Typology of employers offering line manager training for mental health

BACKGROUND

Mental ill health has a high economic impact on society and employers. National and international policy advocates line manager (LM) training in mental health as a key intervention, but little is known about employer training provisions.

AIMS

To explore the prevalence and characteristics of organizations that offer LM training in mental health.

METHODS

Secondary analysis of existing longitudinal anonymised organizational-level survey data derived from computer-assisted telephone interview surveys collected in four waves (2020:1900 firms, 2021:1551, 2022:1904, 2023:1902) in England, before, during and after a global pandemic.

RESULTS

The proportion of organizations offering LM training in mental health increased pre- to post-pandemic (2020:50%, 2023:59%) but 41% do not currently provide it. Logistic regression confirmed that LM training is more likely to be offered by large-sized enterprises, organizations with a larger proportion of employees who are younger (aged 25-49), female, disabled and from ethnic minority communities. Sector patterns were inconsistent, but in 2023, organizations from the 'Hospitality' and 'Business Services' sectors were more likely to provide LM training than other sectors.

CONCLUSIONS

Continued efforts are needed to increase the proportion of employers offering LM training in mental health, particularly small- to medium-sized enterprises, and organizations with predominantly male, White and/or older workforces.

An established abdominal wall multidisciplinary team improves patient care and aids surgical decision making with complex ventral hernia patients

INTRODUCTION

Abdominal wall reconstruction (AWR) is an emerging subspecialty within general surgery. The practice of multidisciplinary team (MDT) meetings to aid decision making and improve patient care has been demonstrated, with widespread acceptance. This study presents our initial experience of over 150 cases of complex hernia patients discussed in a newly established MDT setting.

METHODS

From February 2020 to July 2022 (30-month period), abdominal wall MDTs were held bimonthly. Key stakeholders included upper and lower gastrointestinal surgeons, a gastrointestinal specialist radiologist, a plastic surgeon, a high-risk anaesthetist and two junior doctors integrated into the AWR clinical team. Meetings were held online, where patient history, past medical and surgical history, hernia characteristics and up-to-date computed tomography scans were discussed.

RESULTS

Some 156 patients were discussed over 18 meetings within the above period. Ninety-five (61%) patients were recommended for surgery, and 61 (39%) patients were recommended for conservative management or referred elsewhere. Seventy-eight (82%) patients were directly waitlisted, whereas seventeen (18%) required preoperative optimisation: three (18%) for smoking cessation, eleven (65%) for weight-loss management and three (18%) for specialist diabetic assessment and management. In total, 92 (59%) patients (including operative and nonoperative management) have been discharged to primary care.

DISCUSSION

A multidisciplinary forum for complex abdominal wall patients is a safe process that facilitates decision making, promotes education and improves patient care. As the AWR subspecialty evolves, our view is that the "complex hernia MDT" will become commonplace. We present our experience and share advice for others planning to establish an AWR centre.

Enablers and barriers to mental health initiatives in construction SMEs

BACKGROUND

Mental ill-health is prevalent in the construction industry, and workers in small- to medium-sized enterprises (SMEs) are at high risk. Knowledge about the implementation of mental health initiatives in construction SMEs is limited.

AIMS

To explore enablers and barriers to implementing mental health initiatives within UK SME construction firms from the perspective of the business owners, directors and managers with responsibilities for workplace mental health.

METHODS

Qualitative study involving semi-structured interviews conducted with company owners/managers with responsibilities for workforce mental health. Participants were sampled from construction SMEs in the UK.

RESULTS

Eleven construction professionals were interviewed (10 men, 1 woman; aged 34-55 years, M = 40.6) representing UK SME construction firms that were micro (<10 employees, n = 8), small (<50 employees, n = 1) and medium (<250 employees, n = 2) sized organizations. Reflexive thematic analysis generated four themes: (i) traditional views and macho culture, identified as barriers to implementation; (ii) mental health awareness, knowledge and education; (iii) valuing good mental health and (iv) a reactive or proactive approach to mental health, which all served as both enablers and barriers depending on perspective and context.

CONCLUSIONS

This study sheds light on an under-researched but high-risk category of workers experiencing poor mental health. We provide recommendations for policy and practice with a 'call to action' for SME owners, industry and policymakers to embark on workplace mental health implementation projects in SME settings.

Ultrasound simulation training to meet the 2021 Royal College of Radiologists' curriculum for radiology trainees: South East London experience

AIM

To enhance ultrasound teaching delivery to radiology trainees using a simulation course matched to the 2021 Royal College of Radiologists (RCR) curriculum.

MATERIAL AND METHODS

An ultrasound simulation training course was designed for specialty trainees (ST) 1 in radiology, which was based on the 2021 RCR curriculum and covered the top ultrasound training priorities. The course was piloted initially on two occasions in a 1-day format to the August 2021 and the March 2022 ST1 intake trainees. Based on the feedback, a comprehensive 4-day course was developed and delivered between October and December 2022 for the August 2022 ST1 intake, funded by Health Education England. The outcomes measured were subjective trainee feedback using numerical scores and free text.

RESULTS

All King's College Hospital NHS Foundation Trust radiology ST1 trainees from the August 2021 to the August 2022 intake participated in ultrasound simulation training. The training matched the RCR curriculum and increased the trainees' confidence and competency in medical ultrasound.

CONCLUSIONS

Ultrasound simulation training can be successfully delivered to ST1 trainees to match the 2021 RCR curriculum and enhance training in medical ultrasound for radiologists.

The changing vaccine landscape: rates of COVID-19 vaccine acceptance and hesitancy in young adults during vaccine rollout

AIMS

Development and rollout of vaccines offers the best opportunity for population protection against the SARS-CoV-2 (COVID-19) virus. However, hesitancy towards the vaccines might impede successful uptake in the United Kingdom, particularly in young adults who demonstrate the highest rates of hesitancy. This prospective study explored COVID-19 vaccine hesitancy in young adults and whether the reasons behind these attitudes changed during the initial stages of the United Kingdom's vaccine rollout.

METHOD

Data on vaccination intention were collected from a British university student cohort at three time points: October 2020, February 2021, and March 2021. This online survey included items on intention to receive a vaccine and a free-text response for the reasons behind this intention. Cochran's Q tests examined changes in rates of hesitancy and acceptance over time and free-text responses were analysed thematically.

RESULTS

At baseline, 893 students provided data, with 476 participants completing all three time points. Hesitancy declined over time, with 29.4% of participants expressing hesitancy at baseline, reducing to 9.1% at wave 2 and 5.9% at wave 3. The most commonly endorsed themes for those willing to accept a vaccine were self-protection against COVID-19 and pro-social reasons, including protecting the population or unspecific others, and ending the pandemic/returning to normal life. The most commonly endorsed hesitancy themes related to 'confidence' in the vaccines and potential personal risk, including insufficient testing/scientific evidence, concern about side effects, and long-term effects. These reasons remained the most commonly endorsed at both waves 2 and 3.

