Severe maternal morbidity in Scotland

Using a cohort study design, we analysed 17 diagnoses and 9 interventions (including critical care admission) as a composite measure of severe maternal morbidity for pregnancies recorded over 14 years in Scotland. There were 762,918 pregnancies, of which 7947 (10 in 1000 pregnancies) recorded 9345 severe maternal morbidity events, 2802 episodes of puerperal sepsis being the most common (30%). Severe maternal morbidity incidence increased from 9 in 1000 pregnancies in 2012 to 17 in 1000 pregnancies in 2018, due in part to puerperal sepsis recording. The odds ratio (95%CI) for severe maternal morbidity was higher for: older women, for instance 1.22 (1.13-1.33) for women aged 35-39 years and 1.44 (1.27-1.63) for women aged > 40 years compared with those aged 25-29 years; obese women, for instance 1.13 (1.06-1.21) for BMI 30-40 kg.m-2 and 1.32 (1.15-1.51) for BMI > 40 kg.m-2 compared with BMI 18.5-24.9 kg.m-2 ; multiple pregnancy, 2.39 (2.09-2.74); and previous caesarean delivery, 1.52 (1.40-1.65). The median (IQR [range]) hospital stay was 3 (2-5 [1-8]) days with severe maternal morbidity and 2 (1-3 [1-5]) days without. Forty-one women died during pregnancy or up to 42 days after delivery, representing mortality rates per 100,000 pregnancies of about 365 with severe maternal morbidity and 1.6 without. There were 1449 women admitted to critical care, 807 (58%) for mechanical ventilation or support of at least two organs. We recorded an incidence of severe maternal morbidity higher than previously published, possibly because sepsis was coded inaccurately in our databases. Further research may determine the value of this composite measure of severe maternal morbidity.

Variation in clinical outcomes and process of care measures in community acquired pneumonia: a systematic review

Background

Variation in outcomes of patients with community acquired pneumonia (CAP) has been reported in some, but not all, studies. Although some variation is expected, unwarranted variation in healthcare impacts patient outcomes and equity of care. The aim of this systematic review was to: i) summarise current evidence on regional and inter-hospital variation in the clinical outcomes and process of care measures of patients hospitalised with CAP and ii) assess the strength of this evidence.

Methods

Databases were systematically searched from inception to February 2018 for relevant studies and data independently extracted by two investigators in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Included studies enrolled adults hospitalised with CAP and reported a measure of variation between two or more units in healthcare outcomes or process of care measures. Outcomes of interest were mortality, length of hospital stay (LOS) and re-admission rates. A structured synthesis of the studies was performed.

Results

Twenty-two studies were included in the analysis. The median number of units compared across studies was five (IQR 4–15). Evidence for variation in mortality between units was inconsistent; of eleven studies that performed statistical significance testing, five found significant variation. For LOS, of nine relevant studies, all found statistically significant variation. Four studies reported site of admission accounted for 1–24% of the total observed variation in LOS. A shorter LOS was not associated with increased mortality or readmission rates. For readmission, evidence was mixed; of seven studies, 4 found statistically significant variation. There was consistent evidence for variation in the use of intensive care, obtaining blood cultures on admission, receiving antibiotics within 8 h of admission and duration of intravenous antibiotics. Across all outcome measures, only one study accounted for natural variation between units in their analysis.

Conclusion

There is consistent evidence of moderate quality for significant variation in length of stay and process of care measures but not for in-patient mortality or hospital re-admission. Evidence linking variation in outcomes with variation in process of care measures was limited; where present no difference in mortality was detected despite POC variation. Adjustment for natural variation within studies was lacking; the proportion of observed variation due to chance is not quantified by existing evidence.

Cigarette smoking and the occurrence of influenza - Systematic review

OBJECTIVES

The association of current smoking with influenza infection is not widely recognised. The aim of this systematic review was to summarise published evidence and quantify the risk of influenza infection in tobacco smokers compared to non-smokers.

