The effect of infliximab dose escalation in inflammatory bowel disease patients with antibodies to infliximab

BACKGROUND

Infliximab dose escalation (DE) can be used in inflammatory bowel disease patient; however, the long-term benefit remains unclear, especially in those with antibodies to infliximab (ATI). The aim was to assess the effect of DE in patients with ATI on drug level, clinical response and ATI status.

METHODS

All patients undergoing infliximab DE (a reduction in dose interval between infusions <8 weeks ± an increase in dose up to 10 mg/kg) at a referral centre between April 2016 and August 2019 were included.

RESULTS

Ninety-two patients were DE: 51 were men, 50 had CD and 63 were receiving immunosuppression. A total of 87 people received DE for a median of 44 weeks (range 4-176). Five stopped infliximab after 1 dose of DE: 2 for loss of response and 3 for infusion reaction. In patients with ATI ≤10 vs. >10 AU/mL, DE significantly increased drug levels: median infliximab levels of 1.4 and 0.9 at baseline, respectively, to 3.2 and 3.5 at week 24. After DE, 21/35 ATI-positive patients had a fall in ATI ≤10 AU/mL. At week 24 following DE 62/92 patients were in clinical remission. Duration of clinical remission was shorter in those with ATI >10 AU/mL (median 24 weeks, range 0-88) than in those with transient/ATI ≤10 AU/mL (median 36 weeks, range 0-126, P = 0.06).

CONCLUSIONS

A strategy of DE for selected patients receiving infliximab is associated with an increase in drug levels and reduced ATI positivity. This is associated with clinical remission in approximately 70% of patients at 6 months.

Systematic Review of Factors Affecting Transition Readiness Skills in Patients with Inflammatory Bowel Disease

BACKGROUND AND AIMS

The incidence of inflammatory bowel disease [IBD] diagnosed before adulthood is increasing worldwide. Transition from paediatric to adult health care requires certain skills. The aim of this study was to identify factors affecting these skills.

METHODS

This review was registered on the PROSPERO database [CRD42019152272]. Inclusion criteria were: 1] studies of factors affecting transition readiness skills in patients with IBD; 2] written in English; 3] published since 1999. MEDLINE, CINAHL, and PsychINFO databases were searched between 1999 and 2019. Quality was assessed using the Joanna Briggs Institute critical appraisal tools.

RESULTS

Searches identified 822 papers. Sixteen papers were included. Age was positively associated with skills including disease knowledge and performing self-management behaviours [14 studies]. Improvement often occurs at 18; however, skill deficiency may still remain. Increased self-efficacy [confidence] was associated with greater disease knowledge and performing self-management behaviours [three studies]. Self-efficacy was positively correlated with transition duration [two studies] and health-related quality of life [r = 0.57, p <0.001] [one study], negatively correlated with depression [r = -0.57, p <0.001] and anxiety [r = -0.23, p = 0.03] [one study], and was associated with higher education level [two studies] and a family history of IBD [one study]. Females had higher self-management scores [three studies], and greater health care satisfaction was significantly associated with higher knowledge [one study]. Greater transition communication improved knowledge, self-management, and overall transition readiness [two studies].

CONCLUSIONS

Potentially modifiable factors have been identified that could be supported in the transitioning IBD population, to improve transition readiness. Identification of those with non-modifiable characteristics associated with poor readiness may aid targeted support.

British Society of Gastroenterology guidance for management of inflammatory bowel disease during the COVID-19 pandemic

The COVID-19 pandemic is putting unprecedented pressures on healthcare systems globally. Early insights have been made possible by rapid sharing of data from China and Italy. In the UK, we have rapidly mobilised inflammatory bowel disease (IBD) centres in order that preparations can be made to protect our patients and the clinical services they rely on. This is a novel coronavirus; much is unknown as to how it will affect people with IBD. We also lack information about the impact of different immunosuppressive medications. To address this uncertainty, the British Society of Gastroenterology (BSG) COVID-19 IBD Working Group has used the best available data and expert opinion to generate a risk grid that groups patients into highest, moderate and lowest risk categories. This grid allows patients to be instructed to follow the UK government's advice for shielding, stringent and standard advice regarding social distancing, respectively. Further considerations are given to service provision, medical and surgical therapy, endoscopy, imaging and clinical trials.

Predicting the development of psychological morbidity in inflammatory bowel disease: a systematic review

BACKGROUND

Psychological morbidity in inflammatory bowel disease is common with significant impact on quality of life and health outcomes, but factors which predict the development of psychological morbidity are unclear.

AIM

To undertake a systematic literature review of the predictors of psychological morbidity in patients with inflammatory bowel disease.

METHODS

Electronic searches for English-language articles were performed with keywords relating to psychological morbidity according to the Diagnostic and Statistical Manual of Mental Disorders IV and subsequent criteria, and inflammatory bowel disease; in MEDLINE, PsychInfo, Web of Science and EMBASE for studies published from January 1997 to 25 January 2019.

RESULTS

Of 660 studies identified, seven met the inclusion criteria. All measured depression, with three also measuring anxiety. Follow-up duration was variable (median of 18 months range 6-96 months). Risk factors identified for development of psychological morbidity included physical factors: aggressive disease (HR 5.77, 95% CI 1.89 to 17.7) and greater comorbidity burden (OR 4.31, 95% CI 2.83 to 6.57) and psychological risk factors: degree of gratitude (r=-0.43, p<0.01) and parenting stress (R-change=0.03, F(1,58)=35.6, p<0.05). Age-specific risk was identified with young people (13-17 years) at increased risk.

CONCLUSIONS

Identifiable risks for the development of psychological morbidity in inflammatory bowel disease include physical and psychological factors. Further research is required from large prospective studies to enable early interventions in those at risk and reduce the impact of psychological morbidity.

