Use of topical corticosteroids on chronic leg ulcers

OBJECTIVE

Topical corticosteroids are widely used in the management of chronic wounds, yet there is little evidence to support this. This pilot study aimed to identify current practice by three specialist nurses and to assess the efficacy of topical corticosteroids.

METHOD

Data on healing, pain relief, exudate reduction and control of hypergranulation tissue were collected on 34 patients whose wounds were treated with topical corticosteroids prospectively in three centres over a three-month period.

RESULTS

Twenty-seven patients (79%) benefited from the application of topical corticosteroid either in terms of healing, pain relief, exudate reduction or the control of hypergranulation tissue. Two wounds deteriorated and treatment was immediately withdrawn.

CONCLUSION

Suppression of inflammation plays an important role in healing and pain relief. Applying topical corticosteroids to the wound can accelerate healing and reduce pain in certain cases. However, careful monitoring is essential as there is a risk of sensitisation with prolonged use as well as a potential increased risk of infection.

Predictors, costs and characteristics of out of area placement for people with intellectual disability and challenging behaviour

BACKGROUND

Out of area placements for people with challenging behaviour represent an expensive and often ineffective strategy for meeting the needs of this service user group.

METHODS

More than 800 agencies and service settings in a large area of South Wales were screened to identify children and adults with challenging behaviour against a number of defined operational criteria. Detailed data on identified individuals and the services they received were collected by interviewing key informants. Univariate and multivariate statistics were employed to identify predictors of out of area placement.

RESULTS

In total, 1458 people were identified. Full data were available for 901 participants, 97 of whom were placed out of area. Predictors of out of area placement included behaviours resulting in physical injury and exclusion from service settings, a history of formal detention under the mental health act, the presence of mental health problems, a diagnosis of autism and higher total score on the Adaptive Behaviour Scale. Out of area placements were typically of high cost, and associated with only limited evidence of improved service quality.

CONCLUSIONS

Identifying predictors for out of area placement can be used to highlight deficiencies in local services and individuals at increased risk of exclusion from local services.

Supply of inpatient geriatric medical services in Australia

This study summarizes the findings of a national survey of inpatient geriatric services in Australia conducted in 2001. These data are unique as there are no uniform administrative data systems available to provide this information. Eight hundred and eighty-eight hospitals were surveyed and full responses were received from 690, representing 78% of hospitals and 85% of all hospital beds. The results illustrated wide variation in the style and level of provision of services among hospitals and across regional and state jurisdictions.

A comparative study of the bone-restorative efficacy of anabolic agents in aged ovariectomized rats

INTRODUCTION

The study was designed to compare the bone anabolic effects of basic fibroblast growth factor (bFGF), a selective agonist for prostaglandin E receptor subtype EP4, and parathyroid hormone (PTH) in aged ovariectomized (OVX) rats with severe cancellous osteopenia.

METHODS

Groups of aged OVX rats were maintained untreated for 1 year postovariectomy (15 months of age) to develop severe tibial cancellous osteopenia. These animals were then treated with bFGF or the EP4 agonist (EP4) for 3 weeks. Other groups of aged OVX rats were treated with EP4 or PTH alone for 11 weeks, or sequentially with bFGF or EP4 for 3 weeks followed by PTH for 8 weeks. Cancellous and cortical bone histomorphometry were performed in the right proximal tibial metaphysis and tibial diaphysis respectively.

RESULTS

Treatment with bFGF for 3 weeks markedly increased serum osteocalcin, osteoid volume, and osteoblast and osteoid surfaces to a greater extent than EP4. Basic FGF, but not EP4 or PTH, induced formation of osteoid islands within bone marrow. EP4 stimulated cancellous bone turnover, but failed to restore lost cancellous bone in the severely osteopenic proximal tibia after 11 weeks of treatment. In contrast, EP4, much like PTH, increased cortical bone mass in the tibial diaphysis by stimulating both periosteal and endocortical bone formation. Treatment of aged OVX rats with PTH alone tended to partially reverse the severe tibial cancellous osteopenia, whereas sequential treatment with bFGF and PTH increased tibial cancellous bone mass to near the level of vehicle-treated control rats. These findings indicate that bFGF had the strongest stimulatory effect on cancellous bone formation, and was the only anabolic agent to induce formation of osteoid islands within the bone marrow of the severely osteopenic proximal tibia. Therefore, bFGF may be more effective for the reversal of severe cancellous osteopenia. PTH and EP4 increased cortical bone mass to nearly the same extent, but cancellous bone mass was greater by two-fold in PTH-treated OVX rats than in EP4-treated OVX rats.

