Digitally Recording Comfort Observations in the Last Days of Life

Background: 37.5% of deaths in our area occur in hospital. There are known high unmet needs of adult patients dying in hospital, this unmet need can be reduced by using an individualised care plan and specialist palliative care review. Intervention: In 2022 UHSussex developed an electronic comfort observation chart and individualised care plan, with a centralised dashboard allowing Palliative Care Teams (SPCT) to view trends, target interventions, and a rolling prospective audit. Results: 3000 patients have had their care supported with electronic comfort observations (e-comfort obs). Over 72% of all deaths in the Trust in the last 3 months have been on e-comfort obs, with 2/3 of all deaths in the first 12 months on e-comfort obs. The average length of time on e-comfort obs is 4 days resulting in 70,000 sets of e-comfort obs recorded since launch. Seven percent of e-comfort obs record moderate or severe symptoms. We have identified benefits to people who are dying, those important to them, ward staff, SPCT and on a systems level. Conclusion: E-comfort obs can be successfully embedded in a large acute Trust. This development should improve quality of end of life care in our hospitals both for individuals and for future patients, through on-going targeted education and intervention. Further work is needed to develop the system further including integrating data from electronic prescribing.

Genome sequencing of Porostereum spadiceum to study the degradation of levofloxacin

Despite various plans to rationalize antibiotic use, antibiotic resistance in environmental bacteria is increasing due to the accumulation of antibiotic residues in the environment. This study aimed to test the ability of basidiomycete fungal strains to biotransform the antibiotic levofloxacin, a widely-used third-generation broad-spectrum fluoroquinolone, and to propose enzyme targets potentially involved in this biotransformation. The biotransformation process was performed using fungal strains. Levofloxacin biotransformation reached 100% after 9 days of culture with Porostereum spadiceum BS34. Using genomics and proteomics analyses coupled with activity tests, we showed that P. spadiceum produces several heme-peroxidases together with H2O2-producing enzymes that could be involved in the antibiotic biotransformation process. Using UV and high-resolution mass spectrometry, we were able to detect five levofloxacin degradation products. Their putative identity based on their MS2 fragmentation patterns led to the conclusion that the piperazine moiety was the main target of oxidative modification of levofloxacin by P. spadiceum, leading to a decrease in antibiotic activity.

Altered Expression of Two Small Secreted Proteins (ssp4 and ssp6) Affects the Degradation of a Natural Lignocellulosic Substrate by Pleurotus ostreatus

Pleurotus ostreatus is a white-rot fungus that can degrade lignin in a preferential manner using a variety of extracellular enzymes, including manganese and versatile peroxidases (encoded by the vp1-3 and mnp1-6 genes, respectively). This fungus also secretes a family of structurally related small secreted proteins (SSPs) encoded by the ssp1-6 genes. Using RNA sequencing (RNA-seq), we determined that ssp4 and ssp6 are the predominant members of this gene family that were expressed by P. ostreatus during the first three weeks of growth on wheat straw. Downregulation of ssp4 in a strain harboring an ssp RNAi construct (KDssp1) was then confirmed, which, along with an increase in ssp6 transcript levels, coincided with reduced lignin degradation and the downregulation of vp2 and mnp1. In contrast, we observed an increase in the expression of genes related to pectin and side-chain hemicellulose degradation, which was accompanied by an increase in extracellular pectin-degrading capacity. Genome-wide comparisons between the KDssp1 and the wild-type strains demonstrated that ssp silencing conferred accumulated changes in gene expression at the advanced cultivation stages in an adaptive rather than an inductive mode of transcriptional response. Based on co-expression networking, crucial gene modules were identified and linked to the ssp knockdown genotype at different cultivation times. Based on these data, as well as previous studies, we propose that P. ostreatus SSPs have potential roles in modulating the lignocellulolytic and pectinolytic systems, as well as a variety of fundamental biological processes related to fungal growth and development.

Evaluation of Palliative Care Related Hospital Admissions in a Regional Centre

OBJECTIVES

A significant proportion of adults admitted to hospital are in their last year of life. We evaluated admissions for these patients.

METHODS

We identified ambulance callouts to patients known to the palliative care team. Data collected included admission outcome (e.g. discharge or death).

