Defence Medical Services' REBOA training course

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) enables temporary haemorrhage control and physiological stabilisation. This article describes the bespoke Defence Medical Services (DMS) training package for effectively using REBOA. The article covers how the course was designed, how the key learning objectives are taught, participant feedback and the authors' perceptions of future training challenges and opportunities. Since the inaugural training course in April 2019, the authors have delivered six courses, training over 100 clinicians. For the first time in the UK DMS, we designed and delivered a robust specialist endovascular training programme, with demonstrable, significant increases in confidence and competence. As a result of this course, the first DMS REBOA-equipped forward surgical teams deployed in June 2019. Looking to the future, there is a requirement to develop an assessment of skill retention and the potential need for revalidation.

Pedi-R-MAPP | the development, testing, validation, and refinement of a digital nutrition awareness tool

BACKGROUND & AIMS

The Remote Malnutrition Application (R-MAPP) was developed during the COVID-19 pandemic to provide support for health care professionals (HCPs) working in the community to complete remote nutritional assessments and provide practical guidance for nutritional care. R-MAPP was adapted into Pediatric Remote Malnutrition Application (Pedi-R-MAPP) using a modified Delphi consensus, with the goal of providing a structured approach to completing a nutrition focused assessment as part of a technology enabled care service (TECS) consultation. The aim of this study was to develop and validate a digital version of Pedi-R-MAPP using the IDEAS framework (Integrate, Design, Assess and Share).

METHODS

A ten-step process was completed using the IDEAS framework. This involved the four concept processes; Stage-1, Integrate (Step 1-3) identify the problem, specify the goal, and use an evidence-based approach. Stage-2, (Step 4-7) design iteratively and rapidly with user feedback. Stage 3, (Step 8-9) Assess rigorously, and Stage 4 (Step 9-10) publish and launch of the tool.

RESULTS

Stage 1:Evidence-based development, Pedi-R-MAPP was developed using Delphi consensus methodology. Stage 2:Iteration & design, HCPs (n = 22) from UK, Europe, South Africa, and North America were involved four workshops to further develop a paper prototype of the tool and complete small-scale testing of a beta version of the tool which resulted in eight iterations. Stage 3:Assess rigorously, Small scale retrospective testing of the tool on children with congenital heart disease (n = 80) was completed by a single researcher, with iterative changes made to improve agreement with summary advice. Large scale testing amongst (n = 745) children in different settings was completed by specialist paediatric dietitians (n = 15) advice who recorded agreement with the summary advice compared with their own clinical assessment. Paediatric dietitians were in overall agreement with the summary advice in the tool 86% (n = 640), compared to their own clinical practice. The main reasons for disagreement were i) frequency of planned review 57.1% (n = 60/105), ii) need for ongoing dietetic review due to chronic condition 20.0% (n = 21/105), iii) disagreement with recommendation for discharge 16.2% (n = 17/105) and iv) concerns with faltering growth and/or need for condition specific growth charts 6.7% (7/105). Iterative changes were made to the algorithm, leading to an improvement in agreement of the summary advice on re-evaluation to 98% (p=<0.0001).

CONCLUSION

A digital version of the Pedi-R-MAPP nutrition awareness tool was developed using the IDEAS framework. The summary advice provided by the tool achieved a high level of agreement when compared to paediatric dietetic assessment, by providing a structured approach to completing a remote nutrition focused assessment, along with identifying the frequency of follow-up or an in-person assessment.

Prevalence of multiple risk factors for poor outcomes associated with COVID-19 among an elderly Australian population

BACKGROUND AND OBJECTIVES

Increasing age, male sex and various chronic conditions have been identified as important risk factors for poor outcomes from COVID-19. The aim of this study was to examine the prevalence of risk factors for poor outcomes due to COVID-19 infection in an older population.

METHOD

The proportion of the population with one or more risk factors and the prevalence of individual risk factors and multiple risk factors were calculated among Department of Veterans' Affairs (DVA) clients aged ≥70 years.

