Metal mixtures and oral health among children and adolescents in the National Health and Nutrition Examination Survey (NHANES), 2017-2020

INTRODUCTION

Dental caries is the most common non-communicable human disease, yet little is known about the role of environmental metals, despite teeth consisting of a hard matrix of trace elements. We conducted a cross-sectional study of associations between environmental metals and objective assessment of dental caries and subjective assessments of oral health among a representative sample of U.S. children and adolescents.

METHODS

Data were from the 2017-March 2020 pre-pandemic data file of the National Health and Nutrition Examination Survey (NHANES). To account for metal mixtures, we used weighted quantile sum (WQS) regression to estimate the joint impact of multiple trace elements assessed in blood and urine with oral disease outcomes.

RESULTS

The blood metal mixture index was associated with a 32% (95% CI: 1.11, 1.56) increased risk of decayed surfaces while the urine metal mixture index was associated with a 106%, RR (95% CI = 2.06 (1.58, 2.70) increased caries risk. For both blood and urine, Mercury (Hg) had the largest contribution to the mixture index followed by Lead (Pb). The WQS blood metal mixture index was also significantly associated with poorer self-rated oral health, although the magnitude of the association was not as strong as for the objective oral disease measures, RR (95% CI) = 1.04 (1.02, 1.07).

DISCUSSION

Increased exposure to a metal mixture was significantly related to poorer objective and subjective oral health outcomes among U.S. children and adolescents. These are among the first findings showing that metal mixtures are a significant contributor to poor oral health.

Age-specific Reference Intervals of Abbott Intact PTH-Potential Impacts on Clinical Care

Background

PTH assays are not standardized; therefore, method-specific PTH reference intervals are required for interpretation of results. PTH increases with age in adults but age-related reference intervals for the Abbott intact PTH (iPTH) assay are not available.

Methods

Deidentified serum PTH results from September 2015 to November 2022 were retrieved from the laboratory information system of a laboratory serving a cosmopolitan population in central-west England for individuals aged 18 years and older if the estimated glomerular filtration rate was ≥60 mL/min, serum 25-hydroxyvitamin D was >50 nmol/L, and serum albumin-adjusted calcium and serum phosphate were within reference intervals. Age-specific reference intervals for Abbott iPTH were derived by an indirect method using the refineR algorithm.

Results

PTH increased with age and correlated with age when controlled for 25-hydroxyvitamin D, estimated glomerular filtration rate, and adjusted calcium (r = 0.093, P < .001). The iPTH age-specific reference intervals for 4 age partitions of 18 to 45 years, 46 to 60 years, 61 to 80 years, and 81 to 95 years were 1.6 to 8.6 pmol/L, 1.8 to 9.5 pmol/L, 2.0 to 11.3 pmol/L, and 2.3 to 12.3 pmol/L, respectively. PTH was higher in women compared with men (P < .001). Sex-specific age-related reference intervals could not be derived because of the limited sample size.

Conclusion

Age-specific Abbott iPTH reference intervals were derived. Application of age-specific reference intervals will impact the diagnosis and management of normocalcemic hyperparathyroidism, based on current definitions, and secondary hyperparathyroidism. Additional studies are required to clarify the effect of sex and ethnicity on PTH.

Assessing treatment adherence is crucial to determine adequacy of mineralocorticoid therapy

Background

There is no consensus strategy for mineralocorticoid (MC) therapy titration in patients with primary adrenal insufficiency (PAI). We aim to measure serum fludrocortisone (sFC) and urine fludrocortisone (uFC) levels and to determine their utility, alongside clinical/biochemical variables and treatment adherence to guide MC replacement dose titration.

Methods

Multi-centre, observational, cross-sectional study on 41 patients with PAI on MC replacement therapy. sFC and uFC levels (measured by liquid chromatography-tandem mass spectrometry), plasma renin concentration (PRC), electrolytes (Na+, K+), mean arterial blood pressure (MAP), total daily glucocorticoid (dGC) and MC (dMC) dose, and assessment of treatment adherence were incorporated into statistical models.

