Enhancing the understanding of parental burnout from an empirical and psychometric perspective

Background

Parental burnout (PB) is a relatively new syndrome resulting from chronic parenting stress. Besides efforts to enhance scientific and public understanding of PB, little is known about its link to intimate partner violence (IPV), and the psychometrics of German measures for PB remain an under-researched topic. This study aims to address these gaps by 1) testing the interplay of PB, parenting, couple satisfaction, and IPV, 2) examining the psychometrics of the German version of the Parental Burnout Assessment (PBA).

Methods

Data were collected online as part of an international PB study including Austrian parents aged 18 or older with at least one child at home (0-18). Overall, N = 121 mothers from a community sample reported on family functioning, PB, couple quality and gender roles. Structural equation modeling was applied to assess the fit of the theoretical model. Furthermore, data from N = 220 Austrian and German parents on PB and familial variables during the Covid-19 pandemic were collected to analyze the psychometrics of the German PBA. Confirmatory factor analyses were performed to test the validity of the PBA.

Results

SEM indicated a good model fit, χ^2(37) = 35.51, p = .54; CFI = 1.00; RMSEA = .00, (95% CI = .00 -.06). Furthermore, an indirect effect of couple satisfaction on the link between IPV to PB and IPV to parenting was found.

Conclusions

This study provides preliminary evidence for the importance of couples’ relationship satisfaction in understanding links between IPV and PB as well as parenting in German-speaking mothers. On the basis of these findings, future public health efforts may be organized to focus on preventing PB indirectly or directly by targeting couples’ relationship. Additionally, psychometric results of this study can inform researchers and practitioners about the applicability of the German PBA, improving screening of at-risk parents, and offering support for parents at early stages.

Key messages

178 A RETROSPECTIVE EVALUATION OF PROCESS OUTCOMES OF OLDER ADULTS REFERRED TO A COMMUNITY RE-ENABLEMENT TEAM FROM THE EMERGENCY DEPARTMENT

Background

Emergency Departments (ED) are complex and challenging environments to provide care to older adults. There is currently a paucity of high quality methodological research investigating the effectiveness of interventions focused on transitions of care from the ED to primary care services (Hughes et al, 2019). This study aims to evaluate the impact of a collaborative model of care between primary and secondary care services for older adults discharged home following ED index visit.

Methods

This was an observational retrospective study. Participants aged ≥65 years discharged home from the ED of a University Teaching Hospital and referred to a Multidisciplinary Community Intervention Team (MDCIT) were included. Referral pathways were via the OPTIMEND team (Cassarino et al, 2021) and MDCIT, which is a rapid access re-enablement team based in the community and compromises nursing staff, an occupational therapist, physiotherapist, therapy and healthcare assistants. Descriptive statistics were used to profile the baseline characteristics of study participants and to summarise data related to process outcomes. Ethical approval was granted for this study (020/2021).

Results

In the study period, January—December 2020, 54 patients were referred to the MDCIT. The mean age of participants was 80.1 years (SD 8.2), 57% were female, and the most common Manchester Triage System presenting complaint was ‘limb problems’. The median Patient Experience Time within the ED was 7.4 hours (IQR 13.1); 55% of participants were seen in their home within 24 hours of discharge. A mean of 10 interventions were delivered by the MDCIT. A 9.1% incidence rate of 30 day unscheduled hospital readmission was recorded.

Conclusion

Integrated care programmes have been advocated to improve the continuum of care from the ED into the community. This evaluation has demonstrated the feasibility of implementing such a model of care. However, further methodologically robust research is required to advance the evidence base and should also focus on patient outcomes.

The Effect of Obesity on Fluoroscopy-Assisted Direct Anterior Approach Total Hip Arthroplasty

BACKGROUND

Obesity has been considered a relative contraindication to performing a direct anterior approach total hip arthroplasty (DAA-THA) since it is hypothesized to lead to component malpositioning and poor outcomes. Fluoroscopy-assisted DAA-THA has been reported to diminish variability in acetabular component positioning. However, fluoroscopy-assisted DAA-THA in the obese patients has not been well described. We report on a single surgeon consecutive series of fluoroscopy-assisted primary DAA-THA's examining the radiographic and perioperative outcomes in obese patients.

METHODS

A retrospective review was conducted of 509 consecutive unilateral fluoroscopy-assisted DAA-THAs on a specialized orthopaedic table performed by a single surgeon. All patients were divided into three cohorts according to their body mass index (BMI): Group I (< 30 kg/ m2 ), Group II (≥ 30 to < 35 kg/m2 ), and Group III (≥ 35 kg/ m2 ). Perioperative parameters, outcome scores (EuroQol 5 Dimension and hip disability and osteoarthritis outcome scores), and radiographs were comparatively assessed. Cup position was determined using Widmer's method.

RESULTS

A total of 492 DAA-THAs (minimum follow-up: 2.1 years) with appropriate radiographs were analyzed. Of which 356 (72.2%) were in Group I (average: 25.1 kg/m2 ), 105 (21.3%) in Group II (average: 32 kg/m2 ), and 31 (6.5%) in Group III (average: 38.6 kg/m2 ). There were no differences in any parameters between Group II and III. Group I differed in average age and included more female patients than Groups II and III. There was a statistically significant difference in cup anteversion between all groups with average measurements of 20.8°, 19.5°, and 17.6°, respectively. No other differences were identified in radiographic parameters or postoperative outcomes.

CONCLUSIONS

There were no clinically relevant differences in component positioning or perioperative parameters between obese and non-obese patients. We do not consider a BMI ≥ 30 kg/m2 to be a contraindication for fluoroscopyassisted DAA-THA when performed by a surgeon experienced in the technique.

