Remote app-based management of atrial fibrillation during the COVID-19: The centre characteristics and experiences of the European TeleCheck-AF project

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

TeleCheck-AF Investigators

Aims

Herein we describe the characteristics, inclusion rates and experiences from participating centres in the European TeleCheck-AF project. TeleCheck-AF is a multicentre international project initiated to maintain care delivery for patients with atrial fibrillation (AF) during COVID-19 through teleconsultations supported by an on-demand photoplethysmography-based heart rate and rhythm monitoring app (FibriCheck®). 

Methods

Two surveys exploring centre characteristics (n = 25) and centre experiences (n = 23) were completed.

Results

Most centres were academic (64%) and specialized public cardiology/district hospitals (36%). Majority of centres had AF outpatient clinics (64%) and only 36% had AF ablation clinics. The time required to start patient inclusion and total number of included patients in the project was comparable for centres experienced (56%) or inexperienced in mHealth use. Within 28 weeks, 1930 AF patients were recruited, mainly for remote AF control (31% of patients) and AF ablation follow-up (42%). Average inclusion rate was highest during the lockdown restrictions and reached a steady state at a lower level after easing the restrictions (188 vs 52 weekly recruited patients). Majority (>80%) of the centres reported no problems during the implementation of the TeleCheck-AF approach. Centres agreed that the on-boarding process of their center in the TeleCheck-AF project was simple and access to the patients measurements via stand-alone cloud infrastructure was trouble-free and possible from the first day on. They also agreed that remote heart rate and rhythm assessment by the FibriCheck® app around teleconsulatation supported their medical decision making; that their patients responded positively to use FibriCheck® for seven days; and that they felt comfortable to interpret PPG recordings. 

Conclusions

Despite different health care settings and mHealth experiences, the TeleCheck-AF approach could be set up within an extremely short time and easily used in different European centres during COVID-19.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Pharmacologic interventions for fatigue in cancer and transplantation: a meta-analysis

Background

Our objective was to determine whether, compared with control interventions, pharmacologic interventions reduce the severity of fatigue in patients with cancer or recipients of hematopoietic stem-cell transplantation (hsct).

Methods

For a systematic review, we searched medline, embase, the Cochrane Central Register of Controlled Trials, cinahl, and Psychinfo for randomized trials of systemic pharmacologic interventions for the management of fatigue in patients with cancer or recipients of hsct. Two authors independently identified studies and abstracted data. Methodologic quality was assessed using the Cochrane Risk of Bias tool. The primary outcome was fatigue severity measured using various fatigue scales. Data were synthesized using random-effects models.

Results

In the 117 included trials (19,819 patients), the pharmacologic agents used were erythropoietins (n = 31), stimulants (n = 19), l-carnitine (n = 6), corticosteroids (n = 5), antidepressants (n = 5), appetite stimulants (n = 3), and other agents (n = 48). Fatigue was significantly reduced with erythropoietin [standardized mean difference (smd): -0.52; 95% confidence interval (ci): -0.89 to -0.14] and with methylphenidate (smd: -0.36; 95% ci: -0.56 to -0.15); modafinil (or armodafinil) and corticosteroids were not effective.

Conclusions

Erythropoietin and methylphenidate significantly reduced fatigue severity in patients with cancer and in recipients of hsct. Concerns about the safety of those agents might limit their usefulness. Future research should identify effective interventions for fatigue that have minimal adverse effects.

Antibody mimetic receptor proteins for label-free biosensors

Small synthetic antibody mimetic receptor proteins which offer high stability, specificity and affinity are presented as capture molecules in solid-state electro-chemical biosensors.

Validation of the Children's International Mucositis Evaluation Scale (ChIMES) in paediatric cancer and SCT

BACKGROUND

Objectives were to describe the reliability and validity of a new paediatric-specific mucositis scale, the Children's International Mucositis Evaluation Scale (ChIMES).

METHODS

In a multi-centre prospective study, children aged 0 to ≤18 years were eligible if they were receiving any of the following: myeloablative stem cell transplantation (SCT), ≥60 mg m(-2) course(-1) doxorubicin or ≥12 g m(-2) methotrexate. Multiple measures of mucositis were included along with ChIMES. Respondents were parent proxy report for children aged <12 years, and child self-report for children aged 12-18 years and 8 to <12 years. Mucositis diaries were completed at baseline and on Days 7-17 following chemotherapy/conditioning. On Day 14, the respondent reported presence of mucositis and change since the previous day.