CONCLUSIONS

While a decline in hesitancy was observed over time, the key reasons behind both vaccine acceptance and hesitancy remained consistent. Reasons behind hesitancy aligned with those of the general public, providing support for the use of generalist interventions. Pro-social reasons frequently underpinned vaccine acceptance, so cohort-specific interventions targeting those factors may be of benefit.

Predictors of self-management in patients with chronic low back pain: a longitudinal study

BACKGROUND

Self-management (SM) is a key recommended strategy for managing chronic low back pain (CLBP). However, SM programmes generate small to moderate benefits for reducing pain and disability in patients with CLBP. The benefits of the SM programme can potentially be optimised by identifying specific subgroups of patients who are the best responders. To date, no longitudinal study has examined the predictive relationships between SM and biopsychosocial factors in patients with CLBP. The aim was to determine whether biopsychosocial factors predict SM and its change over time in patients with CLBP.

METHODS

In this multi-centre longitudinal cohort study, we recruited 270 working-age patients with CLBP (mean age 43.74, 61% female) who consulted outpatient physiotherapy for their CLBP. Participants completed self-reported validated measures of pain intensity, disability, physical activity, kinesiophobia, catastrophising, depression and SM at baseline and six months. SM constructs were measured using eight subscales of the Health Education Impact Questionnaire (heiQ), including Health Directed Activity (HDA), Positive and Active Engagement in Life (PAEL), Emotional Distress (ED), Self-Monitoring and Insight (SMI), Constructive Attitudes and Approaches (CAA), Skill and Technique Acquisition (STA), Social Integration and Support (SIS) and Health Service Navigation (HSN). Data were analysed using General Linear Model (GLM) regression.

RESULTS

Physical activity and healthcare use (positively) and disability, depression, kinesiophobia, catastrophising (negatively) predicted (p < 0.05, R² 0.07-0.55) SM constructs at baseline in patients with CLBP. Baseline depression (constructs: PAEL, ED, SMI, CAA and STA), kinesiophobia (constructs: CAA and HSN), catastrophising (construct: ED), and physical disability (constructs: PAEL, CAA and SIS) negatively predicted a range of SM constructs. Changes over six months in SM constructs were predicted by changes in depression, kinesiophobia, catastrophising, and physical activity (p < 0.05, R² 0.13-0.32).

CONCLUSIONS

Self-reported disability, physical activity, depression, catastrophising and kinesiophobia predicted multiple constructs of SM measured using the heiQ subscales in working-age patients with CLBP. Knowledge of biopsychosocial predictors of SM may help triage patients with CLBP into targeted pain management programmes.

TRIAL REGISTRATION

The study protocol was registered at ClinicalTrials.gov on 22 December 2015 (ID: NCT02636777).

Evaluation of opt-in HIV testing in the construction workplace using the socioecological framework

Background

Late diagnosis of HIV remains a challenge and the construction workforce has several risk factors for HIV. In the Test@Work programme, we delivered HIV tests embedded within a general health check to construction workers, with high uptake and acceptability. Here, we report the experiences of construction managers and health professionals involved in Test@Work and explore the suitability of construction worksites as a venue for opt-in HIV testing.

Methods

Qualitative interviews (n = 24) were conducted with construction managers who facilitated events (n = 13), and HIV/health check delivery partners (n = 11) at 21 Test@Work events held on construction sites. Interviews explored experiences of events and views towards workplace HIV testing. Event exit questionnaires (n = 107) completed by delivery partners provided qualitative data identifying facilitators and barriers to effective delivery. Thematic analysis identified themes that were mapped against a socioecological framework (individual, interpersonal, organisational, industry, public health).

Results

Delivery partners reported high engagement of construction workers with workplace HIV testing, peer-to-peer encouragement for uptake, and value for accessibility of onsite testing. HIV professionals valued the opportunity to reach an untested population, many of whom had a poor understanding of their exposure to HIV risk. Managers valued the opportunity to offer workplace health checks to employees but some identified challenges with event planning, or provision of private facilities.

Conclusions

The construction sector is complex with a largely male workforce. Providing worksite HIV testing and education to an untested population who have poor knowledge about HIV risk helped to normalise testing, increase uptake, and reduce HIV stigma. However, there are practical barriers to testing in the construction environment. This has global implications for delivery of HIV testing in construction workplace settings.

Key messages

• Delivering workplace HIV testing as part of a general health check helps to normalise HIV testing and reduce HIV-related stigma.

• Workplace testing is convenient, accessible and reaches populations at risk for HIV, but there are some barriers to implementation of rapid tests on construction sites.

Process evaluation of a university residence-based SARS-CoV-2 testing programme in the UK

Background

Regular testing for SARS-CoV-2 is an important strategy for controlling virus outbreaks on university campuses during the COVID-19 pandemic but testing participation can be low. The Residence-Based Testing Participation Pilot (RB-TPP) was a novel 4-week intervention implemented at two student residences on a UK university campus, aiming to increase asymptomatic testing frequency and normalise university life through relaxed social restrictions onsite.

Methods

Mixed-methods process evaluation determined whether RB-TPP was implemented as planned and identified implementation barriers and facilitators. Data were collected from meeting records, university students (online survey: n = 152; focus groups: n = 30), and staff (interviews, n = 13). Barriers and facilitators to implementation were mapped to the ‘Capability, Opportunity, Motivation-Behaviour’ (COM-B) behaviour change framework.

Results

Uptake was high (n = 464 students opted-in; 98% of those living onsite). Implementation was broadly as planned, with adjustments due to national escalation of the COVID-19 Delta variant. Majority engaged in testing (88%); 46% (52% of testers) were fully compliant with pre-determined testing frequency. Most felt positively towards relaxed social distancing (97.9%). Implementation was facilitated by convenience and efficiency of testing and reduced negative impacts of isolation through opportunities for students to socialise. Barriers to implementation were mixed-messages about the rules, ambivalent attitudes, and lack of adherence to COVID-19 protective measures in the minority.

Conclusions

This is the first process evaluation of the implementation of asymptomatic SARS-CoV-2 testing in university residences. Testing participation increased and student mental wellbeing improved. Rapid adaptions to the changing pandemic context generated complexity and challenge. Findings have global relevance for outbreak prevention and management strategies in higher education settings.

Key messages

• Delivery of asymptomatic SARS-CoV-2 testing and relaxation of social distancing within residences led to high rates of testing participation and benefits for student mental wellbeing.

• This is the first process evaluation of the implementation of asymptomatic SARS-CoV-2 testing in university residences with global relevance for outbreak prevention in higher education settings.

Managing Minds at Work: development of a digital line manager training programme

Background

Mental ill health is the leading cause of sickness absence with high economic burden. Workplace interventions aimed at supporting employers with prevention of mental ill-health in the workforce are urgently required. Managing Minds at Work (MMW) is a digital intervention targeting support for line managers in any work setting to promote better mental health at work through a preventative approach.