Results

We observed a close relationship between sFC and uFC (r = 0.434, P = 0.005) and between sFC and the time from the last fludrocortisone dose (r = -0.355, P = 0.023). Total dMC dose was related to dGC dose (r = 0.556, P < 0.001), K+ (r = -0.388, P = 0.013) as well as sFC (r = 0.356, P = 0.022) and uFC (r = 0.531, P < 0.001). PRC was related to Na+ (r = 0.517, P < 0.001) and MAP (r = -0.427, P = 0.006), but not to MC dose, sFC or uFC. Regression analyses did not support a role for sFC, uFC or PRC measurements and confirmed K+ (B = -44.593, P = 0.005) as the most important variable to guide dMC titration. Of the patients, 32% were non-adherent with replacement therapy. When adherence was inserted into the regression model, it was the only factor affecting dMC.

Conclusions

sFC and uFC levels are not helpful in guiding dMC titration. Treatment adherence impacts on clinical variables used to assess MC replacement and should be included as part of routine care in patients with PAI.

The first drug-related death associated with xylazine use in the UK and Europe

BACKGROUND AND AIMS

On November 8th^, 2022, the United States Food and Drug Administration (FDA) issued a statement alerting healthcare professionals to the increasing prevalence of xylazine in illicit drug overdoses in the country. Xylazine is a veterinary medicine with sedative, analgesic and muscle relaxant properties that is used as a heroin/fentanyl adulterant on the illicit drug market in North America. Here we report the first drug-related death associated with xylazine in the United Kingdom.

METHODS

The National Programme on Substance Abuse Deaths (NPSAD) receives reports on drug-related deaths from coroners In England, Wales and Northern Ireland on a voluntary basis. The NPSAD was searched for cases with xylazine detections in cases received by December 31, 2022.

RESULTS

One drug-related death associated with xylazine use was reported to NPSAD by December 31, 2022. The deceased was a 43-year-old male who was found dead at home with drug paraphernalia located at the property in May 2022. The post-mortem examination identified recent puncture wounds to the groin. Coronial documentation reports that the deceased had a history of illicit drug use. A number of drugs were detected by post-mortem toxicology and xylazine was implicated in death alongside heroin, fentanyl and cocaine.

CONCLUSIONS

To the best of our knowledge, this is the first death associated with xylazine use reported in the UK, and even Europe, and indicates the entry of xylazine into the UK drug supply. This report highlights the importance of monitoring changes in illicit drug markets and the emergence of new drugs.

11β-HSD1 inhibition in men mitigates prednisolone-induced adverse effects in a proof-of-concept randomised double-blind placebo-controlled trial

Glucocorticoids prescribed to limit inflammation, have significant adverse effects. As 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) regenerates active glucocorticoid, we investigated whether 11β-HSD1 inhibition with AZD4017 could mitigate adverse glucocorticoid effects without compromising their anti-inflammatory actions. We conducted a proof-of-concept, randomized, double-blind, placebo-controlled study at Research Unit, Churchill Hospital, Oxford, UK (NCT03111810). 32 healthy male volunteers were randomized to AZD4017 or placebo, alongside prednisolone treatment. Although the primary endpoint of the study (change in glucose disposal during a two-step hyperinsulinemic, normoglycemic clamp) wasn't met, hepatic insulin sensitivity worsened in the placebo-treated but not in the AZD4017-treated group. Protective effects of AZD4017 on markers of lipid metabolism and bone turnover were observed. Night-time blood pressure was higher in the placebo-treated but not in the AZD4017-treated group. Urinary (5aTHF+THF)/THE ratio was lower in the AZD4017-treated but remained the same in the placebo-treated group. Most anti-inflammatory actions of prednisolone persisted with AZD4017 co-treatment. Four adverse events were reported with AZD4017 and no serious adverse events. Here we show that co-administration of AZD4017 with prednisolone in men is a potential strategy to limit adverse glucocorticoid effects.

Interlaboratory comparison study of immunosuppressant analysis using a fully automated LC-MS/MS system

OBJECTIVES

All guidelines recommend LC-MS/MS as the analytical method of choice for the quantification of immunosuppressants in whole blood. Until now, the lack of harmonization of methods and the complexity of the analytical technique have prevented its widespread use in clinical laboratories. This can be seen in international proficiency schemes, where more than half of the participants used immunoassays. With the Cascadion SM Clinical analyzer (Thermo Fisher Scientific, Oy, Vantaa, FI) a fully automated LC-MS/MS system has been introduced, which enables the use of LC-MS/MS without being an expert in mass spectrometry.

