Influenza vaccination during the 2021/22 season: A data-linkage test-negative case-control study of effectiveness against influenza requiring emergency care in England and serological analysis of primary care patients

We present England 2021/22 end-of-season adjusted vaccine effectiveness (aVE) against laboratory confirmed influenza related emergency care use in children aged 1-17 and in adults aged 50+, and serological findings in vaccinated vs unvaccinated adults by hemagglutination inhibition assay. Influenza vaccination has been routinely offered to all children aged 2-10 years and adults aged 65 years + in England. In 2021/22, the offer was extended to children to age 15 years, and adults aged 50-64 years. Influenza activity rose during the latter half of the 2021/22 season, while remaining comparatively low due to COVID-19 pandemic control measures. Influenza A(H3N2) strains predominated. A test negative design was used to estimate aVE by vaccine type. Cases and controls were identified within a sentinel laboratory surveillance system. Vaccine histories were obtained from the National Immunisation Management Service (NIMS), an influenza and COVID-19 vaccine registry. These were linked to emergency department presentations (excluding accidents) with respiratory swabbing ≤ 14 days before or ≤ 7 days after presentation. Amongst adults, 423 positive and 32,917 negative samples were eligible for inclusion, and 145 positive and 6,438 negative samples among children. Those admitted to hospital were further identified. In serology against the circulating A(H3N2) A/Bangladesh/4005/2020-like strain, 61 % of current season adult vaccinees had titres ≥ 1:40 compared to 17 % of those unvaccinated in 2020/21 or 2021/22 (p < 0.001). We found good protection from influenza vaccination against influenza requiring emergency care in children (72.7 % [95 % CI 52.7, 84.3 %]) and modest effectiveness in adults (26.1 % [95 % CI 4.5, 42.8 %]). Adult VE was higher for A(H1N1) (81 % [95 % CI 50, 93 %]) than A(H3N2) (33 % [95 % CI 6, 53 %]). Consistent protection was observable across preschool, primary and secondary school aged children. Imperfect test specificity combined with very low prevalence may have biased estimates towards null. With limited influenza circulation, the study could not determine differences by vaccine types.

COVID-19 vaccination coverage for half a million non-EU migrants and refugees in England

Despite evidence suggesting that some migrants are at risk of under-immunization and have experienced severe health inequities during the pandemic, data are limited on migrants' COVID-19 vaccine coverage globally. Here we linked data from non-European Union migrants and resettled refugees to the national COVID-19 vaccination dataset in England. We estimated patterns in second and third dose delays and overdue doses between 12 December 2020 and 20 April 2022 by age, visa type and ethnicity. Of the 465,470 linked records, 91.8% (427,073/465,470) of migrants received a second dose and 51.3% (238,721/465,470) received a third. Refugees had the highest risk of delayed second (adjusted odds ratio 1.66; 95% confidence interval 1.55-1.79) and third dose (1.55; 1.43-1.69). Black migrants were twice as likely to have a second dose delayed (2.37; 2.23-2.54) than white migrants, but this trend reversed for the third dose. Older migrants (>65 years) were four times less likely to have received their second or third dose compared with the general population in England aged >65 or older. Policymakers, researchers and practitioners should work to understand and address personal and structural barriers to vaccination for diverse migrant populations.

Comparison of the Physical Function Trajectories in Three Birth Cohorts of Chinese Older Adults: A 14-Year Longitudinal Study

OBJECTIVES

It remains uncertain whether the favorable trend of reduction in physical disabilities has become reversed in the recent-born cohorts of older adults. This study aimed to compare the rate of decline with time in self-reported Instrumental Activity of Daily Living (IADL) difficulties, objective measurement of gait speed and grip strength, in three birth cohorts of Chinese older adults.

DESIGN

A prospective cohort study.

SETTING AND PARTICIPANTS

Four thousand Chinese older adults aged 65 years or above in three birth cohorts (1934-1938, 1929-1933, 1905-1928) were recruited from the community in Hong Kong.

MEASUREMENTS

Grip strength, gait speed and IADL difficulties were measured between 2001 to 2017. Joint models were used to examine the trajectories of grip strength, gait speed and IADL difficulties over time, and the interaction effect of age-by-cohort (or also age2-by-cohort) was also examined.

RESULTS

The recently born cohort (1934 - 1938) had worse grip strength and more IADL difficulties at the same age than the earlier two cohorts (1929 - 1933; 1905 - 1928). Furthermore, the most recently born cohort also followed a more rapid decline longitudinally with a greater decline observed in gait speed, grip strength and IADL difficulties for women whereas a greater decline in grip strength and IADL difficulties for men.

CONCLUSIONS

The continuous improvement of physical limitations in old age may have halted and there appears to be a reversal of this favourable trend in the recent born cohort of older adults living in Hong Kong.

Real-world treatment sequencing and survival in previously treated advanced renal cell carcinoma patients receiving nivolumab monotherapy: a UK retrospective cohort study

Background

The CheckMate 025 trial established nivolumab monotherapy as one of the standards of care in previously treated advanced or metastatic renal cell carcinoma (aRCC). However, supporting real-world data is lacking. This study investigated characteristics, treatment sequences and clinical outcomes of patients who received nivolumab monotherapy for previously treated aRCC in the UK.