Prospective Study of Psychological Morbidity and Illness Perceptions in Young People With Inflammatory Bowel Disease

BACKGROUND AND AIMS

Psychological morbidity is increased in young people with inflammatory bowel disease [IBD]. Illness perceptions may be an important factor. This study aimed to describe the prevalence and severity of psychological morbidity and to examine relationships between baseline illness perceptions and anxiety, depression, and health-related quality of life [HRQoL], at baseline and 12 months later, in 16-21 year olds with IBD.

METHODS

IBD patients [n = 121] completed measures of anxiety, depression, HRQoL, and illness perceptions [IPQ-R] at baseline and follow-up [n = 100, 83%].

RESULTS

Among the 121 patients at baseline [median age 19.3 years, 40% female, 62% Crohn's disease, 73% in clinical remission], 55% reported elevated symptoms of anxiety/depression and 83% reported low HRQoL. Negative illness perceptions at baseline were significantly correlated with greater anxiety, depression, and lower HRQoL at baseline and follow-up. In regression analysis at baseline, the IPQ-R domain of greater perception of a cyclical nature of IBD was an independent predictor of anxiety, and a greater perceived emotional impact of IBD was an independent predictor of anxiety, depression, and HRQoL. Female gender and clinical relapse were also independent predictors of lower HRQoL. After controlling for baseline measures, clinical risk factors and illness perceptions did not explain additional variance in psychological morbidity at follow-up.

CONCLUSIONS

A high prevalence of psychological morbidity, stable over 1 year, was demonstrated in young people with IBD. Having negative illness perceptions, being female, and having active disease predicted those at greatest risk of psychological morbidity. Illness perceptions may be an appropriate target for psychological interventions.

Results of the British Society of Gastroenterology supporting women in gastroenterology mentoring scheme pilot

INTRODUCTION

Mentorship has long been recognised as beneficial in the business world and has more recently been endorsed by medical and academic professional bodies. Recruitment of women into gastroenterology and leadership roles has traditionally been difficult. The Supporting Women in Gastroenterology network developed this pilot scheme for female gastroenterologists 5 years either side of the Completion Certificate of Specialist Training (CCST) to examine the role that mentorship could play in improving this discrepancy.

METHOD

Female gastroenterology trainees and consultant gastroenterologists within 5 years either side of CCST were invited to participate as mentees. Consultant gastroenterologists of both genders were invited to become mentors. 35 pairs of mentor:mentees were matched and completed the scheme over 1 year. Training was provided.

RESULTS

The majority of the mentees found the sessions useful (82%) and enjoyable (77%), with the benefit of having time and space to discuss professional or personal challenges with a gastroenterologist who is not a colleague. In the longitudinal study of job satisfaction, work engagement, burnout, resilience, self-efficacy, self-compassion and work-life balance, burnout scale showed a small but non significant improvement over the year (probably an effect of small sample size). Personal accomplishment improved significantly. The main challenges were geography, available time to meet and pair matching. The majority of mentors surveyed found the scheme effective, satisfying, mutually beneficial (70%) and enjoyable (78%).

CONCLUSION

Mentorship is shown to be beneficial despite the challenges and is likely to improve the recruitment and retention of women into gastroenterology and leadership roles, but is likely to benefit gastroenterologists of both genders.

Gender differences in leadership, workforce and scholarly presentation within a national society: a gastroenterology perspective

In the UK, gastroenterology has been a male predominant medical speciality. Data regarding gender within workforce, academia and leadership at a national level are lacking. Data regarding scholarly presentation at the following annual conferences were collected and analysed; British Society of Gastroenterology (BSG) 2013, 2014, and Digestive Diseases Federation (DDF) in 2015. Data from the 2013-2015 BSG annual workforce reports were examined. In 2015, female higher specialty trainees (STs) made up 39% (328/848) of the trainee workforce, versus 37% and 35% in 2014 and 2013. From 2013 to 2015, less than a fifth of all consultant gastroenterologists were women. Female consultant (18%), ST (39%), associate (86%) and student attendance (47%) at DDF 2015 did not change significantly from 2013 to 2014. Female speakers (trainees and consultants) were significantly lower at DDF 2015 compared with BSG 2014; 43/331 (13%) versus 56/212 (26.4%) (p=0.0001) and BSG 2013 63/231 (27%) (p=0.0001). The number of female chairs, delivery of the named lectures and prizes awarded to women did not differ across the 3-year period. Female leadership via representation at Council and Executive at BSG was 4/30 (13%) in 2015 and did not differ in 2013/2014, with no elected council members since 2008 and one female president in 1973. The proportion of female gastroenterology trainees and consultants is increasing, but remains lower than across all medical specialties and is reflected in attendance and scholarly contributions. Action within the BSG is underway to address female under-representation in leadership roles.

