The effect of the COVID-19 pandemic on the mental health of obstetrics and gynaecology trainees: a world-wide literature review

BACKGROUND

Coronavirus (COVID-19) pandemic has affected the training and wellbeing of obstetrics and gynaecology (O&G) trainees. The aim of this review is to offer a worldwide overview on its' impact on the mental health of O&G trainees, so that measures can be put into place to better support trainees during the transition back to the 'new normal'.

METHODS

Key search terms used on PubMed and Google Scholar databases include: mental health, COVID-19, O&G, trainees, residents.

RESULTS

Fifteen articles (cumulative number of respondents = 3230) were identified, of which eight employed validated questionnaires (n = 1807 respondents), while non-validated questionnaires were used in seven (n = 1423 respondents). Studies showed that COVID-19 appeared to exert more of a negative impact on females and on senior trainees' mental health, while protective factors included marriage/partner and having had children. Validated and non-validated questionnaires suggested that trainees were exposed to high levels of anxiety and depression. Their mental health was also affected by insomnia, stress, burnout and fear of passing on the virus.

DISCUSSION

This review analyses the global impact of COVID-19 on O&G trainees' mental health, showing a pervasive negative effect linked to fear of the virus. Limited psychological support has led to prolonged issues, hindering patient safety and increasing sick leave. The study underscores the urgency of comprehensive support, particularly in female-dominated fields. Addressing these challenges is crucial for future pandemics, highlighting the need to learn from past mistakes and prioritise mental health resources for trainee well-being during and beyond pandemics.

Indeterminate thyroid nodules (Thy3): malignancy rate and characteristics in a study of 118 patients

INTRODUCTION

Thyroid nodules are common, and the combined use of ultrasound and fine needle aspiration cytology provides useful information on their malignancy risk. The Thy reporting system is widely used in the United Kingdom, with malignancy rates for Thy3 cytology being quoted between 5% and 30%. This study aims to establish the risk of thyroid cancer in operated patients with Thy3 cytology and correlate it with patient demographics and nodule size.

METHODS

This is a retrospective observational study of all thyroidectomies that took place in a single institution over a 3-year period (2019-2022). Those with a preoperative cytology of Thy3 were analysed further and in particular, nodule size, final histology and patients' demographics were documented.

RESULTS

Some 260 thyroidectomies were performed during the study period. Of these, 118 patients had Thy3 cytology. In the Thy3a group (n = 70), the malignancy rate was 27.1%. The average age of those with thyroid cancer was 51.4 vs 51.2 years for those with benign disease. The nodule size was under 40mm for both groups (36mm vs 39.7mm). In the Thy3f group (n = 48), the malignancy rate was 43.8%. The average age of those with thyroid cancer was 53.5 vs 56.2 years for those with benign disease. The nodule size was similar (24.5mm vs 27.6mm).

CONCLUSIONS

In this study, one in three patients with Thy3 cytology was diagnosed with thyroid cancer. We urge local units to analyse their data, to aid patients' informed decision-making. Within the subgroups, there was no significant difference in average nodule size or patients' age.

Electronic personal assessment questionnaire for vascular conditions (ePAQ-VAS): development and validity

Background

This paper describes the development and validation of an electronic personal assessment questionnaire for vascular conditions (ePAQ-VAS) that captures the symptomatology, quality of life and clinically relevant data of patients presenting to vascular services.

Methods

A two-stage survey was conducted in patients attending a tertiary vascular department. Patients completed the ePAQ-VAS remotely online, or on site using an electronic tablet. In the first stage of the survey, the responses were used to perform confirmatory factor analysis to assess the construct validity and remove redundant items. The internal reliability of disease-specific scales was investigated. In the second stage of the survey, the acceptability, known-group validity, test–retest reliability, and responsiveness of ePAQ-VAS was assessed.

Results

In total, 721 patients completed ePAQ-VAS. Their mean(s.d.) age was 63·5(15·7) years and 468 (64·9 per cent) were men. Some 553 patients (76·7 per cent) completed the questionnaire in clinic and the remainder completed the questionnaire online. The results of the confirmatory factor analysis confirmed the conceptual model for ePAQ-VAS structure and eliminated six items. Internal reliability was acceptable for all the scales (Cronbach's α greater than 0·7). The test–retest reliability measured by the intraclass correlation coefficient ranged from 0·65 to 0·99. The results showed that the instrument was responsive over time with the standardized response mean ranging from 0·69 to 1·60.

Conclusion

ePAQ-VAS is a holistic data-collection process that is relevant to vascular service users and has potential to contribute to patient-focused care and the collection of aggregate data for service evaluation. A demonstration version of the final version of ePAQ can be viewed at http://demo-questionnaire.epaq.co.uk/home/project?id=VASC_1.7&page=1.

Strength of public preferences for endovascular or open aortic aneurysm repair

Background

This study evaluated public preferences for the treatment processes for abdominal aortic aneurysm repair in order to allow them to be incorporated into a cost-effectiveness analysis.

Methods

This was a telephone survey using a trade-off method in UK resident adults (aged at least 18 years) with no previous diagnosis of a vascular condition.