Methods

This was a retrospective cohort study of aRCC patients treated with nivolumab at second line or later (2L +) at 4 UK oncology centres. Eligible patients commenced nivolumab (index date) between 01 March 2016 and 30 June 2018 (index period). Study data were extracted from medical records using an electronic case report form. Data cut-off (end of follow-up) was 31 May 2019.

Results

In total, 151 patients were included with median follow-up of 15.2 months. Mean age was 66.9 years, male preponderance (72.2%), and mostly Eastern Cooperative Oncology Group performance status grade 0–1 (71.5%). Amongst 112 patients with a known International Metastatic RCC Database Consortium score, distribution between favourable, intermediate, and poor risk categories was 20.5%, 53.6%, and 25.9% respectively.

The majority of patients (n = 109; 72.2%) received nivolumab at 2L, and these patients had a median overall survival (OS) of 23.0 months [95% confidence interval: 17.2, not reached]. All patients who received nivolumab at 2L had received TKIs at 1L. Amongst the 42 patients (27.8%) who received nivolumab in third line or later (3L +) the median OS was 12.4 months [95% CI: 8.8, 23.2]. The most common reasons for nivolumab discontinuation were disease progression (2L: 61.2%; 3L: 68.8%) and adverse events (2L: 34.7%; 3L: 28.1%).

Conclusion

This study provides real-world evidence on the characteristics, treatment sequences, and outcomes of aRCC patients who received 2L + nivolumab monotherapy in the UK. Nivolumab-specific survival outcomes were similar to those achieved in the CheckMate 025 trial.

Characteristics associated with COVID-19 vaccine uptake among adults aged 50 years and above in England (8 December 2020-17 May 2021): a population-level observational study

OBJECTIVE

To determine characteristics associated with COVID-19 vaccine coverage among individuals aged 50 years and above in England since the beginning of the programme.

DESIGN

Observational cross-sectional study assessed by logistic regression and mean prevalence margins.

SETTING

COVID-19 vaccinations delivered in England from 8 December 2020 to 17 May 2021.

PARTICIPANTS

30 624 257/61 967 781 (49.4%) and 17 360 045/61 967 781 (28.1%) individuals in England were recorded as vaccinated in the National Immunisation Management System with a first dose and a second dose of a COVID-19 vaccine, respectively.

INTERVENTIONS

Vaccination status with COVID-19 vaccinations.

MAIN OUTCOME MEASURES

Proportion, adjusted ORs and mean prevalence margins for individuals not vaccinated with dose 1 among those aged 50-69 years and dose 1 and 2 among those aged 70 years and above.

RESULTS

Of individuals aged 50 years and above, black/African/Caribbean ethnic group was the least likely of all ethnic groups to be vaccinated with dose 1 of the COVID-19 vaccine. However, of those aged 70 years and above, the odds of not having dose 2 was 5.53 (95% CI 5.42 to 5.63) and 5.36 (95% CI 5.29 to 5.43) greater among Pakistani and black/African/Caribbean compared with white British ethnicity, respectively. The odds of not receiving dose 2 was 1.18 (95% CI 1.16 to 1.20) higher among individuals who lived in a care home compared with those who did not. This was the opposite to that observed for dose 1, where the odds of being unvaccinated was significantly higher among those not living in a care home (0.89 (95% CI 0.87 to 0.91)).

CONCLUSIONS

We found that there are characteristics associated with low COVID-19 vaccine coverage. Inequalities, such as ethnicity are a major contributor to suboptimal coverage and tailored interventions are required to improve coverage and protect the population from SARS-CoV-2.

Impact of the childhood influenza vaccine programme on antibiotic prescribing rates in primary care in England

Vaccines are a key part of the global strategy to tackle antimicrobial resistance (AMR) since prevention of infection should reduce antibiotic use. England commenced national rollout of a live attenuated influenza vaccine (LAIV) programme for children aged 2-3 years together with a series of geographically discrete pilot areas for primary school age children in 2013 extending to older children in subsequent seasons. We investigated vaccine programme impact on community antibiotic prescribing rates. Antibiotic prescribing incidence rates for respiratory (RTI) and urinary tract infections (UTI; controls) were calculated at general practice (GP) level by age category (children<=10 years/adults) and season for LAIV pilot and non-pilot areas between 2013/14 and 2015/16. To estimate the LAIV (primary school age children only) intervention effect, a random effects model was fitted. A multivariable random-effects Poisson regression investigated the association of antibiotic prescribing rates in children with LAIV uptake (2-3-year-olds only) at GP practice level. RTI antibiotic prescribing rates for children <=10 years and adults showed clear seasonal trends and were lower in LAIV-pilot and non-pilot areas after the introduction of the LAIV programme in 2013. The reductions for RTI prescriptions (children) were similar (within 3%) in all areas, which coincided with the start the UK AMR strategy. Antibiotic prescribing was significantly (p < 0.0001) related to LAIV uptake in 2-3-year-olds with antibiotic prescribing reduced by 2.7% (95% CI: 2.1% to 3.4%) for every 10% increase in uptake. We found no evidence the LAIV programme for primary school age children resulted in reductions in RTI antibiotic prescribing, however we detected a significant inverse association between increased vaccine uptake in pre-school age children and antibiotic prescribing at GP level. The temporal association of reduced RTI and UTI antibiotic prescribing with the launch of the UK's AMR Strategy in 2013 highlights the importance of a multifaceted approach to tackle AMR.