Antimicrobial prescribing and infections in long-term care facilities (LTCF): a multilevel analysis of the HALT 2016 study, Ireland, 2017

Background

The 2016 point prevalence survey (PPS) of healthcare-associated infections (HAI) and antimicrobial use (AMU) in Irish long-term care facilities (LTCF) (HALT) showed a 9.8% AMU and 4.4% HAI prevalence, based on aggregated data analysis.

Aim

Our aim was to identify institutional and resident risk factors of AMU and HAI.

Methods

HALT 2016 gathered information using institutional and resident questionnaires, for residents who met the surveillance definition of active HAI and/or AMU, limiting analysis to the aggregated institutional level. In January 2017, we requested additional data on age, sex, urinary catheter use and disorientation of current residents from HALT 2016 LTCF and matched to 2016 HALT data.

Results

Of 224 HALT 2016 LTCF, 80 provided additional information on 3,816 residents; prevalence of AMU was 10.6% and HAI was 4.7%. Presence of a coordinating physician (Odds ratio (OR): 0.3; 95% confidence interval (CI): 0.2–0.6), antimicrobial stewardship committee (OR: 0.2; 95%; CI: 0.1–0.6), healthcare assistants (OR: 0.9; 95% CI: 0.9–1.0), antimicrobial consumption feedback (OR: 0.3; 95% CI: 0.1–0.6) and medical care by personal general practitioner (OR: 0.6; 95% CI: 0.7–1.0) were associated with less AMU and feedback on surveillance of infection prevention and control (IPC) practices (OR: 0.6; 95% CI: 0.3–1.0) with less HAI. AMU and HAI varied significantly between LTCF.

Conclusions

Multilevel modelling identified significant inter-facility variation, as well as institutional factors associated with AMU and HAI. An antimicrobial stewardship committee linked with feedback on IPC and prescribing was associated with reduced AMU and HAI.

The Clinical Evidence Behind Biologic Therapies Promoted at Annual Orthopaedic Meetings: A Systematic Review

PURPOSE

The purpose of this study is to systematically evaluate the available clinical data for biologic therapies promoted for articular cartilage defects and osteoarthritis of the knee at the 2016 American Orthopaedic Society for Sports Medicine Meeting (AOSSM) and the 2017 Arthroscopy Association of North America meeting (AANA).

METHODS

Our sample included all exhibitors at the 2016 AOSSM meeting and 2017 AANA meeting. All biologic products marketed at each conference were identified by reviewing exhibition booths and company websites. A systematic review of the clinical data on each product was then completed using PubMed, EMBASE, and the product's own webpage. All clinical peer-reviewed studies with level I-IV evidence were included in the study. Basic science or preclinical studies were excluded.

RESULTS

There were 16 products promoted for biologic therapy for articular cartilage defects or osteoarthritis of the knee at the AOSSM meeting and 11 products promoted at the AANA meeting. A total of 280 articles detailed clinical findings for the articular cartilage products displayed at AOSSM and AANA. Of the 280, there were 36 level I evidence studies, 37 level II evidence studies, 18 level III evidence studies, and 189 level IV evidence studies. Of these articles, 91% were for 4 products. Of all biologic products promoted at the 2 meetings, 65% did not have any peer-reviewed clinical data supporting their use.

CONCLUSION

Overall, many biologic therapies promoted at leading arthroscopy and sports medicine conferences did not have clinical evidence evaluating their use in the peer-reviewed literature. Although scientific advancement requires new technology, orthopaedic surgeons should be cautious about using biologic therapies in their practice with no proven efficacy. There are likely promising new interventions that, with additional scientific research, will be proven efficacious for our patients.

CLINICAL RELEVANCE

This article gives orthopaedic surgeons a detailed example of some of the biologic treatments being offered on the market for the treatment of knee articular cartilage disease. When patients request these treatments, physicians must be able to explain the data supporting their use.

Sexual Well-Being After Breast or Pelvic Cancer Treatment: A Guide for Women

Background and context: As part of the National Cancer Strategy 2017-2026, the NCCP aims to improve the experience and care for cancer survivors. A key objective of survivorship care is to empower patients to achieve their best possible health outcomes while living with and beyond a diagnosis of cancer. Aim: To develop a guide to provide a support on sexual well-being for women who have completed cancer treatment of breast cancer; gynecologic cancer; bowel, rectal and anal cancer; or bladder cancer. Strategy/Tactics: A project design team was established with stakeholders including healthcare professionals and patients. Program/Policy process: The guides were designed to facilitate conversation around what is a sensitive subject for many people. Having cancer may change the relationships a cancer survivor has with their family and friends; it is natural to need some time to adjust. But while cancer treatment may affect sexuality, sex life doesn't have to end. The guide was reviewed by patient groups prior to printing. It is approved by National Adult Literacy Agency (NALA). The guide was nationally distributed to all clinical areas and is available on the Web. Outcomes: The final publication is entitled Sexual Well-Being After Breast or Pelvic Cancer Treatment: A Guide for Women. It gives details of treatments that may help improve sexual well-being and encourages women to be their own strongest resource. It includes advice on how to talk about sexual well-being, how to create physical and emotional intimacy, and what to do if you are not in a sexual relationship but would like to be. The guide is a companion to the previously published Information for Men on Sexual Well-Being After Pelvic Cancer Treatment, which has been widely used by men to understand the sexual changes caused by cancer treatment. The guide was launched in January 2018. With support from HSE communications it was promoted across social media. It received a positive response with the guides requested nationally. The guide was also distributed to all the cancer centers, support services, and primary care centers. What was learned: Healthcare professionals find it difficult to discuss sexuality with their patients and this booklet allows sexuality to be discussed. Workshops will be required with healthcare professionals to empower themselves and their patients to address the issue of sexuality in survivorship.