RESULTS

The 185 respondents included parents (N=98), children aged 12-18 years (N=66) and children aged 8 to <12 years (N=21). Test-retest reliability was excellent for ChIMES Total Score and ChIMES Percentage Score with r>0.8 for all respondent types. Criteria for construct validation were met across all measures. ChIMES also demonstrated responsiveness with significant differences between baseline and Day 14.

CONCLUSION

ChIMES is a paediatric-specific measure of mucositis with favourable psychometric properties. It exhibits reliability, construct validity and responsiveness. ChIMES should be incorporated into clinical trials of mucositis prevention and treatment in paediatric cancer and SCT.

HIF1A P582S gene association with endurance training responses in young women

Sequence variations in the gene encoding the hypoxia-inducible factor-1alpha, HIF1A, have been associated with physiologic function and could be associated with exercise responses. In the HIF1A P582S gene polymorphism (C1772T; rs 11549465 C/T), a single nucleotide transition from C → T alters the codon sequence from the usual amino acid; proline (C-allele), to serine (T-allele). This polymorphism was examined for association with endurance training responses in 58 untrained young women who completed a 6-week laboratory-based endurance training programme. Participant groups were defined as CC homozygotes versus carriers of a T-allele (CC vs. CT genotypes). Adaptations were examined at the systemic-level, by measuring [Formula: see text] and the molecular-level by measuring enzymes determined from vastus lateralis (n = 20): 3-hydroacyl-CoA-dehydrogenase (HAD), which regulates mitochondrial fatty acid oxidation; cytochrome C oxidase (COX-1), a marker of mitochondrial density; and phosphofructokinase (PFK), a marker of glycolytic capacity. CT genotypes showed 45% higher training-induced gains in [Formula: see text] compared with CC genotypes (P < 0.05). At the molecular level, CT increased the ratios PFK/HAD and PFK/COX-1 (47 and 3%, respectively), while in the CC genotypes these ratios were decreased (-26 and -54%, respectively). In conclusion, the T-allele of HIF1A P582S was associated with greater gains in [Formula: see text] following endurance training in young women. In a sub-group we also provide preliminary evidence of differential muscle metabolic adaptations between genotypes.

Endothelial dysfunction in a murine model of thyroid hormone resistance

BACKGROUND

The development of a knockin mouse model of resistance to thyroid hormone (RTH) has led to a greater understanding of both the molecular and clinical behaviour of this syndrome. We have investigated the vascular response in RTH using a specific (TRbeta PV) knockin mouse model targeting the PV mutation to the thyroid hormone receptor beta gene locus.

MATERIALS AND METHODS

Ring segments of the thoracic aorta were used to assess the response of homozygous, heterozygous and wild-type controls to contractile agents, potassium chloride and phenylephrine. Each genotype after maximal contraction was exposed to increasing concentrations of relaxing agents, acetylcholine (ACh) and sodium nitroprusside (SNP).

RESULTS

The response of these aortic ring segments to ACh and SNP demonstrates that endothelium-dependent relaxation to ACh was significantly impaired in both heterozygous and homozygous mice compared to controls (69.8 +/- 2.0%, 59.7 +/- 1.4% and 75.0 +/- 1.7%, respectively; P < 0.001). However, endothelium independent responses to SNP showed no difference between genotypes (114.4 +/- 3.2%, 116.8 +/- 2.6% and 106.9 +/- 4.9%; P = NS).

CONCLUSION

These data suggest that endothelial function is impaired in the RTH mouse aorta. The respective roles of elevated thyroid stimulating hormone (TSH), elevated thyroid hormone concentrations and the mutated thyroid hormone beta receptor require further elucidation.

