Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Unambiguous identification of Ancylostoma caninum and Uncinaria stenocephala in Australian and New Zealand dogs from faecal samples

Hookworms (Ancylostomatidae) are well-known parasites in dogs due to their health impacts and zoonotic potential. While faecal analysis is the traditional method for detection, improvements in husbandry and deworming have decreased their prevalence in urban owned dogs. Drug resistance in Ancylostoma caninum is becoming a discussion point in small animal practices across the region. This study aimed to identify hookworm species present in Australian and New Zealand dogs using molecular techniques. The ITS-2 and isotype-1 β-tubulin assays were used to identify and quantify hookworm species. Results showed absence of coinfection in Australian samples from Greater Sydney region belonging either to A. caninum or Uncinaria stenocephala, while New Zealand samples were a mixture of A. caninum and U. stenocephala. The amplified isotype-1 β-tubulin sequences exhibited susceptibility to benzimidazole drugs. Rare mutations were identified in A. caninum and U. stenocephala sequences, representing a small percentage of reads. This study highlights the importance of molecular techniques in accurately identifying and quantifying hookworm species in dog populations.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Rib fracture fixation in a patient on veno-venous ECMO for severe blunt thoracic trauma

Thoracic chest wall trauma is a common injury in patients admitted to hospital following injury and is associated with high mortality. British Orthopaedic Association Standards for Trauma and Orthopaedics guidelines recommend consideration of rib fracture fixation in patients with flail chest wall injuries with respiratory compromise or uncontrollable pain. Veno-venous extracorporeal membrane oxygenation (ECMO) can be utilised in patients with severe respiratory dysfunction and we present the case of a patient who underwent rib fracture fixation while receiving ECMO. A 32-year-old male was admitted to our department following a 4.5m fall. He sustained significant thoracic injuries with multiple ribs fractures and a flail segment from the right fourth to ninth ribs. Treatment consisted of bilateral chest drains, ECMO support, tracheostomy and rib fracture fixation to the eighth and ninth ribs. The patient made a rapid recovery following surgery and ECMO support was ceased 2.5 days postoperatively. The case shows that a well-prepared, combined specialty surgical team can safely perform rib fixation for a patient on ECMO.

A survey of gastrointestinal nematode species in red deer (Cervus elaphus) farms in New Zealand using PCR

Gastrointestinal nematodes are recognised as an animal health issue for farmed red deer. The aim of this study was to explore the range of species infecting farmed deer herds and their farm-level prevalence in New Zealand. Faecal samples were collected from 12-24-month-old deer (n = 6-26; mean 19) on 59 farms located in the North (n = 25) and South (n = 34) Islands. Sub-samples of faeces were pooled by farm and cultured to recover third stage larvae. Twenty four larvae were randomly selected and identified to species using a multiplex PCR (total = 1217 larvae). At farm-level the most prevalent nematodes were Oesophagostomum venulosum 83% (n = 49) and the deer-specific nematodes in the subfamily Ostertagiinae (=Ostertagia-type) including, Spiculoptera asymmetrica 73% (n = 43), Ostertagia leptospicularis 47% (n = 28), Spiculoptera spiculoptera 47% (n = 28). The recently identified Trichostrongylus askivali was present on 32% (n = 19) of the farms and Oesophagostomum sikae on 17% (n = 10). In the analysis of the total number of larvae identified, the proportion was in similar order, 45% (n = 548) were O. venulosum, 14% (n = 173) S. asymmetrica, 10% (n = 124) S. spiculoptera, 9% (n = 114) O. leptospicularis, T. askivali, 3% (n = 40) and only 2% were O. sikae (n = 20). This study is the first to show the farm-level prevalence of nematode species in deer in New Zealand and the first to use PCR as a diagnostic tool. It provides data consistent with cross-infection from sheep/cattle to deer, and provided tentative insights into the proportions of the main GIN species across the deer population including O. sikae and T. askivali which have only recently been identified in New Zealand.