RESULTS

There were 162 ambulance callouts between 126 patients known to the palliative care team. 8 patients (6%) died within 72 hours of admission.

CONCLUSION

Our data suggests many palliative care patients can be appropriately treated in the community.

Characterization of a novel polyextremotolerant fungus, Exophiala viscosa, with insights into its melanin regulation and ecological niche

Black yeasts are polyextremotolerant fungi that contain high amounts of melanin in their cell wall and maintain a primar yeast form. These fungi grow in xeric, nutrient depletes environments which implies that they require highly flexible metabolisms and have been suggested to contain the ability to form lichen-like mutualisms with nearby algae and bacteria. However, the exact ecological niche and interactions between these fungi and their surrounding community are not well understood. We have isolated 2 novel black yeasts from the genus Exophiala that were recovered from dryland biological soil crusts. Despite notable differences in colony and cellular morphology, both fungi appear to be members of the same species, which has been named Exophiala viscosa (i.e. E. viscosa JF 03-3 Goopy and E. viscosa JF 03-4F Slimy). A combination of whole genome sequencing, phenotypic experiments, and melanin regulation experiments have been performed on these isolates to fully characterize these fungi and help decipher their fundamental niche within the biological soil crust consortium. Our results reveal that E. viscosa is capable of utilizing a wide variety of carbon and nitrogen sources potentially derived from symbiotic microbes, can withstand many forms of abiotic stresses, and excretes melanin which can potentially provide ultraviolet resistance to the biological soil crust community. Besides the identification of a novel species within the genus Exophiala, our study also provides new insight into the regulation of melanin production in polyextremotolerant fungi.

The Amylolytic Regulator AmyR of Aspergillus niger Is Involved in Sucrose and Inulin Utilization in a Culture-Condition-Dependent Manner

Filamentous fungi degrade complex plant material to its monomeric building blocks, which have many biotechnological applications. Transcription factors play a key role in plant biomass degradation, but little is known about their interactions in the regulation of polysaccharide degradation. Here, we deepened the knowledge about the storage polysaccharide regulators AmyR and InuR in Aspergillus niger. AmyR controls starch degradation, while InuR is involved in sucrose and inulin utilization. In our study, the phenotypes of A. niger parental, ΔamyR, ΔinuR and ΔamyRΔinuR strains were assessed in both solid and liquid media containing sucrose or inulin as carbon source to evaluate the roles of AmyR and InuR and the effect of culture conditions on their functions. In correlation with previous studies, our data showed that AmyR has a minor contribution to sucrose and inulin utilization when InuR is active. In contrast, growth profiles and transcriptomic data showed that the deletion of amyR in the ΔinuR background strain resulted in more pronounced growth reduction on both substrates, mainly evidenced by data originating from solid cultures. Overall, our results show that submerged cultures do not always reflect the role of transcription factors in the natural growth condition, which is better represented on solid substrates. Importance: The type of growth has critical implications in enzyme production by filamentous fungi, a process that is controlled by transcription factors. Submerged cultures are the preferred setups in laboratory and industry and are often used for studying the physiology of fungi. In this study, we showed that the genetic response of A. niger to starch and inulin was highly affected by the culture condition, since the transcriptomic response obtained in a liquid environment did not fully match the behavior of the fungus in a solid environment. These results have direct implications in enzyme production and would help industry choose the best approaches to produce specific CAZymes for industrial purposes.

Agave REVEILLE1 regulates the onset and release of seasonal dormancy in Populus

Deciduous woody plants like poplar (Populus spp.) have seasonal bud dormancy. It has been challenging to simultaneously delay the onset of bud dormancy in the fall and advance bud break in the spring, as bud dormancy, and bud break were thought to be controlled by different genetic factors. Here, we demonstrate that heterologous expression of the REVEILLE1 gene (named AaRVE1) from Agave (Agave americana) not only delays the onset of bud dormancy but also accelerates bud break in poplar in field trials. AaRVE1 heterologous expression increases poplar biomass yield by 166% in the greenhouse. Furthermore, we reveal that heterologous expression of AaRVE1 increases cytokinin contents, represses multiple dormancy-related genes, and up-regulates bud break-related genes, and that AaRVE1 functions as a transcriptional repressor and regulates the activity of the DORMANCY-ASSOCIATED PROTEIN 1 (DRM1) promoter. Our findings demonstrate that AaRVE1 appears to function as a regulator of bud dormancy and bud break, which has important implications for extending the growing season of deciduous trees in frost-free temperate and subtropical regions to increase crop yield.