Dewatered alum sludge: a potential adsorbent for phosphorus removal

Alum sludge refers to the by-product from the processing of drinking water in water treatment works. In this study, groups of batch experiments were designed to identify the characteristics of dewatered alum sludge for phosphorus adsorption. Air-dried alum sludge (moisture content 10.2%), which was collected from a water treatment works in Dublin, was subjected to artificial P-rich wastewater adsorption tests using KH2PO4 as a model P source. Adsorption behaviours were investigated as a function of amount and particle size of alum sludge, pH of solution and adsorption time. The results have shown that pH plays a major role not only in the adsorption process but also in the adsorption capacity. With regard to adsorption capacity, this study reveals the Langmuir adsorption isotherm being the best fit with experimental data (R2 = 0.98-0.99). The maximum adsorption capacities range from 0.7 to 3.5 mg-P/g when the pH of the synthetic P solution was varied from 9.0 to 4.3, accordingly. The outcome of this study indicated that alum sludge is suitable for use as an adsorbent for removal of phosphate from wastewater.

Gingivitis and toothbrushes: potential roles in viridans streptococcal bacteraemia

We report a case of Streptococcus oralis bacteraemia in a paediatric neutropenic patient with acute myeloid leukaemia whose predominant form of oral compromise was severe gingivitis, rather than mucositis. By phenotypic and genotypic analyses, the strain of S. oralis from blood culture was indistinguishable from an isolate from his mouth, suggesting that gingivitis may have provided a portal of entry for viridans streptococci into the bloodstream. To improve the patient's oral and dental hygiene and reduce gingivitis, conventional disposable foam toothettes were substituted with a new soft toothbrush for use as part of the oral care protocol. As there are no guidelines regarding the frequency of replacement of toothbrushes used by immunocompromised patients, the brush was swabbed regularly and culture performed to detect microbial colonization. Viridans streptococci were cultured from the toothbrush after 2 weeks of use. Phenotypic, followed by genotypic analyses, demonstrated that a strain of S. oralis from the toothbrush was indistinguishable from the strain previously isolated from blood culture and mouth. Soft toothbrushes may be useful tools for maintaining oral hygiene in immunocompromised individuals. However the results of this study indicate that regular replacement is warranted, as the toothbrush itself may become colonized with the organisms responsible for bacteraemia.

Adherence to highly active antiretroviral therapy in the real world: experience of twelve English HIV units

In order to describe how human immunodeficiency virus (HIV) clinics in and around London are trying to optimize their patients' adherence to highly active antiretroviral therapy (HAART), we performed a survey of practice and policy in the clinics using a postal questionnaire. Clinics were also asked to review up to 10 randomly selected case notes of patients receiving HAART and complete a questionnaire on each about how adherence was encouraged and assessed. Twelve clinics took part in the project and surveyed the notes of 89 patients. The results show that several clinics define adequate adherence as taking more than 95% of prescribed doses although there was no uniform definition across the participating units. Adherence was encouraged through simplifying HAART regimens, providing dose-dispensing boxes and alarms, arranging early follow-up for patients starting treatment, and offering continuing support through specific health care workers. Adequate discussion and provision of written information was seen as an important aid to adherence but the case note survey showed evidence of deficiencies in this area in approximately 40% of patients. Assessed levels of adherence were less than 95% in 27% of patients. The main reasons for suboptimal adherence were found to be lack of motivation to take treatment by the patients, high pill burden, and drug side effects although there were several other contributing factors. This study shows that the HIV units take HAART adherence seriously but there are several deficiencies in putting policy into practice.

The treatment of retinoblastoma: a case study

Research in the treatment of retinoblastoma and multidrug resistance has led to new treatment protocols for children. This case study introduces information regarding a clinical trial for the treatment of intraocular retinoblastoma. It also highlights important nursing issues in the care of these children and their families.

Management of Chlamydia trachomatis genital tract infection in Genitourinary Medicine clinics in the United Kingdom's North Thames Region 1999

Assessment of clinical management of Chlamydia trachomatis genital tract infection was made, with particular regard to the UK National Guideline. Questionnaires for self-completion, mailed to lead clinicians in 31 Genitourinary Medicine (GUM) clinics in the North Thames Region between May and June 1999, focused on policies and practice. Audit of actual management of up to 10 most recent cases (5 male and 5 female) attending each clinic within the past 2 years was also undertaken. Twenty-two units (71% response) completed the survey questionnaire and 23 units (74% response) audited a total of 229 cases (males=108, females=118, sex not stated=3). Findings indicate that GUM clinics are managing these infections largely as recommended in the national guideline. Nucleic acid amplification techniques will supersede established diagnostic tests for GUM clinics in North Thames, increasing costs for the service, but also sensitivity of detection.