RESULTS

There were 103,422 DVA clients included. Of these, 79% in the community and 82% in residential aged care had at least one risk factor for poor outcomes from COVID-19. Hypertension was most prevalent, followed by chronic heart and airways disease. Over half had ≥2 risk factors, and one in five had ≥3 risk factors across multiple body systems.

DISCUSSION

A substantial proportion of older Australians are at risk of poor outcomes from COVID-19 because of their multimorbid risk profile. These patients should be prioritised for proactive monitoring to avoid unintentional harm due to potential omission of care during the pandemic.

Biological variation of cardiac troponins in chronic kidney disease

Background

Patients with chronic kidney disease often have increased plasma cardiac troponin concentration in the absence of myocardial infarction. Incidence of myocardial infarction is high in this population, and diagnosis, particularly of non ST-segment elevation myocardial infarction (NSTEMI), is challenging. Knowledge of biological variation aids understanding of serial cardiac troponin measurements and could improve interpretation in clinical practice. The National Academy of Clinical Biochemistry (NACB) recommended the use of a 20% reference change value in patients with kidney failure. The aim of this study was to calculate the biological variation of cardiac troponin I and cardiac troponin T in patients with moderate chronic kidney disease (glomerular filtration rate [GFR] 30–59 mL/min/1.73 m2).

Methods and results

Plasma samples were obtained from 20 patients (median GFR 43.0 mL/min/1.73 m2) once a week for four consecutive weeks. Cardiac troponin I (Abbott ARCHITECT® i2000SR, median 4.3 ng/L, upper 99th percentile of reference population 26.2 ng/L) and cardiac troponin T (Roche Cobas® e601, median 11.8 ng/L, upper 99th percentile of reference population 14 ng/L) were measured in duplicate using high-sensitivity assays. After outlier removal and log transformation, 18 patients’ data were subject to ANOVA, and within-subject (CVI), between-subject (CVG) and analytical (CVA) variation calculated. Variation for cardiac troponin I was 15.0%, 105.6%, 8.3%, respectively, and for cardiac troponin T 7.4%, 78.4%, 3.1%, respectively. Reference change values for increasing and decreasing troponin concentrations were +60%/–38% for cardiac troponin I and +25%/–20% for cardiac troponin T.

Conclusions

The observed reference change value for cardiac troponin T is broadly compatible with the NACB recommendation, but for cardiac troponin I, larger changes are required to define significant change. The incorporation of separate RCVs for cardiac troponin I and cardiac troponin T, and separate RCVs for rising and falling concentrations of cardiac troponin, should be considered when developing guidance for interpretation of sequential cardiac troponin measurements.

Association between native T1 mapping of the kidney and renal fibrosis in patients with IgA nephropathy

Introduction

IgA nephropathy (IgAN) is the commonest global cause of glomerulonephritis. Extent of fibrosis, tubular atrophy and glomerulosclerosis predict renal function decline. Extent of renal fibrosis is assessed with renal biopsy which is invasive and prone to sampling error. We assessed the utility of non-contrast native T1 mapping of the kidney in patients with IgAN for assessment of renal fibrosis.

Methods

Renal native T1 mapping was undertaken in 20 patients with IgAN and 10 healthy subjects. Ten IgAN patients had a second scan to assess test-retest reproducibility of the technique. Native T1 times were compared to markers of disease severity including degree of fibrosis, eGFR, rate of eGFR decline and proteinuria.

Results

All patients tolerated the MRI scan and analysable quality T1 maps were acquired in at least one kidney in all subjects. Cortical T1 times were significantly longer in patients with IgAN than healthy subjects (1540 ms ± 110 ms versus 1446 ± 88 ms, p = 0.038). There was excellent test-retest reproducibility of the technique, with Coefficient-of-variability of axial and coronal T1 mapping analysis being 2.9 and 3.7% respectively. T1 correlated with eGFR and proteinuria (r = − 0.444, p = 0.016; r = 0.533, p = 0.003 respectively).