Non-Toxigenic Clostridioides difficile Strain E4 (NTCD-E4) Prevents Establishment of Primary C. difficile Infection by Epidemic PCR Ribotype 027 in an In Vitro Human Gut Model

Clostridioides difficile infection (CDI) remains a significant healthcare burden. Non-toxigenic C. difficile (NTCD) strains have shown a benefit in preventing porcine enteritis and in human recurrent CDI. In this study, we evaluated the efficacy of metronidazole-resistant NTCD-E4 in preventing CDI facilitated by a range of antimicrobials in an in vitro human gut model. NTCD-E4 spores (at a dose of 107) were instilled 7 days before a clinical ribotype (RT) 027 (at the same dose) strain (210). In separate experiments, four different antimicrobials were used to perturb gut microbiotas; bacterial populations and cytotoxin production were determined using viable counting and Vero cell cytotoxicity, respectively. RT027 and NTCD-E4 proliferated in the in vitro model when inoculated singly, with RT027 demonstrating high-level cytotoxin (3-5-log10-relative units) production. In experiments where the gut model was pre-inoculated with NTCD-E4, RT027 was remained quiescent and failed to produce cytotoxins. NTCD-E4 showed mutations in hsmA and a gene homologous to CD196-1331, previously linked to medium-dependent metronidazole resistance, but lacked other metronidazole resistance determinants. This study showed that RT027 was unable to elicit simulated infection in the presence of NTCD-E4 following stimulation by four different antimicrobials. These data complement animal and clinical studies in suggesting NTCD offer prophylactic potential in the management of human CDI.

Co‑cultivation of anaerobic fungi with Clostridium acetobutylicum bolsters butyrate and butanol production from cellulose and lignocellulose

A system for co-cultivation of anaerobic fungi with anaerobic bacteria was established based on lactate cross-feeding to produce butyrate and butanol from plant biomass. Several co-culture formulations were assembled that consisted of anaerobic fungi (Anaeromyces robustus, Neocallimastix californiae, or Caecomyces churrovis) with the bacterium Clostridium acetobutylicum. Co-cultures were grown simultaneously (e.g., 'one pot'), and compared to cultures where bacteria were cultured in fungal hydrolysate sequentially. Fungal hydrolysis of lignocellulose resulted in 7-11 mM amounts of glucose and xylose, as well as acetate, formate, ethanol, and lactate to support clostridial growth. Under these conditions, one-stage simultaneous co-culture of anaerobic fungi with C. acetobutylicum promoted the production of butyrate up to 30 mM. Alternatively, two-stage growth slightly promoted solventogenesis and elevated butanol levels (∼4-9 mM). Transcriptional regulation in the two-stage growth condition indicated that this cultivation method may decrease the time required to reach solventogenesis and induce the expression of cellulose-degrading genes in C. acetobutylicum due to relieved carbon-catabolite repression. Overall, this study demonstrates a proof of concept for biobutanol and bio-butyrate production from lignocellulose using an anaerobic fungal-bacterial co-culture system.

Cancer centre supportive oncology service: health economic evaluation

OBJECTIVES

There have been many models of providing oncology and palliative care to hospitals. Many patients will use the hospital non-electively or semielectively, and a large proportion are likely to be in the last years of life. We describe our multidisciplinary service to treatable but not curable cancer patients at University Hospitals Sussex. The team was a mixture of clinical nurse specialists and a clinical fellow supported by dedicated palliative medicine consultant time and oncology expertise.

METHODS

We identified patients with cancer who had identifiable supportive care needs and record activity with clinical coding. We used a baseline 2019/2020 dataset of national (secondary uses service) data with discharge code 79 (patients who died during that year) to compare a dataset of patients seen by the service between September 2020 and September 2021 in order to compare outcomes. While this was during COVID-19 this was when the funding was available.

RESULTS

We demonstrated a reduction in length of stay by an average of 1.43 days per admission and a reduction of 0.95 episodes of readmission rates. However, the costs of those admissions were found to be marginally higher. Even with the costs of the service, there is a clear return on investment with a benefit cost ratio of 1.4.