OP0284 AN AGENT-BASED SIMULATION OF THE EFFECTS OF VARYING TIME TO TREATMENT WITH BIOLOGICAL AGENTS ON PATIENT HEALTH AND COST IN AXIAL SPONDYLOARTHRITIS USING NATIONAL REGISTER DATA

Background:

Evaluating the long-term impacts of healthcare policies on patient’s health and treatment costs for people with axial spondyloarthritis (axSpA) is challenging due to its chronic nature, and the variation in individual patient journeys post-diagnosis. Agent-based simulations are a novel approach to interrogating this complexity, and allow the consequences of different policy scenarios on outcomes to be explored.

Objectives:

Develop and validate an agent-based simulation of the UK axial spondyloarthritis healthcare system, using real-world data.

Interrogate the effects of earlier biologic treatment on costs and patient outcomes.

Methods:

Anonymised data were obtained from the UK National Early Inflammatory Arthritis Audit, and BSR Biologics Register (BSRBR-AS). This provided data on 162 units, and 702 patients with 1,631 patient-years of follow-up. An agent-based model was designed and programmed on the Netlogo platform to simulate patients and units individually over time. New patients were created based on national disease prevalence statistics. Patients’ disease journeys were modelled with a Bath AS Disease Activity Index (BASDAI) score. The model included hospital outpatient attendances, treatment histories, drug costs, and key patient demographics. The baseline simulation was run for two simulated years, repeated 10 times, and assessed against the BSRBR-AS dataset for validation. The model was subsequently used to explore five experimental scenarios in which the time between the date of diagnosis, to first introduction to biologics (d-b) was varied by increasing the number of appointments. The experiment was run 10 times for each parameter setting.

Results:

In the baseline model in a typical two year run, 13,631 new patients attended 5,167 baseline, and 6,966 follow-up appointments. Of these, 6,324 and 623 were prescribed ≥1NSAID, and biologics, respectively. The validation comparison tests showed a high-level of similarity between simulated output and target datasets. In the target data, d-b was 250 days. In the experimental scenarios, as might be expected, earlier biologic access improved outcomes but at higher-costs (Figure 1; Table 1). Reducing d-b to 150 days doubled the number of patients on biologics at 2 years from 623 to 1,286. It also led to 8% more patients achieving a BASDAI of 0 to 2.5 at 2 years, with 5%, 1%, and 2% less patients achieving 2.5 - 5, 5 to 7.5 and 7.5 to 10 BASDAI, respectively. Reducing d-b to 150 days increased drug costs from £3.2 million to £8.8 million. However, the total number of appointments (a proxy for staff costs) increased proportionality less from 16,000 to 20,000.

Table 1.

Influence of varying the time between diagnosis to biologic treatment (d-b) on drug-use and staffing costs

Diagnosis to Biologic (d-b)Drug Costs Unit (£k)Total AppointmentsNo. patients prescribed NSAIDsNo. patients prescribed Biologics1508,79620,3847,1541,2832205,70218,5926,7969712503,25916,2146,3246212602,05414,7005,9683822651,29713,4115,562233Figure 1.

Influence of varying the time between diagnosis to biologic treatment (d-b) on 2 year BASDAI outcome

Conclusion:

We have successfully developed, and validated an agent-based approach to model the effect of key policy changes on the whole healthcare system, providing output estimates of cost and patient outcomes, based on integrated real-world data. To our knowledge this is the first attempt to explore the patient journey in people with axSpA in this way. The model provides a useful tool for exploring the effects of changing the way healthcare is delivered to patients with this disease. Our experimental analysis lends support to the case for increasing staffing and drug expenditure to achieve current NICE standards of care in AS.

Acknowledgments:

Financial support National Axial Spondyloarthritis Society (NASS), data access BSR.

Disclosure of Interests:

Alan Roach Grant/research support from: I was awarded an I-CRP grant from Pfizer for a similar simulation in RA, this was for about £50k and ran from 1/9/15 28/2/17., Ian Scott: None declared, Gary Macfarlane: None declared, Gareth T. Jones Grant/research support from: Pfizer, AbbVie, UCB, Celgene and GSK., Alex MacGregor: None declared

Observations of tissue reactions following neuroradiology interventional procedures

A study has been undertaken over a period of eight years of tissue reactions in interventional radiology patients receiving cumulative air kerma values to their scalp above 3 Gy. Patients receiving doses to the scalp above this trigger level have been followed up to determine when effects occur and to provide reassurance if they do. The study has shown that hair thinning and hair loss are the more likely effects and may occur in 50% of patients at dose above 4.5 Gy.