127 Electronic Collection of Patient-Reported Outcomes Following Discharge After Surgery: A Systematic Review

Aim

Little is known about the electronic collection and clinical feedback of patient reported outcomes (ePROs) post-surgical discharge. This review summarised the evidence on the collection and uses of electronic systems to collect PROs after discharge from hospital following surgery.

Method

Systematic searches of Medline, Embase, PsycINFO, CINAHL and Cochrane Central were undertaken from database inception to July 2019 using terms for “patient reported outcomes”, “electronic”, “surgery” and “at home”. Primary research of all study designs was included if they used electronic systems to collect PRO data away from formal health care settings. Only studies in adult patients admitted for surgery then discharged from hospital were eligible.

Results

From 9,474 records identified, 15 studies were reviewed including three randomised controlled trials. Seven studies were in orthopaedic surgery. Most studies used commercial ePRO systems (n = 9/12). Six studies reported types of electronic devices used to collect data: tablets or other portable devices (n = 3), smartphones (n = 2), combination of smartphones, tablets/portable devices and computers (n = 1). Systems had limited features or functions such as real-time feedback to clinicians (n = 6) and messaging service for patients to communicate with care teams (n = 3). No studies described integration of the ePRO system with electronic health records to support clinical feedback.

Conclusions

There is limited reporting of ePRO systems in the surgical literature. ePRO systems lack integration with hospital clinical systems. Future research should describe the ePRO system and ePRO questionnaires used, and challenges encountered during the study, to support efficient upscaling of ePRO systems using tried and tested approaches.

Impact of COVID-19 vaccination program on seroprevalence in blood donors in England, 2021

The COVID-19 vaccination programme commenced in England on 8th December 2020 primarily based on age; by 7th March 2021 approximately 93% of the English population aged 70+ years had received at least 1 dose of either the Pfizer BioNTech or AstraZeneca vaccines. Using a nucleoprotein assay that detects antibodies following natural infection only and a spike assay that detects infection and vaccine-induced responses, we aim to describe the impact of vaccination on SARS-CoV-2 antibody prevalence in English blood donors.

Electronic collection of patient-reported outcomes following discharge after surgery: systematic review

Background

Little is known about the electronic collection and clinical feedback of patient-reported outcomes (ePROs) following surgical discharge. This systematic review summarized the evidence on the collection and uses of electronic systems to collect PROs after discharge from hospital after surgery.

Method

Systematic searches of MEDLINE, Embase, PsycINFO, CINAHL and Cochrane Central were undertaken from database inception to July 2019 using terms for ‘patient reported outcomes’, ‘electronic’, ‘surgery’ and ‘at home’. Primary research of all study designs was included if they used electronic systems to collect PRO data in adults after hospital discharge following surgery. Data were collected on the settings, patient groups and specialties, ePRO systems (including features and functions), PRO data collected, and integration with health records.

Results

Fourteen studies were included from 9474 records, including two RCTs and six orthopaedic surgery studies. Most studies (9 of 14) used commercial ePRO systems. Six reported types of electronic device were used: tablets or other portable devices (3 studies), smartphones (2), combination of smartphones, tablets, portable devices and computers (1). Systems had limited features and functions such as real-time clinical feedback (6 studies) and messaging service for patients with care teams (3). No study described ePRO system integration with electronic health records to support clinical feedback.

Conclusion

There is limited reporting of ePRO systems in the surgical literature, and ePRO systems lack integration with hospital clinical systems. Future research should describe the ePRO system and ePRO questionnaires used, and challenges encountered during the study, to support efficient upscaling of ePRO systems using tried and tested approaches.

Optimizing the design of invasive placebo interventions in randomized controlled trials

Background

Placebo‐controlled trials play an important role in the evaluation of healthcare interventions. However, they can be challenging to design and deliver for invasive interventions, including surgery. In‐depth understanding of the component parts of the treatment intervention is needed to ascertain what should, and should not, be delivered as part of the placebo. Assessment of risk to patients and strategies to ensure that the placebo effectively mimics the treatment are also required. To date, no guidance exists for the design of invasive placebo interventions. This study aimed to develop a framework to optimize the design and delivery of invasive placebo interventions in RCTs.

Methods

A preliminary framework was developed using published literature to: expand the scope of an existing typology, which facilitates the deconstruction of invasive interventions; and identify placebo optimization strategies. The framework was refined after consultation with key stakeholders in surgical trials, consensus methodology and medical ethics.

Results

The resulting DITTO framework consists of five stages: deconstruct treatment intervention into constituent components and co‐interventions; identify critical surgical element(s); take out the critical element(s); think risk, feasibility and role of placebo in the trial when considering remaining components; and optimize placebo to ensure effective blinding of patients and trial personnel.

Conclusion

DITTO considers invasive placebo composition systematically, accounting for risk, feasibility and placebo optimization. Use of the framework can support the design of high‐quality RCTs, which are needed to underpin delivery of healthcare interventions.