CONCLUSION

These findings in aged OVX rats suggest that PTH is more efficacious than EP4 for augmentation of cancellous bone in the severely osteopenic, estrogen-deplete skeleton.

67 CELL TYPE AND CULTURE OVER TIME EFFECT DNA METHYLTRANSFERASE 1 EXPRESSION IN BOVINE DONOR FIBROBLAST CELLS

Aberrant chromatin remodeling has been implicated in the low success rates achieved from cloned embryos. Following fertilization, DNA methylation within a normal embryo is rapidly reduced to a very low level and remains low until the 8–16 cell stage when DNA methylation once again increases. In contrast, the majority of cloned embryos fail to exhibit a similar methylation pattern. This may be due to somatic cell-associated DNMT1s keeping methylation high. However, attempts to chemically modify methylation patterns of donor cells prior to cloning have proven problematic. The objective of this study was to determine if a more natural approach, such as culture conditions, time in culture, and/or cell type, could alter DNMT1 expression in donor fibroblast cells. Two experiments were designed to meet these objectives. Donor fibroblast cell lines were produced from biopsies taken from male and female skin, ovaries, and testes, and were grown in Dulbecco's modified Eagle's medium (DMEM) supplemented with 15% fetal bovine serum, 0.1 mM non-essential amino acids, 2 mM L-glutamine, and 0.1 mM β-mercaptoethanol, in a humidified environment of 5% CO2 in air, at 39°C. In Experiment 1, cell lines were maintained at 70% confluence to passage 4, 8, and 12, and analyzed by reverse transcription real-time PCR. In Experiment 2, cell lines were evaluated under 3 culture conditions: proliferating (70% confluence), serum-starved (0.5% FBS), and confluent (100%), and analyzed by reverse transcription real-time PCR. RNA was isolated from cell lines using Trizol reagent (Invitrogen, Carlsbad, CA, USA), reverse transcribed, and analyzed for DNMT1 expression using Taqman real-time PCR, with β-actin as the reference standard. All samples and no template controls were run in triplicate. Final quantitation was done using the comparative CT method, and relative DNMT1 expression was analyzed using one-way ANOVA followed by LS means multiple comparisons. Cell type and passage number had a significant effect on DNMT1 expression. Ovarian fibroblasts had an overall increase in expression in DNMT1 over time (P < 0.05), whereas male skin fibroblasts demonstrated an opposite trend (P = 0.05). Female skin fibroblasts and testes fibroblasts also had a decrease in DNMT1 expression over time, but only approached significance (P < 0.10). For Experiment 2, culture conditions tested did not affect DNMT1 expression for any except one skin cell line. In that case, proliferating cells had significantly higher DNMT1 than quiescent cells (P < 0.005). This research emphasizes the importance of donor cell type and culture effects over time on gene expression. These important aspects should be considered when selecting and growing donor cells to be utilized in somatic cell nuclear transfer. This project was supported by National Research Initiative Competitive Grant no. 2006-35203-16620 from the USDA Cooperative State Research, Education, and Extension Service and the Florida Agricultural Experiment Station.

Illicit drug users in Northern Ireland: perceptions and experiences of health and social care professionals

Over the 30 years of conflict, Northern Ireland escaped the worst excesses of illegal drug trafficking and usage. This was in large part due to the 'policing' of local community crime by paramilitaries. However, since the first 'cease-fire' in 1994 the province has witnessed a dramatic and unprecedented rise in the availability of illicit drugs. This increased availability reflects rising consumption of these drugs in the province. The aim of this study was to explore the perceptions that a sample of health and social care professionals' hold of illicit drug users in Northern Ireland. A survey methodology was used. Community settings across Northern Ireland were accessed. Focus groups and face-to-face interviews were used as data collection methods. Thirty-five health and social care professionals took part in this study. Thirty-two took part in six focus groups; three respondents underwent one-to-one interview. The participating professionals reported to have little or no education or training in the care and treatment of illicit drug users. Some stated that they would reject the offer of education and training in this area to prevent contact with illicit drug users. Many displayed strongly negative views of this client group, often expressing a preference not to care for or treat these people, preferring all their care to be given by specialists in illicit drug treatment. These findings indicate that most of the health and social care professionals who took part in this study appear unprepared and unwilling to meet the challenge of caring for illicit drug users. The findings will be of interest to service providers within and outside the UK.

Effect of childhood eczema and asthma on parental sleep and well-being: a prospective comparative study

BACKGROUND

The psychological impact of childhood atopic eczema on parents and carers is poorly quantified. Objectives To compare the impact of caring for a child with atopic eczema vs. asthma on parents' sleep and well-being.