Objectives

To describe the design and development of the MMW digital training programme, prior to feasibility testing. We adopted a collaborative participatory design involving co-design (users as partners) and principles of user-centred design (pilot and usability testing). Agile methodology was used to co-create intervention content with a stakeholder community of practice. Development processes were mapped to core elements of the Medical Research Council (MRC) framework for developing and evaluating complex interventions.

Results

The program covers five broad areas: (i) promoting self-care techniques among line managers; (ii) designing work to prevent work-related stress; (iii) management competencies to prevent and reduce stress; (iv) having conversations with employees about mental health; (v) building a psychologically safe work environment. Pilot and usability testing (n = 37 surveys) aligned with the Technology Acceptance Model (TAM) demonstrated that MMW was perceived to be useful, relevant, and easy to use by managers across sectors, organization types and sizes. We identified positive impacts on manager attitudes and behavioural intentions related to preventing mental ill-health and promoting good mental well-being at work.

Conclusions

MMW is a digital training programme for line managers that has been co-created using rigorous development processes and aims to support employers with primary prevention in mental health. The next step is to explore the feasibility and acceptability of this intervention with line managers in diverse employment settings.

Key messages

Mixed-methods process evaluation of a residence-based SARS-CoV-2 testing participation pilot on a UK university campus during the COVID-19 pandemic

BACKGROUND

Regular testing for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is an important strategy for controlling virus outbreaks on university campuses during the COVID-19 pandemic but testing participation rates can be low. The Residence-Based Testing Participation Pilot (RB-TPP) was a novel intervention implemented at two student residences on a large UK university campus over 4 weeks. The aim of the pilot was to increase the frequency of asymptomatic SARS-CoV-2 saliva testing onsite. This process evaluation aimed to determine whether RB-TPP was implemented as planned and identify implementation barriers and facilitators.

METHODS

A mixed-methods process evaluation was conducted alongside the RB-TPP. Evaluation participants were students (opting in, or out of RB-TPP) and staff with a role in service provision or student support. Monitoring data were collected from the intervention delivery team and meeting records. Data were collected from students via online survey (n = 152) and seven focus groups (n = 30), and from staff via individual interviews (n = 13). Quantitative data were analysed descriptively and qualitative data thematically. Barriers and facilitators to implementation were mapped to the 'Capability, Opportunity, Motivation-Behaviour' (COM-B) behaviour change framework.

RESULTS

Four hundred sixty-four students opted to participate in RB-TPP (98% of students living onsite). RB-TPP was implemented broadly as planned but relaxed social distancing was terminated early due to concerns relating to national escalation of the COVID-19 Delta variant, albeit testing continued. Most students (97.9%) perceived the period of relaxed social distancing within residences positively. The majority engaged in asymptomatic testing (88%); 46% (52% of testers) were fully compliant with pre-determined testing frequency. Implementation was facilitated by convenience and efficiency of testing, and reduction in the negative impacts of isolation through opportunities for students to socialise. Main barriers to implementation were perceived mixed-messages about the rules, ambivalent attitudes, and lack of adherence to COVID-19 protective measures in the minority.

CONCLUSIONS

This process evaluation identifies factors that help or hinder the success of university residence-based outbreak prevention and management strategies. RB-TPP led to increased rates of SARS-CoV-2 testing participation among students in university residences. Perceived normalisation of university life significantly enhanced student mental wellbeing. The complexity and challenge generated by multiple lines of communication and rapid adaptions to a changing pandemic context was evident.

TRIAL REGISTRATION NUMBER

UKAS 307727-02-01; Pre-results.

CLINICALTRIALS

gov Identifier: NCT05045989 ; post-results (first posted, 16/09/21).

ETHICAL APPROVAL

Faculty of Medicine & Health Sciences Research Ethics Committee, University of Nottingham (Ref: FMHS 96-0920).

Does 4D transperineal ultrasound have additional value over 2D transperineal ultrasound for diagnosing posterior pelvic floor disorders in women with obstructed defecation syndrome?

OBJECTIVE

To establish the diagnostic test accuracy of two-dimensional (2D) and four-dimensional (4D) transperineal ultrasound (TPUS) for diagnosis of posterior pelvic floor disorders in women with obstructed defecation syndrome (ODS), in order to assess if 4D ultrasound imaging provides additional value.

METHODS

This was a prospective cohort study of 121 consecutive women with ODS. Symptoms of ODS and pelvic organ prolapse on clinical examination were assessed using validated methods. All women underwent both 2D- and 4D-TPUS. Imaging analysis was performed by two blinded observers. Posterior pelvic floor disorders were dichotomized into presence or absence, according to predefined cut-off values. In the absence of a reference standard, a composite reference standard was created from a combination of results of evacuation proctography, magnetic resonance imaging and endovaginal ultrasound. Primary outcome measures were diagnostic test characteristics of 2D- and 4D-TPUS for rectocele, enterocele, intussusception and anismus. Secondary outcome measures were interobserver agreement, agreement between the two imaging techniques, and association of severity of ODS symptoms and degree of posterior vaginal wall prolapse with conditions observed on imaging.

RESULTS

For diagnosis of all four posterior pelvic floor disorders, there was no difference in sensitivity or specificity between 2D- and 4D-TPUS (P = 0.131-1.000). Good agreement between 2D- and 4D-TPUS was found for diagnosis of rectocele (κ = 0.675) and moderate agreement for diagnoses of enterocele, intussusception and anismus (κ = 0.465-0.545). There was no difference in rectocele depth measurements between the techniques (19.9 mm for 2D vs 19.0 mm for 4D, P = 0.802). Interobserver agreement was comparable for both techniques, although 2D-TPUS had excellent interobserver agreement for diagnosis of enterocele and rectocele depth measurements, while this was only moderate and good, respectively, for 4D-TPUS. Diagnoses of rectocele and enterocele on both 2D- and 4D-TPUS were significantly associated with degree of posterior vaginal wall prolapse on clinical examination (odds ratio (OR) = 1.89-2.72). The conditions observed using either imaging technique were not associated with severity of ODS symptoms (OR = 0.82-1.13).

CONCLUSIONS

There is no evidence of superiority of 4D ultrasound acquisition to dynamic 2D ultrasound acquisition for the diagnosis of posterior pelvic floor disorders. 2D- and 4D-TPUS could be used interchangeably to screen women with symptoms of ODS. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Effectiveness of cognitive-behavioural therapy on glycaemic control and psychological outcomes in adults with diabetes mellitus: a systematic review and meta-analysis of randomized controlled trials

AIM

Diabetes is a chronic progressive condition presenting physical, social and psychological challenges that increase the risk of comorbid mental health problems. Cognitive-behavioural therapy (CBT) is effective in treating a variety of psychological disorders, and may potentially improve glycaemic control and psychological outcomes in diabetes. This systematic review and meta-analysis aims to establish the effectiveness of CBT on glycaemic control and comorbid diabetes-related distress, depression, anxiety and quality of life in the short, medium and longer term among adults with diabetes.

