The Tommy's Clinical Decision Tool, a device for reducing the clinical impact of placental dysfunction and preterm birth: protocol for a mixed-methods early implementation evaluation study

Background

Disparities in stillbirth and preterm birth persist even after correction for ethnicity and social deprivation, demonstrating that there is wide geographical variation in the quality of care. To address this inequity, Tommy’s National Centre for Maternity Improvement developed the Tommy’s Clinical Decision Tool, which aims to support the provision of “the right care at the right time”, personalising risk assessment and care according to best evidence. This web-based clinical decision tool assesses the risk of preterm birth and placental dysfunction more accurately than current methods, and recommends best evidenced-based care pathways in a format accessible to both women and healthcare professionals. It also provides links to reliable sources of pregnancy information for women. The aim of this study is to evaluate implementation of Tommy’s Clinical Decision Tool in four early-adopter UK maternity services, to inform wider scale-up.

Methods

The Tommy’s Clinical Decision Tool has been developed involving maternity service users and healthcare professionals in partnership. This mixed-methods study will evaluate: maternity service user and provider acceptability and experience; barriers and facilitators to implementation; reach (whether particular groups are excluded and why), fidelity (degree to which the intervention is delivered as intended), and unintended consequences. Data will be gathered over 25 months through interviews, focus groups, questionnaires and through the Tommy’s Clinical Decision Tool itself. The NASSS framework (Non-adoption or Abandonment of technology by individuals and difficulties achieving Scale-up, Spread and Sustainability) will inform data analysis.

Discussion

This paper describes the intervention, Tommy’s Clinical Decision Tool, according to TiDIER guidelines, and the protocol for the early adopter implementation evaluation study. Findings will inform future scale up.

Trial registration

This study was prospectively registered on the ISRCTN registry no. 13498237, on 31^st January 2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04867-w.

Understanding maternal postnatal blood pressure changes following hypertensive disorders in pregnancy: protocol for a prospective cohort study

INTRODUCTION

Hypertensive disorders occur in approximately 10% of women during pregnancy. There is robust population-based data to show that women who have hypertension in pregnancy are much more likely to develop cardiovascular disease (CVD) in the postpartum period. Women with a hypertensive disorder of pregnancy (HDP) are twice more at risk of heart disease and stroke, and four times more likely to develop hypertension after birth. Two out of three women who had HDP will die from CVD. Recent evidence suggests that young women with HDP develop signs of CVD in the immediate postpartum period, rather than several decades later as previously presumed. If confirmed, this concerning finding presents healthcare practitioners with an opportunity to influence women's cardiovascular health by advising on lifestyle choices and considering therapeutic interventions to prevent the development of CVD.

METHODS AND ANALYSIS

This prospective cohort study design will ask approximately 300 participants to complete 3 days of home blood pressure monitoring every fortnight for 12 weeks postpartum and will culminate with a 24-hour episode of ambulatory blood pressure monitoring at 12 weeks postpartum. Women and healthcare professionals will complete questionnaires surrounding postpartum care for women who had HDP and knowledge of CVD risk. In addition, the relationship between hypertension and factors likely to influence outcomes such as severity of HDP, maternal age, body mass index and ethnicity will be analysed using logistic regression. Blood pressure and data from questionnaires will be analysed using descriptive statistics, with temporal stratification.

ETHICS AND DISSEMINATION

Research ethics approval was obtained from London-West London & GTAC Research Ethics Committee. Research outputs will be published and disseminated through midwifery, obstetric or general practitioner targeted academic journals. The patient and public involvement group will disseminate findings to women who have experienced HDP among their peer groups.

TRIAL REGISTRATION NUMBER

NCT05137808.

1006 Impact of The Human Factor on Student Interest in Orthopaedic Surgery: A Randomised Control Trial

Aim

The positive learning experiences of students on surgical rotations which subsequently influence career choice may be delineated into practical and interpersonal themed factors. It remains unclear the relative impact each component has on the student experience and subsequent specialisation. We evaluated the influence of having senior resident mentor during practical simulation in orthopaedic surgery has on medical student interest in surgery; their comfort in theatre; and its role in enhancing knowledge acquisition within the rotation

Method

Medical students undergoing clinical rotations in a Regional University Hospital were randomised to undertaking a a virtual reality simulated operation independently or performing under the guidance of an experienced resident. Baseline levels of interest in surgery, comfort in theatre, perceived barriers to surgical learning and entry to surgery were established and compared to answers following completion of the tutorial. Qualitative feedback was collected regarding the benefits and limitations to the experience. Presented according to CONSORT guidelines.