Euthanasia: from the perspective of HIV infected persons in Europe

BACKGROUND

In the debate about legalization of euthanasia very little attention has so far been given to the opinion of the patient.

OBJECTIVE

To assess the opinion of persons with HIV infection in Europe.

METHODS

A cross-sectional survey of persons with HIV infection attending HIV/AIDS treatment centres or HIV support organizations in 11 European Union Member States was performed. A total of 2751 anonymous patient self-administered questionnaires were distributed between August 1996 and September 1997. The questionnaire contained 108 questions concerning a variety of topics about HIV care, including five questions on euthanasia.

RESULTS

One thousand three hundred and seventy-one people with HIV infection completed the questionnaire, of whom 1341 (98%) responded to the questions concerning euthanasia. Seventy-eight percent of respondents agreed with the legalization of euthanasia in case of severe physical suffering, 47% if there was severe psychological suffering and 24% simply at the patient's request. For physical suffering and at a clear patient's request, accepted practices were: alleviation of pain with double effect (81%), medical euthanasia (62%) and physician assisted suicide (45%). Fifty percent would consider euthanasia for themselves if all treatment options were exhausted. Social indicators such as educational level and employment seemed to play a more significant role in determining attitudes towards legalization, and personal interest in, euthanasia than indicators related to disease status.

CONCLUSION

In this study a majority of HIV infected persons in Europe favoured the legalization of euthanasia.

Skeletal muscle myosin heavy chain isoforms and energy metabolism after clenbuterol treatment in the rat

Prolonged treatment with the beta(2)-adrenoceptor agonist clenbuterol (1-2 mg. kg body mass(-1). day (-1)) is known to induce the hypertrophy of fast-contracting fibers and the conversion of slow- to fast-contracting fibers. We investigated the effects of administering a lower dose of clenbuterol (250 microgram. kg body mass(-1). day (-1)) on skeletal muscle myosin heavy chain (MyHC) protein isoform content and adenine nucleotide (ATP, ADP, and AMP) concentrations. Male Wistar rats were administered clenbuterol (n = 8) or saline (n = 6) subcutaneously for 8 wk, after which the extensor digitorum longus (EDL) and soleus muscles were removed. We demonstrated an increase of type IIa MyHC protein content in the soleus from approximately 0.5% in controls to approximately 18% after clenbuterol treatment (P < 0.05), which was accompanied by an increase in the total adenine nucleotide pool (TAN; approximately 19%, P < 0.05) and energy charge [E-C = (ATP + 0.5 ADP)/(ATP + ADP + AMP); approximately 4%; P < 0.05]. In the EDL, a reduction in the content of the less prevalent type I MyHC protein from approximately 3% in controls to 0% after clenbuterol treatment (P < 0.05) occurred without any alterations in TAN and E-C. These findings demonstrate that the phenotypic changes previously observed in slow muscle after clenbuterol administration at 1-2 mg. kg body mass(-1). day(-1) are also observed at a substantially lower dose and are paralleled by concomitant changes in cellular energy metabolism.

Management of HIV and pregnancy in England's North Thames Region 1999: a survey of practice in 21 hospitals

OBJECTIVES

To ascertain current practices in the diagnosis and management of HIV and pregnancy in the North Thames Region.

METHODS

Postal survey using a self-completed questionnaire sent to the head of all of the Region's 34 units involved in the care of HIV. The survey asked questions on current policy around HIV and pregnancy in the HIV units and associated antenatal clinics and was linked to a case-note survey of pregnant, HIV-positive women in the last 2 years.

RESULTS

Over 50% of the responding antenatal units recommended the HIV test by March 1999. Most HIV units were offering a range of antiretroviral regimens in pregnancy, although a minority (33%) did not offer triple therapy. Elective Caesarean section was the recommended mode of delivery for most women (90%) irrespective of drug therapy or viral load. Most infants were being tested for HIV infection by a combination of PCR, viral culture and antibody testing to 18 months of age. All the infants (19) followed to 6 months of age in the case-note survey were PCR negative. Reporting rates to the National Survey of HIV in Pregnancy were high (87%) but poor for the Drug Exposure Register (33%).