METHOD

An electronic search was conducted in PubMed, Embase, MEDLINE, PsycINFO, CINAHL, Web of Knowledge, Cochrane Central Register of Controlled Trials and references in reviews. Twelve randomized controlled trials (RCTs) were identified that evaluated the effectiveness of CBT on at least one of: glycaemic control, diabetes-related distress, anxiety, depression or quality of life in adults with Type 1 or Type 2 diabetes. The Cochrane Risk of Bias Tool and Review Manager version 5.3 were used for risk of bias assessment and meta-analysis, respectively.

RESULTS

CBT is effective in reducing short-term and medium-term glycaemic control, although no significant effect was found for long-term glycaemic control. CBT improved short- and medium-term anxiety and depression, and long-term depression. Mixed results were found for diabetes-related distress and quality of life.

CONCLUSION

CBT is beneficial in improving depression for adults with diabetes. It may have benefits for improving glycaemic control and other aspects of psychological health, although the findings are inconclusive.

Developing a mHealth intervention to promote uptake of HIV testing among African communities in the UK: a qualitative study

BACKGROUND

HIV-related mHealth interventions have demonstrable efficacy in supporting treatment adherence, although the evidence base for promoting HIV testing is inconclusive. Progress is constrained by a limited understanding of processes used to develop interventions and weak theoretical underpinnings. This paper describes a research project that informed the development of a theory-based mHealth intervention to promote HIV testing amongst city-dwelling African communities in the conditions.

METHODS

A community-based participatory social marketing design was adopted. Six focus groups (48 participants in total) were undertaken and analysed using a thematic framework approach, guided by constructs from the Health Belief Model. Key themes were incorporated into a set of text messages, which were pre-tested and refined.

RESULTS

The focus groups identified a relatively low perception of HIV risk, especially amongst men, and a range of social and structural barriers to HIV testing. In terms of self-efficacy around HIV testing, respondents highlighted a need for communities and professionals to work together to build a context of trust through co-location in, and co-involvement of, local communities which would in turn enhance confidence in, and support for, HIV testing activities of health professionals. Findings suggested that messages should: avoid an exclusive focus on HIV, be tailored and personalised, come from a trusted source, allay fears and focus on support and health benefits.

CONCLUSIONS

HIV remains a stigmatized and de-prioritized issue within African migrant communities in the UK, posing barriers to HIV testing initiatives. A community-based participatory social marketing design can be successfully used to develop a culturally appropriate text messaging HIV intervention. Key challenges involved turning community research recommendations into brief text messages of only 160 characters. The intervention needs to be evaluated in a randomized control trial. Future research should explore the application of the processes and methodologies described in this paper within other communities.

Physical activity interventions in children and young people with Type 1 diabetes mellitus: a systematic review with meta-analysis

AIMS

To synthesize evidence from randomized and non-randomized studies of physical activity interventions in children and young people with Type 1 diabetes so as to explore clinically relevant health outcomes and inform the promotion of physical activity.

METHOD

We conducted a search of CINAHL Plus, the Cochrane Library, EMBASE, MEDLINE, PsycINFO, SCOPUS, SportDiscus and Web of Science between October and December 2012. Eligible articles included subjects aged ≤18 years with Type 1 diabetes and a physical activity intervention that was more than a one-off activity session. Physiological, psychological, behavioural or social outcomes were those of interest.

RESULTS

A total of 26 articles (10 randomized and 16 non-randomized studies), published in the period 1964-2012, were reviewed. Although there was heterogeneity in study design, methods and reporting, 23 articles reported at least one significant beneficial health outcome at follow-up. Meta-analyses of these studies showed potential benefits of physical activity on HbA1c (11 studies, 345 participants, standardized mean difference -0.52, 95% CI -0.97 to -0.07; P = 0.02), BMI (four studies, 195 participants, standardized mean difference -0.41, 95% CI -0.70 to -0.12; P = 0.006) and triglycerides (five studies, 206 participants, standardized mean difference -0.70, 95% CI -1.25 to -0.14; P = 0.01).The largest effect size was for total cholesterol (five studies, 206 participants, standardized mean difference -0.91, 95% CI -1.66 to -0.17; P = 0.02).

CONCLUSIONS

Physical activity is important for diabetes management and has the potential to delay cardiovascular disease, but there is a lack of studies that are underpinned by psychological behaviour change theory, promoting sustained physical activity and exploring psychological outcomes. There remains a lack of knowledge of how to promote physical activity in people with Type 1 diabetes.

Perfusion CT to assess angiogenesis in colon cancer: technical limitations and practical challenges

OBJECTIVE

Perfusion CT may have the potential to quantify the degree of angiogenesis of solid tumours in vivo. This study aims to identify the practical and technical challenges inherent to the technique, and evaluate its feasibility in colorectal tumours.

METHODS

51 patients from 2 institutions prospectively underwent a single perfusion CT on 2 different multidetector scanners. The patients were advised to breath-hold as long as possible, followed by shallow breathing, and were given intravenous buscopan to reduce movement. Numerous steps were explored to identify the challenges.

RESULTS

43 patients successfully completed the perfusion CT as per protocol. Inability to detect the tumour (n=3), misplacement of dynamic sequence co-ordinates (n=2), failure of contrast injection (n=2) and displacement of tumour (n=1) were the reasons for failure. In 14 cases excessive respiratory motion displaced the tumour out of the scanning field along the temporal sequence, leading to erroneous data capture. In nine patients, minor displacements of the tumour were corrected by repositioning the region of interest (ROI) to its original position after reviewing each dynamic sequence slice. In 20 patients the tumour was stable, and data captured from the ROI were representative, and could have been analysed by commercially available Body Tumor Perfusion 3.0® software (GE Healthcare, Waukesha, WI). Hence all data were manually analysed by MATLAB® processing software (MathWorks, Cambridge, UK).

CONCLUSION

Perfusion CT in tumours susceptible to motion during acquisition makes accurate data capture challenging and requires meticulous attention to detail. Motion correction software is essential if perfusion CT is to be used routinely in colorectal cancer.

Relevance of magnetic resonance imaging-detected pelvic sidewall lymph node involvement in rectal cancer

BACKGROUND

The significance of magnetic resonance imaging (MRI)-suspected pelvic sidewall (PSW) lymph node involvement in rectal cancer is uncertain.

