Managing juvenile idiopathic arthritis within the context of their life: What we learnt from children and youth living with juvenile idiopathic arthritis and their parents

INTRODUCTION

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children and causes short- and long-term disability. Optimal management requires pharmacologic and non-pharmacologic interventions. Few studies have explored the youth and family experience of the management of JIA. This study's objective was to explore the management experience of youth with JIA and their parents.

METHODS

This qualitative study used semi-structured interviews with youth 12-18 years of age with JIA receiving biological medication and parents of children with JIA on biological medication. Participants were recruited in clinics using convenience sampling. A thematic analysis approach was employed for data analysis.

RESULTS

Nine youth and 14 parents participated. Four themes were identified that encompassed an overarching theme of participants managing JIA within the context of their life: aspects of life affected by JIA and its management, lived experience with JIA management, medication decision-making, and involvement in decision-making. Juvenile idiopathic arthritis management is situated within the context of their life but is normally (outside acute events) not central.

CONCLUSION

Two dimensions were added to those in the literature: parents' overall approaches to health and the sense of urgency surrounding decision-making. Our findings reinforce the importance of person- and family-centred care in paediatric rheumatology. That is, identifying what matters most to youth and their parents given their current life circumstances to provide a foundation for discussions of how they want to manage their JIA.

A68 HOW REAL ARE YOUR SURVEY RESPONDENTS? IDENTIFYING FRAUDULENT RESPONDENTS IN ONLINE SURVEYS – A CASE EXAMPLE IN INFLAMMATORY BOWEL DISEASE (IBD)

Background

Social media and online surveys are commonly used to recruit and collect data from patients and physicians about GI diseases – they are efficient, convenient, and less resource intensive compared to traditional recruitment approaches and paper surveys. However, online data fraud is increasing and difficult to identify. Online data fraud can include intentional duplicate responses/straight-lining/inattention, bots/malicious software, and professional survey takers who provide fraudulent responses to meet study eligibility.

Purpose

1) Illustrate challenges of identifying fraudulent respondents through an algorithm and verification process we developed for our survey in IBD. 2) Demonstrate potential impact of fraudulent respondents on data and results.

Method

Online survey of Canadian adults (>18 years) with IBD about healthcare processes for managing IBD hosted using Qualtrics. Recruitment was done in clinic and online (mailing lists, social media). A $25 giftcard was offered for participation due to low response after 3 months in field, after which a large influx of ‘respondents’ occurred. Most were fraudulent although not obvious at first. To mitigate further fraudulent responses, we added the following to our survey: reCAPTCHA score, repeated question (year of IBD diagnosis), duplicate ID score, fraud score and honeypot question.

Our algorithm to identify fraudulent responses included 13 binary ‘red flag’ variables: age <18 years, year of diagnosis < year of birth, 2 different year of diagnosis, invalid postal code, survey duration <10 minutes, survey duration 10-15 minutes, suspicious comments for open text questions (x2), duplicate email, suspicious email, duplicate ID score ≥30, fraud score ≥30, and failed honeypot question. These variables were used to generate a fraudulent response score (range: 0-13; 13=most likely fraudulent). ‘Respondents’ with scores >3 were categorized as likely fraudulent. Respondents with scores ≤3 were reviewed individually. Respondents flagged as likely real or unsure were emailed and asked to verify their age; those who correctly verified age were considered likely real and included in the final sample.

Result(s)

Of the 4334 ‘respondents’ who started the survey, based on fraudulent response score we identified 75% (n=3258) as likely fraudulent, 17% (n=727) as unsure and 8% (n=349) as likely real. After age verification, 76% (n=3297) were considered likely fraudulent, 14% (n=592) remained unsure, 10% (n=442) were considered likely real, and <1% (n=3) were duplicates of likely real respondents.

Conclusion(s)

Despite convenience, social media and online surveys can be prone to fraudulent responses, especially when incentives are offered. We developed an algorithm and verification process to identify fraudulent responses using an IBD survey example. Given that only 10% of the full sample was considered likely real, researchers using social media and online surveys should carefully examine data for fraudulent responses and apply strategies to mitigate risks.

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Disclosure of Interest

None Declared

Transitions from pediatric to adult rheumatology care for juvenile idiopathic arthritis: a patient led qualitative study

Background

Juvenile idiopathic arthritis (JIA) is a childhood autoimmune disease that causes swelling and pain in at least one joint. Young people with JIA experience symptoms that persist into adulthood, and thus will undergo a transition including the o transfer of care from a pediatric rheumatologist an adult rheumatologist. Missing from the literature is research that centres the transition experience of young people with JIA in Canada. This goal of this patient-led research was to explore the experience young people with JIA through the process of transition.

Methods

Qualitative study using the Patient and Community Engaged Research (PaCER) approach. Trained patient-researchers conducted three focus groups using the Set, Collect and Reflect PaCER process. Participants, recruited via purposive and snowball sampling using research/personal networks and social media, were young people with JIA in Canada between 18 and 28 years who had experienced with the process of transition to adult care. Recordings were transcribed verbatim. Patient researchers individually coded overlapping sections of the data, and thematic analysis was conducted.