METHODS

To verify the interlaboratory comparison of the immunosuppressant assay on this type of instrument, three centers across Europe compared 1097 routine whole blood samples, each site sharing its own samples with the other two. In other experiments, the effects of freezing and thawing of whole blood samples was studied, and the use of secondary cups instead of primary tubes was assessed.

RESULTS

In the Bland-Altman plot, the comparison of the results of tacrolimus in fresh and frozen samples had an average bias of only 0.36%. The respective data for the comparison between the primary and secondary tubes had an average bias of 1.14%. The correlation coefficients for patient samples with cyclosporine A (n=411), everolimus (n=139), sirolimus (n=114) and tacrolimus (n=433) were 0.993, 0.993, 0.993 and 0.990, respectively.

CONCLUSIONS

The outcome of this study demonstrates a new level of result harmonization for LC-MS/MS based immunosuppressant analysis with a commercially available fully automated platform for routine clinical application.

Peri-operative care of elective adult surgical patients with a learning disability

People with a learning disability can experience significant problems in accessing healthcare and this may be partly reflected in worse health outcomes compared with the general population, including a shorter life expectancy. The Equality Act (2010) requires that organisations and individuals make changes to the way services are provided for all disabled people to mitigate, as far as possible, any disadvantage they may face in accessing these services. These changes are termed 'reasonable adjustments'. This article describes the reasonable adjustments that can be made to facilitate the admission of an adult surgical patient with a learning disability, and therefore reduce health inequality. Each stage of a patient's journey through the hospital needs to be anticipated and planned for. Many of these changes are not only applicable to the wider care of people with a learning disability, but also to any person who lacks capacity and who is struggling to access healthcare. Key recommendations include the development of assessment tools, pathways and policies specific to the learning disabled patient; identification of key personnel including a learning disability lead, an acute liaison learning disability nurse, pre-assessment and operating theatre personnel and ward learning disability champions; regular multidisciplinary team meetings for planning and best interest assessments; and establishing an electronic alert on the patient administration system to identify learning disabled patients. The anaesthetist, operating theatre and learning disability teams play a pivotal role in ensuring individualised admission plans are made for patients with a learning disability to reduce these healthcare inequalities and improve peri-operative care.

A comparison of mdma-assisted psychotherapy to non-assisted psychotherapy in treatment-resistant PTSD: A systematic review and meta-analysis

Introduction

Novel, evidence-based treatments are required for treatment-resistant post-traumatic stress disorder (PTSD). 3,4-Methylenedioxymethamphetamine (MDMA) has beneficially augmented psychotherapy in several small clinical trials.

Objectives

To review the use of MDMA-assisted psychotherapy in treatment-resistant PTSD.

Methods

Systematic searches of four databases were conducted from inception to February 2020. A meta-analysis was performed on trials which were double-blinded, randomised, and compared MDMA-assisted psychotherapy to psychotherapy and placebo. The primary outcomes were the differences in Clinician Administered PTSD Scale (CAPS-IV) score and Beck’s Depression Inventory (BDI). Secondary outcome measures included neurocognitive and physical adverse effects, at the time, and within seven days of intervention.

Results

Four randomised controlled trials (RCTs) met inclusion criteria. When compared to active placebo, intervention groups taking 75mg (MD -46.90; 95% CI -58.78, -35.02), 125mg (MD -20.98; 95% CI -34.35, -7.61) but not 100mg (MD -12.90; 95% CI -36.09, 10.29) of MDMA with psychotherapy, had significant decreases in CAPS-IV scores, as did the inactive placebo arm (MD -33.20; 95% CI -40.53, -25.87). A significant decrease in BDI when compared to active placebo (MD -10.80; 95% CI -20.39, -1.21) was only observed at 75mg. Compared to placebo, participants reported significantly more episodes of low mood, nausea and jaw-clenching during sessions and lack of appetite after seven days.

Conclusions

These results demonstrate potential therapeutic benefit with minimal physical and neurocognitive risk for the use of MDMA-assisted psychotherapy in TR-PTSD, despite little effect on Beck’s Depression Inventory. Better powered RCTs are required to investigate further.