A growth hormone receptor SNP promotes lung cancer by impairment of SOCS2-mediated degradation

Both humans and mice lacking functional growth hormone (GH) receptors are known to be resistant to cancer. Further, autocrine GH has been reported to act as a cancer promoter. Here we present the first example of a variant of the GH receptor (GHR) associated with cancer promotion, in this case lung cancer. We show that the GHRP495T variant located in the receptor intracellular domain is able to prolong the GH signal in vitro using stably expressing mouse pro-B-cell and human lung cell lines. This is relevant because GH secretion is pulsatile, and extending the signal duration makes it resemble autocrine GH action. Signal duration for the activated GHR is primarily controlled by suppressor of cytokine signalling 2 (SOCS2), the substrate recognition component of the E3 protein ligase responsible for ubiquitinylation and degradation of the GHR. SOCS2 is induced by a GH pulse and we show that SOCS2 binding to the GHR is impaired by a threonine substitution at Pro 495. This results in decreased internalisation and degradation of the receptor evident in TIRF microscopy and by measurement of mature (surface) receptor expression. Mutational analysis showed that the residue at position 495 impairs SOCS2 binding only when a threonine is present, consistent with interference with the adjacent Thr494. The latter is key for SOCS2 binding, together with nearby Tyr487, which must be phosphorylated for SOCS2 binding. We also undertook nuclear magnetic resonance spectroscopy approach for structural comparison of the SOCS2 binding scaffold Ile455-Ser588, and concluded that this single substitution has altered the structure of the SOCS2 binding site. Importantly, we find that lung BEAS-2B cells expressing GHRP495T display increased expression of transcripts associated with tumour proliferation, epithelial-mesenchymal transition and metastases (TWIST1, SNAI2, EGFR, MYC and CCND1) at 2 h after a GH pulse. This is consistent with prolonged GH signalling acting to promote cancer progression in lung cancer.

Monitoring adolescents and young people with inflammatory bowel disease during transition to adult healthcare

The transition of adolescents and young people (AYP) with inflammatory bowel disease (IBD) from paediatric to adult healthcare requires coordination between healthcare care providers to achieve optimum outcomes. Transition into adulthood is a time of major challenges physically, developmentally, emotionally and psychosocially for AYP living with IBD. Healthcare professionals must monitor the AYP progress proactively with attention to each of these parameters throughout the transition period to ensure that milestones are attained, and skills for self-management are formed. Thus, achieving the desired goals in both clinical and pastoral areas requires intensive monitoring from a multidisciplinary team across healthcare providers.

Outcome of elective withdrawal of anti-tumour necrosis factor-α therapy in patients with Crohn's disease in established remission

BACKGROUND AND AIMS

Outcomes of cessation of anti-TNF therapy for Crohn's disease (CD) in clinical and/or endoscopic remission in routine clinical practice is uncertain. This study aimed to evaluate clinical outcomes and factors associated with relapse in CD patients following formal disease assessment and elective anti-TNF withdrawal.

METHODS

Prospective observational study of CD patients in whom anti-TNF therapy was stopped electively after ≥12months and follow-up of ≥6months. Investigations at assessment prior to cessation included ≥1 of clinical assessment, endoscopic and/or imaging. Relapse was defined as recurrent symptoms of CD requiring medical or surgical therapy.

RESULTS

Eighty-six patients received anti-TNF for a median duration of 23 (12-80) months for severe active luminal (70%), fistulating perianal (25.5%) and other fistulating disease (4.5%). Relapse rates at 90,180 and 365days were 4.7%, 18.6% and 36%, respectively. If anti-TNF dose escalation occurred 6months prior to withdrawal, 88% (7/8) relapsed. Based on multivariate analysis, risk factors for relapse include ileocolonic disease at diagnosis and previous anti-TNF therapy. An elevated faecal calprotectin (FC) is likely to predict relapse (p=0.02), with a PPV of 66.7% at >50μg/g. Of 36 patients who relapsed, 31 were retreated with anti-TNF, with an overall recapture rate of 93%.

CONCLUSION

Relapse rates at 1year following elective withdrawal of anti-TNF are 36%, with high retreatment response rate. Predictors of relapse include ileocolonic involvement, previous anti-TNF therapy and raised FC. Endoscopic/radiologic assessment prior to cessation of therapy does not appear to predict those at lower risk of relapse.

UK guideline on transition of adolescent and young persons with chronic digestive diseases from paediatric to adult care

The risks of poor transition include delayed and inappropriate transfer that can result in disengagement with healthcare. Structured transition care can improve control of chronic digestive diseases and long-term health-related outcomes. These are the first nationally developed guidelines on the transition of adolescent and young persons (AYP) with chronic digestive diseases from paediatric to adult care. They were commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology under the auspices of the Adolescent and Young Persons (A&YP) Section. Electronic searches for English-language articles were performed with keywords relating to digestive system diseases and transition to adult care in the Medline (via Ovid), PsycInfo (via Ovid), Web of Science and CINAHL databases for studies published from 1980 to September 2014. The quality of evidence and grading of recommendations was appraised using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The limited number of studies in gastroenterology and hepatology required the addition of relevant studies from other chronic diseases to be included.These guidelines deal specifically with the transition of AYP living with a diagnosis of chronic digestive disease and/or liver disease from paediatric to adult healthcare under the following headings;1. Patient populations involved in AYP transition2. Risks of failing transition or poor transition3. Models of AYP transition4. Patient and carer/parent perspective in AYP transition5. Surgical perspective.

Systematic review: psychological morbidity in young people with inflammatory bowel disease - risk factors and impacts

BACKGROUND

Psychological morbidity in young people aged 10-24 years, with inflammatory bowel disease (IBD) is increased, but risk factors for and impacts of this are unclear.

AIM

To undertake a systematic literature review of the risk factors for and impact of psychological morbidity in young people with IBD.

METHODS

Electronic searches for English-language articles were performed with keywords relating to psychological morbidity according to DSM-IV and subsequent criteria; young people; and IBD in the MEDLINE, PsychInfo, Web of Science and CINAHL databases for studies published from 1994 to September 2014.