Results

Some 167 of 209 participants (79·9 per cent) stated that they would prefer endovascular aneurysm repair (EVAR), 40 (19·1 per cent) preferred open surgery and two (1·0 per cent) stated no preference. Participants preferred EVAR because of the less invasive nature of the intervention and quicker recovery. Participants preferring open surgery cited reasons such as having a single follow-up appointment, and a procedure that felt more permanent. When participants were asked to make a sacrifice in order to have their preferred treatment, 122 (58·4 per cent) favoured EVAR, 18 (8·6 per cent) favoured open surgery and 69 (33·0 per cent) had no preference. Those preferring EVAR were willing to give up a mean of 0·135 expected quality-adjusted life-years (QALYs) to have EVAR, compared with a willingness to give up 0·033 expected QALYs among those preferring open repair.

Conclusion

These results indicate a clear preference for EVAR over open surgery for aortic aneurysm.

Sex differences in national rates of repair of emergency abdominal aortic aneurysm

BACKGROUND

The aim of this study was to assess the sex differences in both the rate and type of repair for emergency abdominal aortic aneurysm (AAA) in England.

METHODS

Hospital Episode Statistics (HES) data sets from April 2002 to February 2015 were obtained. Clinical and administrative codes were used to identify patients who underwent primary emergency definitive repair of ruptured or intact AAA, and patients with a diagnosis of AAA who died in hospital without repair. These three groups included all patients with a primary AAA who presented as an emergency. Sex differences between repair rates and type of surgery (endovascular aneurysm repair (EVAR) versus open repair) over time were examined.

RESULTS

In total, 15 717 patients (83·3 per cent men) received emergency surgical intervention for ruptured AAA and 10 276 (81·2 per cent men) for intact AAA; 12 767 (62·0 per cent men) died in hospital without attempted repair. The unadjusted odds ratio for no repair in women versus men was 2·88 (95 per cent c.i. 2·75 to 3·02). Women undergoing repair of ruptured AAA were older and had a higher in-hospital mortality rate (50·0 versus 41·0 per cent for open repair; 30·9 versus 23·5 per cent for EVAR). After adjustment for age, deprivation and co-morbidities, the odds ratio for no repair in women versus men was 1·34 (1·28 to 1·40). The in-hospital mortality rate after emergency repair of an intact AAA was also higher among women.

CONCLUSION

Women who present as an emergency with an AAA are less likely to undergo repair than men. Although some of this can be explained by differences in age and co-morbidities, the differences persist after case-mix adjustment.

Systematic review assessing the measurement properties of patient-reported outcomes for venous leg ulcers

Background

A variety of instruments have been used to assess outcomes for patients with venous leg ulcers. This study sought to identify, evaluate and recommend the most appropriate patient‐reported outcome measures (PROMs) for English‐speaking patients with venous leg ulcers.

Methods

This systematic review used a two‐stage search approach. Electronic searches of major databases including MEDLINE were completed in October 2015, and then updated in July 2016. Additional studies were identified from citation checking. Study selection, data extraction and quality assessment were undertaken independently by at least two reviewers. Evaluation and summary of measurement properties of identified PROMs were done using standard and adapted study‐relevant criteria.

Results

Ten studies with data for four generic PROMS and six condition‐specific measures were identified. No generic PROM showed adequate content and criterion validity; however, the EuroQoL Five Dimensions (EQ‐5D™), Nottingham Health Profile (NHP) and 12‐item Short‐Form Health Survey (SF‐12®) had good acceptability. In general, the EQ‐5D™ showed poor responsiveness in patients with venous leg ulcers. Most condition‐specific PROMs demonstrated poor criterion and construct validity. Overall, there was some evidence of internal consistency for the Venous Leg Ulcer Quality of Life (VLU‐QoL) and the Sheffield Preference‐based Venous Ulcer questionnaire (SPVU‐5D). Test–retest reliability was satisfactory for the Venous Leg Ulcer Self‐Efficacy Tool (VeLUSET).

Conclusion

The NHP and VLU‐QoL questionnaire seemed the most suitable PROMs for use by clinicians. However, a valid condition‐specific PROM is still required.

Clinicopathologic Features and Magnetic Resonance Imaging Findings in 24 Cats With Histopathologically Confirmed Neurologic Feline Infectious Peritonitis

BACKGROUND

Feline infectious peritonitis (FIP) is the most common infectious central nervous system (CNS) disease in the cat and is invariably fatal. Improved means of antemortem diagnosis is required to facilitate clinical decision making. Information regarding the magnetic resonance imaging (MRI) findings of neurologic FIP currently is limited, resulting in the need for better descriptions to optimize its use as a diagnostic tool.

OBJECTIVE

To describe the clinicopathologic features and MRI findings in cases of confirmed neurologic FIP.

ANIMALS

Twenty-four client-owned cats with histopathologic confirmation of neurologic FIP.

METHODS

Archived records from 5 institutions were retrospectively reviewed to identify cases with confirmed neurologic FIP that had undergone antemortem MRI of the CNS. Signalment, clinicopathologic, MRI, and histopathologic findings were evaluated.

