The use of colonic stents as a bridge to surgery in malignant colonic obstruction - A dual trust experience over 10 years

Introduction

Worldwide colonic cancer is the third most common cancer with up to 30% of cases presenting with large bowel obstruction. Self-expanding metal stents (SEMS) have been used as a bridge to surgery (BTS) in the treatment of this malignant obstruction. We review the outcomes of SEMS as a BTS across two high volume colorectal units.

Methodology

A retrospective analysis of patients undergoing colonic stenting as a bridge to surgery was performed; outcomes were compared to previously published figures on emergency colonic resections. Inclusion criteria were adults (>18 years of age) undergoing colonic stenting for colonic obstruction with a view to elective resection. Patients undergoing stenting for palliation of symptoms were excluded.

Results

39 patients were identified across both trusts over a ten-year period. 90 day mortality following BTS was found to be 3.6% and there was an 82.1% (32/39) technical success rate. 46.4% proceeded to an elective resection which was started laparoscopically. Permanent stoma rate was observed at 14.3% for elective surgery.

Conclusion

Stenting for relief of acute malignant obstruction as a bridge to surgery is a viable option in select patients. Further research is required to determine oncological safety and rate of local recurrences.

Perpetrator Perceptions on the Emotions and Motivations Driving Technology-Facilitated Abuse in Relationships: A Story Completion Study

Technology-facilitated abuse in relationships (TAR) is a widespread social problem that has a significant impact on victim-survivors. Most contemporary evidence on TAR focuses on victim-survivor and practitioner perspectives rather than those of perpetrators who choose to enact this form of harm. Addressing this deficit, this study explored perpetrators' discourses on emotions and motivations associated with engaging in TAR. Using story completion method, 35 self-identified perpetrators of TAR completed story stems describing scenarios that may precede the use of abusive online behaviors. Reflexive thematic analysis generated three themes. Abusive behaviors and negative emotions speaks to maladaptive experiences of anger and/or sadness that can precede a decision to use TAR. A loss of trust, a desire for control describes potential motives for using TAR. Finally, inhibitors of abusive behavior investigates rationales perpetrators use for avoidance of TAR behaviors, suggesting avenues for working with perpetrators to refrain from using TAR. We conclude by discussing policy, practice, and research recommendations including strategies for technology designers and suggestions for primary prevention and response to TAR.

A196 CROHN’S DISEASE PATIENT DERIVED MACROPHAGES ARE MORE SUSCEPTIBLE TO HYDROGEN PEROXIDE INDUCED CELL DEATH

Background

Crohn’s disease (CD) is characterized by intestinal inflammation due to the interplay between immunity, genetics, and environmental factors such as diet. Selenium (Se) deficiency is common in patients with CD due to malabsorption or high enteric losses. Selenium is used in the synthesis of selenoproteins that have antioxidant properties (e.g. glutathione peroxidases (GPx)) and are highly expressed in macrophages. However, how Se deficiency affects immune system function in patients with CD is unknown. We hypothesize that characterizing Se status, selenoprotein expression and subsequently macrophage function will advance knowledge of mucosal immunity and provide novel insight into CD.

Purpose

To determine if patients with active CD and healthy controls differ in Se dietary intake and status, oxidative stress, and macrophage cytotoxicity in response to oxidative stress.

Method

Blood was collected from healthy volunteers and patients diagnosed with ileal, ileocolonic or colonic CD (age ≥18 years, with mild or moderate endoscopic disease activity or fecal calprotectin ≥250 µg/g, and Harvey Bradshaw index <16, stable medications including biologics for at least 8-weeks prior to recruitment). Serum was analyzed for GPx activity, malondialdehyde (MDA) and C-reactive protein (CRP) concentrations. Monocytes were isolated by plastic adherence and treated with M-CSF (10 ng/ml, 7d) to derive macrophages. mRNA expression of GPx1, GPx4 and SelenoP was determined by qPCR. Lactate dehydrogenase release was measured in macrophages treated with 500 µM H₂O₂ for 2h.