CONCLUSIONS

A supportive oncology service alongside or allied to acute oncology but in conjunction with palliative care is feasible and cost-effective. This would support investment in such a service and should be nationally commissioned in conjunction with palliative care services seeing all conditions.

GalR, GalX and AraR co-regulate d-galactose and l-arabinose utilization in Aspergillus nidulans

Filamentous fungi produce a wide variety of enzymes in order to efficiently degrade plant cell wall polysaccharides. The production of these enzymes is controlled by transcriptional regulators, which also control the catabolic pathways that convert the released monosaccharides. Two transcriptional regulators, GalX and GalR, control d-galactose utilization in the model filamentous fungus Aspergillus nidulans, while the arabinanolytic regulator AraR regulates l-arabinose catabolism. d-Galactose and l-arabinose are commonly found together in polysaccharides, such as arabinogalactan, xylan and rhamnogalacturonan I. Therefore, the catabolic pathways that convert d-galactose and l-arabinose are often also likely to be active simultaneously. In this study, we investigated the interaction between GalX, GalR and AraR in d-galactose and l-arabinose catabolism. For this, we generated single, double and triple mutants of the three regulators, and analysed their growth and enzyme and gene expression profiles. Our results clearly demonstrated that GalX, GalR and AraR co-regulate d-galactose catabolism in A. nidulans. GalX has a prominent role on the regulation of genes of d-galactose oxido-reductive pathway, while AraR can compensate for the absence of GalR and/or GalX.

Abstract 057: Beyond Convenience: Video Visits Can Increase The Efficiency Of Preventive Care Delivery

Introduction: In response to the COVID-19 pandemic, medical practices have expanded utilization of telehealth. Little is known about the operational impacts of transitioning from in-person to video visits in specialty clinics. In 2018, the Stanford South Asian Translational Heart Initiative (SSATHI), a preventive cardiology clinic focused on high-risk South Asian adults, introduced CardioClick, a program replacing in-person follow-up visits with video visits.

Hypothesis: We hypothesized that implementation of video visits increased the efficiency of clinic operations.

Methods: We extracted visit-level data from the EHR for 134 patients enrolled in CardioClick with video follow-up visits from June 14, 2018 to April 21, 2020 and a cohort of 276 patients enrolled in the in-person SSATHI prevention program with follow-up visits from September 11, 2014 to March 6, 2020.

Results: Patients in CardioClick and the in-person cohort were similar in terms of age (mean 45 years), gender balance (23 vs 21% female), and cardiometabolic risk profiles. There were 181 video and 637 in-person follow-up visits. Video visits were shorter than in-person visits, both in terms of total clinic time [median 22 min (IQR 16, 29) vs 67 min (48, 100)] and provider time required [median 22 min (IQR 16, 29) vs 30 min (12, 58)]. Video visits were more likely to end on time (71 vs 11%, p<0.001). The median video visit ended on time while the median in-person visit ended 32 min late (13, 70) (see Figure). Providers were also more likely to complete video visit documentation the same day (56 vs 42%, p=0.001).

Conclusions: In a preventive cardiology clinic, video follow-up visits required less clinic and provider time than in-person visits, were more likely to end on time, and were associated with increased same-day provider documentation completion. In conclusion, video visits offer benefits beyond their convenience and may increase the operational efficiency of specialty care practices focused on disease prevention, improving value in care delivery.

Self-reported alcohol consumption in doctors

BACKGROUND

The UK government has prioritized reducing the harmful effects of excessive alcohol consumption on mental and physical well-being.

AIMS

To assess self-reported alcohol consumption amongst doctors at an acute London Trust.

METHODS

An opportunistic, anonymous, survey was conducted by Postgraduate Education Fellows over 2 weeks in December 2018. This included all grades of doctors from Foundation Year One to Consultant. The survey consisted of nine questions, modified from the alcohol use disorders identification test (AUDIT) and CAGE questionnaire.