Results

Participants in the resident guided group achieved significantly higher simulated performance scores compared to the control (p < 0001), with an increase in orthopaedic surgery from baseline expressed to a statistically significant degree (p = 0.04). 100% participants strongly agreed it was a beneficial learning experience which would be useful in surgical curricula.

Conclusions

Surgical trainee guided simulation led to improved performance and interest in orthopaedic surgery, while virtual practical experience was felt to be a useful learning tool independent of supervision. Further research is needed to establish the role of interpersonal interactions in student surgical experience.

406 Bioabsorbable Screws in Scaphoid Fractures; a systematic review

Background

Scaphoid fractures account for 90% carpal injury. Due to the limited vascular supply achieving adequate reduction and healing is important to avoid complications including avascular necrosis. Recent technological advances have led to renewed vigour in bioabsorbable material research to develop devices which could be used without the need for removal and complications including stress shielding and suboptimal imaging.

Method

A systematic review was made using PubMed, Ovid Medline, and Google Scholar databases according to PRISMA guidelines.

Results

Initial search results yielded 852 studies. 124 studies were screened, resulting in 7 studies which were included in this review. The level of evidence of studies ranged between III-IV of low power. Analysis demonstrated mixed findings with generally comparable outcomes to traditionally used screws. Heterogeneity of studies prevented a meta-analysis.

Conclusions

Development in bioabsorbable materials has yielded promising results in orthopaedic studies, however there is a dearth in research using these devices in the scaphoid. Further robust research is needed to establish the efficacy and applicability of bioabsorbable devices in the scaphoid bone.

Virtualised care and COVID-19

Following the declaration by the World Health Organization (WHO) of the Covid-19 pandemic on March 11, 2020, health organisations and staff have had to adapt and restructure services in order to respond to this global health emergency. Numerous containment strategies have been, and continue to be, introduced in this rapidly evolving and fluid situation with a significant shift towards virtual or remote patient assessment. The concept of virtual patient evaluation has previously been adopted across a range of medical and surgical specialities yielding safe and efficient pathways associated with good Patient Reported Outcome Measures (PROMs) and patient satisfaction rates. Whilst the idea of virtual patient review may be perceived as counterintuitive to the basic foundations and principles of face-to-face clinical practice, the current global pandemic, now more than ever, highlights the importance, need and benefits of this care model.

An Unusual Case of a Facial Guard Causing Penetrating Soft Tissue Injury in the Game of Hurling

Aim To highlight the dangers of hurling helmet modification. Methods A case report highlighting the consequences of modifying a hurling helmet from factory settings. Results Photographic evidence of a penetrating injury from helmet modification. Conclusion Rule changes to allow referees to inspect helmets before games take place.

Home blood-pressure monitoring in a hypertensive pregnant population

OBJECTIVE

The majority of patients with chronic or gestational hypertension do not develop pre-eclampsia. Home blood-pressure monitoring (HBPM) has the potential to offer a more accurate and acceptable means of monitoring hypertensive patients during pregnancy compared with traditional pathways of frequent outpatient monitoring. The aim of this study was to determine whether HBPM reduces visits to antenatal services and is safe in pregnancy.

METHODS

This was a case-control study of 166 hypertensive pregnant women, which took place at St George's Hospital, University of London. Inclusion criteria were: chronic hypertension, gestational hypertension or high risk of developing pre-eclampsia, no significant proteinuria (≤ 1+ proteinuria on dipstick testing) and normal biochemical and hematological markers. Exclusion criteria were maternal age < 16 years, systolic blood pressure > 155 mmHg or diastolic blood pressure > 100 mmHg, significant proteinuria (≥ 2+ proteinuria on dipstick testing or protein/creatinine ratio > 30 mg/mmol), evidence of small-for-gestational age (estimated fetal weight < 10^th centile), signs of severe pre-eclampsia, significant mental health concerns or insufficient understanding of the English language. Pregnant women in the HBPM group were taught how to measure and record their blood pressure using a validated machine at home and attended every 1-2 weeks for assessment depending on clinical need. The control group was managed as per the local protocol prior to the implementation of HBPM. The two groups were compared with respect to number of visits to antenatal services and outcome.