Assessment of Effectiveness of Seasonal Influenza Vaccination During Pregnancy in Preventing Influenza Infection in Infants in England, 2013-2014 and 2014-2015

Maternal influenza vaccination is increasingly recognized to protect infants from influenza infection in their first 6 months. We used the screening method to estimate vaccine effectiveness (VE) against laboratory-confirmed influenza in infants in England, using newly available uptake data from the Clinical Practice Research Datalink pregnancy register, matched on week of birth and region and adjusted for ethnicity. We found VE of 66% (95% confidence interval [CI], 18%-84%) in the 2013-2014 season and 50% (95% CI, 11%-72%) in 2014-2015, with similar VE against influenza-related hospitalization. VE against the dominant circulating influenza strain was higher, at 78% (95% CI, 16%-94%) against H1N1 in 2013-2014, and 60% (95% CI, 16%-81%) against H3N2 in 2014-2015.

Antioxidant Rich Potato Improves Arterial Stiffness in Healthy Adults

Arterial stiffness is an emerging risk factor for cardiovascular disease and dietary anthocyanins may be important in mediating vascular tone. The present study investigated the effect of consumption of an anthocyanin-rich potato, Purple Majesty on arterial stiffness measured as pulse wave velocity in 14 healthy male and female adults. Participants consumed 200 g/day of cooked purple potato containing 288 mg anthocyanins, or a white potato containing negligible anthocyanins for 14 days, separated by a 7-day washout period. Non-invasive assessment of vascular tone by pulse wave velocity was determined in addition to systolic and diastolic blood pressure, high-density lipoproteins, low-density lipoproteins, triglycerides, glucose, insulin and C-reactive protein. Pulse wave velocity was significantly reduced (p = 0.001) following Purple Majesty consumption for 14-days. There were no significant changes with any other clinical parameter measured, and no changes following white potato consumption. The findings from this short-term study indicate a potential effect of Purple Majesty consumption on arterial stiffness.

Predicting 30-day mortality after hip fracture surgery: Evaluation of the National Hip Fracture Database case-mix adjustment model

OBJECTIVES

The National Hip Fracture Database (NHFD) publishes hospital-level risk-adjusted mortality rates following hip fracture surgery in England, Wales and Northern Ireland. The performance of the risk model used by the NHFD was compared with the widely-used Nottingham Hip Fracture Score.

METHODS

Data from 94 hospitals on patients aged 60 to 110 who had hip fracture surgery between May 2013 and July 2013 were analysed. Data were linked to the Office for National Statistics (ONS) death register to calculate the 30-day mortality rate. Risk of death was predicted for each patient using the NHFD and Nottingham models in a development dataset using logistic regression to define the models' coefficients. This was followed by testing the performance of these refined models in a second validation dataset.

RESULTS

The 30-day mortality rate was 5.36% in the validation dataset (n = 3861), slightly lower than the 6.40% in the development dataset (n = 4044). The NHFD and Nottingham models showed a slightly lower discrimination in the validation dataset compared with the development dataset, but both still displayed moderate discriminative power (c-statistic for NHFD = 0.71, 95% confidence interval (CI) 0.67 to 0.74; Nottingham model = 0.70, 95% CI 0.68 to 0.75). Both models defined similar ranges of predicted mortality risk (1% to 18%) in assessment of calibration.

CONCLUSIONS

Both models have limitations in predicting mortality for individual patients after hip fracture surgery, but the NHFD risk adjustment model performed as well as the widely-used Nottingham prognostic tool and is therefore a reasonable alternative for risk adjustment in the United Kingdom hip fracture population.Cite this article: Bone Joint Res 2017;6:550-556.

Extracting general practice data for timely vaccine coverage estimates: The England experience

In England, primary care providers use standardised coding systems to record health events such as vaccination as well as patient characteristics. This information can be automatically extracted to estimate coverage for vaccine programmes delivered through primary care, in the general population as well as in specific geographical, ethnic, age or clinical groups. This system provides timely vaccine coverage estimates as well as the flexibility to extract tailored data in order to directly inform a continuously evolving national vaccine programme. It is however limited by the quality and completeness of clinical coding in primary care. A centralised, individual-level register would however improve data quality, completeness and reliability and remains the gold standard.

Abstract 4417: The role of EBV infection in aerobic glycolysis in nasopharyngeal carcinoma

Accumulating evidence indicates that oncogenic viral protein exerts a crucial role in activating aerobic glycolysis during tumorigenesis, but the underlying mechanisms are largely undefined. The Epstein-Barr virus (EBV)-encoded latent membrane protein 1 (LMP1) is a trans-membrane protein with potent cell signaling properties and has tumorigenic transformation property. Activation of NF-κB is a major signaling pathway mediating many downstream transformation properties of LMP1. Here we report that activation of mTORC1 by LMP1 is a key modulator for activation of NF-κB signaling to mediate aerobic glycolysis. NF-κB activation is involved for LMP1-induced upregulation of glucose transptor-1 (Glut-1) transcription and growth of nasopharyngeal carcinoma (NPC) cells. Collectively, blocking the activity of mTORC1 signaling effectively suppressed LMP1-induced NF-κB activation and Glut-1 transcription. Interfering NF-κB signaling has no effect on mTORC1 activity but effectively altered Glut-1 transcription. Luciferase promoter assay of Glut-1 also confirmed that Glut-1 is a direct target gene of NF-κB signaling. Furthermore, we demonstrated that the LMP1 C-terminal activating region (CTAR) 2 is the key domain involved in mTORC1 activation, mainly through IKKβ-mediated phosphorylation of TSC2 at Ser939. Depletion of Glut-1 effectively led to suppression of aerobic glycolysis, inhibition of cell proliferation, colony formation, and attenuation of tumorigenic growth property of LMP1-expressing nasopharyngeal epithelial (NPE) cells. These findings suggest that targeting the signaling axis of mTORC1/NF-κB/Glut-1 represents a novel therapeutic target against NPC.

