The development of an intervention to manage pain in amaxhosa women living HIV/AIDS

The profile of HIV/AIDS has changed from that of a terminal illness to one of a chronic debilitating disease which has the potential to become terminal.

Diagnosis and treatment of alcoholic hepatitis

Alcoholic liver disease (ALD) is increasing in incidence in the UK. It is the commonest cause of liver-related deaths, predominantly in people below the age of 60. Alcoholic hepatitis (AH) is an acute form of ALD with high mortality when severe. Jaundice and coagulopathy are clinical hallmarks of severe AH. Histology findings are characterised by parenchymal inflammation and hepatocellular damage although biopsy is only required when diagnostic uncertainty exists; clinical findings are usually sufficient for accurate diagnosis. Patients with AH should be stratified as non-severe or severe using non-invasive scoring systems such as the discriminant function or the Glasgow Alcoholic Hepatitis Score. In patients with non-severe AH, abstinence is the mainstay of treatment, and it is important that steps are taken to help patients stop drinking. Severe AH requires specialist treatment. Consensus guidelines recommend the use of prednisolone although this remains subject to clinical trials. Pentoxifylline may have a survival benefit if corticosteroids are contraindicated. Nutritional support and N-acetylcysteine should be considered for use in conjunction with corticosteroids although evidence of benefit is not conclusive. Patients with severe disease who do not respond to therapy within a week have a very poor outcome. Recent data have shown a survival benefit of liver transplantation in this group although this remains experimental at present. Current and future research should focus on targeted therapies for severe AH and those who fail first-line treatment.

Cervico-mandibular muscle activity in females with chronic cervical pain

Pathophysiological mechanisms behind pain in chroniccervical musculoskeletal conditions (MSC) in office workers remainunclear. Chronic cervical pain has established links with temporomandibular(TM) disorders. Yet there is no current published evidence to reportwhether individuals with cervical dysfunction exhibit altered masseterand cervical extensor (CE) muscle activity. Objective: To explore CE andmasseter surface electromyographic (sEMG) activity and teeth clenchinghabits in females with chronic cervical dysfunction and no TM disorder.Design: Descriptive cross-sectional correlational study with singleblinding.Participants: University students and staff with or without chroniccervical pain and no TM involvement. Methods: Descriptive and paindata captured from Research Diagnostic Criteria for TM disorders, NeckDisability Index, Computer Usage, Brief Pain Inventory, and EuroQoL-5Dquestionnaires. Female participants allocated to a chronic cervical (n = 20) and a control group (n = 22). Investigator blindedto the study groups recorded sEMG of bilateral masseter and CE muscles (C4/5 level) at rest and during light teeth clenching.Results: No differences in socio-demographic profile; or in masseter or CE sEMG activity at rest or during light clench betweengroups. The pain group had higher scores for pain, reported a daytime teeth clenching habit, and had worse scores for the healthrelatedquality of life (HRQoL) sub-sections for pain, anxiety/depression, and lower scores for perceived health status. Conclusion:No relationship established between cervico-mandibular sEMG activity and reported disability in females with chronic cervicaldysfunction and no TM disorder. Association between biopsychosocial factors of teeth clenching and anxiety/depression highlightscomplex pathophysiological mechanisms in chronic recurrent cervical pain.

Physiotherapists’ knowledge of pain: A cross-sectional correlational study of members of the South African Sports and Orthopaedic Manipulative Special Interest Groups

Background. Pain is the most common complaint for which patients seek the help of a physiotherapist. Furthermore, pain has been identified as the fifth vital sign, indicating the attention with which physiotherapists should be assessing pain. Previous studies have found deficits in pain knowledge among healthcare providers. Poor knowledge about pain is recognised to lead to poor assessment ability, and subsequently, to poor pain management.Objective. To investigate the pain knowledge of sports and orthopaedic manipulative physiotherapists in South Africa (SA).Methods. Data were collected online by means of a demographic questionnaire and Unruh’s Revised Pain Knowledge and Attitudes Questionnaire (RPKAQ). Participants were members of the Sports Physiotherapy Group and Orthopaedic Manipulative Physiotherapy Group of the South African Society of Physiotherapy.Results. The mean score for the RPKAQ was 65.5% (standard deviation (SD) ±8.6). Only 14.45% of the physiotherapists scored ≥75%. Lowest scores were obtained for the ‘assessment and measurement of pain’ (47.6%; SD ±15.6) and ‘developmental changes in pain perception’ (58.7%; SD ±20.8) sections of the RPKAQ, while the highest mean score was obtained for the ‘physiological basis of pain’ section (76.8%; SD±14.6). Gender, ethnicity (defined by home language), academic training and clinical experience did not contribute significantly to overall pain knowledge.Conclusion. There is an inadequate level of pain knowledge among members of the sports and orthopaedic manipulative physiotherapy groups in SA, particularly in the areas of the assessment and measurement of pain, and developmental changes in pain perception.