Result(s)

Samples and/or dietary intake data were collected from 9 patients with CD (3 female, 6 male, mean age=36.8 years) and 13 controls (7 female, 6 male, mean age=27.7 years). Dietary Se intake did not differ between patients with CD and controls (126.1 ± 23.2 vs. 123.3 ± 19.8 µg/day). GPx activity was greater in the serum of patients with CD compared to controls (369 ± 49 vs. 169 ± 27 mU/mL, n=6-8, p<0.005). Patients with CD and controls did not differ in serum MDA concentration (7.80 ± 0.57 vs. 6.53 ± 1.1 µM). CRP levels correlated with serum MDA concentration in patients with CD (r=0.95, n=5, p<0.05) but not GPx activity. Macrophages from patients with CD (n=6) and controls (n=7) did not differ in expression of GPx1 and GPx4 mRNA, whereas SelenoP mRNA was ~200-fold lower in macrophages from patients with CD. Macrophages derived from patients with CD were more susceptible to H₂O₂-evoked cell death (10.3 ± 1.1 vs. 4.7 ± 0.7 % n=2-3 p<0.05).

Conclusion(s)

Despite adequate dietary Se intake our findings suggest altered Se metabolism in patients with active CD, with increases in serum GPx potentially indicative of the need for antioxidant activity to counter oxidative stress. The increased sensitivity of macrophages from patients with CD to H₂O₂ emphasizes the role of oxidative stress and redox balance in IBD. Defining how micronutrients, in this instance Se, impacts innate immunity may provide new approaches to the management of CD.

Disclosure of Interest

None Declared

Straight to test reduces time to investigation and treatment

Straight to test (STT) is a recognised pathway for improving the waiting time for red flag referrals. Electronic patient care records (ECR) provide clinicians with a greater volume of clinical information allowing virtual triage and STT. We aimed to assess if using ECR and STT can reduce delays in diagnosis and treatment. A review of 300 colorectal referrals between 2018-2019 was performed. Patients awaiting an appointment were reviewed electronically, by a single colorectal surgeon and re-triaged STT if appropriate. The delay in time from referral to initial review was removed, creating a second group for statistical comparison to demonstrate time saved if the strategy was adopted at the point of original triage. 91.3% (n= 274) were red flag referrals. 94% (n=282) were sent STT. Patients processed via traditional referral and clinic had a median time to scope of 36 days compared with 22.5 days, p < 0.001 if triaged STT via virtual clinic. Median time to management was 59 days for traditional and 35 days for STT, p < 0.001.

Health Misinformation Across Multiple Digital Ecologies: Qualitative Study of Data from Interviews With International Students (Preprint)

Background

Transient migrants such as international students have received limited support from host country governments throughout the COVID-19 pandemic. An increase in misinformation, resulting in poor health outcomes for individuals, may impact an already vulnerable group.

Objective

Existing research examines the spread of misinformation. Similarly, there is extensive literature on the health information behavior of international students. However, there is a gap in the literature focusing on international students’ interaction with health misinformation. This exploratory research aims to address this gap by examining international students’ interaction with health misinformation during the COVID-19 pandemic.

Methods

A total of 11 participants took part in semistructured interviews and a health misinformation-identification exercise via Zoom. The data collected were subjected to qualitative thematic analysis. Multiple rounds of coding, checked by other coders, revealed 2 themes and 6 subthemes.

Results

The 2 main themes that emerged were (1) approaches to dealing with health misinformation and (2) how international students navigate across multiple digital ecologies. Results show that international students who draw on multiple digital ecologies for information reliably identify misinformation, suggesting that the use of multiple digital ecologies may have a protective effect against health misinformation.

Conclusions

Findings show that international students encounter health misinformation across multiple digital ecologies, and they also compare information across multiple ecologies. This comparison may support them in identifying health misinformation. Thus, the findings of this study combat narratives of international students’ susceptibility to misinformation.