RESULTS

Of 446 doctors within our institution, 109 completed the survey (24%). Fourteen per cent of those surveyed abstained from alcohol, 21% drank monthly or less, 31% drank between two to four times per month, 25% drank two to three times per week and 9% drank greater than four times per week. In the preceding 2 years, 9% reported being unable to do what was expected of them on at least one occasion due to alcohol. Five per cent were concerned about alcohol affecting their performance. Two per cent were annoyed by criticism of their drinking, 9% felt guilty about drinking and 4% needed an eye-opener. Eighteen per cent wanted to reduce their alcohol consumption; however, 43% of the 109 doctors surveyed were uncertain where to seek help.

CONCLUSIONS

Twenty per cent of surveyed doctors reported consuming potentially hazardous levels of alcohol and 18% of respondents wanted to cut down. Forty-three per cent were unaware of sources of support. Our findings suggest a role for collaboration between Occupational Health departments and Postgraduate Education teams to support doctors misusing alcohol.

Antagonism of the proinflammatory and pronociceptive actions of canonical and biased agonists of protease-activated receptor-2

BACKGROUND AND PURPOSE

Diverse proteases cleave protease-activated receptor-2 (PAR2) on primary sensory neurons and epithelial cells to evoke pain and inflammation. Trypsin and tryptase activate PAR2 by a canonical mechanism that entails cleavage within the extracellular N-terminus revealing a tethered ligand that activates the cleaved receptor. Cathepsin-S and elastase are biased agonists that cleave PAR2 at different sites to activate distinct signalling pathways. Although PAR2 is a therapeutic target for inflammatory and painful diseases, the divergent mechanisms of proteolytic activation complicate the development of therapeutically useful antagonists.

EXPERIMENTAL APPROACH

We investigated whether the PAR2 antagonist GB88 inhibits protease-evoked activation of nociceptors and protease-stimulated oedema and hyperalgesia in rodents.

KEY RESULTS

Intraplantar injection of trypsin, cathespsin-S or elastase stimulated mechanical and thermal hyperalgesia and oedema in mice. Oral GB88 or par2 deletion inhibited the algesic and proinflammatory actions of all three proteases, but did not affect basal responses. GB88 also prevented pronociceptive and proinflammatory effects of the PAR2-selective agonists 2-furoyl-LIGRLO-NH2 and AC264613. GB88 did not affect capsaicin-evoked hyperalgesia or inflammation. Trypsin, cathepsin-S and elastase increased [Ca(2+) ]i in rat nociceptors, which expressed PAR2. GB88 inhibited this activation of nociceptors by all three proteases, but did not affect capsaicin-evoked activation of nociceptors or inhibit the catalytic activity of the three proteases.

CONCLUSIONS AND IMPLICATIONS

GB88 inhibits the capacity of canonical and biased protease agonists of PAR2 to cause nociception and inflammation.

Sticks and stones: investigating rude, dismissive and aggressive communication between doctors

Destructive communication is a problem within the NHS; however previous research has focused on bullying. Rude, dismissive and aggressive (RDA) communication between doctors is a more widespread problem and underinvestigated. We conducted a mixed method study combining a survey and focus groups to describe the extent of RDA communication between doctors, its context and subsequent impact. In total, 606 doctors were surveyed across three teaching hospitals in England. Two structured focus groups were held with doctors at one teaching hospital. 31% of doctors described being subject to RDA communication multiple times per week or more often, with junior and registrar doctors affected twice as often as consultants. Rudeness was more commonly experienced from specific specialties: radiology, general surgery, neurosurgery and cardiology. 40% of respondents described that RDA moderately or severely affected their working day. The context for RDA communication was described in five themes: workload, lack of support, patient safety, hierarchy and culture. Impact of RDA communication was described as personal, including emotional distress and substance abuse, and professional, including demotivation. RDA communication between doctors is a widespread and damaging behaviour, occurring in contexts common in healthcare. Recognition of the impact on doctors and potentially patients is key to change.

Survival gains needed to offset persistent adverse treatment effects in localised prostate cancer

Background:

Men diagnosed with localised prostate cancer (LPC) face difficult choices between treatment options that can cause persistent problems with sexual, urinary and bowel function. Controlled trial evidence about the survival benefits of the full range of treatment alternatives is limited, and patients' views on the survival gains that might justify these problems have not been quantified.

Methods:

A discrete choice experiment (DCE) was administered in a random subsample (n=357, stratified by treatment) of a population-based sample (n=1381) of men, recurrence-free 3 years after diagnosis of LPC, and 65 age-matched controls (without prostate cancer). Survival gains needed to justify persistent problems were estimated by substituting side effect and survival parameters from the DCE into an equation for compensating variation (adapted from welfare economics).