Twelve tips for clinicians dealing with uncertainty when assessing learners

Clinician educators often experience distress caused by uncertainty regarding how effectively to participate in assessment practices in a way that supports both their programs and their students. Uncertainty is a common state for clinicians, particularly for those who see patients with early or ill-defined illness presentations. While clinicians often feel ill at ease when facing uncertainty in the clinical realm, becoming comfortable with uncertainty and learning to manage such states are now recognized as vital components of clinical practice. Clinicians, as a result, have adopted a series of strategies to lessen the unease that uncertainty can create. While similar experiences plague clinician educators placed in assessment roles, much less attention has been given to how we can support individuals in the education setting. Here, the distress of uncertainty may be greater due to clinician educators having less experience with assessment practices. Fortunately, strategies that are effective in the clinical domain can be translated into the assessment realm to accommodate uncertainty when assessing learners. In this 12 tips article we offer guidance on the translation of such strategies.

Diagnosis of death using neurological criteria in adult patients on extracorporeal membrane oxygenation: Development of UK guidance

The diagnosis of death using neurological criteria is an important legal method of establishing death in the UK. The safety of the diagnosis lies in the exclusion of conditions which may mask the diagnosis and the testing of the fundamental reflexes of the brainstem including the apnoea reflex. Extracorporeal membrane oxygenation for cardiac or respiratory support can impact upon these tests, both through drug sequestration in the circuit and also through the ability to undertake the apnoea test. Until recently, there has been no nationally accepted guidance regarding the conduct of the tests to undertake the diagnosis of death using neurological criteria for a patient on extracorporeal membrane oxygenation. This article considers both the background to and the process of guideline development.

The effect of mid-lactation treatment with topically applied eprinomectin on milk production in nine New Zealand dairy farms

The New Zealand dairy industry has shown little interest in exploring the impact of gastrointestinal parasitism on productivity in adult dairy cattle and as a consequence there has been little research completed. A randomised clinical trial was conducted to evaluate the effect of mid-lactation anthelmintic treatment on milk production under the extensive New Zealand pastoral dairying system. A random sample of cows from nine commercial dairy herds in the Manawatu region of New Zealand was treated once with pour-on eprinomectin at the dose rate of 0.5mg/kg during the afternoon milking in the period 6 Jan 2013 to 24 Jan 2013. The treatment cows (n=540) were matched to control cows (n=540) within their respective herds and the change in milk production, recorded at the first two herd tests after treatment, was analysed using a linear mixed effects model. The study found a small but significant increase in energy corrected milk production of 0.35kg/day (95% CI 0.05-0.64) at the first and second herd tests after treatment. There were no significant interactions found between treatment and age or between treatment and the bulk tank Ostertagia antibody ELISA ODR indicating that the beneficial response to eprinomectin treatment appeared independent of age of animal or ODR result. A concurrent North Island drought may have affected the response to treatment. Even so, the small effect of eprinomectin treatment on milk production found in this trial is, we believe, not sufficient to advocate whole herd treatment of dairy cows in New Zealand.

Adherence to guideline-based antibiotic treatment for acute exacerbations of chronic obstructive pulmonary disease in an Australian tertiary hospital

BACKGROUND

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are an important cause of acute hospital admissions and incur significant costs, which include antibiotic costs.

AIMS

This study aimed to (i) define antibiotic prescribing practice in patients admitted to a tertiary hospital with AECOPD and compare this with current locally and nationally recognised antibiotic prescribing guidelines and (ii) correlate variations in guideline-concordant antibiotic prescribing with mean length of stay (LOS) and rates of unplanned readmission to hospital.

METHODS

Retrospective case series of 84 consecutive patients with uncomplicated AECOPD who met pre-specified selection criteria.

RESULTS

Seventy-two of 84 participants (85.7%) received guideline-discordant antibiotics, of whom the majority (76%) received intravenous antibiotics. Mean LOS was significantly lower among patients receiving guideline-concordant therapy compared with those receiving guideline-discordant therapy (mean 1.6 days vs 3.7 days; P = 0.002). There was no significant difference between groups in rates of readmission. Estimated excess costs per patient associated with guideline-discordant therapy equalled $2642 which, if eliminated, would save approximately $300 000 per annum.