Patients with an eGFR decline > 2 ml/min/year had increased T1 times compared to those with a decline < 2 ml/min/year (1615 ± 135 ms versus 1516 ± 87 ms, p = 0.068), and T1 time was also higher in patients with a histological ‘T’-score of > 0, compared to those with a ‘T’-score of 0 (1575 ± 106 ms versus 1496 ± 105 ms, p = 0.131), though not to significance.

Conclusions

Cortical native T1 time is significantly increased in patients with IgAN compared to healthy subjects and correlates with markers of renal disease. Reproducibility of renal T1 mapping is excellent. This study highlights the potential utility of native T1 mapping in IgAN and other progressive nephropathies, and larger prospective studies are warranted.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1447-2) contains supplementary material, which is available to authorized users.

Systematic review of prehospital haemostatic dressings

Introduction

Haemorrhage is one of the leading causes of battlefield and prehospital death. Haemostatic dressings are an effective method of limiting the extent of bleeding and are used by military forces extensively. A systematic review was conducted with the aim of collating the evidence on current haemostatic products and to assess whether one product was more effective than others.

Methods

A systematic search and assessment of the literature was conducted using 13 health research databases including MEDLINE and CINAHL, and a grey literature search. Two assessors independently screened the studies for eligibility and quality. English language studies using current-generation haemostatic dressings were included. Surgical studies, studies that did not include survival, initial haemostasis or rebleeding and those investigating products without prehospital potential were excluded.

Results

232 studies were initially found and, after applying exclusion criteria, 42 were included in the review. These studies included 31 animal studies and 11 clinical studies. The outcomes assessed were subject survival, initial haemostasis and rebleeding. A number of products were shown to be effective in stopping haemorrhage, with Celox, QuikClot Combat Gauze and HemCon being the most commonly used, and with no demonstrable difference in effectiveness.

Conclusions

There was a lack of high-quality clinical evidence with the majority of studies being conducted using a swine haemorrhage model. Iterations of three haemostatic dressings, Celox, HemCon and QuikClot, dominated the studies, probably because of their use by international military forces and all were shown to be effective in the arrest of haemorrhage.

Is there long-term value of pathology scoring in immunoglobulin A nephropathy? A validation study of the Oxford Classification for IgA Nephropathy (VALIGA) update

Background

It is unknown whether renal pathology lesions in immunoglobulin A nephropathy (IgAN) correlate with renal outcomes over decades of follow-up.

Methods

In 1130 patients of the original Validation Study of the Oxford Classification for IgA Nephropathy (VALIGA) cohort, we studied the relationship between the MEST score (mesangial hypercellularity, M; endocapillary hypercellularity, E; segmental glomerulosclerosis, S; tubular atrophy/interstitial fibrosis, T), crescents (C) and other histological lesions with both a combined renal endpoint [50% estimated glomerular filtration rate (eGFR) loss or kidney failure] and the rate of eGFR decline over a follow-up period extending to 35 years [median 7 years (interquartile range 4.1–10.8)].

Results

In this extended analysis, M1, S1 and T1–T2 lesions as well as the whole MEST score were independently related with the combined endpoint (P &lt; 0.01), and there was no effect modification by age for these associations, suggesting that they may be valid in children and in adults as well. Only T lesions were associated with the rate of eGFR loss in the whole cohort, whereas C showed this association only in patients not treated with immunosuppression. In separate prognostic analyses, the whole set of pathology lesions provided a gain in discrimination power over the clinical variables alone, which was similar at 5 years (+2.0%) and for the whole follow-up (+1.8%). A similar benefit was observed for risk reclassification analyses (+2.7% and +2.4%).

Conclusion

Long-term follow-up analyses of the VALIGA cohort showed that the independent relationship between kidney biopsy findings and the risk of progression towards kidney failure in IgAN remains unchanged across all age groups and decades after the renal biopsy.

Global perspectives on the provision of diabetic retinopathy screening and treatment: Survey of health care professionals in 41 countries

AIM

To assess the level of awareness and provision of screening and treatment for Diabetic Eye Disease (DED) comprising Diabetic Retinopathy (DR) and Diabetic Macular Edema (DME) among health care professionals.