Disclosure

James Rucker has attended trial related meetings paid for by Compass Pathways Ltd.

Co-administration of 5α-reductase Inhibitors Worsens the Adverse Metabolic Effects of Prescribed Glucocorticoids

CONTEXT

Glucocorticoids (GCs) are commonly prescribed, but their use is associated with adverse metabolic effects. 5α-reductase inhibitors (5α-RI) are also frequently prescribed, mainly to inhibit testosterone conversion to dihydrotestosterone. However, they also prevent the inactivation of GCs.

OBJECTIVE

We hypothesized that 5α-RI may worsen the adverse effects of GCs.

DESIGN

Prospective, randomized study.

PATIENTS

A total of 19 healthy male volunteers (age 45 ± 2 years; body mass index 27.1 ± 0.7kg/m2).

INTERVENTIONS

Participants underwent metabolic assessments; 2-step hyperinsulinemic, euglycemic clamp incorporating stable isotopes, adipose tissue microdialysis, and biopsy. Participants were then randomized to either prednisolone (10 mg daily) or prednisolone (10 mg daily) plus a 5α-RI (finasteride 5 mg daily or dutasteride 0.5 mg daily) for 7 days; metabolic assessments were then repeated.

MAIN OUTCOME MEASURES

Ra glucose, glucose utilization (M-value), glucose oxidation, and nonesterified fatty acids (NEFA) levels.

RESULTS

Co-administration of prednisolone with a 5α-RI increased circulating prednisolone levels (482 ± 96 vs 761 ± 57 nmol/L, P = 0.029). Prednisolone alone did not alter Ra glucose (2.55 ± 0.34 vs 2.62 ± 0.19 mg/kg/minute, P = 0.86), M-value (3.2 ± 0.5 vs 2.7 ± 0.7 mg/kg/minute, P = 0.37), or glucose oxidation (0.042 ± 0.007 vs 0.040 ± 0.004 mmol/hr/kg/minute, P = 0.79). However, co-administration with a 5α-RI increased Ra glucose (2.67 ± 0.16 vs 3.05 ± 0.18 mg/kg/minute, P < 0.05) and decreased M-value (4.0 ± 0.5 vs 2.6 ± 0.4 mg/kg/minute, P < 0.05), and oxidation (0.043 ± 0.003 vs 0.036 ± 0.002 mmol/hr/kg, P < 0.01). Similarly, prednisolone did not impair insulin-mediated suppression of circulating NEFA (43.1 ± 28.9 vs 36.8 ± 14.3 μmol/L, P = 0.81), unless co-administered with a 5α-RI (49.8 ± 8.6 vs 88.5 ± 13.5 μmol/L, P < 0.01).

CONCLUSIONS

We have demonstrated that 5α-RIs exacerbate the adverse effects of prednisolone. This study has significant translational implications, including the need to consider GC dose adjustments, but also the necessity for increased vigilance for the development of adverse effects.

0778 Workplace Yoga Program Features and Associations With Shift Work and Sleep Among Nursing Staff

Introduction

Nursing staff are at risk for impaired sleep due to irregular schedules, long work hours, and other occupational stress. Yoga has demonstrated beneficial effects on sleep in healthy adults and patients with chronic diseases. However, yoga interventions are generally offered as 60-75-minute sessions; this long duration might not be suitable as a workplace program for nursing staff. The objective of this study is to examine workplace yoga program features and associations with shift work and sleep among nursing staff.

Methods

Online Qualtrics surveys were distributed among nurses and nursing assistants at a community hospital in the northeast U.S. Hypothetical workplace yoga program features were assessed including general interest, duration, frequency, timing with respect to work shift, and interest in home practice. Sleep duration and disturbances were assessed.

Results

Among the 541 participants (94% female; age 43±13y), over a third reported sleep ≤6hrs/day (38%) and sleep disturbances (38%), and 79% reported interest in workplace yoga. Among those reporting interest, after work (61%), 30min/session (73%), 3 sessions/week (56%), and interests in home practice (64%) were yoga features endorsed by nursing staff. Night or ≥12hr shift was associated with less interest in workplace yoga. Evening or ≥12hr shift was associated with less interest in yoga after work, while day or night shift was associated with less interest in yoga before work. Mild sleep disturbances were associated with more interest while severe disturbances were associated with less interest in yoga after work. Nursing staff with sleep≤6hrs/day reported less interest in yoga before work, but more interest in home yoga practice.