Precarity and progression during a pandemic. Preliminary findings from a study of early career academics’ information behaviour during COVID-19

COVID-19 has increased research, teaching and administrative pressures for all academics and, by doing so, exacerbated inequalities experienced by early career academics, who were already dealing with several sources of uncertainty in trying to establish their careers. This study sought to understand the experiences of the academics during the pandemic. We conducted semi-structured remote interviews with 18 participants (PhDs awarded in past 6 years), from a variety of countries; Canada, US, Australia, UK, New Zealand, and South Africa. Interviews were analysed using a reflexive inductive Thematic Analysis approach. Preliminary findings demonstrate that the pandemic has disrupted information acquisition and sharing among ECAs. The increasing amount of incorrect and irrelevant information disseminated by universities, alongside the de-prioritisation of information that is particularly valued by these academics (e.g., information related to professional development and career development) has led some to avoid information.The COVID-19 pandemic has further exacerbated the precarious situations faced. Universities need to acknowledge uncertainty, reduce information overload by providing relevant and useful information and provide useful information on and support for career progression.

EP.WE.231Emergency Presentations of Colorectal Cancer during the COVID-19 Era

Aims

COVID-19 has reduced the ability to provide red flag investigations for colorectal patients. The aim of this study is to assess the number of emergency presentations of new colorectal malignancy during the COVID-19 era and if there is an increase in palliative cases.

Methods

A retrospective review of all patients presenting to unscheduled care with a new diagnosis of colorectal malignancy from 31st March 2020 - 25th January 2021 in a single UK Trust. An institutional data base and electronic care records were used to review patient demographics, management and curative intent. Data points for the same period in 2019-2020 were recorded for comparison.

Results

45 patients diagnosed with new colorectal malignancy during an unscheduled admission to hospital within the study timeframe. 22% (10/45) presented in January 2021. 29 diagnosed during the same time interval 2019-2020. Median age at presentation was 77.5 and 79 respectively.

40% (18/45) of patients in 2020-2021 proceeded to emergency surgery, compared to 58% (17/29) in 2019-2020 (p = 0.12).

10.3% (3/29) of 2019-2020 patients were managed with colonic stenting. This increased in 2020-2021 to 17.8% (8/45) (p = 0.38).

77.8% (35/45) patients in 2020/2021 presented at a palliative stage of disease compared to 62.1% (18/29) in 2019-2020 (p = 0.15).

Conclusions

Overall the data has not shown a statistically significant difference in patients presenting as an emergency with new colorectal malignancy. However, there was a rise in admissions noted in January 2021; should this trend continue, alongside the persistent pressures of COVID-19 ongoing research is needed to assess the true impact.

Adapting an emergency general surgery service in response to the COVID-19 pandemic

INTRODUCTION

In response to the COVID-19 pandemic, our emergency general surgery (EGS) service underwent significant restructuring, including establishing an enhanced ambulatory service and undertaking nonoperative management of selected pathologies. The aim of this study was to compare the activity of our EGS service before and after these changes.

METHODS

Patients referred by the emergency department were identified prospectively over a 4-week period beginning from the date our EGS service was reconfigured (COVID) and compared with patients identified retrospectively from the same period the previous year (Pre-COVID), and followed up for 30 days. Data were extracted from handover documents and electronic care records. The primary outcomes were the rate of admission, ambulation and discharge.

RESULTS

There were 281 and 283 patients during the Pre-COVID and COVID periods respectively. Admission rate decreased from 78.7% to 41.7%, while there were increased rates of ambulation from 7.1% to 17.3% and discharge from 6% to 22.6% (all p<0.001). For inpatients, mean duration of admission decreased (6.9 to 4.8 days), and there were fewer operative or endoscopic interventions (78 to 40). There were increased ambulatory investigations (11 to 39) and telephone reviews (0 to 39), while early computed tomography scan was increasingly used to facilitate discharge (5% vs 34.7%). There were no differences in 30-day readmission or mortality.

CONCLUSIONS

Restructuring of our EGS service in response to COVID-19 facilitated an increased use of ambulatory services and imaging, achieving a decrease of 952 inpatient bed days in this critical period, while maintaining patient safety.

38 Adapting an Emergency General Surgery Service in Response to the COVID-19 Pandemic

Introduction

In response to the COVID-19 pandemic, our emergency general surgery (EGS) service established an enhanced ambulatory service and undertook non-operative management of selected pathologies. This study compares the activity of our service before and after these changes.

Method

Patients referred by the emergency department were prospectively identified over a four-week period beginning from the date of reconfiguration (COVID) and compared to patients retrospectively identified from the same period the previous year (Pre-COVID) and followed up for 30 days. Data was extracted from handover documents and electronic care records.