METHODS

Ninety-two parents of 55 children who had moderate to severe atopic eczema or asthma took part in this prospective, questionnaire-based study. It was conducted at regional eczema and asthma outpatient clinics within a U.K. tertiary paediatric hospital. The main outcome measures were the number and duration of parents' sleep disturbances, as well as their anxiety and depression scores.

RESULTS

Mothers caring for children with atopic eczema lost a median of 39 min of sleep per night and fathers lost 45 min sleep per night. This compared with a median of 0 min sleep lost by parents who had children with asthma (P < 0.001). These differences were independent of the age of the children, and whether the child came from a single-parent or two-parent family. There was a direct correlation between the severity of sleep disturbance and the level of maternal anxiety (rho = 0.58; P = 0.002) and depression (rho = 0.73; P < 0.001), as well as the level of paternal anxiety (rho = 0.59; P = 0.01).

CONCLUSIONS

Compared with looking after a child with chronic asthma, caring for a child with chronic atopic eczema was associated with greater parental sleep disturbances. Disruption to parental sleep correlated with anxiety levels and, in the case of mothers, depression scores.

Human resource (HR) costs of chemotherapy infusion reactions (IR) in community oncology

16013

Background: Chemotherapy IR are the dose limiting factor for many agents and have clinical consequences ranging from patient symptom burden to death. No work has been done to describe the provider burden of chemotherapy IR. The purpose of this analysis was to describe the clinical interventions associated with mild and severe IR and estimate the associated HR costs. Methods: Staff from a single, free standing, community oncology practice were surveyed regarding involvement in the management of mild and severe chemotherapy IR using a modified time and motion survey to identify tasks required to manage CIR and the HR time required. Mild and severe chemotherapy IR HR events were created. Salary averages for each type of staff were used to estimate HR costs. Results: 39 staff participated in the survey and were 85% (n = 33) female, average age 44, with M = 7.6 years experience. 21 distinct tasks (e.g. initial assessment, patient monitoring, infusion stopped, notify physician) were identified representing the management of the mild and severe chemotherapy IR. 11 types of staff indicated routine participation in ≥ 1 IR related task. Total HR time was 188 and 194 minutes for mild and severe IR respectively, resulting in HR cost of $124 and $187. Conclusions: The above methodology will be used in an expanded analysis of 20 outpatient practices. Recent changes in cancer treatment reimbursement have resulted increased interest in practice efficiency and provider cost. Definitions for quality care should consider minimization of unnecessary direct and indirect costs and maximization of practice efficiency. Models such as the one described are needed to understand provider costs. Clinical processes and chemotherapy agents that reduce rates and severity of CIR should reduce HR burden related to CIR.

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Major Advances Associated with Reproduction in Dairy Cattle

The purpose of this overview is to review some of the major advances in reproductive technologies, and how they may be applied to meet the challenge of enhancing reproductive efficiency in the high-producing dairy cow of the 21st century. The current population of high-producing dairy cows is considered to be subfertile, as characterized by low pregnancy rates and high rates of embryonic mortality. Coordinated systems of reproductive management have been developed based upon a thorough understanding of the endocrine, cellular, and molecular factors controlling ovarian and uterine function. These systems will partially restore herd reproductive performance. Advances in other reproductive technologies offer possibilities for wider use of superior germplasm. Technologies such as sexed semen, cloning, transgenesis, and preimplantation genetic diagnosis offer the potential to enhance the influence of superior animals on production of food for human consumption. However, at this time, additional research is needed to counteract the higher rates of embryonic and fetal mortality associated with some of these technologies. Furthermore, use of genomics, proteomics, and bioinformatics in the study of reproduction will undoubtedly provide investigators with a greater understanding of the limitations to efficient reproductive processes in the subfertile lactating dairy cow.

Elevated plasma concentrations of atrial and brain natriuretic peptide in type 1 diabetic subjects

BACKGROUND

The intravenous infusion of atrial (ANP) and brain (BNP) natriuretic peptides have been shown to increase urinary albumin excretion in type 1 diabetes.

AIMS

To measure plasma ANP and BNP concentrations in patients with type 1 diabetes and to examine the parameters associated with elevated plasma concentrations. Methods We measured plasma ANP and BNP concentrations, UAER, HbA1C systolic blood pressure, and left ventricular mass index. Plasma ANP and BNP were also measured in non-diabetic control subjects for comparison.

RESULTS

Using multivariate regression analysis plasma ANP correlated positively with HbA1C (1.9 + 0.47, p = 0.0002), UAER (0.37 + 0.05, p = 0.00001), SBP (1.26 + 0.5, p = 0.01) and LVMI (00.46 + 0.25, p = 0.07). BNP was positively related with LVMI (0.95 + 0.4, p = 0.02), and UAER (0.56 + 0.08, p = 0.001).