Surgical Decision Making for Thoracolumbar Spine Injuries in Polytrauma Patients

The management of thoracolumbar spine injuries in patients with multiple traumatic injuries is a challenge complicated by multiple competing medical and surgical demands. Safe and effective treatment of polytrauma patients with a thoracolumbar spine injury requires a multidisciplinary approach that involves surgical and critical care teams. The Thoracolumbar Injury Classification and Severity Score, which was developed to facilitate consistent surgical decision making in patients with a thoracolumbar spine injury, provides objective criteria for the classification and management of thoracolumbar spine injuries. The AOSpine study group recently developed a comprehensive thoracolumbar injury classification system that was subsequently used to create the Thoracolumbar AOSpine Injury Score, which helps guide thoracolumbar spine injury management via objective criteria. These scoring systems have been effectively used in clinical practice and allow for a focused and objective assessment of thoracolumbar spine injuries. Both the Thoracolumbar Injury Classification and Severity Score and the Thoracolumbar AOSpine Injury Score should be routinely used in treatment decision making to optimize outcomes and avoid unnecessary surgical treatment in polytrauma patients with a thoracolumbar spine injury.

Preparedness of elderly long-term care facilities in HSE East for influenza outbreaks

Abstract We assessed preparedness of HSE East elderly long-term care facilities for an influenza outbreak, and identified Public Health Department support needs. We surveyed 166 facilities based on the HSE checklist document for influenza outbreaks, with 58% response rate. Client flu vaccination rates were > 75%; leading barriers were client anxiety and consent issues. Target flu vaccine uptake of 40% in staff occurred in 43% of facilities and was associated with staff vaccine administration by afacility-attached GP (p = 0.035), having a facility outbreak plan (p = 0.013) and being anon-HSE run facility (p = 0.013). Leading barriers were staff personal anxiety (94%) and lack of awareness of the protective effect on clients (21%). Eighty-nine percent found Public Health helpful, and requested further educational support and advocacy. Staff vaccine uptake focus, organisational leadership, optimal vaccine provision models, outbreak plans and Public Health support are central to the influenza campaign in elderly long-term care facilities.

Long-term follow-up of women with breast cancer: rationale for policy change

BACKGROUND

The number of breast cancer survivors in our ageing population continues to rise. Policy makers internationally are seeking to identify alternatives to follow-up care in an acute setting.

AIMS

The National Cancer Control Programme set out to develop a new policy for long-term follow-up of breast cancer survivors in Ireland.

METHODS

Policy development was informed by analysis of current attendances at breast surgical clinics for routine follow-up, extraction of the necessary components of follow-up from international guidelines and focus group research with Irish patients.

RESULTS

Intensive follow-up investigations, other than mammography, do not confer additional survival benefit or improved quality of life. Provision of routine follow-up care of breast cancer survivors by GPs has been shown to be equivalent to follow-up by specialist clinics, in terms of clinical outcomes, patient quality of life and patient satisfaction. In Ireland, routine follow-up accounted for 15.4% (95% CI: 13.8-17.0%) of clinic appointments. A third were at least 5 years post-operative. Women highlighted issues such as attachment to specialist services, importance of communication and need for clarity as to where responsibility of care lies. Reassurance, confidence in the primary care practitioner, and coordination of multiple appointments were also identified as important issues.

CONCLUSION

A significant proportion of breast cancer survivors attending hospital surgical clinics for long-term follow-up could be safely discharged at 5 years, with the hospital maintaining responsibility for annual mammography. Successful implementation will depend on informed patients, clinicians' acceptance and communication between primary and secondary care.

Women with pre-gestational diabetes have a higher risk of stillbirth at all gestations after 32 weeks

AIM

To explore the additional risk of stillbirths and to quantify that risk according to gestational age among women with diabetes.

METHODS

Data on pregnancies ending in 2007 and 2008 in women with pre-gestational diabetes in three English regional audits were identified. A prospective audit collected data on all pregnancies delivering between June 2010 and May 2011 in one region and in 13 other units across England. The data on all singleton pregnancies from these two cohorts were combined. Comparisons were made to all births in England and Wales for the same time period using data from the Office for National Statistics.

RESULTS

In the cohort of women with pre-gestational diabetes there were a total of 2085 singleton pregnancies, of which 29 resulted in a stillbirth (overall stillbirth rate 13.9 per 1000, 95% CI 9.7-19.9, relative risk compared with all pregnancies in England and Wales 2.73, 95% CI 2.61-2.84). The relative risk of stillbirth between 32 and 34 weeks' gestation was 4.95 (95% CI 4.24-5.78), 3.77 (95% CI 3.42-4.16) at 35 to 36 weeks, 5.75 (95% CI 5.43-6.09) for deliveries at 37 or 38 weeks and 7.34 (95% CI 6.52-8.25) for those born at 39 weeks or more.

CONCLUSION

Women with diabetes have a significantly higher risk of stillbirth at all gestations after 32 weeks and this additional risk is not just confined to pregnancies at 37 weeks or more.

Use of a geographic information system to map cases of measles in real-time during an outbreak in Dublin, Ireland, 2011

In 2011, there was a large measles outbreak in Dublin. Nationally 285 cases were notified to the end of December 2011, and 250 (88%) were located in the Dublin region. After the first case was notified in week 6, numbers gradually increased, with 25 notified in June and a peak of 53 cases in August. Following public health intervention including a measles-mumps-rubella (MMR) vaccination campaign, no cases were reported in the Dublin region in December 2011. Most cases (82%) were children aged between 6 months and 14 years, and 46 cases (18%) were under 12 months-old. This is the first outbreak in Dublin to utilise a geographic information system for plotting measles cases on a digital map in real time. This approach, in combination with the analysis of case notifications, assisted the department of public health in demonstrating the extent of the outbreak. The digital mapping documented the evolution of two distinct clusters of 87 (35%) cases. These measles cases were infected with genotype D4-Manchester recently associated with large outbreaks across Europe. The two clusters occurred in socio-economically disadvantaged areas and were attributable to inadequate measles vaccination coverage due in part to the interruption of a school-based MMR2 vaccination programme.