Results

In total, nine individuals participated in one or more focus groups. Three themes were identified, with sub-themes: preparedness for transition (readiness for the transfer of care, developing self-advocacy skills), continuity and breadth of care (changing relationships, culture shock, new responsibilities), need for support (social support, mental health support, and ongoing support needs – beyond the transfer of care. Peer support was a connecting concept in the support sub-themes. Transition was more than a change in primary physician but also a change in the care model and breadth of care provided, which was challenging for young people especially if they had insufficient information.

Conclusions

Transition from pediatric to adult care in rheumatology is a significant period for young people living with JIA, and this patient-led study provided insight into the experience from the perspective of young people with JIA which is critical to informing the development of supports for patients through the process. Patients, caregivers, pediatric and adult rheumatologists and members of the multi-disciplinary care team need to collaborate in terms of resources preparing for transfer, and support throughout the transition process to ensure a successful transition process.

Are education, exercise and diet interventions a cost-effective treatment to manage hip and knee osteoarthritis? A systematic review

OBJECTIVE

To identify research gaps and inform implementation we systematically reviewed the literature evaluating cost-effectiveness of recommended treatments (education, exercise and diet) for the management of hip and/or knee OA.

METHODS

We searched Medline, Embase, Cochrane Central Register of Controlled Trials, National Health Services Economic Evaluation Database, and EconLit from inception to November 2019 for trial-based economic evaluations investigating hip and/or knee OA core treatments. Two investigators screened relevant publications, extracted data and synthesized results. Risk of bias was assessed using the Consensus on Health Economic Criteria list.

RESULTS

Two cost-minimization, five cost-effectiveness and 16 cost-utility analyses evaluated core treatments in six health systems. Exercise therapy with and without education or diet was cost-effective or cost-saving compared to education or physician-delivered usual care at conventional willingness to pay (WTP) thresholds in 15 out of 16 publications. Exercise interventions were cost-effective compared to physiotherapist-delivered usual care in three studies at conventional WTP thresholds. Education interventions were not cost-effective compared to usual care or placebo at conventional WTP thresholds in three out of four publications.

CONCLUSIONS

Structured core treatment programs were clinically effective and cost-effective, compared to physician-delivered usual care, in five health care systems. Providing education about core treatments was not consistently cost-effective. Implementing structured core treatment programs into funded clinical pathways would likely be an efficient use of health system resources and enhance physician-delivered usual primary care.

Development of quality indicators for hip and knee arthroplasty rehabilitation

OBJECTIVE

To develop quality indicators (QIs) reflecting the minimum acceptable standard of rehabilitation care before and after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) for osteoarthritis (OA).

METHODS

Informed by high quality evidence and using a modified RAND-UCLA Delphi approach, an 18-member Canadian panel of clinicians, researchers and patients considered 81 proposed QIs (40 for THA, 42 for TKA) addressing rehabilitation before and after elective THA and TKA. Panelists rated QIs for their importance and validity on a 9-point Likert scale through two rounds of online rating interspersed with a moderated and anonymous online discussion forum. Those QIs with median ratings of ≥7 for importance and validity with no disagreement based on the inter-percentile range adjusted for symmetry were included in the final sets.

RESULTS

Fifteen panelists from seven provinces and varied practice settings completed the Delphi process. Of the 81 plus one additional QIs (total of 82), 67 (82%) were rated as both important and valid (31 for THA, 36 for TKA). For THA, 14 pre-op, six acute and eight post-acute QIs were accepted. For TKA, 16 pre-op, 10 acute and eight post-acute indicators were accepted. Two of three 'across-continuum' QIs were rated appropriate for both procedures.

CONCLUSION

This work represents the first QIs with which to measure, report and benchmark quality of care in patients receiving rehabilitation before and after THA/TKA surgery. The QIs will be further tested for reliability and feasibility before being widely disseminated in clinical settings and used to assess care gaps.

Erythritol and Lufenuron Detrimentally Alter Age Structure of Wild Drosophila suzukii (Diptera: Drosophilidae) Populations in Blueberry and Blackberry

We report on the efficacy of 0.5 M (61,000 ppm) erythritol (E) in Truvia Baking Blend, 10 ppm lufenuron (L), and their combination (LE) to reduce egg and larval densities of wild populations of Drosophila suzukii (Matsumura) infesting fields of rabbiteye blueberries (Vaccinium virgatum) and blackberries (Rubus sp.). Formulations included the active ingredients (lufenuron, erythritol, or both), sugar (in control and erythritol treatments), and Dawn hand-soap applied to plants with pressurized 3-gallon garden spray tanks. The three chemical treatments (E, L, and LE) had no effect on D. suzukii ovipositing in blackberry and blueberry fruit, but they did reduce larval infestation by 75%, particularly densities of first and second instars. Erythritol and lufenuron were equally efficacious compounds as a D. suzukii ovicide and larvicide, but they did not display additive or synergistic activity. Extremely high larval mortality in control fruits show an age structure heavily skewed toward egg output.

Productivity costs of work loss associated with osteoarthritis in Canada from 2010 to 2031

OBJECTIVE

To estimate and project the productivity costs of work loss (PCWL) associated with osteoarthritis (OA) in Canada using the Population Health Model (POHEM).