METHODS

We systematically searched MEDLINE, EMBASE, CINAHL, LILACS and Web of Science, from inception to 7 November 2017, to identify relevant randomised control trials, cohort and case-control studies. Study quality was assessed using the Newcastle-Ottawa Scale. We included studies defining influenza as a clinical syndrome and those using confirmatory microbiological tests. Pooled odds ratios (ORs) were estimated by using random effects model.

RESULTS

The mean quality score across the nine included studies (n = 40,685 participants) was 5.4 of 9 (SD 1.07). Current smokers were over 5 times more likely to develop laboratory-confirmed influenza than non-smokers (pooled OR 5.69 (95% CI 2.79-11.60), 3 studies). For studies reporting the occurrence of an influenza-like illness (ILI), current smokers were 34% more likely to develop ILI than non-smokers (pooled OR 1.34 (95% CI 1.13-1.59), 6 studies).

CONCLUSION

Current smokers have an increased risk of developing influenza compared to non-smokers. The association was strongest in studies examining cases with laboratory confirmed influenza.

Evaluating the use of exposure indicators in digital x-ray imaging system: Gauteng South Africa

INTRODUCTION

Exposure indicators (EIs) are the only indicator of correct exposure technique in digital x-ray imaging systems but the use of such indicators remains largely unexplored in a South African setting. With exposure creep in the digital radiography age being a worldwide phenomenon, the study investigated radiographers' familiarity and use of EIs, providing insight into current exposure technique practices in this setting.

METHODS

An explorative and descriptive quantitative study was conducted at 10 randomly selected radiography clinical training facilities in Gauteng, South Africa. The study used a questionnaire consisting of 26 questions based on familiarity with and use of EIs and radiographers' attitude to ionising radiation.

RESULTS

A response of rate of 49.3% was achieved. Results show a low number of respondents (54.3%) had a perfectly correct understanding of the exposure indicator (EI) and only 55.7% of respondents made correct use of the EI.

CONCLUSION

Observable lack of familiarity and use of the EI suggests that improvements could be made to the training radiographers receive on digital imaging systems. Moreover radiographers need to be vigilant against making decisions in digital radiography using knowledge that may relate exclusively to analogue radiography.

The immunobiology of cobalt: demonstration of a potential aetiology for inflammatory pseudotumours after metal-on-metal replacement of the hip

Abnormal wear of cobalt-containing metal-on-metal joints is associated with inflammatory pseudotumours. Cobalt ions activate human toll-like receptor 4 (TLR4), which normally responds to bacterial lipopolysaccharide (LPS) in sepsis. Activation of TLR4 by LPS increases the expression of chemokines IL-8 and CXCL10, which recruit leukocytes and activated T-cells, respectively. This study was designed to determine whether cobalt induces a similar inflammatory response to LPS by promoting the expression of IL-8 and CXCL10. A human monocytic cell line, derived from acute monocytic leukaemia, was treated with cobalt ions and expression of IL-8 and CXCL10 measured at mRNA and protein levels. Cobalt-treated macrophages showed a 60-fold increase in IL-8 mRNA, and an eightfold increase in production of the mature chemokine (both p < 0.001); expression of the CXCL10 gene and protein was also significantly increased by cobalt (both p < 0.001). Experiments were also performed in the presence of CLI-095, a TLR4-specific antagonist which abrogated the cobalt-mediated increase in IL-8 and CXCL10 expression. These findings suggest that cobalt ions induce inflammation similar to that observed during sepsis by the simultaneous activation of two TLR4-mediated signalling pathways. These pathways result in increased production of IL-8 and CXCL10, and may be implicated in pseudotumour formation following metal-on-metal replacement.

YouTube™ as a source of patient information for lumbar discectomy

INTRODUCTION

YouTube™ contains more than 60% of all videos on the internet. Its popularity has increased, and it has now become a source of patient education and information. It is unregulated for the quality of its videos. This project was designed to assess the quality of videos on YouTube™ on lumbar discectomy.