Virchow-Robin spaces in idiopathic normal pressure hydrocephalus: a surrogate imaging marker for coexisting microvascular disease?

BACKGROUND

Virchow-Robin spaces (VRSs) surround perforating cerebral arteries and are reported to be found with increasing frequency with advancing age. In addition, some studies indicate an association between VRSs and vascular dementias. The present study examined the incidence of VRSs in patients with idiopathic normal pressure hydrocephalus (INPH) and considered their use as a potential surrogate imaging marker of coexisting microvascular disease in patients with this condition.

METHODS

The MRI incidence of VRS in the centrum semiovale (CS), basal ganglia (BG), mesencephalon (MES), and the subinsular (SI) region was measured in 12 patients with INPH and in 12 control subjects, using the scoring system proposed by Patankar et al. (Am J Neuroradiology 26:1512, 2005). Historical control data were also used for further comparison.

RESULTS

All 12 INPH patients had clearly visible VRSs, distributed in the CS (all 12), basal ganglia (11/12), SI region (9/12), and MES region (6/12). The mean Patankar scores of the INPH group were BG 2.25, CS 1.66, SI 0.91, and ME 0.5. The respective scores for our control group were 1.41, 1.5, 1.16, and 0.16, and for historical controls were 1.46, 0.51, 0.96, and 0.51. There were, however, no statistically significant differences between the INPH patients and either of the control groups. No correlation was found between age and the overall incidence of VRS.

CONCLUSION

This preliminary study suggests that there may be a higher incidence of VRSs in patients with INPH, when compared with normal patients of similar age, but our small numbers prevent us from demonstrating statistical significance, and larger studies are clearly required.

Porcine intestinal epithelial responses to Campylobacter infection

Campylobacter infection is estimated to cause diarrhoea in 1% of the population of developed countries every year, but our understanding of this disease has been hampered by a lack of a suitable animal model. Colostrum-deprived piglets have been suggested as models since they produce similar clinical signs to humans when infected but little information currently exists regarding the response of this species to Campylobacter at cellular and molecular level. This study shows that intestinal epithelial cells from both species respond in a similar manner to Campylobacter infection regarding invasion, induction of innate immune response and effect on barrier function.

Understanding the impact of meditative homework on depression in the context of mindfulness based cognitive therapy (MBCT): An interpretative phenomenological analysis

NICE guidelines indicate one in five people will suffer from depression at some point in their lives with relapse rates of 50–80% in those who have experienced one or more episodes of depression (National Institute for Health and Clinical Excellence [NICE], 2007). By 2020, depression is predicted to be the second largest cause of death or disability and consequently there is a need to explore and develop the ways of working with depression. Mindfulness based cognitive therapy (MBCT) is a group psycho-educational treatment designed to reduce the risk of recurrent depression by integrating mindfulness based meditation practices with cognitive therapy techniques (Segal, Williams, & Teasdale, 2002). MBCT comprises eight weekly two-hour group sessions with additional time for meditative homework practice. As yet, little is known about how patients experience meditative homework assignments in a UK public health setting. This study examines subjective accounts of the meaning of carrying out meditative homework assignments in terms of impact on the self as well as an exploration of barriers and facilitating factors from a participant's perspective. Six Individual in-depth interviews were conducted, transcribed verbatim and an Interpretative Phenomenological Approach was used to analyse the data. Results focus on perceived facilitating factors and difficulties experienced in carrying out meditative homework as well as implications for clinical practice in the prevention of recurrent depression. Transformation of participant’s experience of the self and social relatedness as a consequence of meditative homework is discussed in relation to existing psychological literature and the practise of MBCT.

Absence of telomere shortening and oxidative DNA damage in the young adult offspring of women with pre-gestational type 1 diabetes

AIMS/HYPOTHESIS

The offspring of mothers with pre-gestational type 1 diabetes (PGDM) may be at increased risk of glucose intolerance and cardiovascular disease in childhood. The underlying causes of these observations, and whether they persist into adulthood, are unknown. The aim of the present study was to test the hypothesis that fetal chromosomal telomere oxidative DNA damage resulting from maternal PGDM programmes the offspring towards a senescent phenotype that is detectable in young adulthood.

METHODS

We studied 21 young adult offspring (age 16-23 years) with a maternal history of PGDM and 23 age- and weight-matched controls with no maternal history of diabetes. All participants underwent anthropometric assessments, a standard 75 g OGTT, measurement of peripheral blood mononuclear cell and skin fibroblast telomere length, fibroblast senescence, cell DNA damage (by determination of 8-oxoguanine levels using flow cytometry), plasma lipoprotein profiles (determined by nuclear magnetic resonance) and plasma levels of soluble adhesion molecules and inflammatory markers.

RESULTS

The groups did not differ significantly with respect to anthropometric measures, glucose tolerance, fasting and 2 h plasma insulin levels during OGTT, estimated peripheral insulin resistance, peripheral blood mononuclear cell or fibroblast telomere length, DNA damage or senescence in vitro, plasma NMR lipoprotein profiles or levels of high-sensitivity C-reactive protein. Plasma concentrations of soluble intercellular adhesion molecule 1 (sICAM-1; p < 0.05) and IL-6 (p = 0.08) were higher in the PGDM offspring.

CONCLUSIONS/INTERPRETATION

Young adult offspring of mothers with PGDM do not differ in terms of glucose tolerance, DNA damage or telomere length from controls of the same weight and BMI. This does not preclude such abnormalities at an earlier age, but there is no evidence of telomere damage as a pre-programming mechanism in the young adults enrolled in this study.