CONCLUSIONS

Plasma concentrations of ANP and BNP are elevated in some patients with type 1 diabetes. Plasma ANP concentrations are closely related to UAER and elevated plasma concentrations are associated with poor glycaemic control and systemic hypertension. Plasma BNP concentration is related to LVMI.

Hydrogen sulphide and the hyperdynamic circulation in cirrhosis: a hypothesis

Cirrhosis is associated with the development of a hyperdynamic circulation, which is secondary to the presence of systemic vasodilatation. Several mechanisms have been postulated to be involved in the development of systemic vasodilatation, including increased synthesis of nitric oxide, hyperglucagonaemia, increased carbon monoxide synthesis, and activation of K(ATP) channels in vascular smooth muscle cells in the systemic and splanchnic arterial circulation. Hydrogen sulphide (H2S) has recently been identified as a novel gaseous transmitter that induces vasodilatation through activation of K(ATP) channels in vascular smooth muscle cells. In this brief review, we comment on what is known about H2S, vascular and neurological function, and postulate its role in the pathogenesis of the vascular abnormalities in cirrhosis.

Using wound area measurement to predict and monitor response to treatment of chronic wounds

A wound measurement system has been launched that incorporates wound tracing and digital planimetry. It is hoped its speed and accuracy will enable more clinicians to use wound area measurements to predict treatment outcomes.

A programme for reducing smoking in pre-operative surgical patients: randomised controlled trial

We assessed the efficacy of a comprehensive programme for stopping smoking in 210 smokers scheduled for surgery, before admission and 3 months after attending a pre-operative clinic. Participants were randomly allocated to receive an intervention incorporating nicotine replacement therapy for patients smoking more than 10 cigarettes per day ("dependent smokers"), or to a control group to receive usual care. Dependent smokers allocated to the intervention group were more likely to report abstinence before surgery than those allocated to receive usual-care (63 (73%) vs. 29 (56%), respectively; OR 2.2 (95% CI 1.0-4.8)), and 3 months after attendance (16 (18%) vs. 3 (5%), respectively; OR = 3.9 (95% CI 1.0-21.7).

Downward resetting of the osmotic threshold for thirst in patients with SIADH

The syndrome of inappropriate antidiuretic hormone (SIADH) is characterized by euvolemic hyponatremia. Patients with SIADH continue to drink normal amounts of fluid, despite plasma osmolalities well below the physiological osmotic threshold for onset of thirst. The regulation of thirst has not been previously studied in SIADH. We studied the characteristics of osmotically stimulated thirst and arginine vasopressin (AVP) secretion in eight subjects with SIADH and eight healthy controls and the nonosmotic suppression of thirst and AVP during drinking in the same subjects. Subjects underwent a 2-h infusion of hypertonic (855 mmol/l) NaCl solution, followed by 30 min of free access to water. Thirst rose significantly in both SIADH (1.5 +/- 0.6 to 8.0 +/- 1.2 cm, P < 0.0001) and controls (1.8 +/- 0.8 to 8.4 +/- 1.5 cm, P < 0.0001), but the osmotic threshold for thirst was lower in SIADH (264 +/- 5.5 vs. 285.9 +/- 2.8 mosmol/kgH(2)O, P < 0.0001). SIADH subjects drank volumes of water similar to controls after cessation of the infusion (948.8 +/- 207.6 vs. 1,091 +/- 184 ml, P = 0.23). The act of drinking suppressed thirst in both SIADH and controls but did not suppress plasma AVP concentrations in SIADH compared with controls (P = 0.007). We conclude that there is downward resetting of the osmotic threshold for thirst in SIADH but that thirst responds to osmotic stimulation and is suppressed by drinking around the lowered set point. In addition, we demonstrated that drinking does not completely suppress plasma AVP in SIADH.