DESIGN

We integrated an employment module based on 2006 Canadian Census into the previously developed microsimulation model of OA. The Canadian Community Health Survey (CCHS) Cycle 2.1 with an OA sample aged 25-64 (n = 7067) was used to calibrate the results of the employment module and to estimate the fraction of non-employment associated with OA. Probabilities of non-employment together with attributable fractions were then implemented in POHEM to estimate PCWL associated with OA from 2010 to 2031.

RESULTS

Among the OA population, 44.4% and 59.4% of non-employment due to illness was associated with OA for those not working full-year and part-year, respectively. According to POHEM projections, the size of the working age population with OA increased from 1.5 million in 2010 to 1.7 million in 2031. The PCWL associated with OA increased from $12 billion to $17.5 billion in constant 2008 Canadian dollars. Around 38% of this increase was due to the increase in OA prevalence and changes in demographics, while the rest was due to increase in real wage growth. Male and female OA patients between 55 and 64 years of age had the highest total projected PCWL, respectively.

CONCLUSIONS

The total PCWL associated with OA in Canada is estimated to be substantial and increasing in future years. Results of this study could be used to inform policies aiming to increase employment sustainability among individuals with OA.

Assessing the comparability of hip arthroplasty registries in order to improve the recording and monitoring of outcome

Aims

We aimed to assess the comparability of data in joint replacement registries and identify ways of improving the comparisons between registries and the overall monitoring of joint replacement surgery.

Materials and Methods

We conducted a review of registries that are full members of the International Society of Arthroplasty Registries with publicly available annual reports in English. Of the six registries which were included, we compared the reporting of: mean age, definitions for revision and re-operation, reasons for revision, the approach to analysing revisions, and patient-reported outcome measures (PROMs) for primary and revision total hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA).

Results

Outcomes were infrequently reported for HRA compared with THA and all hip arthroplasties. Revisions were consistently defined, though re-operation was defined by one registry. Implant survival was most commonly reported as the cumulative incidence of revision using Kaplan-Meier survival analysis. Three registries reported patient reported outcome measures.

Conclusion

More consistency in the reporting of outcomes for specific types of procedures is needed to improve the interpretation of joint registry data and accurately monitor safety trends. As collecting additional details of surgical and patient-reported outcomes becomes increasingly important, the experience of established registries will be valuable in establishing consistency among registries while maintaining the quality of data. Take home message: As the volume of joint replacements performed each year continues to increase, greater consistency in the reporting of surgical and patient-reported outcomes among joint replacement registries would improve the interpretation and comparability of these data to monitor outcomes accurately. Cite this article: Bone Joint J 2016;98-B:442–51.

Access to personalized medicine: factors influencing the use and value of gene expression profiling in breast cancer treatment

Genomic information is increasingly being used to personalize health care. One example is gene expression profiling (gep) tests, which estimate recurrence risk to inform chemotherapy decisions in breast cancer. Recently, gep tests were publicly funded in Ontario. We explored the perceived utility of gep tests, focusing on the factors influencing their use and value in treatment decision-making by patients and oncologists.

METHODS

We conducted interviews with oncologists (n = 14) and interviews and a focus group with early-stage breast cancer patients (n = 28) who underwent gep testing. Both groups were recruited through oncology clinics in Ontario. Data were analyzed using the content analysis and constant comparison techniques.

RESULTS

Narratives from patients and oncologists provided insights into various factors facilitating and restricting access to gep. First, oncologists are positioned as gatekeepers of gep, providing access in medically appropriate cases. However, varying perceptions of appropriateness led to perceived inequities in access and negative impacts on the doctor-patient relationship. Second, media attention facilitated patient awareness of gep, but also complicated gatekeeping. Third, the dedicated administration attached to gep was burdensome and led to long waits for results and also to increased patient anxiety and delayed treatment. Collectively, because of barriers to access, those factors inadvertently heightened the perceived value of gep for patients relative to other prognostic indicators.

CONCLUSIONS

Our study delineates the factors facilitating and restricting access to gep, and highlights the roles of media and organization of services in the perceived value and utilization of gep. The results identify a need for administrative changes and practice guidelines to support streamlined and standardized use of gep tests.

Patients' perceptions of gene expression profiling in breast cancer treatment decisions

INTRODUCTION

Determining the likely benefit of adjuvant chemotherapy for early-stage breast cancer patients depends on estimating baseline recurrence risk. Gene expression profile (gep) testing of tumours informs risk prediction, but evidence of its clinical utility is limited. We explored patient perceptions of gep testing and the impact of those perceptions on chemotherapy decisions.

METHODS

We conducted one focus group (n = 4) and individual interviews (n = 24) with patients who used gep testing, recruited through clinics at two hospitals in Ontario. Data were analyzed using content analysis and constant comparison techniques.