Acknowledgement: 96 800x600 This project was supported by the General Research Fund (HKU 779810M, 17120814 and 17161116), CRF equipment grant (1061402980, Health and Medical Research Fund of Hong Kong (12110782), AoE grant (AoE/M-06/08) and TBRS grant (T12-401/13-R). We thank Prof. Dongyan Jin (Department of Biochemistry, The University of Hong Kong) for the kind gifts of IKK related plasmids and Prof. Zhenguo Wu (Division of Life Science, The Hong Kong University of Science and Technology) for the discussion and interpretation of the data. We also thank Mr. Tony Chan for his technical support.

Note: This abstract was not presented at the meeting.

Citation Format: George S. Tsao, Jun Zhang, Lin Xia, C Tsang, Weitao Lin, Y Yip, W Deng, K Lo, M Lung. The role of EBV infection in aerobic glycolysis in nasopharyngeal carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4417. doi:10.1158/1538-7445.AM2017-4417

Live attenuated influenza vaccine effectiveness against hospitalisation due to laboratory-confirmed influenza in children two to six years of age in England in the 2015/16 season

The United Kingdom is introducing a universal annual influenza vaccination programme for children. Live attenuated influenza vaccine (LAIV) effectiveness (VE) against laboratory-confirmed influenza hospitalisation in 2 to 6 year-olds in England was measured in 2015/16 using the screening method. VE adjusted for age, geography and month was 54.5% (95% confidence interval (CI): 31.5% to 68.4%) for all influenza types combined; 48.3% (95% CI: 16.9% to 67.8%) for A(H1N1)pdm09 and 70.6% (95% CI: 33.2% to 87.1%) for B. The findings support on-going programme roll-out.

Association between patient and general practice characteristics and unplanned first-time admissions for cancer: observational study

Background:

To identify patient and general practice (GP) characteristics associated with emergency (unplanned) first admissions for cancer in secondary care.

Methods:

Patients who had a first-time admission with a primary diagnosis of cancer during 2007/08 to 2009/10 were identified from administrative hospital data. We modelled the associations between the odds of these admissions being unplanned and various patient and GP practice characteristics using national data sets, including the Quality and Outcomes Framework (QOF).

Results:

There were 639 064 patients with a first-time admission for cancer, with 139 351 unplanned, from 7957 GP practices. The unplanned proportion ranged from 13.9% (patients aged 15–44 years) to 44.9% (patients aged 85 years and older, P<0.0001), with large variation by ethnicity (highest in Asians), deprivation, rurality and cancer type. In unadjusted analyses, all included patient and practice-level variables were statistically significant predictors of the admissions being unplanned. After adjustment, patient area-level deprivation was a key factor (most deprived compared with least deprived quintile OR 1.36, 95% CI 1.32–1.40). Higher total QOF performance protected against unplanned admission (OR 0.94 per 100 points; 95% CI 0.91–0.97); having no GPs with a UK primary medical qualification (OR 1.08, 95% CI 1.04–1.11) and being less able to offer appointments within 48 h were associated with higher odds.

Conclusion:

We have identified some patient and practice characteristics associated with a first-time admission for cancer being unplanned. The former could be used to help identify patients at high risk, while the latter raise questions about the role of practice organisation and staff training.

Amorphous and Nanocrystalline Oxide Electrodes for Rechargeable Lithium Batteries

Oxo ions (MO4)n- (M = V, Cr, Mn and Mo) have been reduced in aqueous solutions with potassium borohydride to obtain the binary oxides MO2+δ. While the vanadium and manganese oxides are nanocrystalline, the chromium and molybdenum oxides are amorphous. The nanocrystalline VO2 having a metastable structure and the amorphous CrO2 and MoO2.3 transform to the thermodynamically more stable phases upon heating above 300–400 °C. These metastable oxides after heating in vacuum at 200–300 °C to remove water show good electrode performance in lithium cells. VO2, CrO2 and MoO2.3 show a reversible capacity of, respectively, 290 mAh/g in the range 4–1.5 V, 180 mAh/g in the range 3.3–2.3 V, and 220 mAh/g in the range 3–1 V. MnO2 obtained by this process does not show good electrode properties.

The concepts of family doctor and factors affecting choice of family doctors among Hong Kong people

OBJECTIVES

To identify concepts including misconceptions among the community members regarding family doctors, and determine factors affecting decisions on which doctor to consult in different clinical scenarios.

DESIGN

Household telephone survey conducted between 4 and 13 September 2006.

SETTING

Hong Kong community.

PARTICIPANTS

Cantonese-speaking Hong Kong residents aged 18 years or more were targeted. Randomly selected participants were asked to complete a questionnaire, which was designed based on a literature search and subsequent focus group discussions.