Results

There were 281 and 283 patients during the Pre-COVID and COVID periods, respectively. Rates of admission decreased (78.1% to 41.7%) whilst there were increased rates of ambulation (7.1% to 17.3%) and discharge (6% to 22.6%). Duration of admission decreased (6.9 to 4.8 days), and there were fewer operative and endoscopic interventions (78 to 40). There were increased ambulatory investigations (11 to 39), telephone reviews (0 to 39), and use of early CT to facilitate discharge (5% to 34.7%). There were no differences in 30-day readmission or mortality in any group.

Conclusions

Restructuring of our EGS service in response to COVID-19 facilitated an increased use of ambulatory services and imaging, whilst maintaining patient safety.

From way across the sea: Information overload and international students during the COVID-19 pandemic

This panel examines the interaction between being a transient migrant, using international students as a salient example, and information behaviors in a time of COVID‐19. We address issues such as information overload, selection of information sources, and social networking. The aim of this panel is to bring together interested researchers in the areas of information practices, higher education, and intercultural communication.

Evaluating the impact of Minimum Unit Pricing on population alcohol consumption in Scotland

Background

Scotland experiences high levels of alcohol consumption and related harm. The relationship between alcohol price and consumption is well established. Minimum unit pricing (MUP), introduced in Scotland in 2018, sets a minimum price at which a unit of alcohol can be sold. The intention of MUP is to prevent alcohol being sold at below 50 pence per unit, thereby reducing alcohol consumption and in turn related harm to health. Scotland is the first country to implement this form of MUP; the evaluation of the impact of MUP is therefore of international importance.

Methods

Using commercial alcohol retail sales data, we use a natural experiment design with interrupted time series analysis to assess for changes in the level or trend of the volume of pure alcohol sold in Scotland associated with MUP implementation. Data for England and Wales will be used as a control.

Results

Descriptive analysis shows per adult off-trade sales of pure alcohol in Scotland fell by 3.6% in the year following MUP implementation. An increase in the average price of alcohol of 5 pence per unit in Scotland was also observed. There were reductions in per adult sales in all major drink categories with cider having the greatest relative decline (18.6%); cider also had the greatest increase in average price. Results of the interrupted time series analysis have yet to be reported but will be available for the conference.

Conclusions

The early indication of a reduction in total per adult off-trade sales of pure alcohol is an encouraging sign that MUP is having its intended impact. However, the full impact of MUP can only be judged across a range of outcome areas and over a longer time period.

Key messages

Minimum unit pricing appears to be having its intended impact on alcohol consumption at a population level in Scotland in the short term. Further work is ongoing to assess the impact of MUP on a wide range of outcomes and over a longer time period.

High Pressure Liquid Chromatographic Determination of Monoand Disaccharides in Presweetened Cereals: Collaborative Study

A collaborative study was conducted using a modified AOAC method (sugars in chocolate) for the determination of fructose, glucose, sucrose, and maltose in presweetened cereals by high pressure liquid chromatography (HPLC). Eight samples consisting of 6 products were analyzed in duplicate by the HPLC method and the AOAC Lane-Eynon method. The AOAC method was modified to use water-alcohol (1 + 1) and Sep-Pak C18 cartridges for sample cleanup. The HPLC results indicate precision comparable to the Lane-Eynon method and the chocolate method. The modified HPLC method has been adopted official first action.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

The influence of corporate and political interests on models of illness in the evolution of the DSM

The diagnostic and statistical manual of mental disorders (DSM) is an evolving document that serves the many mental health care disciplines as the primary reference guide for classifying mental disorders. While the successive framers of the DSM have attempted to base it on scientific evidence, political and economic factors have also shaped the conceptualization of mental illness. These economic and institutional forces have reinforced the DSM's use of a medical model in understanding psychopathology. Though the scientific evidence for a medical model is mixed and evidence for other types of conceptualizations have been given less attention, the medical model provides for reliable diagnoses that allot diverse benefits to treatment providers and researchers, as well as to the pharmaceutical and healthcare industries. This article will outline the development of a medical model of mental illness, highlighting connections between this model and corporate and political interests, and will show how this model relates to the various revisions of, and developments within, the DSM. Such an analysis is especially relevant today as the field looks towards the publication of the newest revision of the DSM and attempts to understand and integrate its proposed changes into current treatment, theory, and research.