Physiotherapists’ knowledge of pain: A cross-sectional correlational study of members of the South African Sports and Orthopaedic Manipulative Special Interest Groups

Background. Pain is the most common complaint for which patients seek the help of a physiotherapist. Furthermore, pain has been identified as the fifth vital sign, indicating the attention with which physiotherapists should be assessing pain. Previous studies have found deficits in pain knowledge among healthcare providers. Poor knowledge about pain is recognised to lead to poor assessment ability, and subsequently, to poor pain management.Objective. To investigate the pain knowledge of sports and orthopaedic manipulative physiotherapists in South Africa (SA).Methods. Data were collected online by means of a demographic questionnaire and Unruh’s Revised Pain Knowledge and Attitudes Questionnaire (RPKAQ). Participants were members of the Sports Physiotherapy Group and Orthopaedic Manipulative Physiotherapy Group of the South African Society of Physiotherapy.Results. The mean score for the RPKAQ was 65.5% (standard deviation (SD) ±8.6). Only 14.45% of the physiotherapists scored ≥75%. Lowest scores were obtained for the ‘assessment and measurement of pain’ (47.6%; SD ±15.6) and ‘developmental changes in pain perception’ (58.7%; SD ±20.8) sections of the RPKAQ, while the highest mean score was obtained for the ‘physiological basis of pain’ section (76.8%; SD±14.6). Gender, ethnicity (defined by home language), academic training and clinical experience did not contribute significantly to overall pain knowledge.Conclusion. There is an inadequate level of pain knowledge among members of the sports and orthopaedic manipulative physiotherapy groups in SA, particularly in the areas of the assessment and measurement of pain, and developmental changes in pain perception.

Tissue transglutaminase antibody levels predict IgA deficiency

OBJECTIVE

Measuring serum tissue transglutaminase immunoglobulin A (tTG IgA) levels is the most widely used screening test for coeliac disease. However, given an increased prevalence of IgA deficiency among coeliac patients there is a risk of false negative results. Hence, in addition to specific serum tTG IgA, screening tests frequently include total IgA levels. The objective of this study was to determine whether tTG IgA antibody levels might be used to predict IgA deficiency and hence avoid unnecessary testing of total IgA levels in all individuals.

DESIGN

Retrospective analysis of 9429 serum tTG IgA and corresponding total IgA levels obtained from children and young adults in the East of England between 2007 and 2011.

RESULTS

The overall prevalence of IgA deficiency was found to be very low with only 0.9% of individuals affected. Using receiver operating characteristic curve analysis we identified a cut-off value for tTG IgA of ≥0.10 μ/mL to be predictive for the absence of total IgA deficiency (IgA<0.06 g/L). Specifically, using this cut-off value, total IgA deficiency could be excluded with a sensitivity of 0.92 and specificity of 0.84. In our cohort, only 16.4% of our patient sample would have needed total IgA measurement to rule out a false negative result due to IgA deficiency.

CONCLUSIONS

Our data provide a simple means of avoiding unnecessary total IgA measurements in the assessment of coeliac disease. By using tTG IgA value quantitatively, only values <0.10 μ/mL require total IgA measurements to rule out IgA deficiency and hence a potentially false negative screening result.

Is community treatment best? a randomised trial comparing delivery of cancer treatment in the hospital, home and GP surgery

BACKGROUND

Care closer to home is being explored as a means of improving patient experience as well as efficiency in terms of cost savings. Evidence that community cancer services improve care quality and/or generate cost savings is currently limited. A randomised study was undertaken to compare delivery of cancer treatment in the hospital with two different community settings.