RESULTS

Among the 1811 households with eligible subjects to survey, 1204 completed the questionnaire (response rate, 67%). More than 85% considered a family doctor to be the first doctor they wanted to see even if it was inconvenient. "Clearly knowing my physical conditions", "fast-acting and effective treatment", and "doctor with friendly and sincere attitude" were the three most important factors influencing the choice of a family doctor. When affected by flu-like symptoms, 65% would go to a private clinic, 20% to a general out-patient clinic, 6% to a designated clinic with staff approved by their respective medical insurance/medical benefit scheme, and 5% to a private hospital outpatient clinic. Among the latter two groups, 65% consulted the same doctor every time when they felt sick. More than 50% of those willing to have regular follow-up by a family doctor for hypertension and diabetes paid more than HK$300 per month. Approximately 64% might consider having regular follow-up at a general out-patient clinic by a nurse specialist.

CONCLUSION

Hong Kong inhabitants already have their own ideas regarding how to care for their own health, and what kind of family doctors they prefer. This survey should help both doctors and health care policy makers to realign their current thinking, and thus provide a platform for the development of a primary care model unique to Hong Kong.

A comprehensive "Healthy Schools Programme" to promote school health: the Hong Kong experience in joining the efforts of health and education sectors

Both health and education are linked to economic performance. The success of education depends on good health, and vice versa. Modern education should help young people to determine values, and accept responsibility for their health and social behaviour. The success of health promotion in schools requires the joint efforts of both the health and education sectors. A comprehensive programme is needed to include teachers' training, curriculum development, community participation, changing policies and practices, and research. All these components are needed to build up a successful model of a health promoting school. The "Healthy Schools Programme" in Hong Kong gives a good example of close partnership between the health and education sectors, and moves towards a multidisciplinary approach and active learning towards health promotion.

Biological activity of immunostimulatory CpG DNA motifs in domestic animals

Bacterial DNA contains a much higher frequency of CpG dinucleotides than are present in mammalian DNA. Furthermore, bacterial CpG dinucleotides are often not methylated. It is thought that these two features in combination with specific flanking bases constitute a CpG motif that is recognized as a "danger" signal by the innate immune system of mammals and therefore an immune response is induced when these motifs are encountered. These immunostimulatory activities of bacterial CpG DNA can also be achieved with synthetic CpG oligodeoxynucleotides (ODN). Recognition of CpG motifs by the innate immune system requires engagement of Toll-like receptor 9 (TLR-9), which induces cell signaling and subsequently triggers a pro-inflammatory cytokine response and a predominantly Th1-type immune response. CpG ODN-induced innate and adaptive immune responses can result in protection in various mouse models of disease. Based on these observations, clinical trials are currently underway in humans to evaluate CpG ODN therapies for cancer, allergy and infectious disease. However, potential applications for immunostimulatory CpG ODN in species of veterinary importance are just being explored. In this review, we will highlight what is presently known about the immunostimulatory effects of CpG ODN in domestic animals.

Prospective randomised trial comparing ayurvedic cutting seton and fistulotomy for low fistula-in-ano

The aim of this study was to evaluate the role of ayurvedic setons in the treatment of low fistula-in-ano. One hundred and eight patients were randomised into either conventional fistulotomy (F) or ayurvedic cutting seton insertion (C). Endpoints investigated included time to wound healing and complications of surgery. Post-operative pain scores were measured daily using a visual analog scale. Anal function was compared using a continence score. Pre- and postoperative manometry and ultrasound were also performed. After exclusions, there were 54 patients in group F and 46 in group C. There were no differences in age, sex or follow-up duration between the two groups. Healing time was similar between the groups. Group C reported more pain following operation and on the first 2-4 postoperative days, but both groups experienced the same amount of pain subsequently. In conclusion, chemical seton was more painful than conventional fistulotomy in the first few days following surgery. However, there was no difference in time to wound healing, complications or functional outcome.

Randomized trial assessing anal sphincter injuries after stapled haemorrhoidectomy

BACKGROUND

Conventional stapled haemorrhoidectomy involves the use of a large circular anal dilator (DL technique), which may cause anal sphincter injuries. This study compared whether the procedure can be effectively performed without this dilator (ND technique), with better sphincter preservation.

METHODS

Fifty-eight patients with symptomatic prolapsed irreducible haemorrhoids were randomized to DL (n = 29) and ND (n = 29) groups. Preoperative continence scoring, anorectal manometry and endoanal ultrasonography were performed. These were repeated at up to 14 weeks after operation, with additional pain scores, analgesic requirements and quality of life assessments.

RESULTS

DL haemorrhoidectomy took significantly longer to perform (P = 0.02). However, there were fewer residual skin tags (P = 0.044) and less perianal pruritus (P = 0.007) at 2 weeks, although such symptoms subsided to an equivalent level in both groups afterwards. Internal anal sphincter fragmentation persisting to at least 14 weeks was found in four patients after DL, but not after ND haemorrhoidectomy (P = 0.038). However, these were asymptomatic and no differences were found in continence scores and anal pressures. The pain scores, satisfaction scores, quality of life assessments and time off work were similar.

CONCLUSION

The large circular anal dilator used for stapled haemorrhoidectomy increased the risk of anal sphincter injuries, which may become problematic with ageing.

Stapled hemorrhoidectomy--cost and effectiveness. Randomized, controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three months

PURPOSE

Stapled hemorrhoidectomy is performed without leaving painful perianal wounds. The aim of this study was to assess any benefits, compared with a conventional open diathermy technique.