CONCLUSIONS

Management of HIV and pregnancy in the North Thames units showed a large amount of consistency with regard to testing policies and management. However, there were a few units that did not offer therapy appropriate for advanced disease despite the recommendations of national bodies and a few units still did not recommend HIV testing to all women.

Ambient solar UVR, personal exposure and protection

Ambient solar ultraviolet radiation (UVR) has been monitored around Australia by the Australian Radiation Laboratory (ARL) and its successor ARPANSA since the mid 1980's using a network of radiometric detectors and a spectroradiometer (SRM) for spectral measurements, based in Melbourne. In a continent the size of Australia, the levels vary markedly, basically following a latitude gradient increasing towards the equator but with local geographical and weather effects also evident. ARL also conducts personal exposure studies of various population groups in collaboration with other research centres to gather information on what fraction of the ambient UVR people receive. ARL also undertakes studies on the UVR protection provided by sunscreens, clothing, hats, sunglasses and other materials in an attempt to improve UVR protection used by the public.

Decreased morbidity and use of hospital services in English HIV-infected individuals with increased uptake of anti-retroviral therapy 1996-1997. National Prospective Monitoring System Steering Group

OBJECTIVE

To investigate the relationship between changing morbidity patterns, the use of hospital services by HIV-infected patients and the uptake of antiretroviral therapy (ART) in England.

DESIGN

Prospective serial cross-sectional analyses based on data collected through the National Prospective Monitoring System (NPMS), a multi-centre prospective monitoring system.

SETTING

HIV-infected patients seen in 10 clinics, five London and five non-London, during the three semesters, 1 January 1996 to 30 June 1997.

MAIN OUTCOME MEASURES

The mean use of hospital services per patient-year, mean new HIV-related opportunistic illnesses per 1000 patient-years and percentage uptake of ART.

RESULTS

The use of inpatient services changed particularly among AIDS patients. The mean number of inpatient days for AIDS patients decreased from 19.7 [95% confidence interval (CI) 13.7-25.7] in 1996 to 11.2 (95% CI 6.1-15.6) per patient-year in 1997. Concurrently the number of new AIDS-defining events decreased significantly from 567 (95% CI 529-607) to 203 (95% CI 183-225) per 1000 patient-years. The overall uptake of ART increased significantly from 33% (95% CI 31-35%) to 50% (95% CI 48-52%), and a switch from mono or dual to triple therapy or quadruple or more therapy was observed. However, by mid-1997 only 29% (95% CI 26-32%) of asymptomatic patients and 51% (95% CI 49-54%) of patients with symptomatic non-AIDS were on ART, compared with 69% (95% CI 66-71%) of AIDS patients.

CONCLUSION

The observed reduction in new AIDS-defining events has led to a reduction in the need for inpatient hospital care and has been associated with an increased uptake of ART, including a switch to triple therapy. All of these factors are likely to have contributed to the observed reduction in mortality among English AIDS patients. As the overall uptake of ART remained relatively low in English centres further improvements can be anticipated. However, the medium to long-term effects of these treatment regimens will need to be closely monitored.

Patient satisfaction with HIV service provision in NPMS hospitals: the development of a standard satisfaction questionnaire. NPMS Steering Group

A self-completion satisfaction questionnaire evaluating the standard of care of HIV outpatient services was developed as part of the National Prospective Monitoring System on the Use, Cost and Outcome of HIV Service Provision in English Hospitals (NPMS). The questionnaire was designed in conjunction with service users and health care professionals, and piloted in three London and three non-London HIV clinics. In addition to testing alternative methods of administering the questionnaire, the pilot provided satisfaction scores on a variety of aspects of service provision for participating clinics. The questionnaire was completed by 548 respondents and was most effectively collected using a sealed box in the clinic waiting area. Mean satisfaction scores for the attitude and skills of staff members was 4.7 (95% CI 4.6-4.7) but satisfaction scores were significantly lower for the clinic environment with a mean of 4.1 (95% CI 4.1-4.2). Satisfaction scores did not differ significantly by gender, age, sexual orientation, ethnic group, employment status or severity of symptoms. London respondents were more satisfied with the clinic environment and seeing preferred members of staff than their non-London counterparts, however there were no other differences between clinics. The questionnaire functioned well in practice and provided meaningful and useful information for individual clinics as well as at aggregate level.