METHODS

Magnetic resonance images were reviewed retrospectively by specialist gastrointestinal radiologists for the presence of suspicious PSW nodes. Scans and outcome data were from patients with biopsy-proven rectal cancer and a minimum of 5 years' follow-up in the Magnetic Resonance Imaging and Rectal Cancer European Equivalence Study. Overall disease-free survival (DFS) was analysed using the Kaplan-Meier product-limit method and stratified according to preoperative therapy. Binary logistic regression was used to match patients for propensity of clinical and staging characteristics, and further survival analysis was carried out to determine associations between suspicious PSW nodes on MRI and survival outcomes.

RESULTS

Of 325 patients, 38 (11·7 per cent) had MRI-identified suspicious PSW nodes on baseline scans. Such nodes were associated with poor outcomes. Five-year DFS was 42 and 70·7 per cent respectively for patients with, and without suspicious PSW nodes (P < 0·001). Among patients undergoing primary surgery, MRI-suspected PSW node involvement was associated with worse 5-year DFS (31 versus 76·3 per cent; P = 0·001), but the presence of suspicious nodes had no impact on survival among patients who received preoperative therapy. After propensity matching for clinical and tumour characteristics, the presence of suspicious PSW nodes on MRI was not an independent prognostic variable.

CONCLUSION

Patients with suspicious PSW nodes on MRI had significantly worse DFS that appeared improved with the use of preoperative therapy. These nodes were associated with adverse features of the primary tumour and were not an independent prognostic factor.

Accuracy of multidetector computed tomography in identifying poor prognostic factors in colonic cancer

BACKGROUND

Recent neoadjuvant strategies for high-risk colonic tumours have renewed interest in accurate preoperative staging. The aim of this study was to validate prospectively the accuracy of multidetector computed tomography (MDCT) in stratifying patients into good and poor prognostic groups in a multicentre setting.

METHODS

Staging MDCT scans of 84 patients with colonic cancer were reviewed by two independent radiologists and stratified into low-risk (T1/T2 and T3 with extramural tumour depth (EMD) of less than 5 mm) and high-risk (T3 with EMD of at least 5 mm and T4) tumours. Nodal status and extramural venous invasion (EMVI) were also assessed.

RESULTS

The accuracy, sensitivity, specificity and positive predictive value of stratification by CT compared with histological examination was 74 (95 per cent confidence interval 64 to 82), 78 (65 to 87), 67 (49 to 81) and 81 (68 to 89) per cent respectively. Accuracy for detecting malignant lymph nodes and EMVI was 58 and 70 per cent respectively. The agreement for predicting prognostic stratification was moderate (kappa = 0.54).

CONCLUSION

As the ability of CT to identify node status is poor, the depth of tumour invasion beyond the muscularis propria is the most accurate way to identify patients with a poor prognosis who may be suitable for neoadjuvant treatment.

The price is right: making workplace wellness financially sustainable

Purpose

The public health argument for developing and maintaining workplace wellness programmes in organisations is well‐documented, particularly within the healthcare sector which aims to “set the example” for workplace health. However, workplace wellness also makes good business sense, since it is established that investing in employee health can reduce absenteeism, improve job satisfaction and productivity and enhance corporate image. Organisations often place workplace wellness low in their priorities. The purpose of this paper is to present the case for an initial resource investment and top‐level support to pump‐prime a financially sustainable, and even profitable, programme.

Design/methodology/approach

A discussion is presented based on academic literature and practical applications from the authors' experiences in practice.

Findings

The authors use their own in‐house scheme, “Q‐active” as a case example based in an NHS Trust setting, to demonstrate how such schemes can be developed and successfully implemented and maintained in practice. The paper presents the use of the Business Healthcheck Tool for developing a business case for such schemes.

Originality/value

Workplace wellness schemes are financially viable and can become a vital part of a large organisations' infrastructure embedded within policies and internal “health culture”.

Parental involvement in paediatric cancer treatment decisions

This study investigated parents' information needs and involvement in decision-making processes affecting the care of children diagnosed with cancer. Interviews and questionnaires were used to assess parental satisfaction in 50 mothers and 16 fathers responsible for 58 children in an English Paediatric Oncology Unit. Parents reported that doctors contributed almost twice as much to the decision-making process as they did, but parental satisfaction was positively correlated with the amount of information provided when giving informed consent. Satisfaction about their involvement in this process relied heavily upon the level of support received from others. Parents consenting to their child's involvement in non-randomised trials perceived themselves to be under greater pressure from others during the decision-making process while those whose children were further along the treatment trajectory were more uncertain about decisions previously made. Findings indicate that the accessibility, support, information and degree of control afforded to parents by healthcare professionals impacts upon their satisfaction with both the decision-making process and their confidence in the decisions thus made. Information and support tailored to parents' specific needs may therefore enhance satisfaction with clinical decision making and reassure parents about decisions made in the long-term interest of their child's health.

How effective are physical activity interventions for alleviating depressive symptoms in older people? A systematic review

BACKGROUND

The benefits of physical exercise in reducing clinically defined depression in the general population have been established, although a review of the evidence for older adults is needed.

OBJECTIVES

To assess the efficacy of physical exercise for the treatment of depressive symptoms in older adults (>60 years).

DATA SOURCES

We searched: MEDLINE (1966-May 2008); EMBASE (1980-May 2008); Cumulative Index to Nursing & Allied Health Literature (CINAHL; 1982-May 2008); PsycINFO (1966-May 2008), The Cochrane Library (Issue 2, 2008), and National Research Register (NRR; Issue 2, 2008).

REVIEW METHODS

Randomized controlled trials and quasi-experimental studies of physical exercise interventions for depression were included where 80% or more of participants were >60 years. Abstracts were assessed to determine whether they met specified inclusion criteria. Primary analysis focused on the prevalence of diagnosable depressive disorder following intervention. Secondary outcome was depression or mood scores on standardized scales.

RESULTS

Eleven randomized controlled trials with a total of 641 participants were included in the review. Short-term positive outcome for depression or depressive symptoms was found in nine studies, although the mode, intensity and duration of intervention varied across studies. Medium- to long-term effects of intervention were less clear.

CONCLUSION

Physical exercise programmes obtain clinically relevant outcomes in the treatment of depressive symptoms in depressed older people. Exercise, though not appropriate for all in this population, may improve mood in this group. Further research is needed to establish medium- to long-term effects and cost-effectiveness.

Exercise intervention in brain injury: a pilot randomized study of Tai Chi Qigong

OBJECTIVE

To examine the effects of a brief Tai Chi Chuan Qigong ('Qigong') exercise intervention on individuals with traumatic brain injury.

DESIGN

A single-centre randomized controlled trial pilot study.

SETTING

A registered charity day centre in the community.

SUBJECTS

Twenty individuals with traumatic brain injury.

INTERVENTION

Intervention participants attended a Qigong exercise session for one hour per week over eight weeks. Control participants engaged in non-exercise-based social and leisure activities for the same intervention period.