CONCLUSION

In a tertiary hospital, Australian guidelines for treating patients with an AECOPD were rarely followed. The use of guideline-discordant therapy resulted in longer hospital stays and incurred greater costs. Studies are required to determine the reasons behind such discordant practice and to develop initiatives to improve antibiotic prescribing.

Anthelmintic resistance in equine helminth parasites - a growing issue for horse owners and veterinarians in New Zealand?

There is growing concern that given the high frequency with which anthelmintics are being administered to many horses, anthelmintic resistance amongst equine helminth populations will be an increasing problem, rendering many of the currently available products unusable with little prospect of new products becoming available, at least in the near future. Worldwide, much reliance has been placed on the macrocyclic lactone (ML) group of anthelmintics, but resistance has been reported to these products as well as to the two other major anthelmintic classes used in this species, the benzimidazoles (BZ) and the tetrahydropyrimidines (e.g. pyrantel). In New Zealand, resistance has been reported to the ML and BZ groups, but not yet to pyrantel. As an alternative to interval-based anthelmintic regimens, the highly overdispersed nature of parasite populations in horses can be utilised to decide whether treatment is required, based on whether or not animals exceed a predetermined level of shedding of parasite eggs. If well managed, such a targeted and selective approach can be utilised to eliminate the majority of egg output whilst still providing a refuge for susceptible parasites to persist. Such a system would require that an adequate standard of monitoring be in place and cognisance needs to be taken of parasites or their lifecycle stages that cannot be diagnosed by routine methods. At the same time, using anthelmintics with high levels of efficacy, avoiding practices such as under-dosing, as well as utilising non-chemical means of parasite control when possible, e.g. regular removal of faeces from pasture, should all be considered. Combinations of anthelmintics, specifically of anthelmintics that target the same or a similar spectrum of parasite species, should play an important role in parasite control in horses. As well as providing arguably the highest levels of efficacy, combinations may also slow the rate at which anthelmintic resistance develops.

Ventral dermatitis in rowi (Apteryx rowi) due to cutaneous larval migrans

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Rowi on a crèche island showed loss of feathers and dermatitis.

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We identified cutaneous larval migrans, possibly due to Trichostrongylus.

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This is the first instance of cutaneous larval migrans to be recorded in birds.

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Fatal complications resulted in the death of eight birds from aspergillosis.

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Intensive conservation management can result in pathways for novel infections.

The rowi is a critically endangered species of kiwi. Young birds on a crèche island showed loss of feathers from the ventral abdomen and a scurfy dermatitis of the abdominal skin and vent margin. Histology of skin biopsies identified cutaneous larval migrans, which was shown by molecular sequencing to be possibly from a species of Trichostrongylus as a cause of ventral dermatitis and occasional ulcerative vent dermatitis. The predisposing factors that led to this disease are suspected to be the novel exposure of the rowi to parasites from seabirds or marine mammals due to the island crèche and the limited management of roost boxes. This is the first instance of cutaneous larval migrans to be recorded in birds. Severe and fatal complications of the investigation resulted in the death of eight birds of aspergillosis and pulmonary complications associated with the use of bark as a substrate in hospital. Another bird died of renal failure during the period of hospitalisation despite oral and intravenous fluid therapy. The initiating cause of the renal failure was not determined. These complications have the potential to undermine the working relationship between wildlife veterinarians and conservation managers. This case highlights that intensive conservation management can result in increased opportunities for novel routes of cross-species pathogen transmission.

Lack of efficacy of monepantel against Teladorsagia circumcincta and Trichostrongylus colubriformis

After reports of the apparent failure of monepantel to reduce the egg counts of goats on a farm in the lower North Island of New Zealand, faecal egg count reduction tests were conducted in goats and lambs resident on the property, and a confirmatory, slaughter study was conducted using 12 sheep, sourced elsewhere, that were grazed on the farm for approximately 5 weeks. In the egg count reduction test in goats, 8 animals were given monepantel at 3.9 mg/kg (just over 1.5× the sheep dose rate of 2.5mg/kg), whilst four received 7.7 mg/kg (just over 3× the sheep dose). In the egg count reduction test in sheep, 15 lambs were treated with 3.0mg/kg of monepantel. For the confirmatory study, the sheep were housed indoors for 2 weeks before half were treated with 2.9 mg/kg monepantel and the animals were killed for worm counts 9 days later. There was no evidence of efficacy in either egg count reduction test, or in the goats, the two dose rates used appeared equally ineffective. Likewise, there were no significant reductions in egg counts or worm burdens in the slaughter study. Monepantel was ineffective against at least two gastrointestinal nematode species, Teladorsagia circumcincta and Trichostrongylus colubriformis. These findings represent the first report from the field of resistance having developed to the anthelmintic monepantel with severe resistance developing in more than one species after being administered on 17 separate occasions to different stock classes and in less than 2 years of the product first being used on the farm in question.