The use and cost of HIV service provision in England in 1996. National Prospective Monitoring System (NPMS) Steering Group and NPMS Working Party on Costs

OBJECTIVE

The aim of the study was to measure the use and estimate the cost of HIV service provision in England.

DESIGN AND SETTING

Standardised activity and case-severity data were collected prospectively in 10 English HIV clinics (5 London and 5 non-London sites) for the periods 1 January 1996 to 30 June 1996 and 1 July 1996 to 31 December 1996 and linked to unit cost data. In total, 5440 patients with HIV infection attended during the first 6 months and 5708 during the second 6 months in 1996.

MAIN OUTCOME MEASURES AND RESULTS

The mean number of inpatient days per patient-year for patients with AIDS was 19.7 [95% confidence interval (CI): 13.7 to 25.7] for January to June and 20.8 (95% CI: 15.3 to 26.4) for July to December 1996. The mean number of outpatient visits for asymptomatic patients with HIV infection was 14.8 (95% CI: 11.9 to 17.6) and 13.3 (95% CI: 10.8 to 15.7) for the respective periods and 16.1 (95% CI: 13.21 to 18.97) and 15.7 (95% CI: 11.2 to 20.2), respectively, for patients with symptomatic non-AIDS (i.e. symptomatic patients with HIV infection but without AIDS-defining conditions). Substantial centre-to-centre variation was observed, suggesting that many clinics can continue the shift from an inpatient- to an outpatient-based service. Cost estimates per patient-year for HIV service provision for 1996 varied from 4695 Pounds (95% CI: 3769 Pounds to 5648 Pounds) for asymptomatic patients, to 7605 Pounds (95% CI: 6273 Pounds to 8909 Pounds) for symptomatic non-AIDS patients to 20,358 Pounds (95% CI: 17,681 Pounds to 23,206 Pounds) for patients with AIDS.

CONCLUSIONS

Different combinations of antiretroviral therapy affect the cost estimates of HIV service provision differently. Anticipated reduction in inpatient-related activity through the increased use of combination antiretroviral therapy will further shift service provision from an inpatient- to outpatient-based service and reduce costs per patient-year. The extent and duration of such effects are currently unknown. The long term effects of combination treatment on the morbidity and mortality patterns of individuals infected with HIV are also currently unknown, as are their implications on the use and cost of HIV service provision. Multicentre databases like the National Prospective Monitoring System (NPMS) will provide healthcare professionals with information to improve existing services and anticipate the impact of new developments.

A new concept in radiology QA in a large setting

Determining film quality has traditionally been carried out through review and evaluation of exam retakes. At best, such a system will tell which exam areas the technologist repeated most. Kaiser Permanente Northwest has 80 radiologic technologists and 30 radiologists who rotate through film reading. The program developed at Kaiser is directed toward general diagnostic film quality only and uses the services of two full-time quality assurance (QA) technologists. Working together, the radiologist and QA staff have created a standard of diagnostic image quality. A QA radiologist representative is available to work with the QA technologist if inconsistencies are raised. Every other month, a QA technologist makes a random selection for review of 50 exams performed by each technologist. These evaluations cover view rather than exam, with each view judged on its own merit. The purpose is to look for recurring problems in the technologist's performance. Copies of the review sheet go to each technologist's supervisor who forwards a copy to the technologist. Technologists can request help to understand why certain films meet or fail to meet quality standards. The QA technologists are available to give one-on-one help, and they also offer classes and demonstrations. In turn, radiologist fill out quality control (QC) slips as they read exams. The slips help to educate and correct specific problems, and are a direct communication link between radiologist and technologist. The QA program places importance on having the proper tools for taking quality films. The program also provides several levels of accountability although QA technologists are not responsible for its enforcement. Instead, they give feedback to supervisors who enforce performance levels. An appeals process is also in place. The program helps keep image quality acceptable to both hospital radiologists and customer requirements in the industry. In turn, the technologists use it to further their professional development.