RESULTS

There were 108 women in the HBPM group and 58 in the control group. There was no difference in maternal age, parity, body mass index, ethnicity or smoking status between the groups, but there were more women with chronic hypertension in the HBPM group compared with the control group (49.1% vs 25.9%, P = 0.004). The HBPM group had significantly fewer outpatient attendances per patient (6.5 vs 8.0, P = 0.003) and this difference persisted when taking into account differences in duration of monitoring (0.8 vs 1.6 attendances per week, P < 0.001). There was no difference in the incidence of adverse maternal, fetal or neonatal outcome between the two groups.

CONCLUSION

HBPM in hypertensive pregnancies has the potential to reduce the number of hospital visits required by patients without compromising maternal and pregnancy outcomes. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

A retrospective review of farm injuries presenting to an Irish hospital emergency department in 2013

BACKGROUND

The agricultural and equestrian businesses are an important source of employment in the Midlands. This is a retrospective study examining the demographics, characteristics, and outcomes of agricultural and equestrian related injuries presenting to the Midland Regional Hospital, Tullamore, Co. Offaly. There were a total of 30,700 attendances to the Emergency Department for 2013.

AIMS

This study is an epidemiological review of agricultural injuries, their mechanisms, and consequences presenting to a rural regional hospital over a 1 year period.

METHODS

Every presentation to the Accident and Emergency Department at the Midlands Regional Hospital in 2013 was assessed retrospectively to determine if an injury had been sustained in an agricultural environment. Patient demographics, month of occurrence, mechanism of injury, radiology results, management, and follow-up data were collected and analysed using Microsoft Excel.

RESULTS

There were 144 agricultural-related presentations to the Accident and Emergency Department. 23% of the agricultural injuries were identified as having a radiological abnormality. There were significantly more males involved in agricultural injuries than females (97 vs 3%). 16% of presentations required admission or transfer to tertiary specialist care and 8% required surgical intervention. Farming machinery accidents contributed to more admissions than any other cause in the agricultural category and resulted in more surgical interventions.

CONCLUSION

Our study has identified high-risk mechanisms of injury, which should alert clinicians to the potential for significant injury. In addition, our findings could be used to help policy makers promote safety and awareness through public health policies that target high-risk practices with appropriate training and legislation.

Resting-state connectivity deficits associated with impaired inhibitory control in non-treatment-seeking adolescents with psychotic symptoms

OBJECTIVE

Psychotic symptoms are common in the population and index risk for a range of severe psychopathological outcomes. We wished to investigate functional connectivity in a community sample of adolescents who reported psychotic symptoms (the extended psychosis phenotype).

METHOD

This study investigated intrinsic functional connectivity (iFC) during resting-state functional magnetic resonance imaging (fMRI; rs-fMRI). Following screening in schools, 11 non-treatment seeking, youth with psychotic symptoms (aged 11-13) and 14 community controls participated in the study. Seed regions of interest comprised brain regions previously shown to exhibit aberrant activation during inhibitory control in adolescents with psychotic symptoms.

RESULTS

Relative to controls, adolescents with psychotic symptoms exhibited reduced iFC between regions supporting inhibitory control. Specifically, they showed weaker iFC between the right inferior frontal gyrus (IFG) and the cingulate, IFG and the striatum, anterior cingulate and claustrum, and precuneus and supramarginal gyrus. Conversely, the psychotic symptoms group exhibited stronger iFC between the superior frontal gyrus and claustrum and IFG and lingual gyrus.

CONCLUSION

The present findings are the first to reveal aberrant functional connectivity in resting-state networks in a community sample of adolescents with psychotic symptoms and suggest that disruption in integration between distributed neural networks (particularly between prefrontal, cingulate and striatal brain regions) may be a key neurobiological feature of the extended psychosis phenotype.

Self-reported complication rates following primary total hip arthroplasty in Ireland: fact or fiction

BACKGROUND

There are little data available on complication rates following primary total hip arthroplasty (THA) surgery in Ireland.

AIMS

To determine self-reported complication rates and national data for primary THA.

METHODS

A postal questionnaire surveyed Irish orthopaedic association consultant members. Additional data were obtained from the economic and social research institute (ESRI).