METHODS

A total of 119 consecutive patients with prolapsed irreducible hemorrhoids were randomly assigned (conventional open diathermy technique = 62; stapled hemorrhoidectomy = 57). Preoperative fecal incontinence scoring, anorectal manometry, and endoanal ultrasound were performed. Postoperatively, these were repeated at up to three months with pain scores, analgesic requirements, quality of life assessment, and total related medical costs.

RESULTS

Conventional open diathermy technique was quicker to perform (mean, 11.4 (standard error of the mean, 0.9) vs. 17.6 (3.1) minutes). Hospitalization was similar, but conventional open diathermy technique patients felt more pain during defecation (5.1 (0.4) vs. 2.6 (0.4); P < 0.005) at two weeks, and analgesic requirements were more for up to six weeks (P < 0.05). Up to the latter, 85.5 percent conventional open diathermy technique wounds remained unhealed, with more bleeding (33 (53.2 percent) vs. 19 (33.3 percent); P < 0.05) and pruritus (27 (43.5 percent) vs. 9 (15.8 percent); P < 0.05). Total complication rates were similar (conventional open diathermy technique 16 (25.8 percent) vs. stapled hemorrhoidectomy 10 (17.5 percent)), including mild strictures and bleeding in both groups. Minor incontinence occurred postoperatively in two conventional open diathermy technique and two stapled hemorrhoidectomy patients at six weeks. Endoanal ultrasound internal anal sphincter defects were found in the incontinent conventional open diathermy technique patients, but were asymptomatic in another one conventional open diathermy technique and one stapled hemorrhoidectomy. Only one patient (conventional open diathermy technique with internal sphincter defect) remained incontinent at three months. Changes between preoperative and postoperative anorectal manometry were similar in the two groups. Patients' satisfaction scores and quality of life assessments were also similar. Conventional open diathermy technique patients resumed work later (mean 22.9 (1.8) vs. 17.1 (1.9) days; P < 0.05), but the total costs incurred were less ($921.17 (16.85) vs. $1,283.09 (31.59); P < 0.005).

CONCLUSIONS

Stapled hemorrhoidectomy is a safe and effective option in treating irreducible prolapsed piles. It is more expensive but less painful, with less time needed off work. Nonetheless, long-term results are still awaited.

Anal sphincter injuries from stapling instruments introduced transanally: randomized, controlled study with endoanal ultrasound and anorectal manometry

PURPOSE

Injury sustained from the transanally introduced stapling technique was assessed by comparison with biofragmentable anastomotic ring anastomosis, which excluded anal manipulation.

METHODS

A randomized, controlled trial was conducted on consecutive patients undergoing sigmoid colectomy (where pelvic nerve injury was avoided). A bowel function questionnaire was administered six months after surgery. Anorectal manometry and endoanal ultrasonography were performed preoperatively and at six months postoperatively. The observers were blinded to the randomization.

RESULTS

There were 18 patients in the transanally introduced stapling technique group and 17 patients in the biofragmentable anastomotic ring group, with no differences in age, gender, Dukes staging, and follow-up. Three of the transanally introduced stapling technique patients had occasional liquid soiling, which was absent in biofragmentable anastomotic ring patients. Mean change in resting anal pressures was also significantly impaired when compared with patients with biofragmentable anastomotic ring (P = 0.007). Endosonographic internal sphincter fragmentation was found in five transanally introduced stapling technique patients but none after biofragmentable anastomotic ring anastomosis (P = 0.046). Internal sphincter fragmentation was associated with the impaired resting pressures (P = 0.007). External sphincter deficiencies were found after transanally introduced stapling technique in two patients (biofragmentable anastomotic ring = 0), and these were associated with the soiling (P = 0.005).

CONCLUSIONS

The transanally introduced stapling technique may result in anal sphincter defects and impaired anal pressures when assessed at six months of follow-up.

Salivary lysozyme and related parameters of a predominantly Chinese, HIV-infected cohort in Hong Kong

OBJECTIVES

To evaluate the salivary lysozyme concentration, flow rate and pH of a predominantly Chinese, HIV-infected group in Hong Kong, and to compare with an equal number of age and gender-matched HIV-free individuals.

STUDY DESIGN

A prospective longitudinal study over a 12-month period of 32 predominantly Chinese, male, HIV-infected group in a hospital setting in Hong Kong. Whole saliva collection by expectoration, lysozyme evaluation by 'lysoplate method'; pH and flow rate evaluation using standard methods and correlation with other clinical parameters using regression analysis.

RESULTS

The flow rate and the pH of saliva were lower compared with HIV-free, healthy individuals (both P < 0.0001) and salivary lysozyme concentration of the HIV-infected group was 23% higher compared with the HIV-free group (P < 0.001), though there was no significant difference between the lysozyme output (P > 0.05) expressed as microg min-1. On multiple regression analysis, intravenous drug users had a higher salivary lysozyme concentration compared with the homosexual group (P = 0.0015) though other variables investigated were not significantly related to the salivary lysozyme concentrations.

CONCLUSIONS

The significant changes in the flow rate, pH value and lysozyme concentration of whole saliva of the HIV-infected individuals as compared with the HIV-free, healthy individuals, may be due to the disease itself or a combination of factors including the medications used in the disease management.

Skin stapled bowel anastomosis in a canine model

AIM OF STUDY

The aim of this study is to compare the safety and cost effectiveness of the use of staples designed for skin closure in the construction of colonic anastomoses.

