FDG-PET and MIBI-Tc SPECT as follow-up tools in a patient with cardiac sarcoidosis requiring a pacemaker

A 63-year-old man presented with recent-onset symptoms secondary to third-degree atrio-ventricular block, for which a dual-chamber pacemaker was inserted. Additional investigations resulted in the diagnosis of cardiac sarcoidosis. FDG-PET and MIBI-technetium SPECT were used as follow-up tools for monitoring active granulomatous myocardial infiltration.

A randomised controlled trial of cognitive behaviour therapy in adolescents with major depression treated by selective serotonin reuptake inhibitors. The ADAPT trial

OBJECTIVES

To determine if, in the short term, depressed adolescents attending routine NHS Child and Adolescent Mental Health Services (CAMHS), and receiving ongoing active clinical care, treatment with selective serotonin reuptake inhibitors (SSRIs) plus cognitive behaviour therapy (CBT) compared with SSRI alone, results in better healthcare outcomes.

DESIGN

A pragmatic randomised controlled trial (RCT) was conducted on depressed adolescents attending CAMHS who had not responded to a psychosocial brief initial intervention (BII) prior to randomisation.

SETTING

Six English CAMHS participated in the study.

PARTICIPANTS

A total of 208 patients aged between 11 and 17 years were recruited and randomised.

INTERVENTIONS

All participants received active routine clinical care in a CAMHS outpatient setting and an SSRI and half were offered CBT.

MAIN OUTCOME MEASURES

The duration of the trial was a 12-week treatment phase, followed by a 16-week maintenance phase. Follow-up assessments were at 6, 12 and 28 weeks. The primary outcome measure was the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). Secondary outcome measures were self-report depressive symptoms, interviewer-rated depressive signs and symptoms, interviewer-rated psychosocial impairment and clinical global impression of response to treatment. Information on resource use was collected in interview at baseline and at the 12- and 28-week follow-up assessments using the Child and Adolescent Service Use Schedule (CA-SUS).

RESULTS

Of the 208 patients randomised, 200 (96%) completed the trial to the primary end-point at 12 weeks. By the 28-week follow-up, 174 (84%) participants were re-evaluated. Overall, 193 (93%) participants had been assessed at one or more time points. Clinical characteristics indicated that the trial was conducted on a severely depressed group. There was significant recovery at all time points in both arms. The findings demonstrated no difference in treatment effectiveness for SSRI + CBT over SSRI only for the primary or secondary outcome measures at any time point. This lack of difference held when baseline and treatment characteristics where taken into account (age, sex, severity, co-morbid characteristics, quality and quantity of CBT treatment, number of clinic attendances). The SSRI + CBT group was somewhat more expensive over the 28 weeks than the SSRI-only group (p=0.057) and no more cost-effective. Over the trial period there was on average a decrease in suicidal thoughts and self-harm compared with levels recorded at baseline. There was no significant increase in disinhibition, irritability and violence compared with levels at baseline. Around 20% (n=40) of patients in the trial were non-responders. Of these, 17 (43%) showed no improvement by 28 weeks and 23 (57%) were considered minimally (n=10) or moderately to severely worse (n=13).

CONCLUSIONS

For moderately to severely depressed adolescents who are non-responsive to a BII, the addition of CBT to fluoxetine plus routine clinical care does not improve outcome or confer protective effects against adverse events and is not cost-effective. SSRIs (mostly fluoxetine) are not likely to result in harmful adverse effects. The findings are broadly consistent with existing guidelines on the treatment of moderate to severe depression. Modification is advised for those presenting with moderate (6-8 symptoms) to severe depressions (>8 symptoms) and in those with either overt suicidal risk and/or high levels of personal impairment. In such cases, the time allowed for response to psychosocial interventions should be no more than 2-4 weeks, after which fluoxetine should be prescribed. Further research should focus on evaluating the efficacy of specific psychological treatments against brief psychological intervention, determining the characteristics of patients with severe depression who are non-responsive to fluoxetine, relapse prevention in severe depression and improving tools for determining treatment responders and non-responders.

When would you like to be treated?--A short survey of radiotherapy outpatients

AIMS

To determine whether patients undergoing radiotherapy would choose to attend appointments for a course of treatment scheduled outside the normal working day and working week.

MATERIALS AND METHODS

A survey of radiotherapy outpatients was conducted on two single days in late 2005 and early 2006. There were four departments in the first cohort and five in the second cohort. Departments were selected from across the UK and were chosen to reflect both city centre and out of town locations. Six of the nine departments were working extended hours at the time of the survey. The second cohort received a modified questionnaire that included two additional questions relating to appointments at weekends.