Human microvascular endothelial cellular interaction with atomic N-doped DLC compared with Si-doped DLC thin films

This article reports results of endothelial cell interaction with atom beam source N-doped a-C:H (diamond-like carbon, DLC) as it compares with that of Si-doped DLC thin films. The RF plasma source exhibits up to 40% N-dissociation and N-atomic fluxes of approximately 0.85 x 10(18) atoms/s, which ensures better atomic nitrogen incorporation. Two different types of nitrogen species (with and without the use of sweep plates to remove charged ions) were employed for nitrogen doping. The number of attached endothelial cells is highest on Si-DLC, followed by the N-DLC (where the sweep plates were used to remove ions), the N-DLC (without the use of sweep plates), undoped DLC, and finally the uncoated sample. The contact angle values for these films suggest that water contact angle is higher in the atomic nitrogen neutral films and Si-DLC films compared to the ionized-nitrogen specie doped films and undoped DLC thin films, suggesting that the more hydrophobic films, semiconducting films, and film with relieved stress have better interaction with human microvascular endothelial cells. It seems evident that N-doping increases the Raman I(D)/I(G) ratios, whereas N-neutral doping decreases it slightly and Si-doping decreases it even further. In this study, lower Raman I(D)/I(G) ratios are associated with increased sp(3)/sp(2) ratio, an increased H concentration, photoluminescence intensity, and a higher endothelial cellular adhesion. These investigations could be relevant to biocompatibility assessment of nanostructured biomaterials and tissue engineering.

Cytogenetic alterations in ovarian clear cell carcinoma detected by comparative genomic hybridisation

Ovarian clear cell carcinoma (OCCC) accounts for a small but significant proportion of all ovarian cancers and is a distinct clinical and pathological entity. It tends to be associated with poorer response rates to chemotherapy and with a worse prognosis. Little is known about possible underlying genetic changes. DNA extracted from paraffin-embedded samples of 18 pure OCCC cases was analysed for genetic imbalances using comparative genomic hybridisation (CGH). All of the 18 cases showed genomic alterations. The mean number of alterations detected by CGH was 6 (range 1-15) indicating a moderate level of genetic instability. Chromosome deletions were more common than amplifications. The most prominent change involved chromosome 9 deletions in 10 cases (55%). This correlates with changes seen in other epithelial ovarian cancers. This deletion was confirmed using microsatellite markers to assess loss of heterozygosity (LOH) at four separate loci on chromosome 9. The most distinct region of loss detected was around the IFNA marker at 9p21 with 41% (11 out of 27 cases) LOH. Other frequent deletions involved 1p (five out of 18; 28%); 11q (four out of 18; 22%) and 16 (five out of 18; 28%). Amplification was most common at chromosome 3 (six out of 18; 33%); 13q (four out of 18; 22%) and 15 (three out of 18; 17%). No high-level amplifications were identified. These features may serve as useful prognostic indicators in the management of OCCC.

Tissue-engineered dermal skin grafting in the treatment of ulcerated necrobiosis lipoidica

Necrobiosis lipoidica is a well recognized but comparatively rare cutaneous complication of diabetes mellitus. The aetiology is probably multifactorial with microangiopathy, immune complex formation, abnormal collagen synthesis and breakdown, and altered haemostasis all thought to play a part. Necrobiosis lipoidica often proves very resistant to treatment. We report a case of a 44-year-old woman with ulcerated necrobiosis lipoidica that healed following grafting with a tissue-engineered living dermal tissue.

Successful treatment with ICSI of infertility caused by azoospermia associated with adrenal rests in the testes: case report

Congenital adrenal hyperplasia (CAH) is a well-recognized, but uncommon, cause of azoospermia and infertility in men. Commonly this is due to undertreatment of excessive adrenal androgen secretion which suppresses gonadotrophin stimulation of the testes. A less common complication of CAH is development of adrenal tissue within the testes; this is important to recognize because it may be confused with malignancy leading to unnecessary surgery. In this case report, a man is described with simple virilizing CAH due to 21-hydroxylase deficiency who presented with azoospermia and was found to have adrenal rests. Investigations concluded that there was adequate adrenal suppression with glucocorticoids and that azoospermia was due to obstruction by adrenal rest tissue, strategically situated at the hilum of the testes. Spermatozoa were able to be retrieved by testicular aspiration from the man and these were used to successfully establish a pregnancy using intracytoplasmic sperm injection of his wife's oocytes.

Treatment of chronic digital septic tenosynovitis in 12 horses by modified open annular ligament desmotomy and passive open drainage

A modified open annular ligament desmotomy followed by passive open drainage was used to treat 12 horses with chronic digital septic tenosynovitis due to trauma in the form of open wounds or self-sealing punctures. The surgical approach included complete transection of the palmar/plantar annular ligament of the fetlock and proximal digital annular ligament, which facilitated the removal of fibrin, selective debridement and synovectomy, followed by lavage of the digital sheath. The incision was partially closed leaving a 2 cm gap open distally to allow for passive open drainage. Gentamicin was administered intrathecally during surgery. Postoperatively the horses received ceftiofur and non-steroidal anti-inflammatory drugs. A sterile bandage was used to protect the wound until the gap had healed completely by second intention. Infection was controlled in 11 of the horses which all returned to their previous levels of work, but one horse was euthanased as a result of the persistence of the infection and financial considerations.