METHODS

The study was conducted in two phases. The first phase consisted of a qualitative study, based on semi-structured face-to-face and telephone interviews in 8 countries. The second phase used a quantitative approach utilising online surveys in 41 countries. The survey for health care professionals comprised of 43 questions covering provider information, practice characteristics, management of adults with diabetes and specific information from ophthalmologists on screening and treatments for DR.

RESULTS

There were 2329 health care professionals who participated in the online survey. More than one third of diabetes specialists surveyed reported that they did not discuss eye care with their diabetes patients. Nearly two-thirds of all health care professionals surveyed reported that they had written information about diabetes for patients available in their practice. Only one in five (22%, n = 58) primary care providers reported they had material that contained sufficient information on eye complications, and 37% (n = 252) of ophthalmologists reported that they had sufficient information on eye complications. Sixty-five percent (n = 378) of ophthalmologists reported that most of their patients presented when visual problems had already occurred. Six percent (n = 36) stated that most of their patients presented when it was already too late for effective treatment. The most substantial barriers to eye health mentioned by health care professionals responding to the survey were: a patients' lack of knowledge and/or awareness about eye complications (43%), followed by lack of importance given to eye examinations by patients (33%), and the high cost of care (32%). Ophthalmologists also reported late screening (66%), and lack of patient education materials (55%) as obstacles for improving eye health outcomes.

CONCLUSION

Health care professionals need to be appropriately supported and trained so they can provide adults with diabetes with information about the risks of DR, support them in reducing their risk, and advocate for the provision of affordable DR screening and treatment as required.

4 Use of topical haemostatic dressings in an extended field care model of external haemorrhage

Introduction

The use of Celox gauze has been established in military practice as an adjunct in the treatment of external haemorrhage. The future character of conflict means that casualties may take longer to reach definitive care. The aim of this study was to test whether Celox Rapid, a topical haemostatic dressing, would maintain haemostasis during extended use in a junctional haemorrhage model.

Methods

An anaesthetised swine underwent simultaneous bilateral femoral arteriotomies; after 30 s of free bleeding Celox Rapid gauze was applied to the wound and pressure was maintained for 1 min. Following inspection for re-bleeding the Celox gauze was covered with standard field dressings and checked for re-bleeding every hour until the 6 hours had elapsed or the animal deceased.

Results

There was no evidence of re-bleeding at any point up to and including 6 hours. The animal was declared deceased shortly afterwards. Celox Rapid gauze maintained haemostasis in extended use in this limited single animal model. Post mortem examination revealed a stable clot at the site of the arteriotomy with no evidence of re-bleeding.

Conclusion

Celox Rapid was effective at achieving initial homeostasis and preventing re-bleeding in this limited study using a single anaesthetised swine. Its potential for use in situations where evacuation and definitive care may be delayed should be explored.

The Diabetic Retinopathy Barometer Study: Global perspectives on access to and experiences of diabetic retinopathy screening and treatment

AIM

To assess the level of awareness, prevention and treatment of Diabetic Eye Disease (DED) comprising Diabetic Retinopathy (DR) and Diabetic Macula Edema (DME) retinopathy among adults with diabetes and health professionals.

METHODS

The Diabetic Retinopathy Barometer Study consisted of a qualitative study, which consisted of semi-structured interviews, and a quantitative study using online surveys for adults with diabetes and for health professionals.

RESULTS

A total of 4340 adults with diabetes and 2329 health professionals participated in the surveys. Diabetic eye disease (DED) without macular edema (DME) was reported by 19.5% of adults with diabetes and a further 7.6% reported that they had DME. Although 94% of adults with diabetes saw a health care professional for their diabetes, only 79% had ever had an eye examination for DED, and 23% had not had an eye examination in the last year. Moreover, 65% of the ophthalmologists surveyed reported that most patients presented when visual problems had already occurred. Overall, 62% of people with DED had received treatment. Of these, 74% had laser therapy, 29% surgery and 24% anti-VEGF therapy.

CONCLUSION

Strategic investment is required to enhance patient education and professional training on the importance of regular eye examinations; and in providing accessible DR screening programmes and proactive treatments.