RESULTS

Three distinct clinical syndromes were identified: T3-L3 myelopathy (3), central vestibular syndrome (7), and multifocal CNS disease (14). Magnetic resonance imaging abnormalities were detected in all cases, including meningeal contrast enhancement (22), ependymal contrast enhancement (20), ventriculomegaly (20), syringomyelia (17), and foramen magnum herniation (14). Cerebrospinal fluid was analysed in 11 cases; all demonstrated a marked increase in total protein concentration and total nucleated cell count. All 24 cats were euthanized with a median survival time of 14 days (range, 2-115) from onset of clinical signs. Histopathologic analysis identified perivascular pyogranulomatous infiltrates, lymphoplasmacytic infiltrates, or both affecting the leptomeninges (16), choroid plexuses (16), and periventricular parenchyma (13).

CONCLUSIONS AND CLINICAL IMPORTANCE

Magnetic resonance imaging is a sensitive means of detecting neurologic FIP, particularly in combination with a compatible signalment, clinical presentation, and CSF analysis.

Systematic review of patient-reported outcome measures in patients with varicose veins

Background

Varicose veins can affect quality of life. Patient-reported outcome measures (PROMs) provide a direct report from the patient about the impact of the disease without interpretation from clinicians or anyone else. The aim of this study was to examine the quality of the psychometric evidence for PROMs used in patients with varicose veins.

Methods

A systematic review was undertaken to identify studies that reported the psychometric properties of generic and disease-specific PROMs in patients with varicose veins. Literature searches were conducted in databases including MEDLINE, up to July 2016. The psychometric criteria used to assess these studies were adapted from published recommendations in accordance with US Food and Drug Administration guidance.

Results

Nine studies were included which reported on aspects of the development and/or validation of one generic (36-Item Short Form Health Survey, SF-36®) and three disease-specific (Aberdeen Varicose Vein Questionnaire, AVVQ; Varicose Veins Symptoms Questionnaire, VVSymQ®; Specific Quality-of-life and Outcome Response – Venous, SQOR-V) PROMs. The evidence from included studies provided data to support the construct validity, test–retest reliability and responsiveness of the AVVQ. However, its content validity, including weighting of the AVVQ questions, was biased and based on the opinion of clinicians, and the instrument had poor acceptability. VVSymQ® displayed good responsiveness and acceptability rates. SF-36® was considered to have satisfactory responsiveness and internal consistency.

Conclusion

There is a scarcity of psychometric evidence for PROMs used in patients with varicose veins. These data suggest that AVVQ and SF-36® are the most rigorously evaluated PROMs in patients with varicose veins.

Sex differences in mortality after abdominal aortic aneurysm repair in the UK

BACKGROUND

The UK abdominal aortic aneurysm (AAA) screening programmes currently invite only men for screening because the benefit in women is uncertain. Perioperative risk is critical in determining the effectiveness of screening, and contemporary estimates of these risks in women are lacking. The aim of this study was to compare mortality following AAA repair between women and men in the UK.

METHODS

Anonymized data from the UK National Vascular Registry (NVR) for patients undergoing AAA repair (January 2010 to December 2014) were analysed. Co-variables were extracted for analysis by sex. The primary outcome measure was in-hospital mortality. Secondary outcome measures included mortality by 5-year age groups and duration of hospital stay. Logistic regression was performed to adjust for age, calendar time, AAA diameter and smoking status. NVR-based outcomes were checked against Hospital Episode Statistics (HES) data.

RESULTS

A total of 23 245 patients were included (13·0 per cent women). Proportionally, more women than men underwent open repair. For elective open AAA repair, the in-hospital mortality rate was 6·9 per cent in women and 4·0 per cent in men (odds ratio (OR) 1·48, 95 per cent c.i. 1·08 to 2·02; P = 0·014), whereas for elective endovascular AAA repair it was 1·8 per cent in women and 0·7 per cent in men (OR 2·86, 1·72 to 4·74; P < 0·001); the results in HES were similar. For ruptured AAA, there was no sex difference in mortality within the NVR; however, in HES, for ruptured open AAA repair, the in-hospital mortality rate was higher in women (33·6 versus 27·1 per cent; OR 1·36, 1·16 to 1·59; P < 0·001).

CONCLUSION

Women have a higher in-hospital mortality rate than men after elective AAA repair even after adjustment. This higher mortality may have an impact on the benefit offered by any screening programme offered to women.

Systematic review and qualitative evidence synthesis of patient-reported outcome measures for abdominal aortic aneurysm

BACKGROUND

The aim was to identify and evaluate existing patient-reported outcome measures (PROMs) for use in patients with an abdominal aortic aneurysm (AAA) to inform the selection for use in surgical practice.

METHODS

Two reviews were conducted: a systematic review to identify valid, reliable and acceptable PROMs for patients with an AAA, and a qualitative evidence synthesis to assess the relevance to patients of the identified PROM items. PROM studies were evaluated for their psychometric properties using established assessment criteria, and for their methodological quality using the COSMIN checklist. Qualitative studies were synthesized using framework analysis, and concepts identified were then triangulated using a protocol with the item concepts of the identified PROMs.