Eradication of vancomycin resistant Enterococcus faecium from a paediatric oncology unit and prevalence of colonization in hospitalized and community-based children

We previously reported an outbreak of vancomycin resistant enterococci (VRE) in a paediatric oncology unit in December 1995 which was associated with widespread environmental contamination of the unit with VRE. We undertook this study to evaluate the effectiveness of the infection control policy instituted subsequent to the outbreak and to investigate the underlying prevalence of VRE colonization in hospitalized, outpatient and community-based children. We sought to establish the molecular similarity of VRE isolates from the study. Stool specimens were obtained from outpatients at risk of VRE, hospital inpatients and from healthy community-based children. VRE colonization was eradicated from the inpatient unit within 11 months, but in outpatients, 16 months after the outbreak, 4 of 137 (2.9 %) attending oncology outpatients, 5 of 65 (7.7%) with cystic fibrosis and 1 of 12 (8.3 %) with liver disease were found to be colonized with VRE. The isolates were all Enterococcus faecium, Van A phenotype except one E. casseliflavus of the Van C phenotype. All were unique in SmaI DNA macrorestriction patterns with the exception of two isolates, which were similar to the original outbreak strain and three further isolates of a single strain but which differed from the outbreak strain. Of 315 hospital inpatients, 2.5 % were colonized with VRE of the Van C resistance phenotype but VRE was not detected in 116 healthy, community-based children. We conclude that effective strategies can successfully control spread of VRE but despite a low prevalence of VRE colonization in hospital patients and in community-based children, outbreaks can occur when infection control practices are not optimal. Continued vigilance to detect VRE and limit spread within hospitals is therefore necessary.

An assessment of paediatric diabetes care in three centres in Russia and in Southampton, UK. The Paediatric Teams in Moscow, Tula, Tambov, Southampton

AIMS

Young people in Russia with diabetes have an increased morbidity and a 10-fold increase in mortality compared with many European countries. This joint international study was set up to compare of care and outcomes against published guidelines in three Russian centres and one UK centre.

METHODS

An assessment of the diabetic care of 368 children, based on the principles of the St Vincent Declaration, was undertaken in each centre. Data on prevalence, management, control and complications were collected in young people with diabetes < 16 years of age in each of the four centres over a 4-week period.

RESULTS

The prevalence of diabetes was greater in Southampton (1:702 vs. 1:1378). At diagnosis Russian children had a higher incidence of ketoacidosis (69 vs. 29%) and stayed in hospital longer (30 vs. 3 days). In management Russian children received more injections per day (5 vs. 2). There was no significant difference in insulin dose for those under 10 years between countries (Southampton 0.69 U/kg vs. Russian 0.73 U/kg, P=NS). Older Russian children did not increase their insulin dosage, while children over 10 years in Southampton received significantly more insulin than the Russian children (Southampton 1.0 U/kg vs. Russian 0.77 U/kg, P< or =0.001). Twenty-nine per cent of the Russian children reported that they had insufficient insulin and 14% had to buy extra. HbA1c was higher in the Russian children (9.8% vs. 8.3%), increasing significantly with age. The Russian children showed a height deficit which correlated with HbA1c and diabetes duration. The Southampton children were heavier and with a higher body-mass index and their HbA1c did not rise similarly as in Russia. Severe hypoglycaemia was more common in the Southampton children (32 vs. 12%). Retinopathy was reported in 12% of the Russian children (Southampton 0%) and systolic blood pressure > 95th centile in 21% (Southampton 8%).

CONCLUSIONS

This study demonstrates a significant difference in diabetic control and complications between the two countries which could be partially explained by a decreased availability and prescribing of insulin and blood glucose monitoring in Russia. Southampton has an education and management policy based on ambulatory care resulting in reduced hospital stay.

Depression, illness perception and coping in rheumatoid arthritis

This study aimed to establish the relationship between depression, illness perception, coping strategies, and adverse childhood events in rheumatoid arthritis patients. Sixty-two out-patients with rheumatoid arthritis (RA) completed the Hospital Anxiety and Depression Scale, Illness Perception Questionnaire, London Coping with Rheumatoid Arthritis Questionnaire, and Childhood Development Questionnaire, and underwent a clinical assessment of their physical state. Depressed patients were more disabled than the nondepressed, had a more negative view of their illness, and used more negative coping strategies. There was no association between depression and childhood adversity. Once disability was controlled for, there continued to be a significant correlation between depression and: (i) viewing the consequences of the illness negatively (Spearman's correlation coefficient [r]=0.37, p=0.003); and (ii) the perceived ability to control the illness (r= -0.26, p=0.04). The relationship between depression and negative coping strategies became insignificant. This study indicates the close relationship between depression and a negative view of the illness.

Extended-spectrum beta-lactamase-producing Klebsiella pneumoniae in a Dublin paediatric hospital

Klebsiella pneumoniae resistant to third-generation cephalosporins and gentamicin was isolated from two patients in a paediatric intensive care unit within a two-week period. The double-disc diffusion test indicated the presence of an extended-spectrum beta-lactamase (ESBL). The unit was closed to admissions, and stringent infection control procedures were implemented. Environmental screening and screening of staff and patients on the unit were commenced. Two weeks later, K. pneumoniae with an identical antibiogram was isolated from the urine of a patient in a different ward. Blood-culture isolates possessed the K16 antigen, while the urine isolate was non-typeable. The isolates were shown to be similar when banding patterns of XbaI chromosomal DNA digests were compared. The resistance to the extended-spectrum cephalosporins was shown to be transferable in association with a large plasmid > 98 mDa. Resistance to gentamicin always co-transferred with beta-lactamase resistance and appeared to be encoded by the same plasmid.

Guanosine tetraphosphate (ppGpp)-mediated inhibition of the activity of the bacteriophage lambda pR promoter in Escherichia coli

It was previously demonstrated that the activity of bacteriophage lambda promoter pR is decreased in wild-type Escherichia coli cells starved for amino acids (during the stringent response). Since pR activity is necessary for the transcriptional activation of ori lambda, this leads to inhibition of the replication of plasmids derived from phage lambda. These results led to the proposal that the pR promoter susceptible to control by the stringent response. However, subsequent studies demonstrated that this promoter is activated by the host dnaA gene product and since the dnaA promoter was reported to be controlled by the stringent response, it is possible that the inhibition of pR activity in amino acid-starved cells is indirect, and results from the impairment of DnaA-mediated transcriptional activation. Here we present evidence that pR is negatively regulated by ppGpp, even when DnaA protein is provided in excess as well as in cells devoid of DnaA function. We have checked that the level of ppGpp is increased during prolonged (up to 4 h) starvation for isoleucine in relA+ cells but not in the relA- mutant. At the same time we observed inhibition of lambda plasmid replication during the stringent, but not relaxed, response, even when DnaA was overproduced. Finally, we found that the activity of a pR-lacZ fusion is inhibited after gratuitously induced overproduction of ppGpp in unstarved cells, irrespective of the status of the dnaA gene product. We conclude that the activity of the pR promoter is inhibited directly by ppGpp.