MEASURES

Outcome was assessed at baseline and post intervention using the General Health Questionnaire-12, the Physical Self-Description Questionnaire and the Social Support for Exercise Habits Scale, to measure perceived mood, self-esteem, flexibility, coordination, physical activity and social support.

RESULTS

Groups were comparable at baseline. After the intervention, mood was improved in the exercise group when compared with controls (U = 22.0, P =0.02). Improvements in self-esteem (Z = 2.397, P =0.01) and mood (Z = -2.032, P =0.04) across the study period were also evident in the exercise group only. There were no significant differences in physical functioning between groups. In view of the sample size, these findings are inconclusive.

CONCLUSIONS

This study provides preliminary evidence that a brief Qigong exercise intervention programme may improve mood and self-esteem for individuals with traumatic brain injury. This needs to be tested in a large-scale randomized trial.

Magnetic resonance imaging of abdominal adiposity in a large cohort of British children

OBJECTIVE

To describe abdominal adipose tissue distribution in a large sample of contemporary British children; to determine the influence of gender, stage of maturation and body mass index (BMI) on abdominal adipose tissue distribution; and to compare the ability of BMI and waist circumference to predict abdominal adipose tissue.

SUBJECTS AND METHODS

A total of 74 boys (mean age 13.4+/-0.4 years) and 96 girls (mean age 13.5+/-0.5 years) were selected from volunteer children enrolled in the Avon Longitudinal Study of Parents and Children (ALSPAC). Height, weight and waist circumference were measured and BMI calculated. Stage of sexual maturation was available for 113 children using a self-report questionnaire based on Tanner's criteria. Magnetic resonance imaging was used to assess subcutaneous abdominal adipose tissue (SAAT) and intra-abdominal adipose tissue (IAAT) volumes and patterning.

RESULTS

Boys had lower levels of IAAT (P=0.036) and SAAT (P=0.003) than girls. IAAT and SAAT were higher in overweight and obese boys and girls when compared with normal weight children (P<0.0001). This pattern was also reflected in waist circumference groups. Boys had higher IAAT/SAAT ratios than girls, indicating proportionately more adipose tissue deposited intra-abdominally (P=0.002). However, both boys and girls deposited less than 10% of their abdominal fat as internal adipose tissue. WC predicted 67.4% of the variance in IAAT (P<0.001), and BMI predicted 84.8% of the variance in SAAT (P<0.001). However, BMI as the best single predictor explained only 8.4% of the variance in the IAAT/SAAT ratio (P<0.001).

CONCLUSIONS

At this age and stage of sexual maturation, the amount of IAAT remains relatively small. WC and BMI offer a feasible alternative to the MRI estimation of IAAT and SAAT, respectively, in a population-based sample of boys and girls. International Journal of Obesity (2008) 32, 91-99; doi:10.1038/sj.ijo.0803780; published online 27 November 2007.

Brain donation for research: who donates and why?

Understanding what influences people to donate or not donate body organs is critical for the future of transplant surgery and medical research. Are people involved with a brain donor program for research influenced by the same factors, and are they also donors for organ transplantation? Using web-based technology, people involved in an Australian brain donation program (for research) were asked to complete a questionnaire designed to elicit demographic information, motivational factors and information about involvement in organ transplantation programs. The response rate was 82%. The majority of people involved in the program are young, well-educated Australian females. Seventy-eight percent are involved in other organ and tissue donation programs. People involved in the 'Using our Brains' program are the same group as those who are organ and tissue donors. An improvement in the overall donation rate might be possible if the resources of the research and transplant organisations were combined.

Distribution of mesorectal lymph nodes in rectal cancer: in vivo MR imaging compared with histopathological examination. Initial observations

The aim of this work was to determine the distribution of mesorectal lymph nodes using T2-weighted magnetic resonance (MR) imaging compared with histopathological findings in patients with rectal carcinoma. Sixteen patients with rectal carcinoma undergoing primary surgery without pre-operative neoadjuvant treatment were evaluated using 3-mm axial T2-weighted MR imaging. The position of each visible mesorectal node on imaging was localised by measuring its minimum distance from the mesorectal fascia (d(m)), its minimum distance from the rectal wall (d(r)) and its distance from the distal tumour margin (d(v)). Independent assessment of d(m), d(r) and d(v) was made at histopathological examination. Eighty-five mesorectal nodes on in vivo MR imaging were matched to histopathological findings. On imaging, 67/85 mesorectal nodes were found at the level of the tumour and 84/85 were identified at or within 5 cm proximal to the tumour. Only one out of 85 nodes was seen below the inferior tumour margin. The mean difference of d(m) and d(r) obtained on in vivo MR imaging and histopathological examination was 0.7 mm (95% confidence interval, CI, -0.12 to 1.42 mm) and -1.1 mm (95% CI -2.29 to 0.14 mm), respectively. Almost all mesorectal nodes visible on MR imaging were found at the level of tumour or within 5 cm proximal to the tumour. This has implications for the planning of MR imaging and the level of mesorectal transection at surgery.

Evaluation of cognitive assessment in stroke rehabilitation

OBJECTIVE

To assess the effect of cognitive assessment on the functional outcome of stroke patients and quality of life for both patients and their carers.

DESIGN

A multicentre, single-blind, randomized controlled trial.

SETTING AND PARTICIPANTS

Two hundred and twenty-eight stroke patients were recruited from hospital wards in three UK centres.

INTERVENTIONS

Patients were screened for cognitive impairment and randomly allocated to either routine care (116 patients) or routine care plus a detailed cognitive assessment (112 patients).

MAIN OUTCOME MEASURES

Outcome was assessed three and six months after recruitment by an independent assessor blind to the intervention on Extended ADL, Cognitive Failures Questionnaire, General Health Questionnaire-28 for patients and carers and Carer Strain Index.

RESULTS

There was no significant difference between the two groups in patients' functional outcome, perceived cognitive ability, level of psychological distress or satisfaction with care. There was a trend for the assessment group to have lower levels of carer strain (p = 0.06).

CONCLUSIONS

The provision of information about cognitive assessment in stroke rehabilitation may decrease carer strain.

The additive effect of neurotransmitter genes in pathological gambling

As access to gambling increases there is a corresponding increase in the frequency of addiction to gambling, known as pathological gambling. Studies have shown that a number of different neurotransmitters are affected in pathological gamblers and that genetic factors play a role. Polymorphisms at 31 different genes involved in dopamine, serotonin, norepinephrine, GABA and neurotransmitters were genotyped in 139 pathological gamblers and 139 age, race, and sex-matched controls. Multivariate regression analysis was used with the presence or absence of pathological gambling as the dependent variable, and the 31 coded genes as the independent variables. Fifteen genes were included in the regression equation. The most significant were the DRD2, DRD4, DAT1, TPH, ADRA2C, NMDA1, and PS1 genes. The r(2) or fraction of the variance was less than 0.02 for most genes. Dopamine, serotonin, and norepinephrine genes contributed approximately equally to the risk for pathological gambling. These results indicate that genes influencing a range of brain functions play an additive role as risk factors for pathological gambling. Multi-gene profiles in specific individuals may be of assistance in choosing the appropriate treatment.