Selecting subjects for a therapeutic target in colorectal cancer (CRC): Using a clinical database to enrich for patients harboring the BRAFV600E mutation

11003

Introduction: The BRAFV600E mutation (BRAF) causes constitutive activation of the RAS-induced MAPK pathway and is found in 10% of colon cancers. B-RAF inhibitors are in early clinical development, but their development in CRC will be challenging unless subsets of patients (pts) with higher rates of BRAF can be defined. The mutation rate in rectal tumors, the concordance between primary and metastases, and the prognostic/predictive significance of BRAF are current gaps in knowledge. Methods: 481 primary tumors and 80 matched primary-metastasis (prim-met) pairs were analysed from a pre-defined cohort of pts with CRC based on age (≥ 70 vs < 70 years), gender, tumor site (right-R, left-L and rectum), stage (A to C vs D) and ≥ 2 years follow-up. BRAF was assessed by routine sequencing of exon 15 and by a mutant-specific PCR assay. KRAS (KRAS-codon 12 and 13) and MSI (Bethesda markers) status were also examined. Results: Overall prevalence of BRAF was 11%. BRAF (see table ) was independently associated with increasing age, female gender and R-sided cancer, but not with stage. Mutations were rare in rectal cancers. BRAF was associated with inferior overall survival in stage D pts (log-rank, p = 0.0003; HR 0.38, 95% CI, 0.10–0.51). Survival analysis will be further stratified by treatment received. No difference in outcome was seen in preliminary analysis of earlier stage cancers. Mutation frequencies in the prim-met pairs were 38% (30/80) and 1.3% (1/80) for KRAS and BRAF, respectively. Overall concordance was 88% (70/80) for KRAS and 100% (80/80) for BRAF status. Conclusions: The development of selective B-Raf inhibitors in CRC is potentially more attractive due to the ability to define patient subsets with a higher prevalence of BRAF mutations. Analysis of the primary tumor reliably predicts the status of metastatic disease in the same patient. The association between BRAFand poor outcome will need to be considered when interpreting the result of studies targeting this mutation. [Table: see text]

[Table: see text]

Strongly interacting bosons in a disordered optical lattice

We experimentally probe the properties of the disordered Bose-Hubbard model using an atomic Bose-Einstein condensate trapped in a 3D disordered optical lattice. Controllable disorder is introduced using a fine-grained optical speckle field with features comparable in size to the lattice spacing along every lattice direction. A precision measurement of the disordering potential is used to compute the single-particle parameters of the system. To constrain theories of the disordered Bose Hubbard model, we have measured the change in condensate fraction as a function of disorder strength for several different ratios of tunneling to interaction energy. We observe disorder-induced, reversible suppression of condensate fraction for superfluid and coexisting superfluid-Mott-insulator phases.

Nonadherence consensus conference summary report

This report is a summary of a 'Consensus Conference' on nonadherence (NA) to immunosuppressants. Its aims were: (1) to discuss the state-of-the-art on the definition, prevalence and measurement of NA, its risk factors and impact on clinical and economical outcomes and interventions and (2) to provide recommendations for future studies. A two-day meeting was held in Florida in January 2008, inviting 66 medical and allied health adherence transplant and nontransplant experts. A scientific committee prepared the meeting. Consensus was reached using plenary and interactive presentations and discussions in small break-out groups. Plenary presenters prepared a summary beforehand. Break-out group leaders initiated discussion between the group members prior to the meeting using conference calls and e-mail and provided a summary afterward. Conclusions were that NA: (a) is more prevalent than we assume; (b) is hard to measure accurately; (c) tends to confer worse outcomes; (d) happens for a number of reasons, and system-related factors including the patient's culture, the healthcare provider and the setting and (e) it is not currently known how to improve adherence. This consensus report provided some roadmaps for future studies on this complicated, multifaceted problem.