High-oleate peanut mutants result from a MITE insertion into the FAD2 gene

A high-oleate trait in the cultivated peanut ( Arachis hypogaea L.) was reported to rely on the allelic composition of the two homeologous, microsomal oleoyl-PC desaturase genes ( ahFAD2A or ahFAD2B). The enzyme activity of either ahFAD2A or ahFAD2B is sufficient for a normal oleate phenotype, and a significant reduction in the levels of ahFAD2B and a mutation in ahFAD2A were reported to be responsible for the high-oleate phenotype in one chemically induced mutant (M2-225) and one derived from a naturally occurring (8-2122) mutant. Here, we report an insertion of the same miniature inverted-repeat transposable element (MITE) in the ahFAD2B gene in another chemically induced mutant (Mycogen-Flavo) and the previously characterized M2-225 mutant. In both cases, this MITE insertion in ahFAD2B causes a frameshift, resulting in a putatively truncated protein sequence in both mutants. The insertion of this MITE in ahFAD2B, in addition to the point mutation in ahFAD2A, appears to be the cause of the high-oleate phenotype in Mycogen-Flavo and M2-225 mutants. Utilizing sequences of the MITE, we developed a DNA marker strategy to differentiate the two insertion-containing mutants from the normal oleate peanut variety (AT-108) and the naturally occurring, high-oleate mutant 8-2122. Reverse transcript-PCR/differential digestion results reveal the expression of both ahFAD2A and ahFAD2B genes in Mycogen-Flavo mutant. This result is in contrast to the observation that ahFAD2B transcripts are greatly reduced in the M2-225 mutant having the MITE insertion further 3' in ahFAD2B gene.

Hydroxy-methylglutaryl-coenzyme A reductase inhibition improves endothelial dysfunction in type-1 diabetes

OBJECTIVE

We hypothesize that treatment with Pravastatin, a HMG CoA reductase inhibitor would improve flow-mediated dilation (FMD), a nitric oxide dependent phenomenon and the earliest detectable marker of endothelial dysfunction, in asymptomatic patients with type-1 diabetes.

MATERIALS AND METHODS

FMD of the brachial artery in response to reactive hyperaemia was measured using high-resolution ultrasonography. Young male patients with type-1 diabetes (n=9) were compared with age matched non-diabetic controls (n=8).

RESULTS

The FMD response in the control group was a median increase in diameter of 7.9 (range 3.8-12.6)%. In the diabetic group the FMD response was impaired when compared with controls with a median increase only of 4.4 (range 3.7-5.8)% (p<0.01). Following Pravastatin, 40 mg per day for one month in the diabetic group, there was a significant diameter change in response to reactive hyperaemia with a median of 8.4 (range 6.9-12.6)% (p<0.01).

CONCLUSIONS

These data confirm the presence of endothelial dysfunction in young patients with type-1 diabetes. We have shown that 1-month of Pravastatin treatment normalizes FMD. This suggests that HMG CoA reductase inhibitors may have a role in the management of diabetes mellitus, even in the presence of normal serum cholesterol levels.

Duloxetine vs placebo in the treatment of stress urinary incontinence: a four-continent randomized clinical trial

OBJECTIVES

To further assess, in a phase 3 study, treatment with duloxetine for women with stress urinary incontinence (SUI) in other geographical regions, including Argentina, Australia, Brazil, Finland, Poland, South Africa and Spain, as previous trials in North America and Europe provided evidence for the safety and efficacy of duloxetine as a pharmacological treatment for SUI in women.

PATIENTS AND METHODS

The study included 458 women aged 27-79 years enrolled in a double-blind, placebo-controlled trial. The patients with predominantly SUI were identified using a validated clinical algorithm. They were randomly assigned to receive placebo (231) or duloxetine 40 mg twice daily (227) for 12 weeks. The primary outcome variables included the incontinence episode frequency (IEF) and the Incontinence Quality of Life (I-QOL) questionnaire. Van Elteren's test was used to analyse the percentage changes in IEF where the stratification variable was weekly baseline IEF (IEF < 14 and > or = 14). Analysis of covariance was used to analyse I-QOL scores.

RESULTS

The mean baseline IEF was 18.4/week; 55% of patients had a baseline IEF of > or = 14. There was a significantly greater median decrease in IEF with duloxetine with placebo (54% vs 40%, P = 0.05), with comparable significant improvements in quality of life (I-QOL score increases of 10.3 vs 6.4, P = 0.007). The improvements with duloxetine were associated with significantly greater increases in voiding intervals than with placebo (20.4 vs 8.5 min, P < 0.001). The placebo response was 10.7% and 12.5% higher than those reported in two European and North American phase 3 trials. This may have been related to more patients being naïve for incontinence management in the current trial. Discontinuation rates for adverse events were 1.7% for placebo and 17.2% for duloxetine (P < 0.001), with nausea being the most common reason for discontinuation (3.1%); it was the most common adverse event with duloxetine, but was mild or moderate in most (81%), did not worsen in any patient and resolved within 7 days in 60% and within 1 month in 86% of continuing patients; 88% of women who experienced nausea while taking duloxetine completed the trial.

CONCLUSIONS

These results show improvements in incontinence and quality of life with duloxetine 40 mg twice daily for 12 weeks that are in keeping with those reported in two other recently completed phase 3 trials in Europe and North America.