RESULTS

Four PROMs from three studies were identified in the first review: Short Form 36, Australian Vascular Quality of Life Index, Aneurysm Dependent Quality of Life (AneurysmDQoL) and Aneurysm Symptoms Rating Questionnaire (AneurysmSRQ). None of the identified PROMs had undergone a rigorous psychometric evaluation within the AAA population. Four studies were included in the qualitative synthesis, from which 28 concepts important to patients with an AAA were identified. The AneurysmDQoL and AneurysmSRQ together provided the most comprehensive assessment of these concepts. Fear of rupture, control, ability to forget about the condition and size of aneurysm were all concepts identified in the qualitative studies but not covered by items in the identified PROMs.

CONCLUSION

Further research is needed to develop PROMs for AAA that are reliable, valid and acceptable to patients.

Global variances in infection control practices for vancomycin resistant Enterococcus - results of an electronic survey

An electronic survey was disseminated amongst infection control practitioners to investigate the variation in practices toward vancomycin resistant enterococci. There were 235 analysable responses, mostly from doctors, in 48 countries. The survey considered active surveillance, in-hospital precautions and tagging and untagging processes. There was a great variation in responses between and within countries highlighting a gap in guidance for practitioners on which to base institutional policy.

Clinical Features of Spinal Cord Hemangioblastoma in a Dog

A 2-year-old male, intact Yorkshire terrier presented with a 1-month history of progressive paraparesis. Neurological examination revealed paraplegia with absent deep pain perception, decreased right pelvic limb withdrawal reflex, and lumbar pain consistent with an L4–S2 neurolocalization. Magnetic resonance imaging (MRI) showed a single, well-demarcated, intramedullary mass centered over the L3–4 disk space. A hemilaminectomy was performed, and the mass was removed en bloc. Histopathological evaluation was consistent with a hemangioblastoma. Follow-up MRI 9 months after surgery showed no evidence of tumor recurrence, and the dog was ambulatory paraparetic at that time. This case is consistent with a previous histopathological report of spinal cord hemangioblastoma in a dog and provides additional clinical information regarding diagnosis, treatment, and outcome associated with this tumor type.

Systematic review, network meta-analysis and exploratory cost-effectiveness model of randomized trials of minimally invasive techniques versus surgery for varicose veins

BACKGROUND

A Health Technology Assessment was conducted to evaluate the relative clinical effectiveness and cost-effectiveness of minimally invasive techniques (foam sclerotherapy (FS), endovenous laser ablation (EVLA) and radiofrequency ablation (RFA)) for managing varicose veins, in comparison with traditional surgery.

METHODS

A systematic review of randomized clinical trials (RCTs) was undertaken to assess the effectiveness of minimally invasive techniques compared with other treatments, principally surgical stripping, in terms of recurrence of varicose veins, Venous Clinical Severity Score (VCSS), pain and quality of life. Network meta-analysis and exploratory cost-effectiveness modelling were performed.

RESULTS

The literature search conducted in July 2011 identified 1453 unique citations: 31 RCTs (51 papers) satisfied the criteria for effectiveness review. Differences between treatments were negligible in terms of clinical outcomes, so the treatment with the lowest cost appears to be most cost-effective. Total FS costs were estimated to be lowest, and FS was marginally more effective than surgery. However, relative effectiveness was sensitive to the model time horizon. Threshold analysis indicated that EVLA and RFA might be considered cost-effective if their costs were similar to those for surgery. These findings are subject to various uncertainties, including the risk of bias present in the evidence base and variation in reported costs.

CONCLUSION

This assessment of currently available evidence suggests there is little to choose between surgery and the minimally invasive techniques in terms of efficacy or safety, so the relative cost of the treatments becomes one of the deciding factors. High-quality RCT evidence is needed to verify and further inform these findings.

Clinical effectiveness and cost-effectiveness of minimally invasive techniques to manage varicose veins: a systematic review and economic evaluation

BACKGROUND

Varicose veins are enlarged, visibly lumpy knotted veins, usually in the legs. Uncomplicated varicose veins can cause major discomfort and some complications. They are part of chronic venous disease (CVD), which is reported to have a substantial negative impact on health-related quality of life (HRQoL). Traditional treatments for varicose veins involve surgical stripping and ligation and liquid sclerotherapy (LS), but can be invasive and painful. New minimally invasive treatments offer an alternative. These treatments typically involve use of laser, radiofrequency or foam sclerosant. They are increasingly widely used and offer potential benefits such as reduced complications, faster recovery, fewer physical limitations and improved quality of life.

OBJECTIVE

The aim of this report is to evaluate the clinical effectiveness, safety and cost-effectiveness of the minimally invasive techniques of foam sclerotherapy (FS), endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) in comparison with other techniques, including traditional surgical techniques, LS and conservative management, in the management of varicose veins.

DATA SOURCES

A systematic search was made of 11 bibliographic databases of published and unpublished literature from their inception to July 2011: MEDLINE; EMBASE; Cumulative Index to Nursing and Allied Health Literature; The Cochrane Library; Biological Abstracts; Science Citation Index (SCI); Social Sciences Citation Index; Conference Proceedings Citation Index-Science; UK Clinical Research Network; Current Controlled Trials; and ClinicalTrials.gov.

REVIEW METHODS

A systematic review of randomised controlled trials (RCTs) to assess the clinical effectiveness of minimally invasive techniques compared with other treatments, principally surgical stripping, in terms of recurrence of varicose veins, retreatment and clinical symptoms, as measured by the Venous Clinical Severity Score (VCSS), pain and quality of life. Network meta-analysis and exploratory cost-effectiveness modelling were performed.