METHODS

A systematic search of YouTube™ was performed. The search terms used were 'lumbar' and 'discectomy'. The first ten pages were reviewed. Information was recorded relating to the date of publishing, the publisher and the number of viewings. The content was reviewed using criteria based on recommendations from the British Association of Spine Surgeons website. Content was assessed and points were awarded for information relating to management options, description of the procedure (including anaesthetic, likely recovery and outcome) and complications as well as information relating to the author and his or her institute. An overall rating of 'inadequate', 'poor', 'average' or 'good' was given.

RESULTS

Overall, 81 videos were identified. The total number of viewings was 2,722,964 (range: 139-111,891), with an average number of 34,037 viewings per video. There were 16 with a rating of 'good', 25 with a rating of 'average' and 40 with a rating of 'poor' or 'inadequate'. The most common missing information related to anaesthesia or complications. Most videos (69/81) were broadcast by surgeons or surgical institutes.

CONCLUSIONS

The quality of YouTube™ videos is variable and we believe this represents the unregulated nature of broadcasts on YouTube™. Thought should be given to information in videos prior to placement.

The VANILLA sensor as a beam monitoring device for X-ray radiation therapy

Cancer treatments such as intensity-modulated radiotherapy (IMRT) require increasingly complex methods to verify the accuracy and precision of the treatment delivery. In vivo dosimetry based on measurements made in an electronic portal imaging device (EPID) has been demonstrated. The distorting effect of the patient anatomy on the beam intensity means it is difficult to separate changes in patient anatomy from changes in the beam intensity profile. Alternatively, upstream detectors scatter and attenuate the beam, changing the energy spectrum of the beam, and generate contaminant radiation such as electrons. We used the VANILLA device, a Monolithic Active Pixel Sensor (MAPS), to measure the 2D beam profile of a 6 MV X-ray beam at Bristol Hospital in real-time in an upstream position to the patient without clinically significant disturbance of the beam (0.1% attenuation). MAPSs can be made very thin (~20 μm) with still a very good signal-to-noise performance. The VANILLA can reconstruct the collimated beam edge with approximately 64 μm precision.

Abnormal MDMX degradation in tumor cells due to ARF deficiency

MDMX is a hetero dimeric partner of MDM2 and a critical regulator of p53. MDMX level is generally elevated in tumors with wild type p53 and contributes to p53 inactivation. MDMX degradation is controlled in part by MDM2-mediated ubiquitination. Here we show that MDMX turnover is highly responsive to changes in MDM2 level in non-transformed cells, but not in tumor cells. We found that loss of ARF expression, which occurs in most tumors with wild type p53, significantly reduces MDMX sensitivity to MDM2. Restoration of ARF expression in tumor cells enables MDM2 to degrade MDMX in a dose-dependent fashion. ARF binds to MDM2 and stimulates a second-site interaction between the central region of MDM2 and MDMX, thus increases MDMX-MDM2 binding and MDMX ubiquitination. These results reveal an important abnormality in the p53 regulatory pathway as a consequence of ARF deficiency. Loss of ARF during tumor development not only prevents p53 stabilization by proliferative stress, but also causes accumulation of MDMX that compromises p53 activity. This phenomenon may reduce the clinical efficacy of MDM2-specific inhibitors by preventing MDMX down regulation.

Catastrophic hyperkalaemia following administration of suxamethonium chloride to a patient with undiagnosed amyotrophic lateral sclerosis

The depolarising neuromuscular blocking agent suxamethonium chloride, frequently used during endotracheal intubation, is contraindicated in patients with chronic denervation in whom it can cause a life-threatening hyperkalaemic reaction, thought to be mediated through upregulation of nicotinic alpha7 acetylcholine receptors. An underlying neuromuscular disorder should be considered in all patients with acute respiratory insufficiency, and an alternative neuromuscular blocking drug must be used if there is any possibility of widespread denervation.