RESULTS

We achieved an 83% response rate. 5,424 THAs were self-reported. Mean dislocation rates were 1%, but higher using a posterior surgical approach (p < 0.05). Mean deep infection rates were 0.4%. 29% were MRSA. No reduction was reported from additional barrier prophylaxes. Mean venous thrombo-embolism (VTE) rates were 3.5%. No reduction was reported from commencing prophylaxis preoperatively or extending treatment duration. National rates for dislocation, deep infection and VTE were 25.7, 0.87, and <0.1%, respectively.

CONCLUSIONS

The creation of a National Hip Register is strongly recommended. A register would improve surgical practices and patient outcomes, and provide significant healthcare savings.

Estimating the real cost of adjuvant (A) trastuxumab (T) in patients(pts) with HER-2+ (H+) early stage breast cancer (ESBC)

6081

Background: Pts with H+ metastatic (M) ESBC have a high risk of relapse. T has been reported to reduce the risk of relapse for pts with H+ESBC by approximately 50% when combined with A chemotherapy (CT). We attempted to study the real cost of AT in the context of current use of T in MBC (MT), and of the predicted reduction in the risk of relapse. Methods: We conducted a retrospective analysis of the mean per pt cost of AT and MT, and standard ACT in St. Vincent’s Hospital. The costs/pt for AT and MT were €34k, and €47k respectively, and for the listed agents in standard A: docetaxel(D)-8.8k, paclitaxel(P)-7.4 k, filgrastim(G)-9.3 k. Based on published/presented data (BCIRG 001), we assumed a 35% risk for relapse at five years for pts with H+BC receiving conventional A, and a 50% risk reduction (RR) for AT, giving an absolute benefit of 17.5%. We then devised an equation to calculate the Crp for AT: Crp=[a-M(NRA/104)]/[NRA/104] where a = cost per pt for treatment (Tx) with AT, M = cost per pt for Tx with T in MBC, N = % of pts relapsing after standard A, RA = % reduction in the risk of relapse after Tx with AT (over standard A). Results: The corresponding real T costs/100 pts for the following reductions in relapse rate would be:25%-€3.4m 50%-€2.6m-, 80%-€2.1m, 100%-€1.8m. The Crp for AT with a 50% reduction in relapse rate is €147k. With a 100% reduction in the RR we estimate the Crp to be €50k. We studied D (D-BCIRG 001), P (P-CALGB 9344) and G (G-CALGB 9741 dose-dense), and noted the following published absolute relapse reductions for these tx: D-7%, P-5% and G-4%. The following costs per relapse prevented were calculated: P-148 k; G-231k; D-126k. Conclusions: Using the equation, the real cost per relapse prevented of AT can be calculated, and comparisons made with the cost-effectiveness of other accepted A. Assuming no re-treatment with MT, AT appears to be a relatively cost-efficient means of reducing relapses. Reports of the efficacy of short AT regimens suggest the possibility of even greater cost-effectiveness. This equation could possibly be used to calculate the cost effectiveness of other novel A molecular therapies.

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Primary total hip replacement--a survey of current practice and identifying changing trends

Primary total hip replacement (THR) surgery is the most commonly performed and successful reconstructive procedure in orthopaedic surgery. We performed a survey of Irish Orthopaedic consultants to elucidate current practices of primary THR in elderly and young patients and identify changing trends. There was an 83% response rate. Most respondents use a cemented THR in elderly patients. 69% use a different THR in younger patients compared to older patients. 9% refer younger patients to hip replacement specialist consultant colleagues. 70% report changing to a new implant or new technique in younger patients and 45% use a hybrid THR, 15% an uncemented THR, 15% perform hip resurfacing and 47% use different bearing surfaces. Only 17% use the Charnley hip prosthesis in younger patients. Young and active patients will place high demands on a new THR and newer techniques, implants and bearing surfaces are being adopted in the hope of better outcomes.