RESULTS

Patients' understanding of gep testing was variable, and misapprehensions were common. Patients valued the test because it provided them with certainty amidst confusion, with options and a sense of empowerment, and with personalized, authoritative information. They commonly believed that the test was better and fundamentally different from other clinical tests, attributing to it unique power and truth-value. This kind of "magical thinking" was derived from an amplified perception of the test's validity and patients' need for reassurance about their treatment choices. Despite misperceptions or magical thinking, gep was widely considered to be the deciding factor in treatment decisions.

CONCLUSIONS

Patients tend to overestimate the truth-value of gep testing based on misperceptions of its validity. Our results identify a need to better support patient understanding of the test and its limitations. Findings illustrate the deep emotional investment patients make in gep test results and the impact of that investment on their treatment decisions.

Comparative effectiveness of alternative clinical pathways for primary hip and knee joint replacement patients: a pragmatic randomized, controlled trial

OBJECTIVE

Total hip replacement (THR) and total knee replacement (TKR) (arthroplasty) surgery for end-stage osteoarthritis (OA) are ideal candidates for optimization through an algorithmic care pathway. Using a comparative effectiveness study design, we compared the effectiveness of a new clinical pathway (NCP) featuring central intake clinics, dedicated inpatient resources, care guidelines and efficiency benchmarks vs. the standard of care (SOC) for THR or TKR.

METHODS

We compared patients undergoing primary THR and TKR who received surgery in NCP vs. SOC in a randomised controlled trial within the trial timeframe. 1,570 patients (1,066 SOC and 504 NCP patients) that underwent surgery within the study timeframe from urban and rural practice settings were included. The primary endpoint was improvement in Western Ontario and McMaster University osteoarthritis index (WOMAC) overall score over 12 months post-surgery. Secondary endpoints were improvements in the physical function (PF) and bodily pain (BP) domains of the Short Form 36 (SF-36).

RESULTS

NCP patients had significantly greater improvements from baseline WOMAC scores compared to SOC patients after adjusting for covariates (treatment effect=2.56; 95% confidence interval (CI) [1.10-4.01]). SF-36 BP scores were significantly improved for both hip and knee patients in the NCP (treatment effect=3.01, 95% CI [0.70-5.32]), but SF-36 PF scores were not. Effects of the NCP were more pronounced in knee patients.

CONCLUSION

While effect sizes were small compared with major effects of the surgery itself, an evidence-informed clinical pathway can improve health related quality of life (HRQoL) of hip and knee arthroplasty patients with degenerative joint disorder in routine clinical practice for up to 12 months post-operatively. CLINICALTRIALS.GOV IDENTIFIER: NCT00277186.

Osteoarthritis patients' perceptions of "appropriateness" for total joint replacement surgery

OBJECTIVE

To understand patients' perspectives on 'appropriateness' for hip and knee total joint arthroplasty (TJA).

METHODS

Focus groups were conducted, stratified by history of a previous TJA, in English-speaking men and women aged 40+ years with moderate to severe hip and knee osteoarthritis. Participants discussed: their appropriateness for TJA; the ideal candidate; patients' role in TJA decision making; and the relationship between appropriateness and willingness to consider TJA. Participants self-completed a questionnaire assessing demographics, arthritis severity (Western Ontario McMaster University Osteoarthritis index - WOMAC), perceived TJA candidacy and willingness to consider TJA. Focus groups were audio-taped and transcribed verbatim. Content analysis was performed.

RESULTS

Eleven focus groups were conducted with 58 participants in total: mean age 72 years; 79% female; 25 (43%) with prior TJA; mean WOMAC summary score 43.1. Half reported willingness to consider TJA and 43% felt they were appropriate for TJA. Appropriateness was equated with candidacy for the procedure. Pain intensity and the ability to cope with pain were identified as the most important factors determining surgical candidacy, but felt to be inadequately evaluated by physicians. TJA appropriateness and willingness were felt to be distinct, yet related, concepts; those unwilling had stricter criteria about candidacy than those who were willing.

CONCLUSIONS

Participants equated appropriateness for TJA with surgical candidacy. Patients' pain experience (intensity, impact on quality of life, ability to cope) was seen as most important in determining appropriateness, but felt to be inadequately evaluated currently. Enhanced patient-physician communication, possibly through use of patient decision aids, has potential to improve patient selection for TJA.

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

OBJECTIVE

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

DESIGN AND METHOD

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

RESULTS

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

CONCLUSION

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

Surface Morphology and Microstructure of Al-O Alloys Grown by ECR Plasma Deposition

The growth of polycrystalline and amorphous aluminum-oxygen alloy films using electronbeam evaporation of Al in the presence of an O2 electron-cyclotron-resonance (ECR) plasma was investigated for film compositions varying from 40% Al (A12O3) to near 100% Al (A1Ox). Processing parameters such as deposition temperature and ion energy were varied to study their effects on surface texture and film microstructure. The Al-rich films (AlOx) contain polycrystalline fcc Al grains with finely dispersed second-phase particles of γ-A12O3 (1–2 nm in size). The surface roughness of these films was measured by atomic force microscopy and found to increase with sample bias and deposition temperature. Stoichiometric A12O3 films grown at 100°C and 400°C without an applied bias were amorphous, while an applied bias of -140 V formed a nanocrystalline γ-A12O3 film at 400°C. The surface roughness of the A12O3 increased with temperature while ion irradiation produced a smoother surface

The Gustatory Neural Response Function

With few exceptions, afferent neurons in the various sensory systems respond to wide ranges of stimuli. In those sensory systems for which the stimulus dimensions are understood, the response functions of these neurons may be described; they are usually simple functions with one maximum, although many variations exist. In the chemical senses, the stimulus dimensions are not known, and thus the neural response functions of these neurons have never been described. The present paper presents methods to determine these response functions and the stimulus dimensions for the chemical senses. A tentative response function for taste is developed, and preliminary steps are taken toward disclosing the stimulus dimensions.