Probiotics for induction of remission in ulcerative colitis

BACKGROUND

Ulcerative Colitis (UC) is an inflammatory condition affecting the colon with an incidence of approximately 10-20 per 100,000 per year. No existing intervention is effective in all patients with a proportion requiring colectomy. There are significant proportion of patients who experience adverse effects with current therapies. Consequently, new alternatives for the treatment of UC are constantly being sought. Probiotics are live microbial feed supplements that may beneficially affect the host by improving intestinal microbial balance, enhancing gut barrier function and improving local immune response.

OBJECTIVES

To assess the efficacy of probiotics compared with placebo or standard medical treatment (5-aminosalicylates, sulfasalazine or corticosteroids) for the induction of remission in active ulcerative colitis.

SEARCH STRATEGY

A comprehensive search for relevant randomised controlled trials (RCT's) was carried out using MEDLINE (1966-January 2006), EMBASE (January 1985- 2006) and CENTRAL. The Cochrane IBD/FBD Review Group Specialised Trials Registrar was also searched. The Australasian Medical Index, Chinese Biomedical Literature Database, Latin American Caribbean Health Sciences Literature (LILACS), and the Japan Information Centre of Science and Technology File on Science, Technology and Medicine (JICST-E) were also used to identify abstracts. Conference proceedings from the Falk Symposium, Digestive Disease Week (DDW) and the United European Digestive Disease week were hand-searched. Authors of relevant studies and drug companies were contacted regarding ongoing or unpublished trials that may be relevant to the review.

SELECTION CRITERIA

Randomised controlled trials investigating the effectiveness of probiotics compared to standard treatments in the induction of remission of active ulcerative colitis

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data for analysis. Data were analysed using RevMan 4.2.7. A formal meta-analysis was not preformed due to differences in probiotics, outcomes and trial methodology.

MAIN RESULTS

None of the included studies reported any statistically significant differences in remission or clinical improvement rates between probiotic and placebo or active comparator groups.

AUTHORS' CONCLUSIONS

Conventional therapy combined with a probiotic does not improve overall remission rates in patients with mild to moderate ulcerative colitis. However, there is limited evidence that probiotics added to standard therapy may provide modest benefits in terms of reduction of disease activity in patients with mild to moderately severe ulcerative colitis. Whether probiotics are as effective in patients with severe and more extensive disease and whether they can be used as an alternative to existing therapies is unknown. Further well designed, larger randomised controlled trials are needed to determine whether probiotics can be used as an alternative to current treatment modalities.

The Control of Hypertension In Pregnancy Study pilot trial

OBJECTIVE

To determine whether 'less tight' (versus 'tight') control of nonsevere hypertension results in a difference in diastolic blood pressure (dBP) between groups.

DESIGN

Randomised controlled trial (ISRCTN#57277508).

SETTING

Seventeen obstetric centres in Canada, Australia, New Zealand, and UK.

POPULATION

Inclusion: pregnant women, dBP 90-109 mmHg, pre-existing/gestational hypertension; live fetus(es); and 20-33(+6) weeks. Exclusion: systolic blood pressure > or = 170 mmHg and proteinuria, contraindication, or major fetal anomaly.

METHODS

Randomisation to less tight (target dBP, 100 mmHg) or tight (target dBP, 85 mmHg) blood pressure control.

MAIN OUTCOME MEASURES

Primary: mean dBP at 28, 32 and 36 weeks. Secondary: clinician compliance and women's satisfaction. Other: serious perinatal and maternal complications.

RESULTS

A total of 132 women were randomised to less tight (n = 66; seven had no study visit) or tight control (n= 66; one was lost to follow up; seven had no study visit). Mean dBP was significantly lower with tight control: -3.5 mmHg, 95% credible interval (-6.4, -0.6). Clinician compliance was 79% in both groups. Women were satisfied with their care. With less tight (versus tight) control, the rates of other treatments and outcomes were the following: post-randomisation antenatal antihypertensive medication use: 46 (69.7%) versus 58 (89.2%), severe hypertension: 38 (57.6%) versus 26 (40.0%), proteinuria: 16 (24.2%) versus 20 (30.8%), serious maternal complications: 3 (4.6%) versus 2 (3.1%), preterm birth: 24 (36.4%) versus 26 (40.0%), birthweight: 2675 +/- 858 versus 2501 +/- 855 g, neonatal intensive care unit (NICU) admission: 15 (22.7%) versus 22 (34.4%), and serious perinatal complications: 9 (13.6%) versus 14 (21.5%).