Informing future research priorities into the psychological and social problems faced by cancer survivors: a rapid review and synthesis of the literature

PURPOSE

To establish what is known regarding the psychological and social problems faced by adult cancer survivors (people who are living with and beyond a diagnosis of cancer) and identify areas future research should address.

METHOD

A rapid search of published literature reviews held in electronic data bases was under taken. Inclusion and exclusion criteria, and removal of duplicated papers, reduced the initial number of papers from 4051 to 38. Twenty-two review papers were excluded on grounds of quality and 16 review papers were selected for appraisal.

RESULTS

The psychological and social problems for cancer survivors are identified as depression, anxiety, distress, fear of recurrence, social support/function, relationships and impact on family, and quality of life. A substantial minority of people surviving cancer experience depression, anxiety, and distress or fear associated with recurrence or follow up. There is some indication that social support is positively associated with better outcomes. Quality of life for survivors of cancer appears generally good for most people, but an important minority experience a reduction in quality of life, especially those with more advanced disease and reduced social and economic resources. The majority of research knowledge is based on women with breast cancer. The longer term implications of cancer survival have not been adequately explored.

CONCLUSIONS

Focussing well designed research in the identified areas where less is already known about the psychological and social impact of cancer survival is likely to have the greatest impact on the wellbeing of people surviving cancer.

Characterization of three novel HLA alleles with silent nucleotide substitutions

Characterization of the novel HLA alleles B*35:11:03, B*42:01:03, and B*51:01:35 is described.

Characterization of a novel allele, HLA-B*15:228

B*15:228 differs from B*15:01:01:01 at three nucleotides in exon 4.

Quality of drug prescribing in older patients: is there a problem and can we improve it?

Older patients are at high risk of suboptimal prescribing (overuse, underuse and misuse of drugs), which can lead to serious adverse drug reactions (ADR). About one in four patients admitted to hospital are prescribed at least one inappropriate medication and up to 20% of all inpatient deaths are attributed to potentially preventable ADR. Lists of drugs to avoid (unnecessary or where risks outweigh benefits) and drugs not to be omitted (strong indications if there are no contraindications) can assist in identifying suboptimal prescribing although, to date, no trials have established the ability of such screening, by itself, to improve prescribing quality. Remedial strategies proven to be effective in randomized trials include detailed appraisal of medication lists by multidisciplinary teams, which involve geriatricians and close liaison with specialist clinical pharmacists. A multifaceted quality improvement strategy is proposed that includes an aspirational target of no more than five different drugs be regularly prescribed to vulnerable older patients. Achieving this target involves prioritizing drug selection on the basis of strength of indication which may run counter to current disease-specific clinical guideline recommendations based on trials that have excluded most older patients. Such a strategy is worthy of further evaluation in a multicentre randomized trial.

Objective assessment of the alterations in wrist mobility with the fastrak(®) system following dorsal capsulodesis

The treatment for scapholunate dissociation is challenging and its management is varied depending on type, severity and duration of injury, and surgeon's preferred technique. This study aimed to objectively assess the variations in the range and patterns of wrist movements using the Fastrak(®) system in patients having undergone Blatt's dorsal capsulodesis (BDC). The wrist movements were successively measured between the operated and unoperated wrists, while the patients performed set tasks. Seventeen patients agreed to participate in the study. Following BDC the mean flexion loss was 23° (range 10°-38°). However, functional tasks revealed that the BDC did not adversely affect the function of the operated wrist. This novel study demonstrates objectively the functional restrictions that patients are likely to experience postoperatively following BDC. It would be interesting to note the pattern of wrist motion using the Fastrak(®) system in various other clinical settings.