RESULTS

One thousand four hundred and forty-four studies were identified, of which 30 met the inclusion criteria. The majority measured depression and anxiety symptoms, with a small proportion examining externalising behaviours. Identifiable risk factors for psychological morbidity included: increased disease severity (r(2) = 0.152, P < 0.001), lower socioeconomic status (r(2) = 0.046, P < 0.001), corticosteroids (P ≤ 0.001), parental stress (r = 0.35, P < 0.001) and older age at diagnosis (r = 0.28, P = 0.0006). Impacts of psychological morbidity in young people with IBD were wide-ranging and included abdominal pain (r = 0.33; P < 0.001), sleep dysfunction (P < 0.05), psychotropic drug use (HR 4.16, 95% CI 2.76-6.27), non-adherence to medication (12.6% reduction) and negative illness perceptions (r = -0.43).

CONCLUSIONS

Psychological morbidity affects young people with IBD in a range of ways, highlighting the need for psychological interventions to improve outcomes. Identified risk factors provide an opportunity to develop targeted therapies for a vulnerable group. Further research is required to examine groups under-represented in this review, such as those with severe IBD and those from ethnic minorities.

Problems and solutions in delivering global surgery in the 21st century

BACKGROUND

Surgery has had low priority in global health planning, so the delivery of surgical care in low- and middle-income countries is often poorly resourced. A recent Lancet Commission on Global Surgery has highlighted the need for change.

METHODS

A consensus view of the problems and solutions was identified by individual surgeons from high-income countries, familiar with surgical care in remote and poorer environments, based on recent publications related to global surgery.

RESULTS

The major issues identified were: the perceived unimportance of surgery, shortage of personnel, lack of appropriate training and failure to establish surgical standards, failure to appreciate local needs and poor coordination of service delivery.

CONCLUSION

Surgery deserves a higher priority in global health resource allocation. Lessons learned from participation in humanitarian crises should be considered in surgical developments.

Selective non-operative management of penetrating liver injuries at a UK tertiary referral centre

INTRODUCTION

Selective non-operative management (SNOM) of penetrating abdominal injuries has increasingly been applied in North America in the last decade. However, there is less acceptance of SNOM among UK surgeons and there are limited data on UK practice. We aimed to review our management of penetrating liver injuries and, specifically, the application of SNOM.

METHODS

A retrospective review was performed of patients presenting with penetrating liver injuries between June 2005 and November 2013.

RESULTS

Thirty-one patients sustained liver injuries due to penetrating trauma. The vast majority (97%) were due to stab wounds. The median injury severity score was 14 and a quarter of patients had concomitant thoracic injuries. Twelve patients (39%) underwent immediate surgery owing to haemodynamic instability, evisceration, retained weapon or diffuse peritonism. Nineteen patients were stable to undergo computed tomography (CT), ten of whom were selected subsequently for SNOM. SNOM was successful in eight cases. Both patients who failed SNOM had arterial phase contrast extravasation evident on their initial CT. Angioembolisation was not employed in either case. All major complications and the only death occurred in the operatively managed group. No significant complications of SNOM were identified and there were no transfusions in the non-operated group. Those undergoing operative management had longer lengths of stay than those undergoing SNOM (median stay 6.5 vs 3.0 days, p<0.05).

CONCLUSIONS

SNOM is a safe strategy for patients with penetrating liver injuries in a UK setting. Patient selection is critical and CT is a vital triage tool. Arterial phase contrast extravasation may predict failure of SNOM and adjunctive angioembolisation should be considered for this group.

Adsorption uptake of synthetic organic chemicals by carbon nanotubes and activated carbons

Carbon nanotubes (CNTs) have shown great promise as high performance materials for adsorbing priority pollutants from water and wastewater. This study compared uptake of two contaminants of interest in drinking water treatment (atrazine and trichloroethylene) by nine different types of carbonaceous adsorbents: three different types of single walled carbon nanotubes (SWNTs), three different sized multi-walled nanotubes (MWNTs), two granular activated carbons (GACs) and a powdered activated carbon (PAC). On a mass basis, the activated carbons exhibited the highest uptake, followed by SWNTs and MWNTs. However, metallic impurities in SWNTs and multiple walls in MWNTs contribute to adsorbent mass but do not contribute commensurate adsorption sites. Therefore, when uptake was normalized by purity (carbon content) and surface area (instead of mass), the isotherms collapsed and much of the CNT data was comparable to the activated carbons, indicating that these two characteristics drive much of the observed differences between activated carbons and CNT materials. For the limited data set here, the Raman D:G ratio as a measure of disordered non-nanotube graphitic components was not a good predictor of adsorption from solution. Uptake of atrazine by MWNTs having a range of lengths and diameters was comparable and their Freundlich isotherms were statistically similar, and we found no impact of solution pH on the adsorption of either atrazine or trichloroethylene in the range of naturally occurring surface water (pH = 5.7-8.3). Experiments were performed using a suite of model aromatic compounds having a range of π-electron energy to investigate the role of π-π electron donor-acceptor interactions on organic compound uptake by SWNTs. For the compounds studied, hydrophobic interactions were the dominant mechanism in the uptake by both SWNTs and activated carbon. However, comparing the uptake of naphthalene and phenanthrene by activated carbon and SWNTs, size exclusion effects appear to be more pronounced with activated carbon materials, perhaps due to smaller pore sizes or larger adsorption surface areas in small pores.