Results:

Median (2.5, 97.5 centiles) survival benefits needed to justify severe erectile dysfunction and severe loss of libido were 4.0 (3.4, 4.6) and 5.0 (4.9, 5.2) months. These problems were common, particularly after androgen deprivation therapy (ADT): 40 and 41% overall (n=1381) and 88 and 78% in the ADT group (n=33). Urinary leakage (most prevalent after radical prostatectomy (n=839, mild 41%, severe 18%)) needed 4.2 (4.1, 4.3) and 27.7 (26.9, 28.5) months survival benefit, respectively. Mild bowel problems (most prevalent (30%) after external beam radiotherapy (n=106)) needed 6.2 (6.1, 6.4) months survival benefit.

Conclusion:

Emerging evidence about survival benefits can be assessed against these patient-based benchmarks. Considerable variation in trade-offs among individuals underlines the need to inform patients of long-term consequences and incorporate patient preferences into treatment decisions.

Cultural perspectives of interventions for managing diabetes and asthma in children and adolescents from ethnic minority groups

Both diabetes and asthma are increasingly being recognized as health problems for ethnic groups. Because of cultural differences, ethnicity is reported to be a risk factor for poorer quality in health care, disease management and disease control. Ethnic groups are at risk for poorer quality of life and increased disease complications when compared with non-ethnic counterparts living in the same country. There is little known about how culture is addressed in interventions developed for ethnic groups. The aim of this paper is to systematically review the cultural perspectives of interventions for managing diabetes and asthma in children, adolescents and/or their families from ethnic minority groups. A total of 92 records were identified that were potentially relevant to this review following which, 61 papers were excluded. The full texts of remaining papers (n= 31) were then read independently by both authors, and agreement was reached to exclude a further 27 papers that did not meet inclusion criteria. A total of four papers were eligible for inclusion in this review. Findings indicate that despite growing concerns about health disparities between ethnic and non-ethnic groups in relation to both asthma and diabetes in childhood, there has been little effort to develop cultural specific interventions for ethnic groups. By systematically reviewing asthma and diabetes interventions we have highlighted that few interventions have been developed from a cultural perspective. There are a limited number of interventions published that add knowledge on the specific elements of intervention that is needed to effectively and sensitively educate other cultures. More work is required into identifying which strategies or components of cultural interventions are most effective in achieving positive health outcomes for children, adolescents and/or their families from ethnic groups.

Extracting respiratory data from pulse oximeter plethysmogram traces in newborn infants

To investigate whether valid respiratory data can be extracted from the pulse oximeter plethysmographic (pleth) trace in healthy newborn infants, pleth data were collected from the foot, and respiratory airflow was simultaneously measured using a facemask. The pleth waveform was analysed using fast Fourier transform (FFT), low-pass filtering (LPF), and by plotting the peak-to-peak amplitude variation (PtP). Using FFT in 14 term infants, the median (range) respiratory rate from the pleth signal was 43 (30-65) breaths/min, and from the flow signal it was 44 (30-67) breaths/min (median difference 0.01 breaths/min, p>0.05). Both LPF and PtP analysis yielded waveforms with a frequency similar to the respiratory rate. Respiratory information, including respiratory rate and a respiratory-like waveform, can reliably be extracted from the pleth trace of a standard pulse oximeter in newborn infants. Such analysis may be clinically useful for non-invasive assessment of respiratory problems in infants and young children.

Survival gains needed to justify the side effects of treatment for localized prostate cancer