"I live in a bubble": Speech-language therapy and audiology students' expectations and experiences of a rural community work practicum

INTRODUCTION

Locally and internationally, there have been renewed calls for equitable access to healthcare services. Simultaneously, caseloads have become more challenging and contexts more complex, which may be overwhelming to new graduates. The South African context offers a particularly interesting example of these challenges. Educators need to use innovative ways to ensure that curricula adequately prepare students for rural community work, while developing a sense of leadership that links clinical practice to theory, policy, ethics and social responsibility. Rural practica offer opportunities for sensitizing and equipping students for working in underserviced communities and a number of international studies have documented their potential usefulness. There is limited research, however, that examines how exposure to rural community work may shape students' responses to the realities of working in such contexts. This study aimed to explore the processes underlying a group of South African speech-language therapy and audiology students' appreciation and understanding of the realities of work in a rural community after a rural practicum.

METHODS

A four-day practicum took place in a rural community in South Africa. The practicum incorporated basic audiological tasks and structured observations. Twenty-five third-year students completed anonymous pre- and post-practicum open-ended questionnaires. The questionnaires explored their expectations and perceptions of the practicum, perceived challenges and benefits of working in rural community areas, and considerations that might need to be taken into account. The questionnaires were analysed and compared using thematic analysis principles.

RESULTS

Results revealed a distinction between students' emotional and personal expectations of, and responses to, the practicum compared to their clinical expectations and responses. Before the practicum, students indicated a number of anxieties such as not feeling emotionally prepared or feeling anxious about infection control. The rural practicum appeared to provide a powerful teaching tool that led to growth in students' empathy and awareness of community needs and contextual issues through a shift from an intrapersonal to an interpersonal focus in their responses. A lack of growth was noted in some areas after the practicum, however, such as students' ideas about implementing appropriate therapy and making modifications to materials.

CONCLUSIONS

This study holds significant implications for preparing students to work in challenging contexts and rural communities both in South Africa and abroad. The results suggest that a one-off practicum is not sufficient to sensitize students to the challenges of rural work and enable them to overcome anxieties. Rather, a sustained commitment to rural community work should be introduced early on in the curriculum and educators should be encouraged to reflect on their own attitudes, experiences, biases and anxieties towards community work.

Disease specific biomarkers of abdominal aortic aneurysms detected by surface enhanced laser desorption ionization time of flight mass spectrometry

INTRODUCTION

Biomarkers have the potential to improve the clinical management of patients with AAA.

REPORT

A prospective, proteomics discovery study was undertaken to compare patients with AAA (n = 20) to matched screened controls (n = 19) for plasma protein expression. Surface-Enhanced-Laser-Desorption-Ionization Time of Flight Mass Spectrometry (SELDI ToF MS) coupled with Artificial Neural Networks (ANN) analysis identified six protein related diagnostic biomarker ions with a combined AUC of 0.89.

DISCUSSION

This study discovered a signature plasma protein profile for patients with AAA and demonstrated that mass spectrometric based research for disease specific biomarker of AAA is feasible.

Lumps, bumps and vasculitis

We report an unusual case of primary vasculitis presenting with unilateral submandibular gland enlargement and lymphadenopathy resulting in stridor.

Limited genetic diversity among genotypes of Enterocytozoon bieneusi strains isolated from HIV-infected patients from Sydney, Australia

Microsporidia are intracellular parasites, with over 1200 species belonging to 143 genera described to date. They are opportunistic pathogens in humans and can cause chronic diarrhoea in immunosuppressed patients. Both Enterocytozoon bieneusi and Encephalitozoon intestinalis cause intestinal disease, with Enterocytozoon bieneusi more commonly identified in patients with human immunodeficiency virus (HIV) infection. In this study, intestinal microsporidial clinical isolates from patients in Sydney, Australia, were genotyped. All specimens were from HIV-infected men with low CD4(+) T-cell counts (<100 cells mm(-3)). Genotyping of the internal transcribed spacer regions of the rRNA gene showed the presence of only one genotype, the anthroponotic Enterocytozoon bieneusi genotype B strain. This study thus highlighted the limited genetic diversity among Australian Enterocytozoon bieneusi isolates, and it is hypothesized that, due to the reduced incidence of microsporidia and the subsequent reduction in the human reservoir of the anthroponotic genotype B, locally acquired intestinal microsporidiosis will rarely be seen in HIV-infected persons undergoing highly active antiretroviral therapy in the future in Australia.