Impact of antibiotic administrative restrictions on trends in antibiotic resistance

CONTEXT

In March 2001, in response to concerns about increasing resistance to fluoroquinolone (FQ) antibiotics, the Ontario Drug Benefit (ODB) program limited reimbursement of FQs to ODB beneficiaries defined as high risk or in whom other therapies are not tolerated.

OBJECTIVE

To analyze the impact of the limited use (LU) policy changes on antibiotic resistance rates in Ontario, focussing on community-acquired pathogens.

DESIGN

Ontario data submitted to the Canadian Bacterial Surveillance Network (CBSN) between January 1, 1998 and June 30, 2002 were analyzed for rates of resistance in various pathogen-antibiotic combinations. The effect of the LU policy on the level and rate of change of antibiotic resistance was estimated using time series models.

RESULTS

Resistance rates for S. pneumoniae were 10-12% for penicillin, erythromycin and trimethoprim sulfamethoxazole (TMP/SMX) and less than 3% for amoxicillin and all three FQs tested. There was a statistically significant increasing trend in resistance rates of S. pneumoniae to amoxicillin and levofloxacin throughout the study period. Antibiotic resistance of S. pneumoniae to ciprofloxacin indicated a statistically significant decreasing trend over the study period with a statistically significant increase in the level of antibiotic resistance at the time of the LU policy implementation. No other indication of any statistically significant decrease in resistance rates associated with the LU policy was found.

CONCLUSIONS

Although no direct cause and effect can be proven with these observational data, there is no evidence that the limited use policy to restrict fluoroquinolones decreased antibiotic resistance in any of the pathogen-antibiotic combinations tested.

Impact of antibiotic administrative restrictions on trends in antibiotic resistance

CONTEXT

In March 2001, in response to concerns about increasing resistance to fluoroquinolone (FQ) antibiotics, the Ontario Drug Benefit (ODB) program limited reimbursement of FQs to ODB beneficiaries defined as high risk or in whom other therapies are not tolerated.

OBJECTIVE

To analyze the impact of the limited use (LU) policy changes on antibiotic resistance rates in Ontario, focussing on community-acquired pathogens.

DESIGN

Ontario data submitted to the Canadian Bacterial Surveillance Network (CBSN) between January 1, 1998 and June 30, 2002 were analyzed for rates of resistance in various pathogen-antibiotic combinations. The effect of the LU policy on the level and rate of change of antibiotic resistance was estimated using time series models.

RESULTS

Resistance rates for S. pneumoniae were 10-12% for penicillin, erythromycin and trimethoprim sulfamethoxazole (TMP/SMX) and less than 3% for amoxicillin and all three FQs tested. There was a statistically significant increasing trend in resistance rates of S. pneumoniae to amoxicillin and levofloxacin throughout the study period. Antibiotic resistance of S. pneumoniae to ciprofloxacin indicated a statistically significant decreasing trend over the study period with a statistically significant increase in the level of antibiotic resistance at the time of the LU policy implementation. No other indication of any statistically significant decrease in resistance rates associated with the LU policy was found.

CONCLUSIONS

Although no direct cause and effect can be proven with these observational data, there is no evidence that the limited use policy to restrict fluoroquinolones decreased antibiotic resistance in any of the pathogen-antibiotic combinations tested.

Cost-effectiveness of nucleic acid test screening of volunteer blood donations for hepatitis B, hepatitis C and human immunodeficiency virus in the United States

BACKGROUND AND OBJECTIVES

The aim of this study was to examine the cost-effectiveness of adding nucleic acid testing (NAT) to serological (antibody and antigen) screening protocols for donated blood in the United States (US) with the purpose of reducing the risks of transfusion-transmission of hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV).

MATERIALS AND METHODS

The costs, health consequences and cost-effectiveness of adding either minipool or individual-donor NAT to serological screening (SS) testing were estimated using a decision-analysis model.

RESULTS

With the given modelling assumptions, adding minipool NAT would avoid an estimated 37, 128 and eight cases of HBV, HCV and HIV, respectively, and save approximately 53 additional years of life and 102 additional quality adjusted life years (QALYs) compared with SS, at a net cost of $154 million. SS + minipool NAT - p24 compared with SS alone resulted in an incremental cost-effectiveness ratio of $1.5 million per QALY gained (range in sensitivity analysis $1.0-2.1 million per QALY gained) in this US analysis.

CONCLUSIONS

The cost effectiveness of adding NAT screening is outside the typical range for most healthcare interventions, but not for established blood safety measures.