METHODS

Ninety-seven patients being offered outpatient-based cancer treatment were randomised to treatment delivered in a hospital day unit, at the patient's home or in local general practice (GP) surgeries. The primary outcome was patient-perceived benefits, using the emotional function domain of the EORTC quality of life (QOL) QLQC30 questionnaire evaluated after 12 weeks. Secondary outcomes included additional QOL measures, patient satisfaction, safety and health economics.

RESULTS

There was no statistically significant QOL difference between treatment in the combined community locations relative to hospital (difference of -7.2, 95% confidence interval: -19·5 to +5·2, P=0.25). There was a significant difference between the two community locations in favour of home (+15·2, 1·3 to 29·1, P=0.033). Hospital anxiety and depression scale scores were consistent with the primary outcome measure. There was no evidence that community treatment compromised patient safety and no significant difference between treatment arms in terms of overall costs or Quality Adjusted Life Year. Seventy-eight percent of patients expressed satisfaction with their treatment whatever their location, whereas 57% of patients preferred future treatment to continue at the hospital, 81% at GP surgeries and 90% at home. Although initial pre-trial interviews revealed concerns among health-care professionals and some patients regarding community treatment, opinions were largely more favourable in post-trial interviews.

INTERPRETATION

Patient QOL favours delivering cancer treatment in the home rather than GP surgeries. Nevertheless, both community settings were acceptable to and preferred by patients compared with hospital, were safe, with no detrimental impact on overall health-care costs.

Operator training requirements and diagnostic accuracy of Fibroscan in routine clinical practice

BACKGROUND

Fibroscan is a quick, non-invasive technique used to measure liver stiffness (kPa), which correlates with fibrosis. To achieve a valid liver stiffness evaluation (LSE) the operator must obtain all the following three criteria: (1) ≥10 successful liver stiffness measurements; (2) IQR/median ratio <0.30 and (3) ≥60% measurement success rate.

OBJECTIVES

To assess the operator training requirements and the importance of adhering to the LSE validity criteria in routine clinical practice.

METHODS

We retrospectively analysed the LSE validity rates of 2311 Fibroscans performed (1 August 2008 to 31 July 2011) in our tertiary liver outpatients department at the University Hospital Birmingham, UK. The diagnostic accuracy of Fibroscan was assessed in 153 patients, by comparing LSE (valid and invalid) with the modified Ishak fibrosis stage on liver biopsy.

RESULTS

Learning curve analysis highlighted that the greatest improvement in validity of LSE rates occurs in the operator's first 10 Fibroscans, reaching 64.7% validity by the 50th Fibroscan. The correlation between LSE and the fibrosis stage on liver biopsy was superior in patients with a valid LSE (n=97) compared with those with an invalid LSE (n=56) (rs 0.577 vs 0.259; p=0.022). Area under receiving operating characteristics for significant fibrosis was greater when LSE was valid (0.83 vs 0.66; p=0.048). Using an LSE cut-off of 8 kPa, the negative predictive value of valid LSE was superior to invalid LSE for the detection of significant (84% vs 71%) and advanced fibrosis (100% vs 93%).

CONCLUSIONS

Fibroscan requires minimal operator training (≥10 observed on patients), and when a valid LSE is obtained, it is an accurate tool for excluding advanced liver fibrosis. To ensure the diagnostic accuracy of Fibroscan it is essential that the recommended LSE validity criteria are adhered to in routine clinical practice.

Improvement in quality of life after arthroscopic capsular release for contracture of the shoulder

There is little published information on the health impact of frozen shoulder. The purpose of this study was to assess the functional and health-related quality of life outcomes following arthroscopic capsular release (ACR) for contracture of the shoulder. Between January 2010 and January 2012 all patients who had failed non-operative treatment including anti-inflammatory medication, physiotherapy and glenohumeral joint injections for contracture of the shoulder and who subsequently underwent an ACR were enrolled in the study. A total of 100 patients were eligible; 68 underwent ACR alone and 32 had ACR with a subacromial decompression (ASD). ACR resulted in a highly significant improvement in the range of movement and functional outcome, as measured by the Oxford shoulder score and EuroQol EQ-5D index. The mean cost of a quality-adjusted life year (QALY) for an ACR and ACR with an ASD was £2563 and £3189, respectively.