RESULTS

In total, 471 and 332 questionnaires were returned by the first and second cohorts, respectively. For all age groups, 9.00 am to 12.00 pm was the most preferred time for treatment. Outside the normal working day, the 8.00-9.00 am interval was the most selected, being chosen by 23.4% of respondents. Overall, 32.8% (n=260) of respondents would attend a reasonable appointment time outside the normal working day and 10.7% (n=85) were unsure. On Saturdays, 39.3% (n=130) would attend and 11.5% (n=38) were unsure. For Sundays, 31.1% (n=103) would attend and 10.9% (n=36) were unsure.

CONCLUSIONS

There is sufficient support from patients for attendance outside the normal working day to ensure appointment slots would not go unfilled during a moderate extension to the working day. However, the percentage of patients that would attend varied between departments. This demonstrates the need for local evaluation of patient preference before the introduction of extended working hours.

Cost-effectiveness of selective serotonin reuptake inhibitors and routine specialist care with and without cognitive behavioural therapy in adolescents with major depression

BACKGROUND

Major depression is an important and costly problem among adolescents, yet evidence to support the provision of cost-effective treatments is lacking.

AIMS

To assess the short-term cost-effectiveness of combined selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioural therapy (CBT) together with clinical care compared with SSRIs and clinical care alone in adolescents with major depression.

METHOD

Pragmatic randomised controlled trial in the UK. Outcomes and costs were assessed at baseline, 12 and 28 weeks.

RESULTS

The trial comprised 208 adolescents, aged 11-17 years, with major or probable major depression who had not responded to a brief initial psychosocial intervention. There were no significant differences in outcome between the groups with and without CBT. Costs were higher in the group with CBT, although not significantly so (P=0.057). Cost-effectiveness analysis and exploration of the associated uncertainty suggest there is less than a 30% probability that CBT plus SSRIs is more cost-effective than SSRIs alone.

CONCLUSIONS

A combination of CBT plus SSRIs is not more cost-effective in the short-term than SSRIs alone for treating adolescents with major depression in receipt of routine specialist clinical care.

Posterior dislocation of the long head of biceps tendon: case report and review of the literature

Posterior or lateral dislocation of the long head of biceps is a rare complication of shoulder dislocation that can result in inability to relocate the humerus. The diagnosis should be suspected when certain radiographic features are present at the initial presentation. Other imaging modalities can aid diagnosis when clinical management is unsuccessful or protracted. We present a case of surgically proven posterior dislocation of the biceps tendon with conventional radiographic, computed tomography and magnetic resonance imaging assessment. The literature on this subject is reviewed, and imaging features associated with the diagnosis are described.

Extended hours working in radiotherapy in the UK

AIMS

To analyse extended hours working patterns within UK cancer centres and to assess alternatives to the normal 9.00 am to 5.00 pm working day.

MATERIALS AND METHODS

Questionnaires were sent to 62 radiotherapy managers in June and July 2005 to survey where extended hours working had been implemented, the objectives for using a longer working day and how departments organised their service issues, including staffing levels, costs and patients. This was followed by visits to six departments that were working extended hours. A second questionnaire sent to 60 radiotherapy physics managers in September 2005 requested information for the hours of daily, monthly and annual megavoltage machine servicing and quality assurance (QA). A third questionnaire was distributed to all radiotherapy outpatients from four departments who attended on a single day of survey in 2005. It looked at patient preference for treatment hours.

RESULTS

In total, 57 (92%) radiotherapy managers responded. Thirty-one departments (55%) were working extended hours, 22 (39%) had short-term experience and three (5%) departments had no experience. Increasing capacity to reduce waiting lists was the main reason for working extended hours. The additional hours were predominantly worked by radiographers, with little or no support from the other department disciplines. The servicing and QA spreadsheet was returned by 53% (n=32) of physicists. The average amount of servicing and Quality Assurance (QA) work being scheduled out of hours in each department was 35% (0-100%). The patient questionnaire was completed by 470 patients. When asked if patients would want to come to a reasonable appointment time outside of the normal working day, 29% (n=136) said 'yes' and 12% (n=55) were unsure.

CONCLUSION

It was concluded that two shifts covering an 11.5 h working day is a robust alternative to the normal working day, taking into consideration efficient use of radiographers and patient preference for out of hours appointments.