Conclusion

Nursing staff reported a high prevalence of short and disturbed sleep and interest in workplace yoga. Workplace yoga programs need to be designed according to nursing staff’s interest while considering the effect of shift work and sleep problems reported by nursing staff.

Support

Drs. Yuan Zhang and Jeanne F. Duffy were supported by NIH grant R01 AG044416.

0409 The Efficacy of Afternoon-Evening Sleep Following Night Shifts on Sleep and Alertness in Nurses with Rotating Shift Work Schedule: Real World Data

Introduction

The aim of this study was to investigate the efficacy of changing sleep timing to afternoon-evening following nightshifts in hospital nurses with three rapid rotating shift schedules.

Methods

Hospital nurses with three rotating shift schedules were enrolled for a 1-month pre-intervention and a 1-month intervention study. During the Intervention, sleep timing following nightshifts was directed to afternoon-evening sleep for 8h time-in-bed (TIB) after 1 PM, and ad-lib sleep schedule for other shifts. Baseline and follow-up evaluation included sleep schedule, sleep duration, Epworth sleepiness scale (ESS), insomnia severity index (ISI) for each shift, Beck depression inventory (BDI), and Beck anxiety inventory (BAI). Sleep was assessed by sleep diary and actigraphy. Alertness during the night shift was evaluated using the Karolinska sleepiness scale (KSS) in the beginning and at the end of the shift by texts sent to their cell phones. The participants were asked to give feedback and a willingness to continue this intervention.

Results

A total of 26 subjects (30.7±8.5years, 25 female) finished the study among 29 nurses who participated in the study. The shift work was 6.5±8.0years. The mean morningness-eveningness scale was 42.1±8.0(31-62). TIB following nightshifts were 379.9±91.2 and 478.4±48.7 min for preintervention and intervention, respectively (p=0.001). Total sleep time (TST) was 328.0±91.0 vs. 361.0±70.4min, respectively following nightshifts (p=0.187, Cohen’s drm = 0.467). BDI, BAI, ESS, and ISI were significantly improved after the intervention. 60.7% and 49% of the participants reported improved alertness, and work efficiency during the nightshift. 17.9% and 42.9% of the participants reported increased sleep duration, and improved sleep quality after nightshift, respectively. Only eight participants were willing to continue the afternoon-evening sleep schedule following night shifts. KSS was not different between pre-intervention and intervention.

Conclusion

The afternoon-evening sleep schedule modestly increased total sleep time following nightshift. The overall mood, sleepiness and insomnia scale improved after the intervention although the alertness assessed by KSS failed to show the difference. The individual difference should be considered for applying afternoon-evening sleep for rapid rotating shift schedules.

Support

2018 Research award grants from the Korean sleep research society and NRF-2019R1A2C1090643 funded by the Korean national research foundation

1024 Associations Of Low Back Pain And Sleep Among Nursing Staff

Introduction

Nursing is one of the top occupations suffering musculoskeletal disorders, especially low back pain (LBP). Nursing staff also experience short and disturbed sleep. Although there is a known relationship between pain and sleep, the specific associations between different aspects of LBP (e.g., duration, frequency, intensity) and sleep have not been studied. The objective of this study is to examine different aspects of LBP and their cross-sectional associations with sleep among nursing staff.

Methods

Online Qualtrics surveys were distributed among nurses and nursing assistants at a community hospital in the northeast U.S. LBP was assessed in terms of duration, frequency, intensity, and intensity change from before to after the work shift. Sleep duration and disturbances were assessed with validated scales.

Results

Among the 541 participants (94% female; age 43±13y), more than a third reported short sleep duration (≤6hrs/day; 38%) or sleep disturbances (38%), and more than half (60%) reported LBP in the past 6 months. Among those with LBP, 82% had ongoing pain for at least 6 months; 44% had ongoing pain for at least half the days in the past 6 months; 39% had LBP intensity ≥4 out of 10; and 79% reported post-shift LBP intensity increased of at least 1 level. Short sleep duration was associated with ongoing LBP for at least half the days in the past 6 months, intensity ≥4, and post-shift LBP intensity increase. Sleep disturbances were associated with prevalent LBP and intensity ≥4.