B-cell O-galactosyltransferase activity, and expression of O-glycosylation genes in bone marrow in IgA nephropathy

In IgA nephropathy (IgAN), pathogenic IgA1 is likely derived from bone marrow (BM) cells and exhibits reduced O-galactosylation. Defective O-galactosylation may arise from the compromised expression or function of the enzyme beta-galactosyltransferase and/or its molecular chaperone (Cosmc). We measured B-cell O-galactosylation activity and the relative gene expression of beta-galactosyltransferase and Cosmc in peripheral blood and BM taken from patients with IgAN and controls. O-galactosylation activity was measured in peripheral and BM B cells by the incorporation of radiolabeled galactose into an asialo-mucin acceptor. Gene expression of beta-galactosyltransferase and Cosmc was measured by real-time PCR and related to that of the enzyme GalNAc-T2 (UDP-N-acetyl-alpha-D-galactosamine:polypeptide N-acetylgalactosaminyltransferase-2), which synthesizes the core O-glycan. Neither the B-cell O-galactosylation activity nor the gene expression of the enzyme or chaperone was different between patients and controls. However, the relationships between the O-glycosylation of serum IgA1, galactosylation activity, and beta-galactosyltransferase gene expression showed different patterns in IgAN and controls. In IgAN, O-galactosylation activity correlated with beta-galactosyltransferase gene expression, but not with IgA1 O-glycosylation, suggesting that factors other than the availability of beta-galactosyltransferase or Cosmc are responsible for altered IgA1 O-glycosylation.

Treatment of IgA nephropathy

IgA nephropathy (IgAN) is an important cause of progressive kidney disease with 25-30% of patients developing end-stage renal disease within 20 years of diagnosis. There is still no treatment to modify mesangial IgA deposition and available treatments are those extrapolated from the management of other patterns of chronic glomerulonephritis. There remains no consensus on the use of immunosuppressive agents for treatment of progressive IgAN and this is compounded by the relative lack in IgAN of randomized controlled trials relevant to current clinical practice. Patients with recurrent macroscopic hematuria or isolated microscopic hematuria and proteinuria <1 g/24 h require no specific treatment. Those with nephrotic syndrome and minimal change on renal biopsy should be managed as for minimal change nephropathy. There is no evidence to support the use of corticosteroids for nephrotic IgAN outside this group of patients. Patients presenting with acute renal failure require evaluation to distinguish acute tubular necrosis, which requires supportive therapy only, from crescentic IgAN, for which treatment with cyclophosphamide and corticosteroids in a regimen similar to that for renal small vessel vasculitis is indicated in the absence of significant chronic histologic injury. Patients at greatest risk of progressive renal impairment are those with hypertension, proteinuria >1 g/24 h, and reduced glomerular filtration rate at diagnosis. All such patients should be treated to a blood pressure of 125/75 mm Hg with dual blockade of the renin-angiotensin system with angiotensin-converting enzyme inhibition and angiotensin receptor blockade. At present, there is insufficient evidence for the additional use of immunosuppressive agents, antiplatelet agents, or anticoagulants.

Does the provision of cooled filtered water in secondary school cafeterias increase water drinking and decrease the purchase of soft drinks?

BACKGROUND

Secondary school students often do not drink sufficient quantities of water during the school day to prevent dehydration, promote learning and good health. The study aimed to measure the effect of health promotion and the free provision of cooled filtered water on the consumption of water and soft drinks. It also aimed to explore students' views of drinking water provision.