Control of a nosocomial outbreak of vancomycin resistant Enterococcus faecium in a paediatric oncology unit: risk factors for colonisation

In order to determine the extent of vancomycin resistant enterococcus (VRE) colonisation within a paediatric oncology unit, the risk factors for the acquisition of the organism, the molecular epidemiology of the isolates and the impact of infection control measures, extensive patient and environmental surveillance was undertaken with identification, antibiotic susceptibility testing and pulsed-field gel electrophoresis (PFGE) of all VRE isolates. A matched case control study was carried out. Fourteen patients (19% of screened patients) with VRE colonisation were identified (12 with Enterococcus faecium). All isolates manifested the Van A phenotype. Extensive environmental contamination with VRE was present. PFGE of E. faecium isolates from 10 patients and from five of six environmental cultures revealed patterns suggesting genetic relatedness. Following comparison of the 14 cases with 41 controls matched for age (+/- 4 years) and cohabitation on the oncology unit, risk factors for colonisation with VRE included duration of neutropenia, (OR, 3.72; 95% CI, 1.0-13.1), and antibiotic therapy, (OR, 4.07; 95% CI, 1.08-15.3), the number of antibiotic agents received, (OR, 8.4; 95% CI, 1.34-34.3) and the duration of therapy with amikacin, (OR, 10.7; 95% CI, 1.4-81.5), ceftazidime, (OR, 11.5; 95% CI, 2.2 59.9) or teicoplanin, (OR, 12.3; 95% CI, 2.25-67.4). Implementation of stringent infection control measures reduced environmental contamination from 25% of samples in week 1 to none in week 11. Two additional colonised patients were identified during the subsequent 6 months.

CONCLUSION

Risk factors for VRE colonization in paediatric oncology patients included duration of neutropenia, duration of any antibiotic therapy, exposure to ceftazidime, amikacin or teicoplanin and the number of antibiotics used. The study suggests that environmental contamination played an important role in patient-to-patient transmission of VRE and interventions including implementation of infection control measures were associated with a decreased incidence of gastro-intestinal colonisation.

Guanosine tetra- and pentaphosphate promote accumulation of inorganic polyphosphate in Escherichia coli

High levels of guanosine tetraphosphate (ppGpp) and guanosine pentaphosphate (pppGpp), generated in response to amino acid starvation in Escherichia coli, lead to massive accumulations of inorganic polyphosphate (polyP). Inasmuch as the activities of the principal enzymes that synthesize and degrade polyP fluctuate only slightly, the polyP accumulation can be attributed to a singular and profound inhibition by pppGpp and/or ppGpp of the hydrolytic breakdown of polyP by exopolyphosphatase, thereby blocking the dynamic turnover of polyP. The Ki values of 10 microM for pppGpp and 200 microM for ppGpp are far below the concentrations of these nucleotides in nutritionally stressed cells. In the complex metabolic network of pppGpp and ppGpp, the greater inhibitory effect of pppGpp (compared with ppGpp) leading to the accumulation of polyP, may have some significance in the relative roles played by these regulatory compounds.

Gestational diabetes mellitus: antenatal variables as predictors of postpartum glucose intolerance

OBJECTIVE

To determine whether antepartum variables can predict postpartum glucose intolerance.

METHODS

Glucose tolerance was assessed 6 weeks postpartum in 94 of 238 women with gestational diabetes using a 2-hour, 75-g oral glucose tolerance test (GTT). Selected antepartum variables were analyzed for predictive ability for postpartum glucose intolerance.

RESULTS

Of 238 patients, 94 (39%) returned for a GTT. Those returning and those not returning were similar in all variables. Postpartum glucose intolerance occurred in 34%: impaired glucose tolerance in 18%, overt diabetes in 16%. No single maternal, intrapartum, or neonatal variable was predictive of postpartum glucose intolerance in all cases. Predictive variables included: requirement for insulin (insulin versus diet: 25 versus 3% impaired glucose tolerance, 26 versus 0% diabetes; P = .001), poor glycemic control (any 2-hour postprandial blood sugar level of 150 mg/dL or higher: 34 versus 5% diabetes; P = .005), and the 50-g GTT value (200 mg/dL or higher: 32 versus 6% diabetes; P = .01). For insulin requirement, the relative risk (RR) was 17.28 (95% confidence interval [CI] 2.46-121.45), and for the above three variables combined, the RR was 19.68 (95% CI 2.88-134.2). When the insulin dose was at least 100 U/day, all patients had abnormal glucose tolerance postpartum (RR = 34.00, 95% CI 4.93-234.39).

CONCLUSIONS

Postpartum glucose screening is not warranted for women at low risk who do not require insulin during pregnancy. The incidence of postpartum glucose intolerance in this group is very low. Women with risk factors should receive postpartum screening. Patients receiving at least 100 U/day of insulin have a 100% incidence of postpartum glucose intolerance.

Diabetes in childhood

Insulin-dependent diabetes mellitus is the most common endocrine disorder of childhood. Early diagnosis is important. A multidisciplinary team approach enables families to assume responsibility for self-management. The paediatric diabetes nurse specialist is a key member of the team.