CONCLUSION

The CHIPS pilot trial confirms the feasibility and importance of a large definitive trial to determine the effects of less tight control on serious perinatal and maternal complications.

In vivo anergized T cells form altered immunological synapses in vitro

T cells contact allogeneic antigen presenting cells (APCs) and assemble, at their contact interface, a molecular platform called the immunological synapse. Synapse-based molecules provide directional signals for the T cell--either positive signals, resulting in T-cell activation, or negative signals causing T-cell inactivation or anergy. To better understand the molecular basis of in vivo T-cell anergy we analyzed the contacts made between in vivo anergized T cells and APCs, and determined which signaling molecules were included or excluded from their immunological synapses. Anergy was induced in TCR transgenic mice by the intravenous injection of semiallogeneic donor spleen cells. T cells from anergized mice were mixed with APCs, the T-cell/APC synapses imaged using deconvolution microscopy, and their molecular compositions were determined. T cells from anergic mice formed unstable immunological synapses in vitro with allogeneic APCs and failed to recruit the signaling proteins necessary to initiate T-cell activation. These findings suggest that T-cell anergy induced by exposure to semiallogeneic donor cells is associated with defects in the earliest events of T-cell activation, immunological synapse formation and recruitment of TCR-mediated signaling proteins.

Parkinsonism–hyperpyrexia syndrome: The role of electroconvulsive therapy

Herein, we present a case of a parkinsonism-hyperpyrexia syndrome (PHS) in a 58-year-old man with a 10-year history of Parkinson's disease. The patient presented with a 2-week history of fever and increasing confusion, in the context of a number of changes to his medication regimen. On presentation, he was noted to be febrile with autonomic instability, diaphoresis and marked rigidity. He was disoriented and responding to visual hallucinations. Investigations revealed an elevated creatine kinase and a provisional diagnosis of PHS was made. After the patient failed to respond during a 2-week period to supportive measures, electroconvulsive therapy (ECT) treatment was commenced. A good response to eight bilateral ECT treatments was achieved, with resolution of his confusional state and associated psychotic phenomena. We discuss the nosological and management issues associated with this case and discuss the role of ECT as a treatment modality in this condition.

Prevalence of environmental Aeromonas in South East Queensland, Australia: a study of their interactions with human monolayer Caco-2 cells

AIMS

To investigate the prevalence of Aeromonas in a major waterway in South East Queensland, Australia, and their interactions with a gut epithelial model using Caco-2 cells.

METHODS AND RESULTS

A total of 81 Aeromonas isolates, collected from a major waterway in South East Queensland, Australia, were typed using a metabolic fingerprinting method, and tested for their adhesion to HEp-2 and Caco-2 cells and for cytotoxin production on Vero cells and Caco-2 cells. Aeromonas hydrophila had the highest (43%) and Aeromonas veronii biovar sobria had the lowest (25%) prevalence. Four patterns of adhesion were observed on both HEp-2 and Caco-2 cell lines. Representative isolates having different phenopathotypes (nine strains) together with two clinical isolates were tested for their translocation ability and for the presence of virulence genes associated with pathogenic Escherichia coli. The rate and degree of translocation across Caco-2 monolayers varied among strains and was more pronounced with LogA pattern. Translocation was associated with the adherence of strains to Caco-2 cells microvilli, followed by internalization into Caco-2 cells. Two Aer. veronii biovar sobria strains were positive for the presence of heat-labile toxin genes, with one strain also positive for Shiga-like toxin gene.

CONCLUSIONS

Pathogenic strains of Aeromonas carrying one or more virulence characteristics are highly prevalent in the waterways studied and are capable of translocating across a human enterocyte cell model.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study indicates that Aeromonas strains carrying one or more virulence properties are prevalent in local waterways and are capable of translocating in a human enterocyte cell culture model. However, their importance in human gastrointestinal disease has yet to be verified under competitive conditions of the gut.