METHODS

A study was conducted with three secondary schools in North Tyneside. Over a 3 month period one school was given cooled filtered water and active promotion (W + P), another had water only (W). The control school (C) took part in post-intervention focus group work.

RESULTS

The average volume of water drunk by students, in school 'W + P' was greater (P = 0.05) than that drunk in school 'W' and control school 'C'. The volume of soft drinks purchased by students in all three schools before and during the intervention remained static. Focus group data revealed that students viewed their existing water provision as poor and wanted sufficient supplies of cooled filtered water in school.

CONCLUSIONS

This pilot study indicates that active promotion of water drinking increased consumption of water by secondary school students. Further developments of the project are suggested.

Expression of T cell receptor variable region families by bone marrow gammadelta T cells in patients with IgA nephropathy

IgA nephropathy (IgAN) is characterized by mesangial deposition of polymeric IgA (pIgA). Abnormalities of the IgA system include reduced mucosal and increased bone marrow (BM) pIgA production. Gammadelta T cells are regulators of mucosal IgA production and oral tolerance. We have described previously a deficiency of gammadelta T cells expressing Vgamma3 and Vdelta3 from the duodenal mucosa in IgAN. Since pIgA production is displaced to the BM, we have now studied BM gammadelta T cells in IgAN. Peripheral blood and BM aspirates were obtained from 14 patients with IgAN and 15 controls. Expression of TCR gamma and delta V region families was analysed by semiquantitative RT-PCR, and CDR3 spectratyping of Vgamma1-4 and Vdelta3 genes was performed. We found no difference between IgAN and controls in the V region usage of blood gammadelta T cells. However, in the BM of patients with IgAN, there was significantly reduced expression of the V region families Vgamma3 and Vdelta3, with the decrease in Vdelta3 being particularly striking. CDR3 spectratyping showed no abnormalities in blood or BM samples. Vgamma3 and Vdelta3 are underexpressed in the duodenum and the BM in IgAN. The combination of imbalanced mucosal and systemic pIgA production with deficient expression of gammadelta T cells using Vgamma3 and Vdelta3 in both sites may imply a role for these gammadelta T cells in the normal regulation of IgA immune responses, and in the complex immunopathogenesis of IgAN.

Improving the nutritional status of people with dementia

The attention given to the nutritional needs of older adults receiving hospital care has been the subject of research over recent years. It has been suggested that older people are suffering from malnutrition as a result of poor nursing care. Those involved in care of persons with dementia are faced with considerable difficulty when trying to respond to their nutritional care needs and there is concern that there may come a time when the care team will withdraw food and fluid. However, in Southern Derbyshire we believe that we now have a set of standards for nutritional care of older adults with dementia that can ensure adequate and good nutrition despite the numerous and complex problems posed by dementia. This article discusses the progress of a sample of 20 residents of a long-stay ward over a period of 6 years and shows how a multidisciplinary team accessed, developed and applied an evidence base to practice to the benefit of the sample group. The outcomes show that malnutrition can be reversed, and that people who are considered to be in the final stages of dementia can improve their nutritional status.

Mesangial IgA1 in IgA nephropathy exhibits aberrant O-glycosylation: observations in three patients

BACKGROUND

In IgA nephropathy (IgAN), circulating IgA1 molecules display an abnormal pattern of O-glycosylation. This abnormality may potentially contribute to mesangial IgA1 deposition, but this is unproven because the O-glycosylation of mesangial IgA1 has not been analyzed.

METHODS

IgA1 was eluted from glomeruli isolated from the kidneys of three IgAN patients obtained after nephrectomy or at postmortem. Serum from these patients, other patients with IgAN, and controls was subjected to the same treatment as the glomerular eluates. The O-glycosylation of eluted and serum IgA1 was measured by lectin binding using an enzyme-linked immunosorbent assay-based system.

RESULTS

In all three cases, the lectin binding of IgA1 eluted from the glomeruli of IgAN patients was markedly higher than that of the serum IgA1 of the same individual, and also all but one of a series of serum IgA1 samples from other patients and controls.