Practical experience of using the IPEM 2003 electron code of practice

From 1 January 2007, the Institute of Physics and Engineering in Medicine (IPEM) 2003 code of practice (COP) for electron dosimetry replaces the old air kerma-based Institute of Physics and Engineering in Medicine and Biology 1996 COP as the recommended protocol for the UK. The IPEM 2003 COP requires a secondary standard ionisation chamber calibrated directly in terms of absorbed dose to water. This paper examines the differences between the new and old COP and indicates that the dose measured using the 2003 COP appears to be greater than that using the 1996 COP by approximately 2+/-1%, based on a survey of radiotherapy centres in the UK. The paper also compares the characteristics of the NACP (Scanditronix) and Roos (PTW) chambers recommended by the 2003 COP. No practical difference was found between adopting the NACP or Roos chambers as a secondary standard chamber.

p53 mutational status, but not immunohistochemical staining (IHC), is associated with a clinical response of the primary tumor in women receiving neoadjuvant docetaxel-capecitabine chemotherapy for locally advanced breast cancer

Abstract #6047

Background: The XeNa trial enrolled 157 patients in a multicenter Phase II study of neoadjuvant capecitabine and docetaxel in women with operable early stage breast cancer (T2-T3, N0-N1). HER2-positive patients also received trastuzumab. The primary endpoint was the rate of pathological complete response (pCR; residual cancer burden [RCB] = 0) and near-complete response (npCR; RCB = 1). A secondary endpoint of the study was to evaluate the association between p53 alterations and response to chemotherapy.&#x2028; Methods: p53 status was assessed in by mutational analysis on all cases using a microarray-based resequencing assay (AmpliChip p53 – Roche Molecular Systems, Pleasanton, CA); and also by IHC (using the Bp-53-11 antibody (CONFIRM™, Ventana, Tucson, AZ) in 120/157 (76%) of the cases. Gene expression profiling for breast cancer subtypes was also performed using a new 50-gene centroid-based method.&#x2028; Results: p53 mutations were detected in 78/157 (50%) of cases with 70% missense, 17% nonsense, 11% frame shift and 1% splice site. Silent mutations were rare (1%). Concordance of AmpliChip mutation status with IHC + staining was 65% (78/120 samples). Of the 16/60 (27%) cases which were IHC - and AmpliChip p53 mutation +, 10 (63%) had non-missense mutations which are typically IHC -. In the 60 mutation negative cases with IHC data, there were 26/60 (46%) IHC + cases. p53 mutation + status by AmpliChip was highest in Basal-like (75%) and HER2-enriched (57%) subtypes and lower in Luminal A (29%), Luminal B (12%) and Normal-like (39%). p53 IHC + staining varied little among the subtypes (35 to 50%) and did not correlate with p53 mutational status. The frequency of pCR and npCR was significantly higher in cases with p53 sequence mutations (20/58 - 35%) than in patients without mutations (7/52 - 13%; p = 0.014; 2-tailed Fisher's Exact Test), and this trend was apparent in both HER2+ and HER2- cases. IHC status did not correlate with treatment response (18% pCR and npCR in IHC- cases vs. 27% in IHC + cases; p = 0.35). Notably 3 cases achieving pCR had non-missense p53 mutations and were IHC -.&#x2028; Conclusion: P53 mutations were found in 50% of locally advanced breast cancers and were more frequent in Basal-like and HER2-enriched subtypes and less common in other subtypes. IHC staining lacks sensitivity and specificity for the presence of p53 mutations. In contrast to studies of anthracycline-based therapy, tumors harboring p53 mutations, especially missense mutations, respond better to this taxane-based regimen than wild-type tumors. P53 mutational analysis is a more accurate predictor of treatment response than IHC.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6047.