Spatial learning ability of rats following differing levels of exposure to alcohol during early postnatal life

Rats exposed to a relatively high dose (7.5 g/kg body weight) of alcohol on either the fifth or tenth postnatal day of age have been reported to have long-lasting deficits in spatial learning ability as tested on the Morris water maze task. The question arises concerning the level of alcohol required to achieve this effect. Wistar rats were exposed to either 2, 4 or 6 g/kg body weight of ethanol administered as a 10% solution. This ethanol was given over an 8-h period on the fifth postnatal day of age by means of an intragastric cannula. Gastrostomy controls received a 5% sucrose solution substituted isocalorically for the ethanol. Another set of pups raised by their mother were used as suckle controls. All surgical procedures were carried out under halothane vapour anaesthesia. After the artificial feeding regimes all pups were returned to lactating dams and weaned at 21 days of age. The spatial learning ability of these rats was tested in the Morris water maze when they were between 61-64 days of age. This task requires the rats to swim in a pool containing water made opaque and locate and climb onto a submerged platform. The time taken to accomplish this is known as the escape latency. Each rat was subjected to 24 trials over 3 days of the test period. Statistical analysis of the escape latency data revealed that the rats given 6 g/kg body weight of ethanol had significant deficits in their spatial learning ability compared with their control groups. However, there was no significant difference in spatial learning ability for the rats given either 2 or 4 g/kg body weight of ethanol compared with their respective gastrostomy or suckle control animals. We concluded that ethanol exposure greater than 4 g/kg over an 8-h period to 5-day-old rats is required for them to develop long-term deficits in spatial learning behaviour.

Male duct ectasia associated with HIV infection

The incidence of male duct ectasia (periductal mastitis) is extremely rare, only eight cases having been reported. The underlying cause (as in females) is uncertain. Two cases in HIV positive males of recurrent unilateral nipple lesions are reported with histology consistent with duct ectasia. At presentation neither patient had an AIDS defining illness. An impaired immunity secondary to HIV infection may result in an increased susceptibility to repeated nipple infections, and the clinical as well as histological features of duct ectasia. The consideration of HIV infection in future cases of male duct ectasia may be warranted.

Liposomal-entrapped doxorubicin: an active agent in AIDS-related Kaposi's sarcoma

PURPOSE

A phase II study was performed of single-agent liposomally entrapped doxorubicin ([LED] Doxil; Liposome Technology Inc, Menlo Park, CA) against locally advanced cutaneous/systemic AIDS-related Kaposi's sarcoma (KS).

PATIENTS AND METHODS

Thirty-four patients with AIDS-related advanced cutaneous/systemic KS were treated with 20 mg/m2 of LED every 3 weeks on an outpatient basis. The median age was 39 years and the median Karnofsky score was 70. All patients had poor prognostic disease as judged by AIDS Clinical Trials Group (ACTG) criteria. Nineteen of 34 patients had received prior chemotherapy for KS, although no patient had received prior anthracyclines.

RESULTS

An overall response rate of 73.5% (25 of 34) was observed. Partial responses (PRs) occurred in 67.7% (23 of 34) and complete responses (CRs) in 5.8% (two of 34). In patients who had received previous chemotherapy, the response rate was 68.4% (13 of 19), and all responses were PRs. The median time to response was 6 weeks. The median duration of response was 9 weeks. Toxicity according to World Health Organization (WHO) criteria was as follows: neutropenia (grade > or = 3), 34%; alopecia (grade 1 only), 9%; and nausea and vomiting (grade 1), 18%. One patient died of heart failure, which was not considered to be anthracycline-induced.

CONCLUSION

LED appears to be highly active against AIDS-related KS. The major toxicity is neutropenia, which seems to be progressive in patients who receive several cycles of therapy. Comparative studies of LED versus conventional chemotherapy are needed.

Smoking cessation counseling by emergency physicians: opinions, knowledge, and training needs

OBJECTIVES

To determine: 1) the extent of emergency physicians' (EPs') training in smoking cessation counseling; 2) their understanding of counseling and pharmacologic treatment techniques; 3) their current practices in screening, counseling, and referring patients who smoke; and 4) perceived barriers to routine smoking cessation counseling in emergency medical practice.

METHODS

A 26-item questionnaire addressing the above issues was mailed to all 256 members of the Colorado Chapter of the American College of Emergency Physicians.