RESULTS

The literature search identified 1453 unique citations, of which 34 RCTs (54 papers) satisfied the criteria for the clinical effectiveness review. The minimally invasive techniques reported clinical outcomes similar to surgery. Rates of recurrence were slightly lower for EVLA, RFA and FS, especially for longer follow-up periods; VCSS score was lower for EVLA and FS than for stripping, but slightly higher for RFA; short-term pain was less for FS and RFA but higher for EVLA; higher quality-of-life scores were reported for all evaluated interventions than for stripping. Differences between treatments were therefore negligible in terms of clinical outcomes, so the treatment with the lowest cost appears to be most cost-effective. Our central estimate is that total FS costs were lowest and FS is marginally more effective than stripping. However, this result was sensitive to the model time horizon. Threshold analysis indicated that EVLA and RFA might be considered cost-effective if their costs are equivalent to stripping. These findings are subject to uncertainty on account of the risk of bias present in the evidence base and the variation in costs.

LIMITATIONS

The relative clinical effectiveness and cost-effectiveness of the techniques are principally based on rates of post-operative technical recurrence rather than symptomatic recurrence, as this was the reported outcome in all trials. The true proportion of treated individuals who are likely to present with symptoms of recurrence requiring retreatment is therefore not certain. A figure reflecting the likely proportion of treated individuals who would experience symptomatic recurrence requiring retreatment (with its associated costs), therefore, had to be calculated by the authors based on a small number of studies. The findings of this report also need to be verified by data from future trials with longer follow-up and using more standardised outcome measures.

CONCLUSIONS

This assessment of the currently available evidence suggests there is little to choose between the minimally invasive techniques in terms of efficacy or cost, and each offers a viable, clinically effective alternative to stripping. FS might offer the most cost-effective alternative to stripping, within certain time parameters. High-quality RCT evidence is needed. Future trials should aim to measure and report outcomes in a standardised manner, which would permit more efficient pooling of their results.

STUDY REGISTRATION

PROSPERO number CRD42011001355.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Food label accuracy of common snack foods

Nutrition labels have raised awareness of the energetic value of foods, and represent for many a pivotal guideline to regulate food intake. However, recent data have created doubts on label accuracy.

OBJECTIVE

We tested label accuracy for energy and macronutrient content of prepackaged energy-dense snack food products. We measured "true" caloric content of 24 popular snack food products in the U.S. and determined macronutrient content in 10 selected items.

DESIGN AND METHODS

Bomb calorimetry and food factors were used to estimate energy content. Macronutrient content was determined according to Official Methods of Analysis. Calorimetric measurements were performed in our metabolic laboratory between April 20th and May 18th and macronutrient content was measured between September 28th and October 7th of 2010.

RESULTS AND CONCLUSION

Serving size, by weight, exceeded label statements by 1.2% [median] (25th percentile -1.4, 75th percentile 4.3, P = 0.10). When differences in serving size were accounted for, metabolizable calories were 6.8 kcal (0.5, 23.5, P = 0.0003) or 4.3% (0.2, 13.7, P = 0.001) higher than the label statement. In a small convenience sample of the tested snack foods, carbohydrate content exceeded label statements by 7.7% (0.8, 16.7, P = 0.01); however fat and protein content were not significantly different from label statements (-12.8% [-38.6, 9.6], P = 0.23; 6.1% [-6.1, 17.5], P = 0.32). Carbohydrate content explained 40% and serving size an additional 55% of the excess calories. Among a convenience sample of energy-dense snack foods, caloric content is higher than stated on the nutrition labels, but overall well within FDA limits. This discrepancy may be explained by inaccurate carbohydrate content and serving size.

Systematic review of the efficacy of cilostazol, naftidrofuryl oxalate and pentoxifylline for the treatment of intermittent claudication

BACKGROUND

A systematic review and network meta-analysis was undertaken to consider the evidence for the efficacy and tolerability of placebo, cilostazol, naftidrofuryl oxalate and pentoxifylline in patients with intermittent claudication due to peripheral arterial disease (PAD).

METHODS

MEDLINE, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Conference Proceedings, BIOSIS, National Research Register and MetaRegister databases were searched. Eligible studies were randomized controlled trials (RCTs) and published systematic reviews of patients with intermittent claudication due to PAD and whose symptoms persisted despite a period of conservative management. Study selection was conducted by one reviewer with involvement from a clinician. Data were extracted by one reviewer with no blinding to authors or journal, and checked by a second reviewer. Outcome measures were maximum walking distance (MWD) and pain-free walking distance (PFWD).

RESULTS

The review identified 1876 citations; 26 RCTs met the inclusion criteria for the systematic review. Eleven trials provided data relevant for the meta-analysis. Naftidrofuryl oxalate was ranked first for both MWD and PFWD (probability of 0·947 and 0·987, respectively, of being the best treatment) followed by cilostazol and pentoxifylline. For naftidrofuryl oxalate, cilostazol and pentoxifylline, MWD increased by 60 (95 per cent credible interval 20 to 114) per cent, 25 (11 to 40) per cent and 11 (-1 to 24) per cent respectively relative to placebo, and PFWD increased by 49, 13 and 9 per cent.