Measuring the effect of clinical guidelines on patient outcomes

OBJECTIVES

To identify and examine the methodologic issues related to evaluating the effectiveness of treatment adherence to clinical guidelines. The example of antiretroviral therapy guidelines for human immunodeficiency virus (HIV) disease is used to illustrate the points.

METHODS

Regression analysis was applied to observational HIV clinic data for patients with CD4+ cell counts less than 500 per microL and greater than 50 per microL at baseline (n = 704), using Cox proportional hazards time-varying covariates models controlling for baseline risk. The results are compared with simpler models (Cox model [without time-varying covariates] and logistic regression). In addition, the effect of including a measure of exposure to antiretroviral guidelines in the model is explored.

RESULTS

This study has three implications for modeling clinical guideline effectiveness. To capture events that are time-sensitive, a duration model should be used, and covariates that are time-varying should be modeled as time-varying. Thirdly, incorporating a threshold measure of exposure to reflect the minimum period of time for guideline adherence required for a measurable effect on patient outcome should be considered.

CONCLUSIONS

The methods proposed in this paper are important to consider if guidelines are to evolve from being a tool for summarizing and transferring the results of research from the literature to clinicians into a practical tool that influences clinical practice patterns. However, the methodology tested in this study needs to be validated using additional data on similar patients and using data on patients with other diseases.

Recommendations for the application of bone density measurement. What can you believe?

This study examined the conclusions of published reports that review the literature and make recommendations about appropriate applications of bone density measurement. It is based on a survey of 22 organizations producing such reports between 1986 and Spring 1995. Overall, the application of bone density measurement for the diagnosis of osteoporosis was supported by 65% of reports, by 44% for the monitoring and follow-up of patients with previously diagnosed disease, and by 59% for monitoring and follow-up of patients receiving treatment that may affect their bone density. A smaller proportion of reports from government and public organizations compared with other types of organizations and a smaller proportion of reports using more rigorous methods supported the applications for bone density measurement identified in the survey. A larger proportion of the reports published after 1990 compared with those published between 1986 and 1990 support the applications of bone density measurement, with the exception of population screening. The results of this survey suggest that there is considerable disagreement about the potential applications of bone density measurement. Publicly funded organisations and those using more rigorous methods tended to be more conservative in their conclusions.

Pericardial involvement in systemic sclerosis

OBJECTIVE

To determine the frequency and histological characteristics of pericardial involvement in systemic sclerosis.

METHOD

Necropsy sections of pericardium from 44 patients with systemic sclerosis were studied, together with sections from 19 age/sex matched controls. Sections were stained with haematoxylin and eosin, acid toluidine blue, and elastic van Gieson. Mast cells were counted in 10 random high power fields and the degree of fibrosis was quantified using a Chalkley count.

RESULTS

Chronic pericarditis was seen in 31 (77.5%) of the systemic sclerosis cases, but in only one of the controls. The characteristic changes of uraemic pericarditis were not seen. The degree of fibrosis was greater in those with systemic sclerosis, though numbers of mast cells, thought to be important in fibrogenesis, were similar in both groups. Myocardial fibrosis was seen in 15 (37.5%) of systemic sclerosis cases but in none of the controls.

CONCLUSION

The incidence of pericarditis and myocardial fibrosis is much greater than in controls. The results indicate that pericarditis is a primary disease (rather than secondary to uraemia).

Fatal disseminated intravascular coagulation complicating dental extraction

A case is reported of fatal disseminated intravascular coagulation occurring 8 h after routine extraction of wisdom teeth in a 24-year-old woman. Since all bacteriological specimens taken were sterile and no other precipitant was found, we believe this case represents an example of the generalised Shwartzman reaction to the local trauma of dental extraction leading to fatal initiation of the coagulation system.

Helmets! All the pros wear them

OBJECTIVE

To assess the outcome of a multidisciplinary community campaign to increase helmet use and determine the success of a school education and helmet distribution program.

DESIGN

Survey research.

SETTING

Large metropolitan area and two elementary schools.

PARTICIPANTS

Five hundred representative families in a metropolitan area and students enrolled in two elementary schools.

INTERVENTIONS

A 1-year-long regional media campaign and a helmet distribution program in one elementary school after 4 weeks of safety instruction.

RESULTS

Evaluation of the community component 1 year after initiation of the campaign revealed a 23% awareness of the promotion. Factors associated with wearing a helmet in the community included higher income levels, higher level of education, and male sex. The school component survey revealed that 73% of the children in school A reported helmet use vs 23% in school B. This multifaceted approach to affect helmet use demonstrated variable success in our community.

CONCLUSION

This campaign effort achieved its greatest success in promoting community awareness of the importance of helmet use. However, further studies need to be performed to determine the success of the school education and helmet distribution program.