Red blood cell methotrexate polyglutamate concentrations in inflammatory bowel disease

Methotrexate (MTX) use in inflammatory bowel disease (IBD) is complicated by unpredictable efficacy and toxicity. In rheumatoid arthritis, total and individual red blood cell MTX polyglutamates (RBC MTXGlu1-5) correlate with disease activity and possibly toxicity, and therefore may be useful in guiding treatment. It is unclear if this applies in IBD. The aim of this pilot study was to measure total and individual RBC MTXGlu1-5 concentrations in patients with IBD to see if these relate to efficacy and adverse effects. RBC MTXGlu1--5 concentrations were measured on three occasions in 18 patients with IBD receiving MTX at a constant dose for 3 or more months. The intrapatient variability, expressed as the coefficient of variation, of RBC MTXGlu1-5 concentrations at steady state was determined, and disease activity and adverse effects were assessed against concentrations. The intrapatient coefficients of variation of individual MTXGlu1-5 varied from 12% to 27%. In Crohn's disease, higher RBC MTXGlu4&5 concentrations correlated with worse disease activity (r = 0.42 and 0.53, respectively, P </= 0.03). RBC MTXGlu5 concentrations were higher in patients experiencing at least one adverse effect as a result of MTX compared with those without adverse effects (mean, 26.7 versus 11.1 nmol/8 x 10 RBCs; mean difference, 15.6; 95% confidence interval, 3.5-27.7; P = 0.04). Similar trends were observed for RBC MTXGlu4. Furthermore, patients who specifically experienced gastrointestinal adverse effects had higher RBC MTXGlu4&5 concentrations than patients without (P = 0.03 and 0.04, respectively). In summary, RBC MTXGlu1-5 concentrations can be measured accurately with low intrapatient variation. Unexpectedly, RBC MTXGlu4&5 concentrations correlated inversely with efficacy in Crohn's disease. RBC MTXGlu4&5 concentrations were higher in patients experiencing adverse effects. These findings suggest that RBC MTXGlu1-5 concentration monitoring may be of value in IBD and could assist with planning of larger studies.

Training For Overseas Operational Deployments And The DMCC

Through the DMCC and similar comprehensive training, Military and NGO personnel can prepare for deployment with a greater understanding of the issues that will confront them whilst there. Progression through the modules will provide them with a greater skill set to meet the challenges that await them and allow them to be an effective and valuable member of the team.

Information required to provide informed consent for endoscopy: an observational study of patients' expectations

BACKGROUND AND STUDY AIMS

The aim of this study was to determine how much information patients require about the risk of complications in order to provide informed consent to undergo endoscopy.

PATIENTS AND METHODS

Endoscopic complications and their consequences were discussed with consecutive patients who had undergone endoscopy. The patients were asked how common each complication would have to be for them to require information about the complication before providing adequately informed consent.

RESULTS

Data were obtained from 150 gastroscopy patients (51% male, median age 55.5 years) and 150 colonoscopy patients (60% male, median age 54.4 years). Patients in both groups were more likely to want to know about major rather than minor complications at a lower level of risk (P < 0.001 at a risk greater than one in 1000). Similar proportions of gastroscopy patients (n = 29, 19%) and colonoscopy patients (n = 21, 14 %) wanted to know about all possible complications, no matter how inconsequential or rare. Colonoscopy patients were less likely to want no information about any complications than gastroscopy patients (n = 1, 0.7% and n = 15, 10%, respectively; P < 0.001).

CONCLUSIONS

The information patients require in order to provide informed consent is very variable. Many appear to make a judgement about the need for information depending on the perceived severity of the complication, but some want information about all complications, irrespective of risk and severity. The level of risk at which they require this information is likely to be higher than the level used by doctors who are obtaining consent from patients. The process may be improved by providing procedure-specific information leaflets that offer information regarding common and serious complications.

Synchronous liver resection and cryotherapy for colorectal metastases: survival analysis

INTRODUCTION

The value of synchronous liver resection and cryotherapy ablation remains controversial for colorectal metastases where complete resection is not possible by conventional liver surgery alone.

OBJECTIVE

To review the long-term survival of patients treated using this approach at our institution.

METHODS

A review was undertaken of data held in the prospectively collected liver surgery database of all patients who underwent synchronous liver resection and cryotherapy. Survival analysis was performed and data recorded on the total number of metastases at initial surgery and the number of lesions treated by cryoablation.

RESULTS

Ninety-three patients with colorectal metastases underwent synchronous liver resection and cryotherapy. Data were available on 86 patients with a median follow-up of 18 months (range 1-83). The median number of metastases at initial surgery was four (range 2-11) and the number of lesions treated by cryotherapy ablation was two (range 1-8). Eighty-four per cent had a hepatic artery catheter inserted at surgery and at least one cycle of post-operative hepatic artery chemotherapy. One-, three- and five-year survival was 85%, 43% and 19% respectively, with a median survival of 33 months (95% confidence interval 19.9-42.1). Site of recurrence was recorded and presented.

CONCLUSIONS

Patients with liver metastases that are not amenable to resection alone can achieve worthwhile median survival with synchronous liver resection and cryotherapy ablation.

Validation of direct intraabdominal pressure measurement using a continuous indwelling compartment pressure monitor

BACKGROUND

According to recommendations, intraabdominal pressure should be monitored every 8 hours for patients at high risk of abdominal compartment syndrome. Continuous intraabdominal pressure monitoring may be valuable for these patients.

METHODS

For 15 patients undergoing laparoscopic surgery, a pressure monitor was introduced after formation of pneumoperitoneum. During the procedure, the laparoscopic insufflator pressure was varied. The pressure monitor values and the time to equilibrium were recorded.

RESULTS

Altogether, 152 pressure recordings were taken for the patients studied. The measurements from the insufflator and pressure monitor were compared using a Bland-Altman plot. The mean difference between the techniques was 0.04 +/- 3.8, and 95% of the points from the pressure monitor were within two standard deviations of the mean difference. Pressure changes were essentially "real time."

CONCLUSIONS

The intracompartmental pressure monitor provides accurate, rapid, and direct measurement of intraabdominal pressure, and may be a useful tool for continuous intraabdominal pressure measurement among patients at risk of abdominal compartment syndrome.