CONCLUSION

Naftidrofuryl oxalate and cilostazol are both effective treatments for claudication; naftidrofuryl oxalate is likely to be the most effective, with minimal serious adverse events.

A systematic review and economic evaluation of cilostazol, naftidrofuryl oxalate, pentoxifylline and inositol nicotinate for the treatment of intermittent claudication in people with peripheral arterial disease

BACKGROUND

Peripheral arterial disease (PAD) is a condition in which there is blockage or narrowing of the arteries that carry blood to the legs and arms. It is estimated to affect around 4.5% of people aged between 55 and 74 years within the UK. The most common symptom of PAD is intermittent claudication (IC), characterised by pain in the legs on walking that is relieved with rest.

OBJECTIVE

To assess the effectiveness and cost-effectiveness of cilostazol, naftidrofuryl oxalate, pentoxifylline and inositol nicotinate, compared with no vasoactive drugs, for IC due to PAD in adults whose symptoms continue despite a period of conventional management.

DATA SOURCE

Electronic bibliographic databases were searched during April to June 2010 (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, The Cochrane Library databases, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Conference Proceedings Citation Index, BIOSIS Previews).

REVIEW METHODS

Effectiveness outcomes sought were maximal walking distance (MWD), pain-free walking distance (PFWD), ankle-brachial pressure index, cardiovascular events, mortality, adverse events (AEs) and health-related quality of life (HRQoL). A narrative synthesis was provided for all outcomes and a network meta-analysis was undertaken for the walking distance outcomes. A Markov model was developed to assess the relative cost-effectiveness of the interventions from a NHS perspective over a lifetime. The model has three states: vasoactive drug treatment, no vasoactive drug treatment and death. Each 1-week cycle, patients may continue with the drug, discontinue the drug or die. Regression analysis was undertaken to model the relationship between MWD and utility so that a cost per quality-adjusted life-year (QALY) outcome measure could be presented. Univariate and probabilistic sensitivity analyses were undertaken. All costs and outcomes were discounted at 3.5%.

RESULTS

Twenty-six randomised controlled trials were identified that met the inclusion criteria for the clinical effectiveness review. There was evidence that walking distance outcomes were significantly improved by both cilostazol and naftidrofuryl oxalate; the 95% credible intervals for the difference from placebo in the logarithm mean change MWD from baseline were 0.108 to 0.337 and 0.181 to 0.762, respectively. It was not possible to include inositol nicotinate within the meta-analysis of MWD and PFWD owing to the lack of 24-month data; however, the shorter-term data did not suggest a significant effect. AEs were minor for all drugs and included headaches and gastrointestinal difficulties. The incidence of serious adverse events (SAEs), including cardiovascular events and mortality, was not increased by the vasoactive drugs compared with placebo; however, most studies had a relatively short follow-up time to address this outcome. HRQoL data were limited. Two studies of limited quality were identified within the review of cost-effectiveness. The de novo model developed suggests that naftidrofuryl oxalate dominates cilostazol and pentoxifylline and has a cost per QALY gained of around £6070 compared with no vasoactive drug. This result is reasonably robust to changes within the key model assumptions. Inositol nicotinate was not included within the main analysis owing to lack of data. However, it is unlikely to be considered to be cost-effective due to its high acquisition cost (£900 vs £100-500 per year for the other drugs).

CONCLUSIONS

Naftidrofuryl oxalate and cilostazol both appear to be effective treatments for this patient population, with minimal SAEs. However, naftidrofuryl oxalate is the only treatment that is likely to be considered cost-effective. The long-term effectiveness is uncertain and hence a trial comparing cilostazol, naftidrofuryl oxalate and placebo beyond 24 weeks would be beneficial. Outcomes associated with naftidrofuryl oxalate could also be compared with those associated with supervised exercise programmes and angioplasty.

Dystrophin-compromised sarcoglycan-δ-knockout diaphragm requires full wild-type embryonic stem cell reconstitution for correction

Limb-girdle muscular dystrophy-2F (LGMD-2F) is an incurable degenerative muscle disorder caused by a mutation in the sarcoglycan-δ (SGδ)-encoding gene (SGCD in humans). The lack of SGδ results in the complete disruption of the sarcoglycan complex (SGC) in the skeletal and cardiac muscle within the larger dystrophin-glycoprotein complex (DGC). The long-term consequences of SG ablation on other members of the DGC are currently unknown. We produced mosaic mice through the injection of wild-type (WT) embryonic stem cells (ESCs) into SGδ-knockout (KO) blastocysts. ESC-derived SGδ was supplied to the sarcolemma of 18-month-old chimeric muscle, which resulted in the restoration of the SGC. Despite SGC rescue, and contrary to previous observations obtained with WT/mdx chimeras (a mouse rescue paradigm for Duchenne muscular dystrophy), low levels of ESC incorporation were insufficient to produce histological corrections in SGδ-KO skeletal muscle or heart. The inefficient process of ESC rescue was more evident in the SGδ-KO diaphragm, which had reduced levels of dystrophin and no compensatory utrophin, and needed almost full WT ESC reconstitution for histological improvement. The results suggest that the SGδ-KO mouse model of LGMD is not amenable to ESC treatment.