CONCLUSIONS

The higher lectin binding of glomerular compared with serum IgA1 suggests that O-glycosylated IgA1 molecules abnormally and selectively deposit in the kidney. These results provide the first evidence that mesangial IgA1 is abnormally O-glycosylated, and support a direct role for abnormal IgA1 O-glycosylation in the mechanism of mesangial IgA deposition in IgAN.

Diet-related knowledge, beliefs and actions of health professionals compared with the general population: an investigation in a community Trust

BACKGROUND

Dietary change is advocated for the prevention and treatment of a number of major diseases, and the implicit and explicit assumption is that health professionals have a major role in promoting diet change. Previous studies of doctors and nurses have shown their knowledge to be inadequate. Other health professionals have not been investigated.

METHODS

Parts of a questionnaire used in a national study of the general public were administered to groups of health professionals from a variety of disciplines working in a community Trust. The results were compared with those from the study of the general public, for which the questionnaire had been devised.

RESULTS

358 questionnaires were completed. There was little difference between the knowledge, beliefs and actions of health professionals and the general public.

CONCLUSION

If health professionals are to continue to be expected to promote healthy eating messages there will need to be a more systematic approach to their training about nutrition.

Outcome of acute renal failure following surgical repair of ruptured abdominal aortic aneurysms

OBJECTIVES

to establish the mortality of ARF following surgical repair of ruptured abdominal aortic aneurysms (AAAs) and to identify clinical variables which might assist in predicting outcome.

DESIGN, MATERIALS AND METHODS

all cases of ARF complicating repair of ruptured AAAs treated at Leicester General Hospital between 1984 and 1996 were identified in a retrospective study based on review of clinical records. The main outcome measures were overall mortality, duration of hospital treatment and renal function in survivors.

RESULTS

in 65 cases identified, overall hospital mortality was 75%. Six patients did not receive RRT, since their clinical state was judged irreversible; all died. Of the 16 survivors, 11 were left with irreversible renal impairment and one patient required maintenance dialysis. Over half of the survivors had died at 5 years>> follow-up. Non-survivors had more vascular disease (p=0.048), required more surgery during AAA repair (p=0.042) and were more likely to have developed multiple organ failure (p=0.01). A clinical severity score based on these three variables allowed stratification into prognostic groups.

CONCLUSIONS

ARF following surgical repair of ruptured AAA has an overall hospital mortality of 75%. A clinical severity score, calculated at the time dialysis was considered, may assist in prediction of outcome.

Identification of a novel Fcalpha receptor expressed by human mesangial cells

BACKGROUND

IgA nephropathy (IgAN) is characterized by mesangial deposits of polymeric IgA (pIgA). The pathological consequences of IgA deposition are believed to center on direct interaction between IgA and the glomerular mesangial cell (MC). We have characterized a novel mesangial receptor that recognizes the Fc portion of IgA.

METHODS

Five primary MC cultures were evaluated for IgA binding by flow cytometry, and specificity of binding was determined by competitive inhibition. Relative affinities of the receptor for all IgA isoforms were also determined, and binding of pIgA1 was compared to monomer. The identified Fc receptor was then compared with CD89, hitherto the only other Fcalpha receptor reported. CD89 protein and mRNA expression were detected by conventional and intracellular flow cytometry, sequencing of reverse transcription-polymerase chain reaction (RT-PCR) products, and Northern blotting.

RESULTS

All MCs constitutively expressed a receptor that bound IgA in an Fcalpha-dependent fashion. The receptor recognized secretory and serum IgA1 and IgA2 equally, but pIgA bound with much greater affinity than monomer. At no time were we able to detect CD89 synthesis, although three novel CD89-related mRNA transcripts were identified by RT-PCR.

CONCLUSIONS

We have clearly demonstrated that MCs consistently express an FcalphaR distinct from the myeloid FcalphaR CD89. This novel receptor binds pIgA with high affinity and may therefore mediate the mesangial injury that follows IgA deposition in IgAN. While immunogenically distinct, the mesangial Fcalpha receptor may share some molecular homology with CD89, as mRNA transcripts with partial identity to CD89 were found in all five MC cultures.