Double blind, placebo controlled study of metronidazole as a disease modifying agent in the treatment of rheumatoid arthritis

Anecdotal reports suggest that metronidazole may have disease modifying activity in the treatment of rheumatoid arthritis. To assess possible beneficial effects a double blind, comparative trial of metronidazole and placebo was performed. Fifty patients with active rheumatoid arthritis were randomly allocated to receive active drug (n = 24) or placebo (n = 26) and reviewed at weeks 0, 1, 4, 8, 12, 16, and 24. Detailed assessment of drug safety, biochemical and haematological parameters, and efficacy was made at these dates. Dose regimen was 400 mg twice daily from weeks 0 to eight, increasing to 400 mg three times a day from weeks nine to 24 provided that no adverse effects were recorded. Most patients were unable to tolerate metronidazole because of side effects or lack of efficacy, with only five (21%) continuing to take the drug at 24 weeks. For those patients attaining 12 weeks of treatment an overall improvement in articular index and morning stiffness was found. No improvement in laboratory indices of disease activity was seen, however. In this study metronidazole did not have disease modifying properties and was unacceptably toxic.

Early aortic valve cusp rupture in relapsing polychondritis

Aortic regurgitation associated with relapsing polychondritis usually occurs late in the disease as a result of aortic root dilatation. A case where aortic regurgitation occurred early and was due to cusp rupture with a normal aortic root is reported. The patient required urgent aortic valve replacement within six weeks of developing a murmur despite apparent control of inflammation with immunosuppressive treatment. The possibility of cusp rupture with sudden haemodynamic deterioration should be considered in patients with relapsing polychondritis who develop aortic regurgitation.

Metastatic pancreatic polypeptide producing tumour presenting with diabetes mellitus

A metastatic pancreatic polypeptide tumour is described which presented clinically with diabetes mellitus. This is the first case to present this way.

Taste responses of dogs to ethylene glycol, propylene glycol, and ethylene glycol-based antifreeze

Although it is widely believed that ethylene glycol-based antifreeze (AF) is an attractive tastant to dogs and other animals, empirical data on this point are not available. In experiment 1, we examined the propensity of 178 adult mixed-breed dogs to approach, sniff, and lick a concentration of AF commonly used in automotive cooling systems (50%). Despite the fact that most of the dogs approached and sniffed the AF in these 5-minute tests, only 9% initiated lick responses and most of these were brief and not followed by additional licking. In experiment 2, the lick responses of five gastric-cannulated dogs to aqueous solutions of 20% sucrose, 50% ethylene glycol, 50% propylene glycol, water, and 50% AF were examined in 14-minute tests before and after periods of food and water deprivation. Under the latter conditions, 2 of the 5 dogs drank amounts of ethylene glycol that would have been lethal to uncannulated dogs. None of the five dogs drank potentially lethal amounts of AF. The preference order for these tastants was sucrose greater than water greater than ethylene glycol greater than AF = propylene glycol. Although these findings question the general belief that AF is highly palatable to most dogs, they do imply that large individual differences in responsiveness exist and that AF ingestion is likely influenced by motivational state. Furthermore, they suggest the possibility that unpleasant-tasting additives could be successfully developed to eliminate the ingestion of AF, because the initial attractiveness of AF is relatively low. Such additives would have to be stable in vehicular cooling systems and not adversely affect the functional aspects of AF performance.

Ethics committees in Canadian hospitals: report of the 1989 survey

A survey of English-language hospitals with more than 300 beds in Canada was conducted in 1989 to assess institutional ethics committees. A dramatic increase was found in the growth of such committees, compared with a similar survey taken in 1984. The growth and the activities of institutional ethics committees are discussed, noting the need for more attention for research on their effectiveness.

Occlusive dressings. Does dressing type influence the growth of common bacterial pathogens?

We studied the effect of different occlusive dressings and of air exposure on the growth of four pathogenic bacteria in wounds. Partial-thickness wounds on domestic pigs were inoculated with Staphylococcus aureus, Clostridium perfringens, Bacteroides fragilis, or Pseudomonas aeruginosa. Each wound was covered with three dressings (DuoDERM, Opsite, or Vigilon), or left exposed to air. Groups of wounds were sampled at 24, 48, and 72 hours. Staphylococcus aureus reached high levels beneath all of the dressings and in the air-exposed wounds. The numbers of C perfringens and B fragilis were greatly reduced in the air-exposed wounds and slightly reduced in the Opsite-covered wounds. The numbers of P aeruginosa were greatest in the Opsite- and Vigilon-covered wounds. The results indicate that occlusive dressings are not indicated in wounds that clinically appear to be grossly contaminated or that may contain anaerobic organisms.

Infective endocarditis caused by Streptococcus agalactiae

We report a series of five cases of infective endocarditis caused by Streptococcus agalactiae (group B streptococcus) in Glasgow over a 30 month period. There were three males and two females mean age 48.6 years (range 28-63 years). Only one patient had previous valvular heart disease. The infections were characterised by an acute presentation and an aggressive course with major arterial emboli. Despite early diagnosis and appropriate intravenous antibiotics three patients died, one after valve replacement and two before surgery could be undertaken. The remaining two patients had successful valve surgery and have recovered. S. agalactiae endocarditis is an uncommon but important condition which carries a high mortality. The infection is difficult to control with antibiotics alone and therefore early surgery may be indicated.