Conclusion

Nursing staff reported a high prevalence of LBP as well as short and disturbed sleep. Overall, poor sleep was associated with higher LBP prevalence, frequency, intensity, and post-shift increase. Future longitudinal studies are needed to clarify the causal directions of these relationships. Workplace interventions should address the widespread problems of LBP and sleep deficiency of nursing staff.

Support

Drs. Yuan Zhang and Jeanne F. Duffy were supported by NIH grant R01 AG044416.

Development and Clinical Application of a Prednisolone/Cortisol Assay to Determine Adherence to Maintenance Oral Prednisolone in Severe Asthma

BACKGROUND

Nonadherence to oral prednisolone is an important driver of poor control in severe asthma, and its detection is warranted to guide management.

RESEARCH QUESTION

The goal of this study was to evaluate the utility of liquid chromatography and tandem mass spectrometry (LC-MS/MS) in determining the adherence status to oral prednisolone in severe asthma.

STUDY DESIGN AND METHODS

Timeline serum levels of prednisolone, cortisol, and metabolites were measured by using a validated LC-MS/MS assay following observed intake of prednisolone in patients receiving maintenance oral prednisolone. Patterns of adherence and nonadherence were determined from analysis of peak blood levels. The performance of a spot test for adherence (detectable prednisolone and suppressed cortisol) was assessed in a second cohort of patients receiving maintenance prednisolone and a control group.

RESULTS

In the prednisolone absorption test, 27 patients (mean age, 38.6 years; age range, 17-63 years; 83% female) were included. We identified adherence in 13 (48%), nonadherence in 13 (48%), and malabsorption in one (3.7%). The median [interquartile range] peak serum assays of the adherent group compared with the nonadherent group were: cortisol, 36 [39.5] vs 295 [153] nmol/L; and prednisolone, 1,810 [590] vs 1,730 [727] nmol/L. The spot test cohort included 111 patients (67 on maintenance prednisolone and 44 control subjects); the mean age was 42.4 years, and 79% were female. Nonadherence was detected in 40.3% of patients; comparison of the adherent vs nonadherent groups revealed median [interquartile range] levels for cortisol of 27 [48] nmol/L vs 211 [130] nmol/L and for prednisolone of 259 [622] nmol/L vs < 20 nmol/L, respectively. Adherent patients had higher mean BMI (38.4 ± 8.7 vs 32 ± 7.5 kg/m²; P = .03), lower median blood eosinophils (0.09 [0.31] vs 0.51 [0.53] × 10⁹/L; P < .001), and a trend toward reduced mean annual severe exacerbations (3.0 ± 2.6 vs 4.3 ± 2.4; P = .3) than nonadherent patients.

INTERPRETATION

Nonadherence to oral prednisolone is common in severe asthma and can be reliably detected in the clinic by using the LC-MS/MS assay.

Use of progression criteria to support monitoring and commissioning decision making of public health services: lessons from Better Start Bradford

BACKGROUND

Commissioning and monitoring of community-based interventions is a challenge due to the complex nature of the environment and the lack of any explicit cut-offs to guide decision making. At what point, for example, is participant enrolment to interventions, course completion or satisfaction deemed to be acceptable or sufficient for continued funding? We aimed to identify and quantify key progression criteria for fourteen early years interventions by (1) agreeing the top three criteria for monitoring of successful implementation and progress; and (2) agreeing boundaries to categorise interventions as 'meeting anticipated target' (green); 'falling short of targets' (amber) and 'targets not being met' (red).

METHODS

We ran three workshops in partnership with the UK's Big Lottery Fund commissioned programme 'Better Start Bradford' (implementing more than 20 interventions to improve the health, wellbeing and development of children aged 0-3) to support decision making by agreeing progression criteria for the interventions being delivered. Workshops included 72 participants, representing a range of professional groups including intervention delivery teams, commissioners, intervention-monitoring teams, academics and community representatives. After discussion and activities, final decisions were submitted using electronic voting devices. All participants were invited to reconsider their responses via a post-workshop questionnaire.