A second case of Marburg’s variant of multiple sclerosis with vasculitis and extensive demyelination

Marburg’s variant of multiple sclerosis is a rapidly progressive and malignant form of multiple sclerosis (MS) that usually leads to severe disability or death within weeks to months without remission. Few cases have been described in the literature since the original description by Marburg. The classic pathological findings usually include highly destructive zones of extensive demyelination, necrosis with dense cellular infiltrate, and giant reactive astrocytes. We report a case of a 31-year-old woman with Marburg’s variant of MS who, over a period of eight months, became totally disabled, blind, and quadriplegic, with vocal cord paralysis, requiring a tracheostomy. The patient underwent diagnostic stereotactic brain biopsy. Clinical findings, magnetic resonance imaging (MRI), serologic and cerebrospinal fluid (CSF) findings, and neuropathology are discussed. MRI showed extensive white matter involvement in the brain and spinal cord that continuously progressed over time. A diagnostic stereotactic brain biopsy revealed extensive active demyelination with unexpected finding of active vasculitis and fibrinoid necrosis with a vascular inflammatory cell infiltrate, including polymorphonuclear neutrophils and rare eosinophils. Serologic work-up for vasculitis and neuromyelitis optica was unremarkable and the CSF showed only one oligoclonal band (OCB) not present in serum. This is the second case of Marburg’s variant of MS that demonstrated both demyelination and vasculitis. In our case these features were demonstrated simultaneously, even though the demyelination was the predominant pathological finding. Since vasculitis is not a feature of classic MS, these findings pose the question as to whether Marburg’s variant of MS is a true variant or different entity altogether.

The use of peptones as medium additives for the production of a recombinant therapeutic protein in high density perfusion cultures of mammalian cells

Protein hydrolysates as substitutes for serum havebeen employed by many in cell culture mediumformulation, especially with the shift to low proteinor protein-free media. More recently, vegetablehydrolysates have also been added as nutritionalsupplements to fortify the amino acid content in smallpeptide form for batch and fed-batch fermentations. Several of these new hydrolysates (peptones of soy,rice, wheat gluten etc.) were tested as protein-freemedium supplements for the production of a recombinanttherapeutic protein. Multiple peptone-supplemented,continuous perfusion bioreactor experiments wereconducted, varying dilution rates and basal mediumcomposition over the various runs. Cell specificrates and product quality studies were obtained forthe various peptones and compared with peptone-freemedium. The potential for peptones to decreaseintrinsic and proteolytic degradation of the productwas also investigated.It was found that peptones confer a nutritionalbenefit, especially at low dilution rates, for therecombinant BHK cell line used in this investigation.The specific productivity increased 20-30% comparedto the peptone-free controls. However, this benefitwas also fully delivered by using fortified medium inplace of the peptone-enriched media. Therefore, whilepeptones may be considered as useful medium additiveswhen development time is limited, their addition maybe avoided by systematic medium development ifpermitted by the time line of the project.

Differential requirement for utrophin in the induced pluripotent stem cell correction of muscle versus fat in muscular dystrophy mice

Duchenne muscular dystrophy (DMD) is an incurable degenerative muscle disorder. We injected WT mouse induced pluripotent stem cells (iPSCs) into mdx and mdx∶utrophin mutant blastocysts, which are predisposed to develop DMD with an increasing degree of severity (mdx <<< mdx∶utrophin). In mdx chimeras, iPSC-dystrophin was supplied to the muscle sarcolemma to effect corrections at morphological and functional levels. Dystrobrevin was observed in dystrophin-positive and, at a lesser extent, utrophin-positive areas. In the mdx∶utrophin mutant chimeras, although iPSC-dystrophin was also supplied to the muscle sarcolemma, mice still displayed poor skeletal muscle histopathology, and negligible levels of dystrobrevin in dystrophin- and utrophin-negative areas. Not only dystrophin-expressing tissues are affected by iPSCs. Mdx and mdx∶utrophin mice have reduced fat/body weight ratio, but iPSC injection normalized this parameter in both mdx and mdx∶utrophin chimeras, despite the fact that utrophin was compromised in the mdx∶utrophin chimeric fat. The results suggest that the presence of utrophin is required for the iPSC-corrections in skeletal muscle. Furthermore, the results highlight a potential (utrophin-independent) non-cell autonomous role for iPSC-dystrophin in the corrections of non-muscle tissue like fat, which is intimately related to the muscle.

Reversal of longstanding neurological deficits after a late release of tethered spinal cord

The importance of early surgery for tethered cord syndrome in the pediatric population is well established. Optimal treatment and prognosis of tethered cord in adults, on the other hand, is less clear. Some advocate a conservative approach in asymptomatic patients, while others recommend early detethering in all patients. For symptomatic patients, however, there is a consensus in favor of early surgery to prevent progression of neurological deficit. Many studies have reported cessation of neurological decline or reversal of recently acquired neurological deficits in patients with adult tethered cord syndrome. There are limited data in the literature about late surgery for the treatment of tethered spinal cords when the neurological deficits are longstanding. We report on a 37-year-old woman who demonstrated dramatic neurological improvement after surgical release of a tethered spinal cord more than 20 years after the onset of progressive neurological deficits.