Hot flashes are associated with CYP2D6 genotype in breast cancer survivors taking tamoxifen

Abstract #6045

Background: We have previously shown that participants in the Women's Healthy Eating and Living (WHEL) study comparison group who reported hot flashes after breast cancer treatment had more favorable disease-free survival than women who did not report hot flashes. However, this was not the case in the intervention group. The polymorphic CYP450 enzyme CYP2D6 catalyzes the conversion of tamoxifen (TAM) to one of its key active metabolites, endoxifen. Some studies have suggested that certain genetic variants of CYP2D6 are associated with a decreased likelihood of hot flashes, reduced endoxifen levels and an increased risk of disease recurrence in women receiving adjuvant TAM therapy. This analysis was performed to estimate the association between CYP2D6 genotype and hot flashes in early stage breast cancer survivors who took adjuvant TAM in the WHEL study.&#x2028; Methods: The WHEL study was a randomized trial of a dietary intervention in breast cancer survivors, who enrolled in the study within 4 years of diagnosis from 1995-2000. Participants self-reported TAM use, hot flash severity and menopausal status at study entry. Clinical characteristics (tumor stage, estrogen receptor status, chemotherapy) were extracted from medical records. Blood samples were obtained by venipuncture, separated and stored at -80 deg. DNA was extracted from stored buffy coat and analyzed using the Roche AmpliChip CYP450 Test. Women were classified according to their predicted CYP2D6 phenotype as Extensive (EM), Heterozygous Extensive (Het EM), Intermediate (IM), Poor (PM), or Ultrarapid (UM) Metabolizers.&#x2028; Results: Overall, 1434 WHEL participants had verified estrogen receptor-positive stage I or II breast cancers and reported taking TAM at baseline for at least 4 months. A total of 1411 women were successfully genotyped and their CYP2D6 phenotypes were classified as follows: 468 EM (33.2%); 665 Het EM(47.1%), 164 IM (11.6%), 86 PM (6.1%) and 28 UM (2.0%). In univariate analyses, there was a significant difference among CYP2D6 genotype in relation to hot flashes reported at baseline: 79.8% of EMs, 76.3% of Het EMs, 80.1% of IMs, 63.9% of PMs, and 75% of UMs reported hot flashes (χ2= 11.3, p=0.02). After controlling for age, menopausal status, and time since diagnosis, the PM group was half as likely to report hot flashes as the referent EM group (OR= 0.46; 95% CI= 0.28-0.78; p=0.003). Additional analyses of serum endoxifen levels and associations with disease outcome are underway.&#x2028; Conclusion: In the WHEL study, women who were classified as Poor Metabolizers of TAM, based on their CYP2D6 genotype, were half as likely as Extensive Metabolizers to report experiencing hot flashes while receiving adjuvant TAM treatment for early stage breast cancer.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6045.

Teenage and adult tonsillectomy: dose-response relationship between diathermy energy used and morbidity

OBJECTIVE

To determine whether an increase in the use of bipolar diathermy energy to perform a tonsillectomy is associated with an increase in postoperative pain and haemorrhage.

STUDY DESIGN

Prospective study.

SETTING

District General Hospital.

METHODS

In all, 101 patients above the age of 13 years who underwent a tonsillectomy that involved the use of bipolar diathermy during the study period were included. The cumulative amount of diathermy energy used to perform each tonsillectomy was calculated with the help of a digital stop clock timing device connected to the diathermy foot-pedal.

MAIN OUTCOME MEASURES

Postoperative pain scores and the incidence of secondary haemorrhage were recorded for each patient at four points in time following surgery, up to the tenth postoperative day. The haemorrhage rates were categorised into three groups (no bleeding, minor bleeding and major bleeding) according to severity. Associations between the diathermy energy used to perform each tonsillectomy and the corresponding postoperative pain scores and secondary bleeding rates were investigated.

RESULTS

There was a statistically significant positive relationship between the total amount of bipolar diathermy energy used per tonsillectomy and the pain scores at all the four recorded points in time (r(s) = 0.44-0.72, P < 0.001). When the median energy consumption in the three groups (no bleeding, minor bleeding and major bleeding) were compared using the Kruskal-Wallis test, we found that there was limited evidence of a difference between the groups, but this was not statistically significant at the 5% level [H (2) = 5.374, P = 0.065, 99% CI 0.058-0.071].