METHOD

Twenty healthy dogs were prospectively randomised to either skin stapled or sutured anastomosis. The ascending colon was transected and reanastomosed. This segment was excised and used to test early bursting strength. There was no significant difference between the two groups. The ends of the colon were reanastomosed.

RESULTS

The time taken to perform the anastomosis and the cost of the suture or staples were noted. The time taken for the stapled anastomosis was significantly faster (p < 0.001) with a mean of 7.95 minutes versus a mean of 23.5 minutes for the handsewn anastomosis. The cost was also significantly less (p = 0.18) with a mean of SGD17.85 compared to a mean of SGD21.15 for the handsewn anastomosis. Two weeks later, the dogs were sacrificed and the late bursting pressures were tested and no significant difference was found between the two groups. The anastomotic site was then sent for histological examination. The four animals, one in the handsewn group and 3 in the skin stapled group, dying prior to sacrifice, were subjected to post-mortem.

CONCLUSION

The results show that skin stapled anastomoses are easy to learn and perform and may constitute a viable alternative to hand suture techniques.

Prospective, randomized trial comparing pain and complications between diathermy and scissors for closed hemorrhoidectomy

PURPOSE

The aim of this study was to assess pain and complication rates after closed hemorrhoidectomy with the use of either scissors or diathermy excision.

METHODS

Ninety-one consecutive patients were prospectively randomly assigned by use of sealed envelopes to Group A (diathermy dissection; n = 44) or Group B (scissors dissection; n = 47). The resulting hemorrhoidal pedicle after hemorrhoidal dissection was transfixed and buried under the mucosa, which was closed with 3-0 chromic catgut.

RESULTS

The median time taken for surgery was ten minutes in both groups. The range for Group A was 5 to 25 minutes, and the range for Group B was 5 to 20 minutes. There were no statistically significant differences in the pain scores between the two groups for any of the seven postoperative days studied. The median number of pethidine injections in Group A was 1 and in Group B was 0 (P < 0.009). The number of oral analgesic tablets used was 8 (range, 4-10) and 14 (range, 0-10) for Groups A and B, respectively (P < 0.001). The number of tubes of topical lignocaine jelly used was 14 (range, 0-22) and 14 (range, 7-88) in Groups A and B, respectively. Two patients in each group developed secondary hemorrhage, but no patient had anal stricturing.

CONCLUSION

No excessive complications are seen with closed hemorrhoidectomy, and diathermy seems to require less postoperative analgesic medicine than scissors for closed hemorrhoidectomy except in the first 24 hours.

Reduction of Aqueous Na(2)WO(4) by NaBH(4) at Ambient Temperatures To Obtain Lower Valent Tungsten Oxides

A systematic investigation of the reduction of aqueous Na(2)WO(4) with aqueous NaBH(4) at ambient temperatures reveals the formation of several lower valent tungsten oxides such as the tetragonal (x < 0.38) and cubic (x > 0.43) tungsten bronzes Na(x)()WO(3) and the binary oxides WO(2) and W(24)O(68). The nature of the product formed is influenced both by the (i) reducing power of NaBH(4), which is controlled by the volume and concentration of the borohydride and the reaction pH, and (ii) the degree of condensation of the tungstate ions, which is controlled by the reaction pH. Although the reducing power of NaBH(4) increases with decreasing pH, an increasing degree of condensation of the tungstate tends to lower the degree of reduction in many instances. The as-prepared samples are amorphous as revealed by X-ray diffraction and crystallize around 450 degrees C as revealed by differential scanning calorimerty. The tungsten bronzes undergo interesting crystal-chemical changes with the temperature of heating.

Clinical pathway for pediatric parenteral nutrition

The nutrition support team at Lucile Salter Packard Children's Hospital at Stanford developed a clinical pathway for infants and children receiving parenteral nutrition (PN). Use of clinical pathways for health care delivery is one way in which clinicians and institutions are responding to pressure from managed care organizations to reduce costs and maintain or improve quality. This pathway was developed to standardize the process for ordering, implementing, and monitoring PN. Specific goals for the pathway are as follows: to decrease the number of patients receiving PN inappropriately, to decrease the duration of PN for those patients who require it, to determine complication rates, and to monitor outcomes of therapy. Such comprehensive monitoring will help identify areas for improvement. By developing and implementing action plans to address these issues, we expect to improve continuously the processes and outcomes associated with PN therapy.

Synthesis of Lower Valent Molybdenum Oxides by an Ambient Temperature Reduction of Aqueous K(2)MoO(4) by KBH(4)

Reduction of aqueous K(2)MoO(4) with aqueous KBH(4) at ambient temperatures has been investigated systematically to obtain lower valent molybdenum oxides. Several lower valent oxides such as MoO(2), Mo(4)O(11), K(0.26)MoO(3) (red bronze), K(0.30)MoO(3) (blue bronze), and K(0.85)Mo(6)O(17) are formed during the reduction process; however, only MoO(2) has been obtained as single-phase product. The nature of the product formed is strongly influenced by the reducing power of KBH(4). The reducing power increases with decreasing pH or increasing concentration and volume of KBH(4). The as-prepared samples are amorphous as revealed by X-ray diffraction and transmission electron microscopy. They crystallize sharply at around 350-500 degrees C as revealed by differential scanning calorimetry. Since the products formed are amorphous in nature, they may become particularly attractive for battery electrodes and catalysis.