Ultrasound-guided insertion of subclavian venous access ports

INTRODUCTION

Central venous cannulation is an integral part of venous access port (portacath) placement for intravenous chemotherapy. NICE guidelines have suggested that CVC should be performed under ultrasound guidance. The technique of ultrasound-guided subclavian cannulation is reviewed and our experience presented.

PATIENTS AND METHODS

Retrospective analysis of data on patients undergoing ultrasound-guided portacath placement for the failure rate and the incidence of complications.

RESULTS

We were successful in cannulating the subclavian vein in 44 of 55 patients. There was one arterial puncture and no haemothorax or pneumothorax with the technique (complication rate 1.8%).

CONCLUSION

An ultrasound-guided approach should be the standard technique for central venous cannulation in portacath placement.

Handheld ultrasound diagnosis of extremity fractures

Hand portable ultrasound has been validated in trauma patients using the FAST technique. The machine's light and rugged design make it suitable for military deployment and they have been successfully used on deployments in Kosovo, Afghanistan and Iraq. Ultrasound is widely accepted in the diagnosis of abdominal and thoracic trauma, however, little work exists on its use in extremity trauma. Although the diagnosis of fractures usually relies on X-ray this may not be readily available at Role 1 or 2. We successfully identified long bone fractures in three patients using hand portable ultrasound during Operation Telic. The technique and ultrasound findings are described and the current literature on this technique is reviewed.

Liver tissue partial pressure of oxygen and carbon dioxide during partial hepatectomy

BACKGROUND

Data on tissue oxygen partial pressure (PtO2) and carbon dioxide partial pressure (PtCO2) in human liver tissue are limited. We set out to measure changes in liver PtO2 and PtCO2 during changes in ventilation and a 10 min period of ischaemia in patients undergoing liver resection using a multiple sensor (Paratrend Diametrics Medical Ltd, High Wycombe, UK).

METHODS

Liver tissue oxygenation was measured in anaesthetized patients undergoing liver resection using a sensor inserted under the liver capsule. PtO2 and PtCO2 were recorded with FIO2 values of 0.3 and 1.0, at end-tidal carbon dioxide partial pressures of 3.5 and 4.5 kPa and 10 min after the onset of liver ischaemia (Pringle manoeuvre).

RESULTS

Data are expressed as median (interquartile range). Increasing the FIO2 from 0.3 to 1.0 resulted in the PtO2 changing from 4.1 (2.6-5.4) to 4.6 (3.8-5.2) kPa, but this was not significant. During the 10 min period of ischaemia PtCO2 increased significantly (P<0.05) from 6.7 (5.8-7.0) to 11.5 (9.7-15.3) kPa and PtO2 decreased, but not significantly, from 4.3 (3.5-12.0) to 3.3 (0.9-4.1) kPa.

CONCLUSION

PtO2 and PtCO2 were measured directly using a Paratrend sensor in human liver tissue. During anaesthesia, changes in ventilation and liver blood flow caused predictable changes in PtCO2.

Improved clinical status in fibromyalgia patients treated with individualized homeopathic remedies versus placebo

OBJECTIVE

To assess the efficacy of individualized classical homeopathy in the treatment of fibromyalgia.

METHODS

This study was a double-blind, randomized, parallel-group, placebo-controlled trial of homeopathy. Community-recruited persons (N = 62) with physician-confirmed fibromyalgia (mean age 49 yr, s.d. 10 yr, 94% women) were treated in a homeopathic private practice setting. Participants were randomized to receive oral daily liquid LM (1/50,000) potencies with an individually chosen homeopathic remedy or an indistinguishable placebo. Homeopathic visits involved joint interviews and concurrence on remedy selection by two experienced homeopaths, at baseline, 2 months and 4 months (prior to a subsequent optional crossover phase of the study which is reported elsewhere). Tender point count and tender point pain on examination by a medical assessor uninvolved in providing care, self-rating scales on fibromyalgia-related quality of life, pain, mood and global health at baseline and 3 months, were the primary clinical outcome measures for this report.

RESULTS

Fifty-three people completed the treatment protocol. Participants on active treatment showed significantly greater improvements in tender point count and tender point pain, quality of life, global health and a trend toward less depression compared with those on placebo.

CONCLUSIONS

This study replicates and extends a previous 1-month placebo-controlled crossover study in fibromyalgia that pre-screened for only one homeopathic remedy. Using a broad selection of remedies and the flexible LM dose (1/50,000 dilution factor) series, the present study demonstrated that individualized homeopathy is significantly better than placebo in lessening tender point pain and improving the quality of life and global health of persons with fibromyalgia.

Characterisation of inter- and intra-molecular interactions of the dengue virus RNA dependent RNA polymerase as potential drug targets

Our research is directed towards enhancing the understanding of the molecular biology of dengue virus replication with the ultimate goal being to develop novel antiviral strategies based on preventing critical inter- or intra-molecular interactions required for the normal virus life cycle. The viral RNA-dependent RNA polymerase (NS5) and the viral helicase (NS3) interaction offers a possible target for inhibitors to bind and prevent replication. In this study the yeast-two hybrid system was used to show that a small region of NS5 interacts with NS3, and also with the cellular nuclear transport receptor importin-beta. Furthermore, intramolecular interaction between the two putative domains of NS5 can also be detected by the yeast two-hybrid assay. We have also modified the colony lift assay for the beta-galactosidase reporter activity in intact yeast cells which reflects the strength of interaction between two proteins to a microtiter plate format. This assay offers a unique opportunity to screen for small molecule compounds that block physiologically important interactions.