RESULTS

Three key progression criteria were assigned to each of the 14 interventions. Overall, criteria that participants most commonly voted for were recruitment, implementation and reach, but these differed according to each intervention. Cut-off values used to indicate when an intervention moved to 'red' varied by criteria; the lowest being for recruitment, where participants agreed that meeting less than 65% of the targeted recruitment would be deemed as 'red' (falling short of target).

CONCLUSIONS

Our methodology for monitoring the progression of interventions has resulted in a clear pathway which will support commissioners and intervention teams in local decision making within the Better Start Bradford programme and beyond. This work can support others wishing to implement a formal system for monitoring the progression of public health interventions.

The impact of the Nurse Faculty Scholars program on schools of nursing

BACKGROUND

The Robert Wood Johnson Foundation Nurse Faculty Scholars program was conceptualized as not only promoting the growth and development of early-career faculty but as enhancing the research infrastructure of scholars' schools of nursing.

PURPOSE

At the completion of the scholars' three years of support, deans/directors were asked to provide feedback regarding the institutional impact of the scholars' participation in the program.

METHODS

Phone interviews were conducted on the first five completed cohorts and a six-item questionnaire was developed to obtain some quantitative data.

DISCUSSION

The program was viewed as having accelerated the scholars' leadership and scholarship, and their influence within the school/university and regionally/nationally. Deans/directors generally agreed that the scholars' experience helped build the school's research portfolio.

CONCLUSION

Looking back on how the participating schools of nursing fared, one can say that the program's institutional expectations were achieved most of the time. The program helped scholars build their own reputations and that in turn had consequences for the school's standing as a whole. A number of components are described that can be replicated singly or in various combinations by schools/universities interested in adopting aspects of this program.

Vitamin D and tuberculosis: review and association in three rural provinces of Afghanistan

OBJECTIVES

1) To update the 2006 systematic review and meta-analysis by Nnoaham & Clarke exploring the association between serum vitamin D and risk of active tuberculosis (TB) following discrepant evidence; and 2) to identify whether TB and vitamin D are associated in rural Afghanistan.

METHODS

Systematic review and meta-analysis of studies published between January 1980 and June 2014 using Nnoaham & Clarke's methodology. For this case-control study, 90 age- and sex-matched pairs were recruited from rural provinces, and blood 25-hydroxyvitamin D concentrations were measured using enzyme-linked immunosorbent assay.

RESULTS

Sixteen studies were eligible for review. Eleven showed differences between vitamin D levels in TB patients and controls, two showed partial differences and three showed none. Studies on African and European populations show lower vitamin D levels in TB patients, but results from Asia vary. No significant differences were found in vitamin D levels in our rural Afghan population. Controls had a higher body mass index (BMI) (mean control BMI 21.50 kg/m(2), mean case BMI 18.86 kg/m(2), P < 0.001), and were more likely to have been employed (40% of controls, 15.6% of cases, P = 0.002).

CONCLUSION

Genetic differences may account for the differences among study results in the systematic review. Vitamin D levels are not associated with TB among Afghans living in these rural provinces.

Pediatric health-related quality of life after intestinal transplantation

As outcomes after ITx improve, greater emphasis is needed on HRQOL. The primary aims of this study were to (i) assess the feasibility of measuring HRQOL in pediatric ITx recipients, (ii) measure HRQOL using validated instruments, and (iii) compare HRQOL in ITx recipients to healthy normal (NL) children. The CHQ and Pediatric Quality of Life (PedsQL4.0) instruments were administered to both patients and parents at outpatient visits. All 24 eligible patients were enrolled. The median age at study enrollment was 6.0 yr (range: 2-18 yr), and the median time from transplant to study enrollment was 2.8 yr (range: 0.5-11.8 yr). The majority of subjects were male (58%), Latino (58%), and liver-inclusive (92%) recipients. For CHQ and PedsQL4.0, parental responses were significantly lower in multiple categories including physical health and social functioning compared to healthy norms. Patient responses were not different from NL using CHQ but using PedsQL4.0 were significantly lower in the school functioning subcategory and psychosocial health summary score. HRQOL as reported by children and families after ITx is significantly lower in multiple categories compared to NL.