Staphylococcal diaphyseal subacute osteomyelitis of the ulna in a child: an unusual cause of post-traumatic forearm swelling

Paediatric subacute osteomyelitis (SAO) presents a diagnostic and therapeutic challenge to clinicians. Typically located in the metaphysis of long bones, diaphyseal SAO of the upper limb is rare. We present the case of a three-year-old girl referred to our fracture clinic as an occult fracture following trauma to her forearm with normal initial radiographs. Follow-up radiographs one week later showed cortical erosion of the distal ulna, while a subsequent MRI scan showed soft tissue swelling with an area of high signal in the distal ulna. A limited biopsy diagnosed staphylococcal subacute osteomyelitis of the ulna. The patient responded to high dose antibiotic therapy and made a full recovery. We present this case to highlight the high index of suspicion required to diagnose and appropriately manage this insidious condition, which may easily be confused with any number of benign and malignant bony lesions and provide a review of the relevant literature.

Adhesion of Staphylococcus to orthopaedic metals, an in vivo study

This study describes a new model of biofilm study in rabbits. The primary focus of this study was to assess biofilm adhesion to orthopaedic metals in their first 48 h in a femoral intramedullary implantation model. Two previous inoculation methods i.e. that of pre- and direct inoculation were studied with two bacterial isolates namely Staphylococcus aureus and epidermidis, on titanium and stainless steel metallic implants. A method of sonication and log dilution/plating was used to assess biofilm bacteria adhering to implants. Silver coated metals were then compared with their respective control metals in the new model. The direct inoculation model gave larger and more reproducible biofilm adhesion to implanted metals. Staphylococcus epidermidis shows lower adhesion ability to metals, and biofilms adhere in greater numbers to stainless steel over titanium. Silver coated metals show no statistical difference over control metals when exposed to orthopaedic biofilms.

Lumbar Chance fracture associated with use of the lap belt restraint in an adolescent

The use of the 2-point seat belt or lap belt in motor vehicles, particularly to restrain young rear seat passengers, remains an issue of some concern. The occurrence of lumbar spinal flexion-distraction injuries in lap belt restrained children and adolescents during road traffic accidents is a well known phenomenon, but is still occurring. High velocity paediatric Chance fractures are frequently associated with significant intra-abdominal trauma. We present the case of a Chance fracture sustained by a 15 year old girl, involved in a motor vehicle collision, while wearing a lap belt. We emphasise the need to develop safer seat belt designs for juvenile car passengers.

Diagnosis and management of an intra-articular foreign body in the foot

We describe a case of a small intra-articular foreign body in the foot presenting 48 hours following injury, which at operation showed early evidence of septic arthritis. It is essential to accurately localise periarticular foreign bodies in the foot and proceed to arthrotomy and debridement in all cases where there is radiological or clinical evidence to suggest intra-articular retention of a foreign body.

Hip arthroplasty, changing trends in a national tertiary referral centre

BACKGROUND

Despite changes in techniques and management, little has been published comparing hip replacement surgery over a three-decade time span.

AIMS

To document change in the practice of hip arthroplasty in a large elective orthopaedic centre.

METHODS

A retrospective analysis of 100 patients in 1979 and in 1999 comparing demographics, surgical approaches, blood loss, transfusion requirements, morbidity and length of stay.

RESULTS

In 1999, males predominated, spinal anaesthesia had largely superceded general anaesthesia, the anterolateral approach had replaced the trans-trochanteric approach, osteoarthritis remained the main aetiology and the Charnley prosthesis remained the implant of choice. Average blood loss was higher in 1999 compared to 1979 (1,378 vs 1,225 ml) but all patients in 1979 were transfused with an average of 2.8 units while in 1999 one-third of patients were transfused with an average of 1.6 units (p<0.0001). Length of stay had fallen from 30.5 days in 1979 to 16.2 days in 1999 (p<0.0001). Thromboembolic complications fell from 13% to 2% (p=0.0083).

CONCLUSION

The incidence of deep venous thrombosis (DVT), pulmonary embolus (PE) and length of hospital stay has fallen. Blood loss had changed little but fewer patients receive blood transfusion.

A stage-of-change classification system based on actions and beliefs regarding dietary fat and fiber

PURPOSE

The objectives of this study were to develop a stage-of-change classification system and to determine the degree to which various adult subgroups have adopted the behavioral changes necessary to achieve a low-fat and/or high-fiber diet as recommended by the Dietary Guidelines for Americans.

DESIGN

The study used a mail survey randomly sent to 7110 adults.

SETTING

The survey was conducted in 11 states and the District of Columbia.

SUBJECTS

The random sample included males and females over age 18. Of the eligible respondents, 3198 (51.5%) were included in this analysis, with 2004 and 2066 unambiguously classified into stages of change for fat and fiber, respectively.