Infection of Psoroptes mites with the fungus Metarhizium anisopliae

The astigmatid mite, Psoroptes ovis (Hering) (Acari: Psoroptidae), is an obligatory ectoparasite that causes psoroptic mange in a range of domesticated animals, particularly sheep, where the clinical disease is known as sheep scab. A series of laboratory assays were used to assess the use of the fungus, Metarhizium anisopliae (Metchnikoff) (Deuteromycotina: Hyphomycetes) as a biocontrol agent for P. ovis derived from rabbits (syn. P. cuniculi). The immersion of mites in a suspension of conidia of M. anisopliae resulted in the acquisition of fatal infections. The number of mites which developed infections increased significantly with the increasing concentration of the conidial suspension to which they were exposed; 77% of mites developed infections when exposed to the highest concentration used (1 x 10(8) conidia ml(-1)). Controls developed no fungal infections. Mites allowed simply to walk across a surface which had been treated with a suspension of conidia also acquired fungal infections; the number infected was again related to the concentration of conidia present. After contact for 24 h with a surface treated with 1 x 10(8) conidia ml(-1), 73% of the mites became infected. To determine whether dead infected mites could act as sources of infection, infected cadavers were placed in chambers with live uninfected mites. The uninfected mites acquired fatal infections from the cadavers; a higher ratio of infected cadavers to uninfected mites resulted in greater transmission of infection. The time after death of the infected cadaver was also an important factor influencing the number infected, 5-day-old cadavers were the most infective and 18-day-old cadavers the least infective. The results indicate that M. anisopliae is a good candidate control agent for Psoroptes mites.

A meta-analytic approach to growth curve analysis

A meta-analytic approach to growth curve analysis is described and illustrated by applying it to the evaluation of the Arizona Pilot Project, an experimental project for financing the treatment of the severely mentally ill. In this approach to longitudinal data analysis, each individual subject for which repeated measures are obtained is initially treated as a separate case study for analysis. This approach has at least two distinct advantages. First, it does not assume a balanced design (equal numbers of repeated observations) across all subjects; to accommodate a variable number of observations for each subject, individual growth curve parameters are differentially weighted by the number of repeated measures on which they are based. Second, it does not assume homogeneity of treatment effects (equal slopes) across all subjects. Individual differences in growth curve parameters representing potentially unequal developmental rates through time are explicitly modeled. A meta-analytic approach to growth curve analysis may be the optimal analytical strategy for longitudinal studies where either (1) a balanced design is not feasible or (2) an assumption of homogeneity of treatment effects across all individuals is theoretically indefensible. In our evaluation of the Arizona Pilot Project, individual growth curve parameters were obtained for each of the 13 rationally derived subscales of the New York Functional Assessment Survey, over time, by linear regression analysis. The slopes, intercepts, and residuals obtained for each individual were then subjected to meta-analytic causal modeling. Using factor analytic models and then general linear models for the latent constructs, the growth curve parameters of all individuals were systematically related to each other via common factors and predicted based on hypothesized exogenous causal factors. The same two highly correlated common factors were found for all three growth curve parameters analyzed, a general psychological factor and a general functional factor. The factor patterns were found to be nearly identical across the separate analyses of individual intercepts, slopes, and residuals. Direct effects on the unique factors of each subscale of the New York Functional Assessment Survey were tested for each growth curve parameter by including the common factors as hierarchically prior predictors in the structural model for each of the indicator variables, thus statistically controlling for any indirect effect produced on the indicator through the common factors. The exogenous predictors modeled were theoretically specified orthogonal contrasts for Method of Payment (comparing Arizona Pilot Project treatment or "capitation" to traditional or "fee-for-service" care as a control), Treatment Administration Site (comparing various locations within treatment or control groups), Pretreatment Assessment (comparing general functional level at intake as assigned by an Outside Assessment Team), and various interactions among these main effects. The intercepts, representing the initial status of individual subjects on both the two common factors and the 13 unique factors of the subscales of the New York Functional Assessment Survey, were found to vary significantly across many of the various different treatment conditions, treatment administration sites, and pretreatment functional levels. This indicated a severe threat to the validity of the originally intended design of the Arizona Pilot Project as a randomized experiment. When the systematic variations were statistically controlled by including intercepts as hierarchically prior predictors in the structural models for slopes, recasting the experiment as a nonequivalent groups design, the effects of the intercepts on the slopes were found to be both statistically significant and substantial in magnitude. (ABSTRACT TRUNCATED)

Education of the trauma team: video evaluation of the compliance with universal barrier precautions in resuscitation

OBJECTIVE

To assess the effectiveness of an educational symposium designed to improve compliance with universal barrier precautions by the use of video analysis of resuscitations.

DESIGN

Prospective single blind analysis of data.

SETTING

Hospital Trauma Unit, Johannesburg, South Africa.

SUBJECTS

100 severely injured patients who presented to the emergency room, divided into two study periods.

INTERVENTIONS

An educational symposium held between the study periods, which focused on universal barrier precautions and the risk of occupational transmission of HIV.

MAIN OUTCOME MEASURES

Compliance with items of universal precautions; mechanism; Injury Severity Score and Revised Trauma Score.

RESULTS

There was a significant improvement in compliance from 48% to 74% after the symposium (p = 0.007), with specific improvement in the wearing of masks and visors. Initially there was poor compliance with universal precautions in severely injured patients, which significantly improved to 83% compliance (p = 0.0004).

CONCLUSION

Video analysis of resuscitations is an effective audit and educational tool that allows analysis of compliance with protocol. The education symposium was effective in altering attitudes and behaviour towards universal barrier precautions.

AKA unknown male Foxtrot 23/4: alias assignment for unidentified emergency room patients

OBJECTIVES

To introduce a unique system of alias assignment for patients whose identity is initially unknown at time of admission to the emergency unit; to prevent confusion and cases of mistaken identity.