RESULTS

Completed questionnaires were returned by 196 physicians (77% response rate). The majority of respondents were men (80%), practiced in urban settings (87%), and were board-certified in emergency medicine (82%). Most EPs lacked formal smoking cessation training (55%) and felt poorly prepared to counsel patients about smoking cessation (65%). A minority (27%) of the physicians reported routinely asking patients to quit smoking. The physicians with formal smoking cessation training were more likely to counsel and refer patients routinely (34% vs 20%, p = 0.03). The physicians cited the following barriers to routine smoking cessation counseling: a lack of time; a perception that patients are not interested; a belief that the ED setting is inappropriate for counseling; and a sense that counseling is ineffective. Lack of reimbursement was cited by only 13% of the respondents. The physicians who had formal smoking cessation training perceived fewer barriers to ED-based counseling.

CONCLUSIONS

Emergency physicians have received little training in smoking cessation and perceive many barriers to ED-based smoking cessation interventions. Not surprisingly, they infrequently take action to encourage or assist their patients to quit smoking.

Smoking habits of emergency department patients: an opportunity for disease prevention

OBJECTIVE

To determine smoking habits, levels of addiction, readiness to quit, and access to primary care among ED patients.

METHODS

A questionnaire was administered prospectively to all noncritical adult patients who presented to one university hospital ED during 23 randomly selected four-hour time blocks; 336 (89%) of 376 eligible patients responded. Self-reported smoking was validated by carbon monoxide breath testing in a pilot sample of 49 patients.

RESULTS

The study patients were mostly young (mean age = 35 +/- 15 years), female (59%), white (62%), and high school-educated (73%). Of the 336 ED patients, 41% were current smokers (95% CI = 0.36-0.46); 42% of these were "moderately" to "very highly" dependent on nicotine (Fagerstrom Test for Nicotine Dependence > 4). Of those who smoked, 68% stated they wanted to quit, and 49% wanted to quit within the month. Fifty-six percent of all those who smoked stated that they had never been told to quit smoking by any physician. Thirty-five percent of the ED sample (118 patients) relied upon EDs for most or all of their routine, primary health care; 55% (95% CI = 0.46-0.64) of these patients were current smokers.

CONCLUSIONS

The prevalence rates of smoking and nicotine addiction among ED patients are high. Almost half of ED smokers are ready to quit, but most state they have never been told by a physician to do so. Finally, a large proportion of ED smokers receive their primary care in EDs. Therefore, the ED may be an underused setting for smoking cessation intervention.

Randomised controlled trial comparing problem solving treatment with amitriptyline and placebo for major depression in primary care

OBJECTIVE

To determine whether, in the treatment of major depression in primary care, a brief psychological treatment (problem solving) was (a) as effective as antidepressant drugs and more effective than placebo; (b) feasible in practice; and (c) acceptable to patients.

DESIGN

Randomised controlled trial of problem solving treatment, amitriptyline plus standard clinical management, and drug placebo plus standard clinical management. Each treatment was delivered in six sessions over 12 weeks.

SETTING

Primary care in Oxfordshire.

SUBJECTS

91 patients in primary care who had major depression.

MAIN OUTCOME MEASURES

Observer and self reported measures of severity of depression, self reported measure of social outcome, and observer measure of psychological symptoms at six and 12 weeks; self reported measure of patient satisfaction at 12 weeks. Numbers of patients recovered at six and 12 weeks.

RESULTS

At six and 12 weeks the difference in score on the Hamilton rating scale for depression between problem solving and placebo treatments was significant (5.3 (95% confidence interval 1.6 to 9.0) and 4.7 (0.4 to 9.0) respectively), but the difference between problem solving and amitriptyline was not significant (1.8 (-1.8 to 5.5) and 0.9 (-3.3 to 5.2) respectively). At 12 weeks 60% (18/30) of patients given problem solving treatment had recovered on the Hamilton scale compared with 52% (16/31) given amitriptyline and 27% (8/30) given placebo. Patients were satisfied with problem solving treatment; all patients who completed treatment (28/30) rated the treatment as helpful or very helpful. The six sessions of problem solving treatment totalled a mean therapy time of 3 1/2 hours.

CONCLUSIONS

As a treatment for major depression in primary care, problem solving treatment is effective, feasible, and acceptable to patients.