MEASURES

Stage of change was defined by an algorithm based on self-reported intent and behaviors to limit fat and/or increase fiber.

RESULTS

45% of the respondents were classified as being in action/maintenance for fat and 38% for fiber. Women, older adults, individuals with advanced education, persons with diet-related chronic disease, people with higher levels of relevant nutrition knowledge and attitudes, and persons who indicated that health concerns were a primary influence on their diet were more likely to be in action/maintenance than other respondents.

CONCLUSIONS

The algorithm in this study presents a model that more closely reflects the proportions of the adult population that have achieved low-fat diets and classifies a greater proportion in the preparation stage than classification systems in previous studies.

Attitudes toward health risks and sunbathing behavior

Sunbathing confers the benefits of looking and feeling good but presents the long-term risk of skin cancer. In a disguised experiment exploring attitudes toward sunbathing by British adults, participants were asked to rate their willingness to take a hypothetical new drug (with different levels of risk) that would make them look and feel good. One aspect of the resulting risk profiles was significantly related to a positive attitude to open-air sunbathing but not to sunbed use, possibly because it was erroneously thought that using a sunbed is not risky. The well-established finding that women are more cautious was confirmed; the risk function for men was curvilinear, in contrast to women, who were willing to increase their risk linearly over their lifetime.

Parent satisfaction with services in an emergency department located at a paediatric teaching hospital

OBJECTIVE

To evaluate parents' satisfaction with the services provided in an emergency department located at a paediatric hospital.

METHODOLOGY

A descriptive study in which the parents of children with non-life-threatening illnesses attending an emergency department completed a questionnaire describing their satisfaction with services in the department.

RESULTS

The majority of parents were satisfied with the services provided. However, less satisfied parents reported having to wait significantly longer before receiving medical attention than satisfied parents. Consistent with this finding, 77% of less satisfied parents reported that staff did not attend to their children's needs quickly enough and 62% felt that there were insufficient staff available to provide help. Twenty-nine per cent of the less satisfied parents reported that they did not know what was required for the ongoing care of their children after their discharge from the emergency department.

CONCLUSIONS

In order to address the concerns of less satisfied parents, emergency departments need to give careful attention to the maintenance of reasonable waiting times, the provision of adequate staffing, and the quality of staff-parent communication. Addressing these issues may improve the ongoing care of children after their discharge from emergency departments.

Basilic vein transposition: an underused autologous alternative to prosthetic dialysis angioaccess

PURPOSE

Provision of lifelong angioaccess for hemodialysis generally requires multiple procedures. To extend the availability of each extremity as an access site, we have used the transposed basilic vein for fistula construction since 1988. Our purpose is to present our initial experience, with follow-up of 30 months.

METHODS

We have used the transposed proximal basilic vein in 65 procedures to construct an autogenous arteriovenous fistula (AVF) to the brachial artery in 58 patients without suitable superficial venous anatomy. There were 25 males and 33 females, with a mean age of 47 years (range 10 to 77). The basilic vein transposition was the initial angioaccess procedure in only 25% of cases and secondary in 75%. Three additional patients underwent exploration of an inadequate basilic vein with subsequent prosthetic grafting.

RESULTS

There were no operative deaths. Two postoperative complications included a wound infection and a transient steal syndrome. The actuarial life-table patency rate for all successfully completed AVFs was 49% at 30 months. Late revisions with continued patency were required in 11 cases, including repair of a focal stenosis in six, pseudoaneurysm resection in two, and thrombectomy in one. Sixty-seven percent of patients who required subsequent prosthetic grafting for a failed basilic vein AVF had an ipsilateral procedure. Patient preference for the opposite arm was the usual indication for contralateral grafting in the remainder.

CONCLUSIONS

The transposed basilic vein AVF was technically feasible in 95% of cases, can frequently be performed in patients with multiple previous access procedures, does not compromise the arm for future prosthetic grafting, and has a long-term patency rate that is comparable to more traditional autologous AVFs. This underused procedure should be considered before placement of polytetrafluoroethylene graft for long-term angioaccess.