Strain and psychological distress among informal supporters of reflex sympathetic dystrophy patients

PURPOSE

A study to investigate strain and psychiatric morbidity in informal caregivers of patients with reflex sympathetic dystrophy (RSD).

METHOD

Fifty one caregivers of RSD patients in the community, identified from a support group in Leeds or a conference in Eastbourne completed standardized questionnaire measures of strain, mood, adjustment, positive and negative affectivity and social support.

RESULTS

Fifty seven percent of caregivers experienced significant strain and 53% had poor mood. Adjusting for age and gender, partial correlations showed that the experience of strain in caregivers was associated with poor mood, poor psychological adjustment to the patient's illness, high levels of negative affectivity, increased handicap and disability of the patient.

CONCLUSIONS

A high proportion of caregivers of RSD patients experience poor mood and significant levels of strain. Caregivers who are poorly adjusted to the illness experience the most strain. These findings suggest a need for intervention to alleviate the negative impacts of caregiving and facilitate adjustment.

A multivariate analysis of 59 candidate genes in personality traits: the temperament and character inventory

Cloninger (Cloninger CR. Neurogenetic adaptive mechanisms in alcoholism. Science 1987: 236: 410-416) proposed three basic personality dimensions for temperament: novelty seeking, harm avoidance, and reward dependence. He suggested that novelty seeking primarily utilized dopamine pathways, harm avoidance utilized serotonin pathways, and reward dependence utilized norepinephrine pathways. Subsequently, one additional temperament dimension (persistence) and three character dimensions (cooperativeness, self-directedness, and self-transcendence) were added to form the temperament and character inventory (TCI). We have utilized a previously described multivariate analysis technique (Comings DE, Gade-Andavolu R, Gonzalez N et al. Comparison of the role of dopamine, serotonin, and noradrenergic genes in ADHD, ODD and conduct disorder. Multivariate regression analysis of 20 genes. Clin Genet 2000: 57: 178-196; Comings DD, Gade-Andavolu R, Gonzalez N et al. Multivariate analysis of associations of 42 genes in ADHD, ODD and conduct disorder. Clin Genet 2000: in press) to examine the relative role of 59 candidate genes in the seven TCI traits and test the hypothesis that specific personality traits were associated with specific genes. While there was some tendency for this to be true, a more important trend was the involvement of different ratios of functionally related groups of genes, and of different genotypes of the same genes, for different traits.

Multivariate analysis of associations of 42 genes in ADHD, ODD and conduct disorder

In a previous study (Comings DE et al. Comparison of the role of dopamine, serotonin, and noradrenergic genes in ADHD, ODD and conduct disorder. Multivariate regression analysis of 20 genes. Clin Genet 2000: 57: 178-196) we examined the role of 20 dopamine, serotonin and norepinephrine genes in attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD), using a multivariate analysis of associations (MAA) technique. We have now brought the total number of genes examined to 42 by adding an additional 22 candidate genes. These results indicate that even with the inclusion of these additional genes the noradrenergic genes still played a greater role in ADHD than any other group. Six other neurotransmitter genes were included in the regression equation - cholinergic, nicotinic, alpha 4 receptor (CHNRA4), adenosine A2A receptor (ADOA2A), nitric oxide synthase (NOS3), NMDAR1, GRIN2B, and GABRB3. In contrast to ADHD and ODD, CD preferentially utilized hormone and neuropeptide genes These included CCK, CYP19 (aromatase cytochrome P-450), ESR1, and INS (p = 0.005). This is consistent with our prior studies indicating a role of the androgen receptor (AR) gene in a range of externalizing behavors. We propose that the MAA technique, by focusing on the additive effect of multiple genes and on the cummulative effect of functionally related groups of genes, provides a powerful approach to the dissection of the genetic basis of polygenic disorders.

Factors associated with strain in co-resident spouses of patients following stroke

OBJECTIVE

To identify the factors associated with carer strain following stroke.

DESIGN

Co-resident spouses of stroke patients were sent questionnaire measures of their perceptions of strain, stress, mood, handicap, adjustment, social support, life satisfaction and personality, and patient's mood and independence in activities of daily living.

SETTING

Stroke spouses were identified from the stroke register at City Hospital, Nottingham.

RESULTS

In a sample of 222 carers, 37% had significant strain. Strain was highly correlated with negative affectivity on the Positive and Negative Affectivity Scale, carer mood on the General Health Questionnaire-12 (GHQ-12) and carer's perceptions of patient's independence in activities of daily living on the Extended Activities of Daily Living Scale (EADL). Logistic regression analysis of 96 of these carers supported the correlations and showed three factors, carer GHQ-12, patient EADL and negative affectivity, were independently associated with carer strain.

CONCLUSION

The relationship between these factors and strain needs to be tested prospectively. Early identification of carers who may be at risk of strain later on will enable services to be targeted at prevention rather than cure.

Association of the neutral endopeptidase (MME) gene with anxiety

Enkephalins have been implicated in the regulation of mood, anxiety, reward, euphoria and pain. One of the major enzymes for enkephalin degradation is neutral endopeptidase [enkephalinase, membrane metalloendopeptidase (MME)]. We identified a dinucleotide polymorphism in the 5' region of the MME gene. Subjects were placed into three genotypes, 3/3, 3/x, and x/x since the 3 allele was the most common of the six alleles. Using one-way analysis of variance, we examined the association of these genotypes with the mean SCL-90 scores for anxiety, depression, obsessive-compulsive and phobic anxiety symptoms in 120 Caucasian males from an addiction treatment unit. There was a significant association between the MME genotypes and the SCL-90 scores for phobic anxiety, obsessive-compulsive and anxiety at a Bonferroni corrected alpha value of 0.0125. These results support a role of genetic variants of enkephalin metabolism in anxiety.

Comparison of the role of dopamine, serotonin, and noradrenaline genes in ADHD, ODD and conduct disorder: multivariate regression analysis of 20 genes

The present study is based on the proposal that complex disorders resulting from the effects of multiple genes are best investigated by simultaneously examining multiple candidate genes in the same group of subjects. We have examined the effect of 20 genes for dopamine, serotonin, and noradrenergic metabolism on a quantitative score for attention deficit hyperactivity disorder (ADHD) in 336 unrelated Caucasian subjects. The genotypes of each gene were assigned a score from 0 to 2, based on results from the literature or studies in an independent set of subjects (literature-based scoring), or results based on analysis of variance for the sample (optimized gene scoring). Multivariate linear regression analysis with backward elimination was used to determine which genes contributed most to the phenotype for both coding methods. For optimized gene scoring, three dopamine genes contributed to 2.3% of the variance, p = 0.052; three serotonin genes contributed to 3%, p = 0.015; and six adrenergic genes contributed to 6.9%, p = 0.0006. For all genes combined, 12 genes contributed to 11.6% of the variance, p = 0.0001. These results indicate that the adrenergic genes play a greater role in ADHD than either the dopaminergic or serotonergic genes combined. The results using literature-based gene scoring were similar. An examination of two additional comorbid phenotypes, conduct disorder and oppositional defiant disorder (ODD), indicated they shared genes with ADHD. For ODD different genotypes of the same genes were often used. These results support the value of the simultaneous examination of multiple candidate genes.