Exercise training improves cutaneous microvascular endothelial function in post-surgical varicose vein patients

This study investigated the effects of exercise training on cutaneous microvascular function in post-surgical varicose vein patients. Sixteen post-surgical (4-5 weeks) varicose vein patients were randomised to a treadmill-walking exercise group or a non-exercise control group. The exercise group trained twice weekly for 8 weeks. Changes in cutaneous microvascular function of the gaiter area were assessed using laser Doppler flowmetry combined with incremental-dose iontophoretic administration of acetylcholine chloride (ACh) and sodium nitroprusside (SNP) in both supine and standing positions. At 8 weeks, peak flux responses to ACh in the supine position were increased in the exercise group (44+/-30 to 62+/-33 PU; P=0.03) with a similar trend in the standing position (37+/-27 to 74+/-31 PU; P=0.08). There were no such changes in the control group (P>0.05). Additionally, peak flux responses to SNP were unchanged in both groups and body positions (P>0.05). The results suggest that moderate-intensity lower-limb exercise training improves microvascular endothelial vasodilator function in post-surgical varicose vein patients.

Modelling the long-term cost-effectiveness of endovascular or open repair for abdominal aortic aneurysm

Background

Recent randomized trials have shown that endovascular abdominal aortic aneurysm repair (EVAR) has a 3 per cent aneurysm-related survival benefit in patients fit for open surgery, but it also has uncertain long-term outcomes and higher costs. This study assessed the cost-effectiveness of EVAR.

Methods

A decision model was constructed to estimate the lifetime costs and quality-adjusted life years (QALYs) with EVAR and open repair in men aged 74 years. The model includes the risks of death from aneurysm, other cardiovascular and non-cardiovascular causes, secondary reinterventions and non-fatal cardiovascular events. Data were taken largely from the EVAR trial 1 and supplemented from other sources.

Results

Under the base-case (primary) assumptions, EVAR cost £3800 (95 per cent confidence interval (c.i.) £2400 to £5200) more per patient than open repair but produced fewer lifetime QALYs (mean − 0·020 (95 per cent c.i. − 0·189 to 0·165)). These results were sensitive to alternative model assumptions.

Conclusion

EVAR is unlikely to be cost-effective on the basis of existing devices, costs and evidence, but there remains considerable uncertainty.

A preliminary study of peritraumatic dissociation, social support, and coping in relation to posttraumatic stress symptoms for a parent's cancer

This study examined predictors of posttraumatic stress disorder (PTSD) symptoms in adults who, as children, had a parent diagnosed with cancer. Possible predictors of adulthood PTSD examined were peritraumatic dissociation, satisfaction with social support, coping through denial, behavioral disengagement and self-distraction, and whether or not the parent died. Thirty research participants (20 women and 10 men, ages 18-38) were recruited who were 8-17-years old at the time of a parent's cancer diagnosis. Each participant completed measures of their current PTSD symptoms in response to their parent's cancer, peritraumatic dissociative experiences, demographic characteristics, and satisfaction with social support and use of coping strategies at the time of their parent's cancer diagnosis. Seventeen percent met screening criteria for likely PTSD. As hypothesized, PTSD symptoms were strongly and positively correlated with peritraumatic dissociation. Furthermore, PTSD symptoms were greater among females and were related to greater use of denial and behavioral disengagement and to less satisfaction with social support. These results suggest that health care providers need to recognize symptoms of peritraumatic dissociation in the children of parents who are diagnosed with cancer so that steps can be taken to minimize the children's development of PTSD that may extend into their adult lives.

Mortality following aortic surgery as a possible indicator of clinical performance

Background

The mortality rate following aortic surgery has been suggested as a possible indicator of clinical performance.

Methods

Routine hospital data on mortality following aortic surgery were collected for a 2-year interval in the Trent region. Procedural and diagnostic codes, mode of admission, district of residence, treatment and specialty data were analysed and compared with audit data and the Operating Theatre Information System.

Results

Inaccuracies in coding using the HRG (Health Resource Group) codes meant that 21·4 per cent of elective aortic cases (HRG Q01) were probably emergencies and 26 per cent of probable emergency ruptures were not coded as vascular emergencies. The HRG system does not identify complex procedures carried out in specialist centres, thereby distorting the overall mortality figures. Case mix and patient selection introduced a bias, apparent between tertiary and district general hospitals, with higher-risk elective and lower-risk emergency cases at tertiary referral centres. For patients aged over 80 years, two districts undertook no elective aortic surgery, and the rates for emergency surgery varied between 16 and 25 per cent in the districts and 77 per cent in the tertiary centre. After correction for these factors, there remains significant variation in mortality rates between tertiary referral centres and the district hospitals (Table).

Conclusion

Some of the difficulties in using crude mortality rates as an indicator of performance have been highlighted. They are subject to bias and distortions owing to the collection of incorrect information, patient selection differences between hospitals, case-mix differences and tertiary transfer of complicated cases. Other case-mix factors can be accounted for only with more detailed collection of clinical data such as POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) scores. However, there remains considerable and worrying variation in selection and outcomes of patients undergoing aortic surgery.