Health after childbirth: a comparison of normal and assisted vaginal delivery

413 women were included in the study: 100 who had had a normal delivery and 313 who had participated in a randomised controlled comparison of forceps or ventouse delivery. The study comprised a questionnaire and assessment at 24-48 hours after delivery and a questionnaire in the second year after delivery. There was significantly more morbidity in the women in the instrumental delivery group compared to women in the normal delivery group at both the early assessment and long-term follow-up.

The nucleotide sequence of recG, the distal spo operon gene in Escherichia coli K-12

A gene is identified in the Escherichia coli K-12 spo operon as recG. Previously identified genes in the spo operon were spoS, alias rpoZ, encoding the omega (omega) subunit of RNA polymerase, as well as the spoT gene encoding the major cellular source of guanosine 3',5'-bispyrophosphate hydrolase activity. The gene order within the spo operon is: spoS (rpoZ), spoT, spoU, recG. A convergent gltS gene is present beyond the spo operon. Mutants bearing recG deletion-insertion alleles display mild sensitivities to both ultraviolet irradiation and to mitomycin C, which is expected to be due to a known recG insertion allele. Deletion-insertion mutations in upstream operon genes (spoT and spoU) show polar effects on these assays of recG function. The deduced 693-amino acid (aa) RecG sequence shows a weak, but significant, relatedness to aa sequence motifs previously reported for putative helicases involved in replication, recombination, and DNA repair.

Effects of in-utero exposure to oral hypoglycaemic drugs

The observation that several Mexican-American women were taking oral hypoglycaemic agents while pregnant led to a study to confirm reports of associations between these agents and congenital abnormalities. 20 non-insulin-dependent (NIDDM) pregnant diabetic women with exposure to oral hypoglycaemic drugs during embryogenesis and 40 pregnant NIDDM women matched for age, race, parity, weight, and glycaemic control but not exposed to oral hypoglycaemic drugs were followed up. 10 infants (50%) in the exposed group had congenital malformations, compared with only 6 (15%) in the control group (p less than 0.002). 5 (25%) infants in the exposed group had ear malformations, anomalies not commonly described in diabetic embryopathy. Hyperbilirubinemia (p less than 0.04), polycythaemia, and hyperviscosity requiring partial exchange transfusions (p less than 0.03) were commoner among babies in the exposed than in the control group. 3 babies in the exposed group but none in the comparison group had severe prolonged neonatal hypoglycaemia lasting 2, 4, and 7 days; 2 of the 3 had been exposed for 22 and 28 weeks during gestation, whereas the third had been exposed throughout the first trimester. Although exposure to oral hypoglycaemic drugs during fetal life seems to be associated with congenital malformations and neonatal hypoglycaemia, a large, prospective study is needed to exclude the confounding effect of maternal metabolic derangement secondary to diabetes.

rhlB, a new Escherichia coli K-12 gene with an RNA helicase-like protein sequence motif, one of at least five such possible genes in a prokaryote

A newly recognized gene we name rhlB, after RNA helicase-like genes, has been found in the 85-minute region of the Escherichia coli chromosome. This gene encodes protein sequence motifs similar to those known for "D-E-A-D box" gene products. Proteins in this gene family occur in eukaryotes as well as prokaryotes, and, as far as tested, have been found to participate in ATP-dependent RNA helicase or RNA-dependent ATPase activities. The functions of these enzymes are poorly understood. In yeast, mutant phenotypes of various D-E-A-D genes suggest that they function in RNA splicing, processing, or translation. We find that rhlB is necessary for viability only in some genetic backgrounds. Conditional rhlB lethality is not complemented by another E. coli RNA helicase-like gene (srmB). Using primers with homology to consensus sequences in D-E-A-D box proteins, we have recovered DNA fragments amplified from E. coli genomic DNA by polymerase chain reactions. Sequence analysis of these fragments suggests that E. coli possesses at least five RNA helicase-like (rhl) D-E-A-D box genes at widely separated chromosomal locations. The multiplicity of such genes in a prokaryote raises the possibility of important roles for the corresponding class of biologically widespread proteins.

Obstetrics without an on site paediatrician

A ten year review (1980-89) of Wexford perinatal statistics is presented. Particular emphasis was placed on neonatal deaths and transfer rates of normally formed infants. Increased visits by paediatricians in the last two years have been associated with an increased neonatal transfer rate to a regional unit 40 miles away. Neonatal mortality rates have not improved, though any beneficial effects on infant morbidity was not assessed. The case for on site paediatric expertise with at least two consultants to provide a continuous service is argued.

Forced relocation of hospitalized psychiatric patients

By virtue of their disability and hospital program requirements, severely and chronically mentally ill patients are subject to involuntary transfer from the community to hospitals, within hospitals, between hospitals, and from hospitals to the community. These forced relocations, no matter how humanely they were initially conceived to be, have become highly routine. The consequence is loss of the sense of the patient as a human being with individual needs. This research elicited the patients' own descriptions and the meanings they attached to the experience of forced relocation. The findings point to the need for greater success of programs designed to keep patients in their home communities to the greatest extent possible. The findings also suggest the need for hospital staff to eliminate or reduce intrahospital transfers and to develop and maintain humane transfer procedures when forced relocation becomes necessary.

Intrahospital relocation of psychiatric patients and effects on aggression

Aggression is a recurring problem with psychiatric patients and can pose special problems on inpatient units. The purpose of this study were to identify changes in patients aggression as a consequence of routine individual relocation and to identify the relationship of certain variables with patterns of aggression. Using an adaptation of the Overt Aggression Scale (Yudofsky, Silver, Jackson, Endicott, & Williams, 1986), data were collected from the patient records of 201 individuals who had been admitted to a state hospital and subsequently transferred to another ward in the same hospital. There was a phase by day interaction with the day-to-day pattern of aggression in the pretransfer phase differing significantly from that in the posttransfer phase. The highest mean aggression for a single day was the day following transfer; the second highest was the day before transfer. There were main effects for age and number of hospital admissions.