Motor cortex excitability after thalamic infarction

Transcranial magnetic stimulation was used to map hand muscle representations in the motor cortex of a patient in whom infarction of the sensory thalamus deprived the sensorimotor cortex of sensory input. The threshold for activation of the motor cortex on the affected side was higher and the cortical representational maps of individual muscles were less well defined than those on the normal side. It is concluded that electrophysiological changes in cortical organisation can be demonstrated following withdrawal of, or imbalance in sensory afferent activity to the cerebral cortex in humans.

Amyand's hernia causing necrotising fasciitis of the anterior abdominal wall

The finding of appendicitis within an inguinal hernia is a recognized phenomenon: Amyand's hernia. The development of necrotising soft tissue infection-necrotising fasciitis-is associated with high morbidity and mortality. We present a case of Amyand's hernia resulting in a severe, life-threatening necrotising soft tissue infection, which is previously unreported in English literature. We outline features relating to the diagnosis of this rare condition, and improve awareness among clinicians of the possibility of appendicitis within a direct inguinal hernia, and highlight the importance of appropriate initial surgical intervention for necrotising soft tissue infection to improve survival for these patients.

Bacterial flora from the gut of the wild and cultured banana prawn, Penaeus merguiensis

AIMS

There is growing awareness of the influence of the bacterial composition of the gut on the health and growth of the host. This study compared the bacterial flora from the digestive system of the wild and cultured prawn, Penaeus merguiensis.

METHODS AND RESULTS

Whole guts were dissected from wild and cultured prawns and divided into sections corresponding to the foregut, digestive gland, midgut and hindgut. Homogenates of these sections were plated onto seawater nutrient agar and the colonies identified to genus level and, in some cases, species. Quantitative and qualitative comparisons amongst gut regions for both wild and cultured prawns are presented.

CONCLUSIONS

Both wild and cultured prawns supported remarkably similar bacterial floral compositions, which included members from the genera Aeromonas, Plesiomonas, Photobacterium, Pseudoalteromonas, Pseudomonas and Vibrio. Members of the genus Vibrio were quantitatively dominant. A number of Vibrio species were recovered solely from cultured prawns. Of these, Vibrio gazogenes was the most notable (numerically dominating in all but the midgut). The opportunistic pathogen V. parahaemolyticus was also recovered.

SIGNIFICANCE AND IMPACT OF THE STUDY

The remarkable similarity of gut compositions between wild and cultured prawns, despite being drawn from very different habitats, suggests an influence of the host on the establishment of the gut flora. An understanding of host/gut floral interactions has significance in fostering conditions which promote the growth of cultivated hosts.

Species richness, abundance, and composition of hypogeous and epigeous ectomycorrhizal fungal sporocarps in young, rotation-age, and old-growth stands of Douglas-fir (Pseudotsuga menziesii) in the Cascade Range of Oregon, U.S.A

Knowledge of the community structure of ectomycorrhizal fungi among successional forest age-classes is critical for conserving fungal species diversity. Hypogeous and epigeous sporocarps were collected from three replicate stands in each of three forest age-classes (young, rotation-age, and old-growth) of Douglas-fir (Pseudotsuga menziesii (Mirb.) Franco) dominated stands with mesic plant association groups. Over four fall and three spring seasons, 48 hypogeous and 215 epigeous species or species groups were collected from sample areas of 6300 and 43 700 m2, respectively. Cumulative richness of hypogeous and epigeous species was similar among age-classes but differed between seasons. Thirty-six percent of the species were unique to an age-class: 50 species to old-growth, 19 to rotation-age, and 25 to young stands. Seventeen species (eight hypogeous and nine epigeous) accounted for 79% of the total sporocarp biomass; two hypogeous species, Gautieria monticola Harkn., and Hysterangium crassirhachis Zeller and Dodge, accounted for 41%. Average sporocarp biomass in young and rotation-age stands compared with old-growth stands was about three times greater for hypogeous sporocarps and six times greater for epigeous sporocarps. Average hypogeous sporocarp biomass was about 2.4 times greater in spring compared with fall and for epigeous sporocarps about 146 times greater in fall compared with spring. Results demonstrated differences in ectomycorrhizal fungal sporocarp abundance and species composition among successional forest age-classes.Key words: ectomycorrhizal fungi, sporocarp production, forest succession, Pseudotsuga menziesii, Tsuga heterophylla zone, biodiversity.