CONCLUSIONS

Increased use of bipolar diathermy during the performance of a tonsillectomy is associated with a statistically significant increased amount of postoperative pain. The dose-response relationship between diathermy energy and postoperative bleeding is less clear. This suggests that there could be other important factors such as surgical instrument characteristics and degree of tonsillar adherence that have an additional influence and are therefore possible areas for future research.

Comparison of the GOHAI and OHIP-14 as measures of the oral health-related quality of life of the elderly

OBJECTIVES

This paper compares the performance of the GOHAI and the OHIP-14 as measures of the oral health-related quality of life of the compromised elderly.

METHODS

Data were obtained from a cross-sectional survey of 225 participants, most of whom lived in a large geriatric care centre.

RESULTS

The mean age of subjects was 83 years and the majority had one or more chronic medical conditions and physical disabilities. Their main oral problems were high rates of tooth loss and xerostomia. Additive and simple count methods were used to derive GOHAI and OHIP-14 scores. Using the additive method, 8.4% had a GOHAI score of zero and 30.3% an OHIP-14 score of zero. Using the simple count method the percentage with a score of zero was 15.1% and 45.8%. Both measures discriminated between dentate subjects with and without one or more dentures, with and without a chewing problem and with and without dry mouth. Both also showed significant associations with self-rated oral health and satisfaction with oral health status. Associations tended to be stronger between GOHAI scores and these variables. The measures were equally good at predicting overall psychological well-being and life satisfaction. Although the GOHAI identified more oral functional and psychosocial impacts than the OHIP-14, neither was markedly superior to the other when used as discriminatory measures. However, the high prevalence of subjects with zero scores may compromise the ability of the OHIP-14 to detect within-subject change.

A study of the effect of antenatal physiotherapy coaching on labour pain in the nullipara

An observational study was performed on nulliparous labour pain in an area with a low epidural rate which facilitated the comprehensive assessment of pain. Patients who had attended antenatal physiotherapy classes showed consistently less reaction to pain while experiencing the same level of perceived pain as the untrained. Duration of the first stage was the main factor associated with high pain levels. There was some evidence that training was particularly effective when there were fetal positional problems.

An evaluation of the alternatives approach to drug abuse prevention

An alternatives-oriented, school-based drug abuse prevention program, Positive Alternatives for Youth (PAY), was evaluated over a 2-year period. Using a random-assignment, pretest-posttest control group design, 135 PAY students and 106 control group students were assessed on several attitudinal and behavioral measures of drug use. During the first year significant differences were detected between PAY and control students. Fewer differences were found in the second year, although a special analysis showed evidence of impact on PAY students rated as more involved in program activities. Reasons for specific results are discussed and implications are drawn for the alternatives approach and the field of drug abuse prevention.

Post-traumatic bronchial stenosis and acute respiratory insufficiency

A 31-year-old woman sustained multiple injuries, including severe contusion of the right lung with massive subcutaneous emphysema. Four weeks later she was transferred to our institution with post-traumatic adult respiratory distress syndrome and carbon dioxide retention, resulting from a postlaceration stenosis of the left main-stem bronchus. Bronchoplasty was contraindicated because of the serious condition of the patient. Repeated bronchial dilatations produced initial improvement in oxygenation and minute ventilation requirements. However, because of the nature of the stenosis and the lack of recovery of right lung function, the patient's encouraging clinical course reached a plateau and attempts at weaning from the respirator were unsuccessful. Bronchoplasty was performed on postadmission day 50 and resulted in gradual recovery of pulmonary function. Six months following discharge, the patient continues a steady improvement. Management of the patient's injuries represented a unique challenge previously unencountered.

Prevention and treatment of some obstetric and gynaecological conditions

Some obstetric and gynaecological conditions are examined and measures suggested from preventive and therapeutic angles with a view to alerting specialists to a broad spectrum of patient management in this field.

The physiotherapist in the obstetric team

With the term obstetric physiotherapist coming into more frequent use, it seems opportune to examine what it means.