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Background: Men diagnosed with localized prostate cancer face difficult treatment decisions. Evidence about the relative survival benefit of treatment options is lacking or piecemeal. Side-effects can vary widely with treatment, affecting some fundamental aspects of quality of life (QOL). Little is known about patients’ views of the relative tolerability of these side-effects or the survival gains needed to justify them. Methods: QOL data were collected prospectively 3 years post-diagnosis in a population-based cohort of men treated for localized prostate cancer (n=1642); these data were used to identify common side-effect profiles. A patient preference survey was conducted in a subset (n=357, stratified by treatment); hypothetical treatment alternatives were described in terms of side-effects and survival. Random parameter logit models were estimated. We adapted the concept of compensating variation from welfare economics to derive a parameter function for the value of changes in QOL in terms of survival time; i.e., the survival gains needed to justify persistent side-effects. Bootstrap confidence intervals (CI) were constructed. Results: The table shows the survival gains needed for a range of common treatment profiles, relative to the base case of active surveillance (in which men typically experienced mild loss of libido and mild fatigue). For example, radical prostatectomy often resulted in severe impotence and mild urinary leakage; men required an extra 8.0 months (95% CI 7.4–8.7) of life to make this worthwhile. Generally, urinary dysfunction and bowel symptoms were considered the least tolerable, hormonal symptoms and fatigue came next, and sexual dysfunction was considered relatively benign. This pattern was relatively consistent across treatment groups. Conclusions: These results highlight the need for better evidence about the actual survival benefits of alternative treatments. They also help to target supportive care to optimize patient QOL after treatment for localized prostate cancer.

[Table: see text]

No significant financial relationships to disclose.

Research priorities for nursing and midwifery in Southern Ireland

AIM

To identify research priorities for nursing and midwifery in the Southern Health Board area in Ireland for the immediate and long term.

METHOD

Ten focus groups were conducted over a 2-month period with 70 nurses and midwives working in clinical, managerial and educational roles participating. Based on focus group findings and a literature review a multi-item Likert type questionnaire was constructed and administered to 520 nurses and midwives (response rate 95%n=494).

RESULTS

Research priorities were identified as: (1) impact of staff shortages on retention of RNs/RM's (80%); (2) quality of life of chronically ill patients (76%); (3) stress and bullying in the workplace (76%); (4) assessment and management of pain (75%); (5) skill mix and staff burnout (73%); (6) cardio-pulmonary resuscitation decision making (72%); (7) coordination of care between hospital and primary care settings (69%); (8) medication errors (67%); and (9) promoting healthy lifestyles (64%). Respondents also indicated that these priorities warranted immediate attention. Implications for practice include the need for: (1) emphasis on quality pain control; (2) recognition and exploration of the ethical issues relating to resuscitation; and (3) management of the context within which clinical care is given.

Weight and energy: parents' and children's perspectives on managing cystic fibrosis diet

AIMS

To explore the meanings that parents and children attach to food and eating, and how these influence their approaches to dietary management of cystic fibrosis (CF).

METHODS

Ethnographic design using in-depth interviews with 32 children with CF (aged 6-14 years) and their parents, and participant observations during visits to CF clinics with a sub-group of 21 children. Data were analysed using the constant comparative method and theoretical sampling was used to further explore and develop emergent themes.

RESULTS

Dietary management was found to be a demanding task for children and their parents, and priorities differed between them. A priority of feeding for parents was to protect their children's long term physical health and survival by keeping their weight up. A challenge for parents was to ensure their children's cooperation with eating. A priority for children in being healthy was to have energy for physical activities and so energy rather than weight was of immediate relevance to their daily lives. These differences between parents and children gave rise to tensions and conflicts in their interactions with one another in managing diet.

CONCLUSIONS

Healthcare professionals should take account of the meanings that children and their parents attach to food and eating that can influence their decisions about implementing CF dietary recommendations. The role of children in making food choices has implications for acknowledging them as active participants in their dietary care and for adopting child centred approaches to dietary advice for CF.

Improving adherence to screening follow-up among women with abnormal Pap smears: results from a large clinic-based trial of three intervention strategies

In a large randomized trial involving over 2,000 women with abnormal cervical cytology (pap smear), three clinic-based interventions were tested as strategies to increase return rates for screening follow-up: 1) a personalized follow-up letter and pamphlet; 2) a slide-tape program on pap smears; and 3) transportation incentives (bus passes/parking permits). The three interventions were evaluated using a 2 x 2 x 2 factorial design. Results of this study confirm a high rate of loss to screening follow-up (i.e., no return visits) among women with abnormal pap smears (29% overall), with substantial variability among the 12 participating clinics (13% to 42/%). For the sample as a whole, both transportation incentives and the combined intervention condition of personalized follow-up and slide-tape program had a significant positive impact on screening follow-up. However, transportation incentives emerged as the dominant intervention condition among patient subgroups that can be characterized as more disadvantaged socioeconomically and at higher risk of developing cervical cancer, including patients receiving care from the county health department (odds ratio (OR) = 1.51; P less than .05); patients without health insurance (OR = 1.77; P less than .01); and patients with more severe pap smear results (OR = 1.71; P less than .05). In contrast, among patient subgroups that can be characterized as relatively more advantaged and at lower risk of developing cervical cancer, only the combined intervention condition of personalized follow-up and slide-tape program was associated with a higher patient return rate. Subgroups reflecting this pattern included patients seen in noncounty clinics (OR = 4.54; P less than .05) and patients with less severe pap smear results (OR = 5.16; P less than .01). The implications of these findings are discussed in terms of designing clinic-based interventions to improve screening follow-up.