Caspase-14: a new player in cytotrophoblast differentiation

The human placenta is responsible for the exchange of nutrients, gas and wastes through the trophoblast maternal-fetal barrier, which is formed by the fusion of villous cytotrophoblasts to form the continuous multinucleated syncytiotrophoblast separating the maternal and fetal circulations. Caspase-14 is a seemingly non-apoptotic caspase involved in keratinocyte differentiation and cornification. It is proposed that caspase-14 has a conserved role in cellular differentiation and a role in differentiation and fusion in the trophoblast. The human choriocarcinoma BeWo cell line was treated with staurosporine and forskolin to induce apoptosis and differentiation respectively. Staurosporine initiated apoptosis within 3 h of treatment, while apoptosis was completed following 6 h treatment. Caspase-14 gene and protein expression was unchanged throughout this process. During BeWo differentiation, caspase-14 mRNA was elevated after 48 h forskolin treatment, while its protein was increased after 24 h. Therefore, caspase-14 is up-regulated during trophoblast differentiation, as represented by the BeWo cell line. Moreover, caspase-14 may interact with other signalling molecules to facilitate differentiation. This new data confirms the potential for the BeWo cell line in the functional dissection of this unusual caspase and its prospective role in trophoblast differentiation.

Exercise for treating isolated anterior cruciate ligament injuries in adults

BACKGROUND

The anterior cruciate ligament (ACL) is the most frequently injured ligament of the knee. Injury causes pain, effusion and inflammation leading to the inability to fully activate the thigh muscles. Regaining muscular control is essential if the individual wishes to return to pre-injury level of function and patients will invariably be referred for rehabilitation.

OBJECTIVES

To present the best evidence for effectiveness of exercise used in the rehabilitation of isolated ACL injuries in adults, on return to work and pre-injury levels of activity.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PEDro - The Physiotherapy Evidence Database, CINAHL, AMED, and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised trials testing exercise programmes designed to rehabilitate adults with isolated ACL injuries. Trials where participants were randomised to receive any combination of the following: no care, usual care, a single-exercise intervention, and multiple-exercise interventions. The primary outcome measures of interest were returning to work and return to pre-injury level of activity post treatment, at six months and one year.

DATA COLLECTION AND ANALYSIS

All trials judged to have met the inclusion criteria were independently assessed for methodological quality by use of a 15 point checklist. Pairs of authors independently extracted data. For each study, relative risk and 95% confidence intervals were calculated for dichotomous outcomes and mean differences and 95% confidence intervals calculated for continuous outcomes.

MAIN RESULTS

Nine trials, involving 391 participants met the inclusion criteria of the review. Only two trials, involving 76 participants, reported conservative rehabilitation and seven trials, involving 315 participants, evaluated rehabilitation following ACL reconstruction. Methodological quality scores varied considerably across the trials, with the nature of participant and assessor blinding poorly reported. Trial comparisons fell into six categories. Pooling of data was rarely possible due to lack of appropriate data as well as the wide variety in outcome measures and time points reported. Insufficient evidence was found to support the efficacy of one exercise intervention over another.

AUTHORS' CONCLUSIONS

This review has demonstrated an absence of evidence to support one form of exercise intervention against another and the use of supplementary exercises in the management of isolated ACL injuries. Further research in the form of large scale well designed randomised controlled trials with suitable outcome measures and surveillance periods, using standardised reporting should be considered.

A randomized, double blind study of the prophylactic effect of hyperbaric oxygen therapy on migraine

In a double blind, placebo-controlled study to assess the prophylactic effect of hyperbaric oxygen therapy on migraine, 40 patients were randomly assigned to a treatment group receiving three sessions of hyperbaric oxygen, or a control group receiving three hyperbaric air treatments. The patients were instructed to keep a standardized migraine diary for eight weeks before and after the treatment. Thirty-four patients completed the study. Our primary measure of efficacy was the difference between pre- and post-treatment hours of headache per week. The results show a nonsignificant reduction in hours of headache for the hyperbaric oxygen group compared to the control group. Levels of endothelin-1 in venous blood before and after treatment did not reveal any difference between the hyperbaric oxygen and control groups. We conclude that the tested protocol does not show a significant prophylactic effect on migraine and does not influence the level of endothelin-1 in venous blood.

Bluetongue surveillance methods in the United States of America

Historical surveillance for bluetongue virus (BTV) exposure in the United States of America (USA) has relied on periodical serological surveillance using samples collected from cattle at slaughter. Most of this surveillance has been focused on the north-eastern portion of the USA due to the lack of competent vectors of BTV in this region. For most of the states tested in this region, the prevalence of seropositive animals has been less than 2%. Recently, a study was conducted in north-central USA using sentinel cattle herds. Results of serological testing showed an increasing gradient of exposure from north to south. In addition, detection of Culicoides sonorensis showed a similar gradient with detection in the northern areas being relatively rare. The results of these studies indicate that cattle herds in the northern and north-eastern areas of the USA are likely to be free of BTV.