Calmodulin-specific monoclonal antibodies inhibit DNA replication in mammalian cells

The involvement of calmodulin in the proliferation of Chinese hamster embryo fibroblast cells has been studied with a specific monoclonal antibody to calmodulin. We observed that calmodulin levels increase 2-fold in the late G1 period in these cells, and this coincides with the increase in DNA polymerase alpha activity as the cells progress synchronously from a quiescent state in the G1 to the S phase. However, there is a concurrent 10-fold enhancement of thymidine kinase activity, which is tightly coupled to the entry of cells into the S phase. Incubation of permeabilized S-phase cells with calmodulin-specific murine monoclonal antibody resulted in a dose-dependent inhibition of DNA replication. This inhibitory effect of anti-calmodulin antibodies on DNA replication is completely reversed by the addition of exogenously purified calmodulin. These observations provide evidence for the involvement of calmodulin in DNA replication and, therefore, in cell proliferation during the S phase.

The effectiveness of adherence intervention in a colon cancer prevention field trial

BACKGROUND

Adherence interventions were implemented in a 1-year community-based colon cancer prevention clinical trial (n = 110) using wheat bran fiber and calcium dietary supplements. The adherence promotion strategy was guided by a theoretical model.

METHODS

The adherence intervention contains both a generalized portion given to all participants and an individualized portion given to marginal (50-74% intake) and low (under 50% intake) adherers. A regression model was employed to assess the effectiveness of the interventions both at the first intervention and at subsequent times.

RESULTS

The Health Behavior in Cancer Prevention Model-based adherence promotion intervention was associated with retention of participants, both during the run-in period and after randomization (P = 0.05); and maximization of the percentage of the 13.5-g recommended fiber supplement consumed during the trial (92.5%). The positive effects of the adherence intervention were greater with first-time nonadherers and the control group than with the experimental group. The high-fiber group had notably more biological GI effects from the increased fiber intake, more preexisting comorbidities, and lower perceived cognitive and physical health status.

CONCLUSIONS

Randomized participants had excellent adherence overall. Retention rates in the trial were better than would be expected without the adherence intervention, especially among those participants who may have been at higher risk for dropping out of the study. This suggests that a systematic, theoretically based adherence strategy should be further tested in clinical trial settings in which lower adherence is a problem.

Epidural versus general anesthesia for infrainguinal arterial reconstruction

A prospective evaluation of 213 consecutive infrainguinal bypass procedures was performed to determine the effect of anesthesia technique on the postoperative complication rate. Limb salvage was the indication for surgery in 92% of cases. No significant differences were observed in age, sex, indication for surgery, presence of cardiovascular and pulmonary risk factors, American Society of Anesthesiologists classification, or Goldman scores between patients receiving epidural anesthesia and those receiving general endotracheal anesthesia. Epidural anesthesia was used for 96 procedures and general endotracheal anesthesia was used in 117 cases. Cardiac complications for the epidural anesthesia and general endotracheal anesthesia groups, respectively, included a mortality rate of 5% versus 3%, nonfatal infarctions in 6% versus 7%, and reversible cardiac events in 14% versus 16%. A high-risk subgroup of 69 patients (American Surgical Association classes IV and V or Goldman score greater than 10 points) also had no significant difference in outcome between epidural anesthesia and general endotracheal anesthesia. Major noncardiac complications occurred in an additional 8% of each group. Regional and general anesthesia therefore produce equivalent cardiovascular risk for infrainguinal arterial reconstruction. These results suggest that indicated operations should not be postponed or avoided for patients either requiring or requesting general anesthesia. Furthermore, other investigations of cardiac risk in vascular surgery do not require a uniform anesthetic technique for valid interpretation of results.

MCMI-II report style and bias: profile and validity scales analyses

This study examines the behavior of the Millon Clinical Multiaxial Inventory-II (MCMI-II) in the face of various response styles and biases. The profiles and validity configurations of eight different test-taking styles were analyzed. Four hundred MCMI-II inventories (50 for each of the following categories) were administered or generated to produce the following: (a) normal endorsement by subjects, (b) fake good for administrative reasons, (c) fake good for clinical reasons, (d) fake bad administratively, (e) fake bad clinically, (f) 50% true/50% false computer generated, (g) 95% true computer generated, and (h) 95% false computer generated. Good statistical and clinically relevant separation of the profiles was found for normal, fake good, fake bad, and the randomly generated profiles with 44% of the variance predicted. The percentage of profiles identified by validity scales, however, was modest.