Ciprofloxacin monotherapy for acute pelvic infections: a comparison with clindamycin plus gentamicin

This prospective, randomized controlled study compared the efficacy and safety of ciprofloxacin alone versus a conventional two-drug regimen, clindamycin with gentamicin. The study group included 71 patients hospitalized for pelvic infections such as acute (N = 33) and chronic (N = 8) salpingitis, tubo-ovarian abscesses (N = 11), endometritis (N = 9), septic abortion (N = 3), and other categories (N = 7). Twenty-two of 35 patients on ciprofloxacin and 20 of 36 on clindamycin plus gentamicin had culturable pathogens: gonococci in 28, anaerobes in six, chlamydia in four, and associated pathogens in 19. Complete clinical and bacteriologic cure was achieved in 21 of 22 (95%) in the ciprofloxacin group and 19 of 20 (95%) in the clindamycin plus gentamicin group. The mean duration of intravenous/oral ciprofloxacin therapy was 3.7/7.2 days, and it was 3/6.6 days for clindamycin plus gentamicin. Ciprofloxacin, a new quinolone, appears to be safe as a single-drug therapy and was as effective as the combination of clindamycin plus gentamicin for the treatment of severe pelvic infections requiring hospitalization.

Screening for cervical cancer in emergency centers and sexually transmitted disease clinics

Low-income women are at increased risk of developing cervical cancer compared with middle- and upper-income women. How can poor women be reached for screening and early diagnosis of cervical cancer and its precursor stages? One answer to this question is based on the observation that a high percentage of the unscreened population has received some form of medical care within the previous 5 years. Emergency centers and sexually transmitted disease (STD) clinics often provide such care to patients who lack a regular source of health care. Thus, they represent potential resources for cervical cancer screening. However, in a survey of 19 hospitals whose patient populations include a high proportion of low-income patients, only five reported a protocol for cervical cancer screening in their emergency centers. Similarly, all 11 STD clinics included in this survey reported that fewer than 5% of their female patients had a Papanicolaou smear taken even though virtually all of them received a pelvic examination. Based on these findings, it appears that health care administrators and policymakers could intensify their cancer prevention programs by mobilizing these resources for cancer control.

The effect of large volume paracentesis on plasma volume--a cause of hypovolemia?

Large volume paracentesis, while effectively relieving symptoms in patients with tense ascites, has been generally avoided due to reports of complications attributed to an acute reduction in intravascular volume. Measurements of plasma volume in these subjects have been by indirect methods and have not uniformly confirmed hypovolemia. We have prospectively evaluated 18 patients (20 paracenteses) with tense ascites and peripheral edema due to chronic liver disease undergoing 5 liter paracentesis for relief of symptoms. Plasma volume pre- and postparacentesis was assessed by a 125I-labeled human serum albumin dilution technique as well as by the change in hematocrit and postural blood pressure difference. No significant change in serum sodium, urea nitrogen, hematocrit or postural systolic blood pressure difference was noted at 24 or 48 hr after paracentesis. Serum creatinine at 24 hr after paracentesis was unchanged but a small but statistically significant increase in serum creatinine (+0.1 +/- 0.3 mg per dl, p less than 0.01) was noted at 48 hr postparacentesis. Plasma volume changed -2.7% (n = 6, not statistically significant) during the first 24 hr and -2.8% (n = 12, not statistically significant) during the 0- to 48-hr period. No complications from paracentesis were noted. These results suggest that 5 liter paracentesis for relief of symptoms is safe in patients with tense ascites and peripheral edema from chronic liver disease.