ACR is thus a cost-effective procedure that can restore relatively normal function and health-related quality of life in most patients with a contracture of the shoulder within six months after surgery; and the beneficial effects are not related to the duration of the presenting symptoms.

Cite this article: Bone Joint J 2013;95-B:942–6.

Systematic review: pentoxifylline for the treatment of severe alcoholic hepatitis

BACKGROUND

Acute alcoholic hepatitis (AH) is a severe manifestation of alcoholic liver disease with a grave prognosis. Pentoxifylline, an oral antitumour necrosis factor agent, has been reported to reduce mortality and incidence of hepatorenal syndrome (HRS) in severe alcoholic hepatitis (SAH).

AIM

To summarise evidence for the use of pentoxifylline in SAH.

METHODS

A literature search was undertaken using MeSH terms 'hepatitis, alcoholic' and 'pentoxifylline' using the set operator AND. We included randomised controlled trials examining pentoxifylline in SAH, published as abstracts or full manuscripts. Risk ratios (RRs) were calculated for pooled data using random effects modelling. Risk of bias was assessed using Cochrane group criteria and quality of trials assessed using 'Consolidated Standards of Reporting Trials' CONSORT guidelines.

RESULTS

Ten trials including 884 participants were included, from six papers and four abstracts. There was significant heterogeneity between trials regarding control groups and trial end-points. Treatment was given for 28 days in all trials except one. Pooling of data showed a reduced incidence of fatal HRS with pentoxifylline compared with placebo (RR: 0.47, 0.26-0.86, P = 0.01), but no survival benefit at 1 month (RR: 0.58, 0.31-1.07, P = 0.06). There were no significant differences between treatment groups in trials of pentoxifylline vs. corticosteroid, or vs. combination therapy.

CONCLUSIONS

Pentoxifylline appears superior to placebo in prevention of fatal HRS and thus may be effective treatment of SAH when corticosteroids are contraindicated. However, multiple trials have failed to show conclusive superiority of either pentoxifylline or corticosteroids.

Esophageal cancer awareness in Bomet district, Kenya

BACKGROUND

Esophageal cancer is the most common malignancy in Western Kenya and patients present with advanced disease.

OBJECTIVE

To determine baseline level of knowledge of esophageal cancer in Bomet District in order to develop targeted and effective educational classes.

METHODS

A questionnaire with twelve questions testing knowledge about esophageal cancer and eight questions aimed at determining barriers to healthcare was conducted out of Tenwek Hospital from June to July 2010.

RESULTS

Eighty-one questionnaires were completed. 33% thought that cancer is a virus and 35% thought that it is contagious. 47% did not think that family history is a risk factor. 79% accurately claimed dysphagia as the most common symptom for esophageal cancer. 40% thought that herbal therapy is the optimal treatment for esophageal cancer. Cost and fear of diagnosis were cited as the most significant barriers to healthcare. Most participants had a monthly income of less than 3000 Kenyan schillings (37.5 US dollars); for 37% of participants, the cost of transport to the hospital represented a third of their monthly income.

CONCLUSION

The questionnaire provided population-specific information on cancer knowledge and aided in targeting barriers to healthcare access. These factors will be incorporated into the cancer education outreach program of Tenwek Hospital.

Expression of an alternatively spliced ercc1 messenger-RNA species, is related to reduced DNA-repair efficiency in human T-lymphocytes