METHODS

At the triage area the "unknown" patient is given a "forename" using the phonetic alphabet according to the stage of the current name cycle. The sex of the patient is included as well as the unknown status and a "surname" is added as the numerical date. Thus an unknown male patient admitted on the 24th of April at the start of a new name cycle would be known as "unknown male Alpha 24/4".

RESULTS

Ten thousand alias assignments have been issued to patients since the introduction of the system in 1985.

CONCLUSION

This system is a simple yet effective, tried and tested method for the unique identification of unknown patients, which allows easy communication and retrieval of data for inquiries.

Blunt abdominal injuries

The management of blunt abdominal injury (BAI) has undergone quite significant changes over recent years. The emphasis is now on the recognition and limitation of the underlying metabolic insult associated with severe abdominal injury. The concepts of damage control and non-operative management while seeming diametrically opposed have both found favour in selected patient groups. The interventional radiologist has opened a new dimension in the control of inaccessible bleeding and is able to contribute to non-operative approaches. The complimentary use of the methods of investigation available for BAI will also improve the accuracy and specificity of diagnosis allowing more appropriate management. Embracing these new concepts of management by all institutions dealing with trauma victims will hopefully reduce the morbidity and mortality of BAI.

Carotid string sign resulting from an aberrant branch of the internal carotid artery

Branches of the extracranial internal carotid artery are very rare. A case is reported wherein an aberrant artery originated from the bulb of the internal carotid artery (ICA) approximately 2 cm from the bifurcation. The ICA was occluded distal to the branch's origin. Arteriography in this case gave the appearance of a carotid "string sign". Vascular surgeons and radiologists should be aware of this anomaly when interpreting carotid arteriograms.

A family based model of Hispanic adolescent substance use

While adolescent substance use has been the focus of extensive research over the last few decades, Hispanic adolescent substance use has received only limited attention. Studies exploring predictors of Hispanic adolescent substance use have failed to adequately explore the contribution of the family on substance use. The present study examined the relative influence of family, school and peer influences, perceived student substance use, family substance use, and acculturation on a sample of Mexican-American early adolescents using structural equations modeling. The findings varied for males and females. Family functioning and family use directly influenced substance use for males. Family functioning influenced school and peer variables, however, these were unrelated to use. For females, family use and student use directly influenced substance use. Family functioning influenced family use and school and peer attachments. School and peer attachment predicted perceived student use. These findings suggest that family functioning has a primary role in Hispanic adolescent substance use.

Medication management issues for adolescents with asthma

Issues related to medication use by teens with asthma were studied. Adolescents 13-17 years old who were receiving drug therapy for asthma were recruited to participate in focus groups. Facilitators asked open-ended questions, and the discussion was recorded and coded for content. Participants were asked to complete questionnaires covering attitudes and beliefs, family issues, and communication with physicians and pharmacists. Of 28 teens participating in the focus groups, 26 returned completed questionnaires. The teens considered themselves compliant with medication therapy. They said they talked more to physicians than to pharmacists and received more oral and written information from the physicians. Focus group responses indicated that teens wanted complete responsibility for taking their medications and experienced conflict with adults--parents, teachers, school nurses, and physicians--about medication use. The teens were concerned about adverse effects and the cost of medications and wanted more information about asthma and its treatment. The teens did not disobey their parents or physicians by refusing to take their medications, and peers did not have a negative influence on the teens' asthma management. The primary medication issue for this group of adolescents was managing their medication to control their asthma in spite of inappropriate rules or behavior by adults.

Extracorporeal shock-wave lithotripsy. Initial Australian experience

Fifty patients were treated with extracorporeal shock-wave lithotripsy for upper urinary tract calculi. The procedure was performed by means of either epidural or general anaesthesia. There were minimal postoperative complications with a mean length of stay of 3.6 days. Six patients required a repeat extracorporeal shock-wave lithotripsy procedure for residual fragments during their initial admission to hospital. Forty (80%) patients were free of all stone fragments within one month of their discharge from hospital. Three patients have residual fragments of greater than 2 mm in axial length. The remainder underwent other procedures to remove residual stones or will be treated with further extracorporeal shock-wave lithotripsy therapy.

A comparison of flushing fluids for initial perfusion of kidneys for transplantation

Four solutions for initial flushing of kidneys prior to transplantation were tested under conditions designed to resemble those of clinical cadaveric donor renal transplantation. The experimental model was the dog subjected to bilateral nephrectomy with renal autograft. Kidney grafts were subjected to 15 minutes' anoxia in vivo, 30 minutes' warm ischaemia at 37 degrees C ex vivo, and two hours' cold ischaemia before reimplantation. The four solutions used were Collins (C3), Perfudex (P), hyperosmolar citrate (HC), and a solution of bovine albumin containing dog red blood cells (BBA). Effects of the flushing fluids were compared by parameters relating to dog survival, renal function, and serum enzyme levels. With all parameters studied the best results occurred in HC perfused kidneys. Results with BBA perfusion were marginally worse, while C3 perfused kidneys were again inferior. P perfused kidneys clearly did least well. The results support the use of HC for clinical application.

Distal lower limb arterial reconstruction with modified allograft saphenous veins

Cadaveric donor saphenous veins subjected to proteolytic enzymatic digestion, crossbonding and heparin bonding were used for arterial reconstruction in the legs of 13 patients threatened with amputation and without suitable autogenous saphenous veins. Distal anastomoses were to the tibial and peroneal vessels. Twelve patients (92 per cent) were discharged from hospital with functioning grafts; 9 grafts (69 per cent) continue to function 2-16 (average 8) months after operation. Amputation was avoided in 11 patients (85 per cent). Although early results are encouraging, late results are yet to be determined.