What are the most effective strategies for improving quality and safety of health care?

There is now a plethora of different quality improvement strategies (QIS) for optimizing health care, some clinician/patient driven, others manager/policy-maker driven. Which of these are most effective remains unclear despite expressed concerns about potential for QIS-related patient harm and wasting of resources. The objective of this study was to review published literature assessing the relative effectiveness of different QIS. Data sources comprising PubMed Clinical Queries, Cochrane Library and its Effective Practice and Organization of Care database, and HealthStar were searched for studies of QIS between January 1985 and February 2008 using search terms based on an a priori QIS classification suggested by experts. Systematic reviews of controlled trials were selected in determining effect sizes for specific QIS, which were compared as a narrative meta-review. Clinician/patient driven QIS were associated with stronger evidence of efficacy and larger effect sizes than manager/policy-maker driven QIS. The most effective strategies (>10% absolute increase in appropriate care or equivalent measure) included clinician-directed audit and feedback cycles, clinical decision support systems, specialty outreach programmes, chronic disease management programmes, continuing professional education based on interactive small-group case discussions, and patient-mediated clinician reminders. Pay-for-performance schemes directed to clinician groups and organizational process redesign were modestly effective. Other manager/policy-maker driven QIS including continuous quality improvement programmes, risk and safety management systems, public scorecards and performance reports, external accreditation, and clinical governance arrangements have not been adequately evaluated with regard to effectiveness. QIS are heterogeneous and methodological flaws in much of the evaluative literature limit validity and generalizability of results. Based on current best available evidence, clinician/patient driven QIS appear to be more effective than manager/policy-maker driven QIS although the latter have, in many instances, attracted insufficient robust evaluations to accurately determine their comparative effectiveness.

Effects of Teladorsagia (Ostertagia) circumcincta infection on lambs selected for high fleece weight

The physiological processes leading to the expression of the resilient phenotype, which allow animals to maintain a relatively higher production level during infection, have been investigated in lambs from a closed flock selected for 40 generations for high fleece weight (HFW), but with higher FEC and worm burdens than their unselected control (C) flock run in parallel. After recovery from surgery to implant abomasal cannulae, eight parasite-naive lambs from each flock were infected intraruminally at 4.5 months-of-age with 50,000 Teladorsagia circumcincta L3. Blood, abomasal fluid and faecal samples were collected daily for measurement of serum gastrin and pepsinogen concentrations, blood eosinophils, abomasal pH and FEC. Four lambs from each flock were euthanased on Day 8 post-infection and the other four on Day 28 post-infection. At necropsy, abomasal contents and tissues were collected for worm counts, abomasal lymph nodes and fundic tissue for cytokine gene expression and fundic tissue for histopathology. Expression of resilience appeared to be age-dependent as there were no significant differences in either FEC or worm burden between lambs from the two flocks, unlike older HFW lambs in a previous study. Abomasal secretion did not differ between flocks. Histopathological changes were typical of parasitism: inflammatory cells, mainly eosinophils and lymphocytes, were numerous in nodular areas and there were fewer TGF-alpha positive parietal cells, many of which were vacuolated. By Day 28 p.i., globule leucocytes were present. Mucosal thickness was significantly greater on Day 8 than Day 28 p.i. (p=0.000) and in C than HFW lambs. There were fewer parietal cells on Day 28 than on Day 8 p.i. (p=0.003) for pooled data. Circulating eosinophil counts increased moderately in both groups, significantly less in the HFW lambs. Fewer tissue and blood eosinophils in the HFW than C group on Day 8 p.i. were consistent with cytokine gene expression patterns, particularly lower IL-5 levels. Worm count decreased by 90% by Day 28 p.i., along with declining tissue eosinophil counts and IL-13 gene expression and increasing IL-10 and IL-4 gene expression. Food intake was depressed less in the HFW lambs, suggesting that maintenance of appetite could be an important aspect of the physiological basis for resilience. Although the resilient phenotype was not apparent at the younger age, lesser effects on food intake, differences in ALN cytokine profiles and lower blood and tissue eosinophil numbers in the HFW lambs may lead to the expression of resilience when older.