We have previously shown that in non-drug-selected human T lymphocytes, DNA repair is the primary determinant of cellular resistance to cisplatin (1). In this system, we have assessed mRNA levels of expression of the nucleotide excision repair (NER) genes ERCC1 and XPA, as well as the alternatively spliced species of ERCC1 which lacks exon VIII. The focus of these studies, was to try to identify the possible relative roles of normal XPA, full-length ERCC1, and alternatively spliced ERCC1, in a system where DNA repair is a clear determinant of cisplatin resistance. ERCC1 expression was directly related to cisplatin-DNA adduct repair capability, as well as directly related to cisplatin resistance, suggesting a primary role for ERCC1 in effecting DNA repair. XPA expression was approximately equivalent in each cell line, regardless of the level of DNA repair activity, suggesting a helper role for the product of this gene. The mRNA levels of the alternatively spliced species of ERCC1 were strongly inversely related to DNA repair activity, suggesting a possible inhibitory influence on the DNA repair process. This interpretation is consistent with alternative splicing of several known oncogenes, where the alternatively spliced species has an inhibitory effect on the full-length gene product. The NER pathway appears to be vitally important in effecting cisplatin resistance in non-drug-selected T lymphocytes. Further, it appears that NER may have at least one inhibitory regulatory component.

Platinum-DNA adduct in head and neck-cancer patients receiving Cisplatin and Carboplatin chemotherapy

Sixteen patients with squamous cell carcinoma of the head and neck region were studied for the formation of platinum-DNA adduct in leukocyte DNA. Every patient received carboplatin and cisplatin, each given intravenously on day 1 of 21-day treatment cycles. Blood was obtained for DNA isolation 24 hours after treatment on cycles 1 and 2; and on the morning before cycle 2 of therapy (21 days after cycle 1 drug delivery). Adduct was measured by atomic absorbance spectrometry with Zeeman background correction. As has been shown in previous studies, adduct persistence and accumulation could be demonstrated in a portion of the cohort. Adduct removal from blood cell DNA during the 21 days of cycle number 1, was determined for 12 patients. In these patients, adduct removal was directly i-elated to clinical resistance to the cisplatin/carboplatin treatment regimen; and adduct removal was inversely related to leukocyte toxicity. These data demonstrate that changes in adduct levels with time may provide valuable information, in the study of the human in vivo biology of platinum-DNA damage and repair.

An ORS-ICP-MS method for monitoring trace levels of cobalt and chromium in whole blood samples from hip arthroplasty patients with metal-on-metal prostheses

OBJECTIVE

To develop a rapid and reliable method, using an octopole reaction system (ORS) ICP-MS, capable of monitoring trace levels of Co and Cr in whole blood samples from hip arthroplasty patients with metal-on-metal prostheses.

DESIGN AND METHOD

Whole blood is diluted 10-fold with an alkaline diluent and analyzed using an Agilent 7500 CE ORS-ICP-MS.

RESULTS

Limit of quantification of 0.03 μg/L Co and 0.20 μg/L Cr in patient samples. <6% covariance obtained for quality control materials analyzed over 10 runs.

CONCLUSION

This method is capable of monitoring trace levels of Co and Cr in diluted whole blood samples with a vial to vial run time of approximately 2 min. Results are comparable to those obtained using high resolution (HR) ICP-MS with sample digestion.

Cardiovascular tissue banking in Europe

INTRODUCTION

In the past 50 years, human cardiovascular tissue allografts, also called homografts, have been implanted into patients with different valvular diseases. The use of these allografts and  the number of cardiovascular tissue banks and their respective techniques increased. We conducted a survey to establish the quantity of allografts processed, and issued by, European tissue banks. The survey also included the collection of other relevant statistics.

METHODS

In 2011, the Foundation of European Tissue Banks collected data from 19 different cardiovascular tissue banks in 11 European countries.

RESULTS

From  2007 to 2010 the  data show a decrease in the number of hearts received, from 1700 to 1640 in 18 tissue banks; the average number of hearts received for cardiovascular tissue processing decreased from 113 to 91. The number of heart valves issued for transplantation increased from 1272 in 2007 to 1486 in 2010. The average rate of discard because of microbiological contamination was 20.7%, while 4.2% of the grafts were not used because of positive serology. Half of the tissue banks issued arterial grafts, while 3 banks also issued veins and pericardium. An overview of decontamination methods shows considerable methodological differencesbetween 17 cardiovascular tissue banks.

CONCLUSIONS

From the experience in Europe, it can be concluded that cardiovascular tissue banks have an established place in the domain of cardiovascular surgery. The statistics show fluctuating data concerning the demand for human cardiovascular allografts and methodological questions. There is room for growth and improvement with respect to validation of decontamination methods.