Model for studying bacterial adherence to skin wounds

The adherence of bacterial pathogens to wounded skin is probably the first step in wound infection. This report describes the development of a bioassay to simulate the adherence of bacteria to wounds. The adherence of bacteria was examined by exposing wounds to known quantities of pathogens, washing the wounds with distilled water, and quantitating the number of adherent bacteria per cm2 of tissue. Our studies focused on the effects of naturally occurring mediators of bacterial adherence, such as wound fluid, serum, and fibronectin. Bacterial adherence was shown to be challenge dependent. Addition of wound fluid, serum, and heat-inactivated serum was shown to reduce the adherence of Pseudomonas aeruginosa to the wound surface compared with that of a saline control. Additional fibronectin treatment of the wound had no effect on the adherence of Staphylococcus aureus. The ability to identify what affects the binding of bacteria to wounded skin can lead to a better understanding of wound infection.

Povidone-iodine in polyethylene oxide hydrogel dressing. Effect on multiplication of Staphylococcus aureus in partial-thickness wounds

We studied the ability of a polyethylene oxide hydrogel dressing (Vigilon) containing povidone-iodine to prevent Staphylococcus aureus proliferation in partial-thickness wounds. We previously reported that a single application of povidone-iodine on wounds challenged with 2 X 10(6) S aureus was not effective in reducing the number of S aureus after 24 hours. It was therefore hypothesized that povidone-iodine might be effective if it was available continuously and applied to wounds containing a smaller number of bacteria. To test this hypothesis, we made multiple partial-thickness wounds (5 X 7 X 0.3 mm) on six domestic pigs. We then inoculated the wounds by scrubbing them with either a low concentration (log 3.5) or a high concentration (log 7) of S aureus suspension. The wounds were either treated with Vigilon or Vigilon containing povidone-iodine or left air exposed. Wounds from each of these treatment groups were cultured by the scrub technique for S aureus with a 0.5% sodium thiosulfate-polysorbate (Tween) 80 solution 5 minutes, 30 minutes, 24 hours, or 48 hours later. A significant reduction in the number of S aureus recovered from wounds treated with Vigilon containing povidone-iodine was seen with the group inoculated with a low bacterial concentration after 24 hours; but no reductions were observed when wounds were inoculated with the higher bacterial concentration of log 7. We found Vigilon containing povidone-iodine to be an effective inhibitor of S aureus in wounds over a 24-hour period when the organism was present in low numbers.

Masera's organ responds to odorants

Electroolfactogram (EOG) recordings from the rat septal olfactory organ (SO) provide the first demonstration of its broad-range chemosensitivity, and clearly establish this structure as a functioning component of the mammalian intranasal chemosensory system. SO sensitivity to lower concentrations of at least one common test odorant (pentyl acetate) exceeds that at sites located on the septal portion of the main olfactory neuroepithelium. Signals from the SO, as first proposed, thus could have an alerting function and provide information relevant to odor stimulus assessment.

Rat trigeminal, olfactory and taste responses after capsaicin desensitization

Experiment 1 showed that capsaicin injections severely reduced or eliminated nasal trigeminal responses to 3 odorants. Experiments 2 and 3 investigated whether desensitized animals could behaviorally detect and discriminate odors. Capsaicin treated animals had no measurable deficits in locating buried food, in odor aversion learning, or in operant odor detection and discrimination. Experiment 4 examined whether behavioral responsiveness to salty, sour and bitter tastes was affected by desensitization. Capsaicin injections did not affect responsiveness to salty or sour, but may have raised rejection thresholds for bitter. Broadly, the present results suggest that substance P-containing fibers mediate trigeminal responsiveness to odorants and irritants but that the loss of this responsiveness does not appreciably affect smell or taste, per se.

Occlusive wound dressings to prevent bacterial invasion and wound infection

This study was designed to examine the possibility that some occlusive dressings are barriers to wound penetration by pathogenic bacteria. Two common skin pathogens, the nonmotile, Staphylococcus aureus, and the motile, Pseudomonas aeruginosa, were used to challenge dressings placed on partial-thickness wounds in swine. S. aureus was recovered from 100% of air-exposed wounds (log, 5.5 +/- 1.1) and from 50% of Op-Site-treated and Vigilon-treated wounds (log, 6.1 +/- 1.1). S. aureus was not isolated from DuoDERM-covered wounds. P. aeruginosa was recovered from 100% of air-exposed wounds (log, 5.1 +/- 0.5) and 100% of Op-Site-covered and Vigilon-covered wounds (log, 5.8 +/- 1.8). P. aeruginosa was not recovered from DuoDERM-covered wounds. These studies lend support to the idea that dressings may protect wounds from invasion by pathogenic bacteria and demonstrate the need to evaluate their bacterial barrier properties in situ.

Position reversal training in the Virginia opossum: evidence for the acquisition of a learning set

To obtain an estimate of the learning ability of opossums, five tame ones were trained on a series of position reversals to a criterion. With 4 trials per day there was no consistent improvement over a series of 15 reversals. When each daily session was increased to as many trials as needed to reach criterion, errors dropped sharply, indicating the formation of a position learning set. Upon return to 4 trials per day, 3 of 4 animals continued to perform with few errors, showing transfer of learning set. Opossums do more poorly than rats on this task, which is in agreement with the relative phyletic level of the two species.