorly. Videofluoroscopy allows visualization of the appliance and soft palate positioning.

MAIN OUTCOME MEASURES/RESULTS

The procedure improved soft palate positioning, as demonstrated by videofluoroscopy, and objective speech outcomes.

CONCLUSIONS

The appliance was well tolerated and led to improved speech outcomes for the patient. Adjustments were quick and easy for both clinician and patient. Further studies are needed to definitively determine the efficacy of the appliance.

Abstract P2-12-06: Implementing a comprehensive genetic risk assessment and testing service at an outpatient breast imaging center

Breast cancer is the most common cancer in women, and there are a variety of available methods to determine which women have an above-average risk to develop breast cancer. However, it can be a challenge to identify patients who may benefit from genetic counseling and should be offered genetic testing. This study examines our data and experience in performing genetic risk assessment and offering on-site genetic counseling in an outpatient breast imaging center. A screening questionnaire asking about personal and family cancer history was created and given to every patient coming in for either screening or diagnostic mammogram. The questionnaires were reviewed by both the breast radiologist and nurse navigator, and those identified as appropriate were offered appointments with the genetic counselor. Genetic counseling appointments are available two days per month. Data was obtained over an eight month period from August 2012- March 2013. During this time, 8768 mammograms were performed and 406 individuals were identified as having a history suspicious for hereditary breast and ovarian cancer and offered an appointment with a genetic counselor. Out of these 406 individuals, 83 scheduled appointments with the genetic counselor, 108 declined appointments, and 215 are pending. Some of the genetic counseling appointments were made after March 31, 2013 and the outcomes are not included at this time. Thirty-six patients were ultimately seen for genetic counseling and risk assessment in this time frame, with 28 undergoing testing. Out of the 28 patients tested during this time period, one was positive and one had a variant of unknown significance. Out of the 36 patients seen for genetic counseling, 27 were identified as increased risk for breast cancer either by having a Gail risk assessment score ≥1.67% or Tyrer-Cuzick risk assessment score ≥19.5% and were eligible for chemoprevention or breast MRI, respectively. This clinic model demonstrates that on-site genetic counseling is feasible in an outpatient breast imaging setting. Prior to offering on-site genetic counseling, this center used the same questionnaire to identify patients and sent a recommendation for genetic counseling to the referring physician ordering the mammogram. This system relied on the physician to make a referral to an off-site genetic counselor. From the period of May 2012- August 2012, 139 patients were identified by the same questionnaire with 17 patients being referred to genetic counseling, and only 3 of these patients were ultimately seen by the genetic counselor. By providing on-site genetic counseling, the percentage of patients seen for genetic counseling increased from 2.15% (3/139) to 8.87% (36/406). In addition, more outcomes are known since 100% of patients identified to be at risk for Hereditary Breast and Ovarian cancer were offered genetic counseling, and if a patient declined, a reason was documented. The risk assessment algorithm outlined here identified more patients that either tested positive for a BRCA mutation or were at an increased 5-year or lifetime risk to develop breast cancer that may not have been detected otherwise.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-12-06.

Bacterial expression of human kynurenine 3-monooxygenase: solubility, activity, purification

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This is the first report of soluble and active bacterially expressed human KMO protein.

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Partial purification of the enzyme was achieved and the two protein co-elutants identified.

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Steady state kinetic parameters were comparable to those reported for mammalian expressed.

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The C-terminal membrane targetting domain of human KMO is required for its enzymatic activity.

Kynurenine 3-monooxygenase (KMO) is an enzyme central to the kynurenine pathway of tryptophan metabolism. KMO has been implicated as a therapeutic target in several disease states, including Huntington’s disease. Recombinant human KMO protein production is challenging due to the presence of transmembrane domains, which localise KMO to the outer mitochondrial membrane and render KMO insoluble in many in vitro expression systems. Efficient bacterial expression of human KMO would accelerate drug development of KMO inhibitors but until now this has not been achieved. Here we report the first successful bacterial (Escherichia coli) expression of active FLAG™-tagged human KMO enzyme expressed in the soluble fraction and progress towards its purification.

Final results of Australasian Gastrointestinal Trials Group ARCTIC study: an audit of raltitrexed for patients with cardiac toxicity induced by fluoropyrimidines

BACKGROUND

Cardiac toxicity an uncommon but serious side-effect of some fluoropyrimides. Cardiac toxicity from raltitrexed is rarely reported. With this background, we initiated this study to investigate the incidence of cardiac events in patients who had switched to raltitrexed following cardiac toxicity from fluoropyrimidines (5-fluorouracil or capecitabine).

PATIENTS AND METHODS

Pharmacy records were used to identify patients receiving raltitrexed from January 2004 till March 2012. Medical records were then reviewed to confirm the use of raltitrexed after cardiac toxicity from 5-fluorouracil or capecitabine. The primary end point was the rate of further cardiac events after commencing raltitrexed.

RESULTS

Forty-two patients were identified and the majority had colorectal cancer. Prior regimens included 5-fluorouracil ± leucovorin, capecitabine alone, FOLFOX, FOLFIRI, epirubicin/cisplatin/5-fluorouracil, and capecitabine/oxaliplatin. Seven patients (17%) had bolus 5-fluorouracil regimens, 26 patients (62%) had infusion 5-fluorouracil regimens, and 9 patients (21%) had capecitabine alone or in combination. Angina was the most common cardiac toxicity from 5-fluorouracil or capecitabine and usually occurred in the first or the second cycle. Four patients after their first cardiac event continued with the same 5-fluorouracil or capecitabine regimen with the addition of nitrates and calcium antagonists but still had further cardiac events. After changing to raltitrexed, either as a single agent or a continuing combination regimen, no patients experienced further cardiac toxicity.

CONCLUSION

Raltitrexed is associated with no significant cardiac toxicity in patients who have experienced prior cardiac toxicity from 5-fluorouracil or capecitabine. Raltitrexed, alone or in combination with oxaliplatin or irinotecan, provides a safe option in terms of cardiac toxicity for such patients.