The proenkephalin gene (PENK) and opioid dependence

We tested the hypothesis that the alleles at the (CA)n repeat of the proenkephalin gene (PENK) might be associated with opioid addiction in 31 non-Hispanic Caucasian subjects with opioid dependence (heroin), 89 ethnically matched subjects with substance dependence other than opioid dependence and 132 controls. Among the subjects with opioid dependence, 66% carried the > or = 81 bp allele compared with 40% of subjects with other types of substance abuse (chi2 = 11.31, p < 0.004) and 49% of controls (chi2 = 6.0, p < 0.015). These results are consistent with a role of the PENK gene in opioid dependence.

Additive effect of three noradrenergic genes (ADRA2a, ADRA2C, DBH) on attention-deficit hyperactivity disorder and learning disabilities in Tourette syndrome subjects

Halperin et al. (Halperin JM. Newcorn JH, Koda VH, Pick L, McKay KE, Knott P. Noradrenergic mechanisms in ADHD children with and without reading disabilities: a replication and extension. J Am Acad Child Adolesc Psychiatry 1997: 36: 1688 1696) reported a significant increase in plasma norepinephrine (NE) in attention-deficit hyperactivity disorder (ADHD) children with reading and other cognitive disabilities compared to ADHD children without learning disabilities (LD). We examined the hypothesis that ADHD + LD was associated with NE dysfunction at a molecular genetic level by testing for associations and additive effects between polymorphisms at three noradrenergic genes the adrenergic alpha2A receptor (ADRA2A), adrenergic alpha2C receptor (ADRA2C), and dopamine beta-hydroxylase (DBH) genes. A total of 336 subjects consisting of 274 individuals with Tourette syndrome (TS) and 62 normal controls were genotyped. Regression analysis showed a significant correlation between scores for ADHD, a history of LD, and poor grade-school academic performance that was greatest for the additive effect of all three genes. Combined, these three genes accounted for 3.5% of the variance of the ADHD score (p = 0.0005). There was a significant increase in the number of variant NE genes progressing from subjects without ADHD (A-) or learning disorders (LD-) to A + LD - to A - LD + to A + LD + (p = 0.0017), but no comparable effect for dopamine genes. These data support an association between NE genes and ADHD, especially in ADHD + LD subjects.

The use of rectosigmoid stents in the management of acute large bowel obstruction

The management of the acutely obstructed colon is controversial. Initial decompression of the bowel is still favoured by many surgeons, but the resulting colostomy has significant morbidity and mortality. Instead, stenting of the obstruction would permit defunctioning of the bowel, without the need for surgery and stoma formation. In this study we present our experience of the use of stents in the initial management of six patients with acute and sub-acute large bowel obstruction.

Association between the gamma-aminobutyric acid A3 receptor gene and multiple sclerosis

BACKGROUND

In a prior study we observed an association between the dopamine D2 receptor gene (DRD2) and the age of onset and/or diagnosis of multiple sclerosis (MS). We hypothesized that this effect was mediated through the dopaminergic control of the release of prolactin, a modulator of immune response. Since gamma-aminobutyric acid also modulates the release of prolactin, we examined the possible association between alleles of the GABRA3 (gamma-aminobutyric acid A3 receptor) gene and MS.

DESIGN

We examined the GABRA3 alleles of 189 subjects with MS who died of their disease. They were divided into test group 1 (n=64) and retest group 2 (n=56). Each group had a separate set of controls (group 1, n=109; group 2, n=430). All subjects were white. All were tested at a dinucleotide cytosine-adenosine repeat polymorphism with 6 alleles representing 11 to 16 repeats.

RESULTS

In the first group there was a significant difference in the frequency of the GABRA3 alleles (P<.002), with the most notable difference being an increase in the frequency of the 16-repeat allele in subjects with MS and a relative decrease in the other alleles. In the replication group there was again a significant difference in the distribution of the GABRA3 alleles (P<.001), and again the greatest difference was an increase in the frequency of the 16-repeat allele in subjects with MS. For both groups combined, a significant difference in the frequency of the 16-repeat allele was noted (chi2=46.30; P<.001).

CONCLUSIONS

These results suggest the GABRA3 gene may be a risk factor for MS. As with the DRD2 gene, the effect may be mediated through its regulation of prolactin release.

Correlation of length of VNTR alleles at the X-linked MAOA gene and phenotypic effect in Tourette syndrome and drug abuse

Abnormalities in monoamine oxidase (MAO) levels have been implicated in a wide range of psychiatric disorders. We have examined a VNTR polymorphism at the X-linked MAOA gene to test two hypotheses: (1) Do variants of the MAOA gene play a role in any of the behavioral disorders associated with Tourette syndrome or drug abuse? (2) If so, is there any correlation between the length of the alleles and the phenotypic effect? We examined two independent groups: 375 TS patients, relatives and controls, and 280 substance abusers and controls. The alleles were divided into four groups of increasing size. There was a significant association between the MAOA gene and behavioral phenotypes in both groups, and in both the longest alleles were associated with the greatest phenotypic effect. The strongest effect was for the diagnosis of drug dependence (P=0.00003). The VNTR allele groups were in significant linkage disequilibrium with the Fnu4H1 polymorphism previously shown to be associated with MAO-A activity. While these results are consistent with the possibility that different-sized alleles of the short-repeat polymorphisms themselves may play a role in gene regulation, further studies directly linking these alleles with enzyme levels need to be done.

A prospective audit of the usefulness of evacuating proctography

Fifty-nine evacuating proctograms were performed over a 4 month period. We sought to identify how useful this technique is in diagnosing the cause of various anorectal symptoms and indicating which treatment option may be beneficial to the patient. The main reasons for referral were faecal soiling (60%) and obstructed defaecation (47%). Of the proctograms, 90% revealed some pathology. The most common abnormalities detected were rectocele (56%), rectal intussusception (39%), enterocele (19%) and rectal prolapse (12%). Of the patients, 45% were treated with an operation specific to the pathology detected on the proctogram; 29% did not require any active treatment and the remainder were managed with biofeedback conditioning or injection sclerotherapy. Evacuating proctography is of value in providing a diagnosis in patients with anorectal symptoms and thereby allowing specific treatment, operative or nonoperative, to be directed to the underlying pathology.