Randomized controlled trial of intubation with the McGrath Series 5 videolaryngoscope by inexperienced anaesthetists

BACKGROUND

The McGrath Series 5 videolaryngoscope might reduce the incidence of unexpected difficult tracheal intubation. If it also performs as well as a standard laryngoscope during uncomplicated intubations, there would be an argument for the McGrath to become the laryngoscope of choice in higher risk settings, such as rapid sequence induction by inexperienced anaesthetists. Therefore, we compared the McGrath and the Macintosh laryngoscopes during routine tracheal intubation performed by inexperienced anaesthetists.

METHODS

Single-blind randomized controlled trial with 120 adult patients allocated to intubation by first-year anaesthetic trainees, using a McGrath or Macintosh laryngoscope. The primary outcome was time to intubation. Secondary outcomes were quality of view at laryngoscopy and evidence of differential learning between using the two laryngoscopes. A Cox proportional hazards model was used to determine the effect of the laryngoscopes on time to intubation.

RESULTS

Duration of intubation was significantly longer (P<0.001) in the McGrath group [median (IQR); 47.0 (39.0-60.0) vs 29.5 (23.0-36.8) s]. There were no significant differences in other outcomes, including grade of laryngoscopy view, visual confirmation of tube placement, number of laryngoscopies, or complications (oesophageal intubation, hypoxaemia, and airway trauma). There was no differential learning effect.

CONCLUSIONS

There were no advantages to using the McGrath laryngoscope for uncomplicated tracheal intubation and duration of intubation was longer, so it should not be used as a first-line laryngoscope instrument by inexperienced anaesthetists.

Who visits mobile UK services providing cancer information and support in the community?

People can access a variety of sources of information and support when they have questions about cancer according to their needs. There are various sources of information and support for cancer beyond the health-care setting. In this study, we set out to assess reasons for visiting two mobile cancer information and support services in the UK during 2006. Data were collected about each visitor by staff on the mobile services. The two mobiles travelled to 109 UK locations over a 7-month period. Fifty-nine per cent of visitors were women. Thirty-one per cent of visitors had (had) cancer; very few were still undergoing treatment. For 95% of visitors the visit had been spontaneous rather than pre-planned, and 89% of visits lasted <15 min. Most visitors required information or support for themselves, but a third requested information for someone else. A quarter of enquiries were about cancer prevention and early detection (e.g. screening, genetic testing, lifestyle). The mobiles appear to serve an important function in providing information and support in the community where visitors can drop in for an informal conversation with trained members of staff to ask questions and receive support in relation to cancer.

Correlation of gene and mediator expression with clinical endpoints in an acute interleukin-1beta-driven model of joint pathology

OBJECTIVE

Interleukin-1beta (IL-1beta) plays a key role in the pathogenesis of chronic joint diseases, including osteoarthritis (OA), and drives a cascade of inflammatory and destructive responses within the synovial joint. Animal models of arthritis support the role of IL-1beta in joint pathology, however, the molecular changes downstream of IL-1beta are poorly understood in vivo. This study aimed to evaluate the intra-articular (i.a.) injection of IL-1beta in the rat joint as an acute model of joint disease and associate gene and mediator expression with clinical endpoints and pathological changes.

METHODS

The effects of i.a. administration of a pathologically relevant dose of IL-1beta on joint swelling, mechanical hyperalgesia, histopathology, gene expression and biochemical changes were measured from 2 to 24h.

RESULTS

IL-1beta-induced joint swelling and mechanical hyperalgesia. Gene expression analysis of joint tissue and biochemical analysis of joint lavage fluid identified pro-inflammatory and destructive mediators induced by IL-1beta. Histopathology of joint tissues showed evidence of synovitis and connective tissue inflammation, but not cartilage destruction. However, biochemical analysis of glucosaminoglycan levels in joint lavage fluids indicated cartilage breakdown and might be a sensitive marker of cartilage pathology.

CONCLUSIONS

Intra-articular injection of IL-1beta is a reproducible acute model of joint pathology that is potentially useful to evaluate IL-1 pathway inhibitors. The correlation of molecular events with clinical and pathological changes in this model has enhanced the understanding of the role of IL-1beta in joint disease. Methods developed for gene expression analysis using multi-gene microfluidics cards and for biochemical analysis of joint lavage fluid might have utility for characterisation of other arthritis models and corresponding human disease.