Prevalence of genital chlamydial infection among a community sample of young international backpackers in Sydney, Australia

We conducted a chlamydia prevalence study from January to June 2009 among a community sample of young international backpackers by recruiting at hostels in Sydney, Australia. Participants completed a questionnaire; men provided a urine sample and women provided a self-collected vaginal swab, which were tested for Chlamydia trachomatis DNA by strand displacement amplification. We recruited 225 men (median age 24 years) and 207 women (median age 23 years). Most (87%) of the travellers came from Europe. A new sexual partner during travel was reported by 67%, and 51% had more than one new sexual partner. Of those reporting a new sexual partner, 40% always used condoms. Prevalence of chlamydia was 3.5% (3.1% in men, 3.9% in women). Previous testing for chlamydia was reported by 40%. Drinking alcohol at hazardous levels was reported by 58% of men and 29% of women. Despite the reporting of new sexual partners and inconsistent condom use, the prevalence of chlamydia in these backpackers was not higher than that found in more general populations, and may relate to good health-care seeking behaviour. Young travellers need education about sexual risks and promotion of condom use prior to travel, and access to public sexual health services.

Extended criteria donor and severe intraoperative glucose variability: association with reoperation for hemorrhage in liver transplantation

Reoperations for hemorrhage following liver transplantation (OLT) are commonly associated with increased morbidity and mortality. We sought to determine the incidence and risk factors for reoperation for hemorrhage among adult liver transplantations. We retrospectively analyzed 668 patients transplanted between January 2004 and November 2007. Within 30 days following transplantation one hundred eleven patients (16.6%) underwent 156 reoperations for hemorrhage, averaging 1.4 reoperations per patient. More than half of the reoperations occurred during the first 2 postoperative days. One-third of patients required 2 or more reoperations. Multivariate logistic regression analysis showed 4 independent risk factors: grafts from donors with multiple extended criteria, severe intraoperative glucose variability, intraoperative use of vasopressors, and red blood cell transfusion requirement. In conclusion, we identified several independent risk factors for reoperation due to hemorrhage following OLT. Avoidance of severe intraoperative glucose variability and careful evaluation of the benefits and risks of utilizing extended criteria donors must be considered before transplantation.

Pain relief in hysterosalpingography

BACKGROUND

Hysterosalpingography (HSG) is a method of testing for tubal patency. Various pharmacological strategies are available that may reduce the pain during the procedure.

OBJECTIVES

To compare the effectiveness of different types of pharmacological interventions for pain relief in women undergoing hysterosalpingography (HSG) for investigation of subfertility.

SEARCH STRATEGY

This review has drawn on the search strategy developed for the Menstrual Disorders and Subfertility Group. In addition MEDLINE and EMBASE were searched up to July 2006.

SELECTION CRITERIA

All randomised controlled trials investigating the pharmacological interventions for pain relief during HSG were investigated.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by the first two authors. Differences of opinion were registered and resolved by the third author. Results for each study were expressed as mean pain score and standard error of the mean with 95% confidence intervals.

MAIN RESULTS

The included eight trials reported on 570 women undergoing HSG.Overall, there was no evidence of benefit of using any analgesia compared with placebo for pain relief during the procedure (standard mean difference (SMD) of -0.05 (95%CI -0.25 to 0.14) or up to 29 minutes after HSG SMD 0.17, (95%CI -1.00 to 1.34)). Four RCTs involving 219 women found evidence of benefit with any analgesia in comparison to placebo for pain relief more than 30 minutes after HSG, with the SMD of -0.82(95%CI-1.18 to -0.45). One RCT involving 91 women compared the effectiveness of opioid analgesics versus non-opioid analgesics and reported no evidence of difference in pain relief at any stage of the procedure. One RCT involving 20 women compared the use of topical analgesia with a paracervical block, with analysis demonstrating more benefit to be gained from using topical analgesia during HSG, with the SMD of -2.03 (95%Cl-3.16 to -0.91).

AUTHORS' CONCLUSIONS

There is little evidence of benefit in terms of pain relief of any of the interventions considered in this study during or immediately after HSG. However, there is limited evidence of pain reduction 30 minutes after the procedure. Further RCTs should consider the role of non steroidal antiinflammatories (NSAIDs) and intrauterine anaesthetic during HSG.

Effects of elevated temperature and nickel pollution on the immune status of Japanese medaka

Changes in a host's environment (i.e. physical or chemical) can alter normal immune function. In aquatic organisms, exposure to stress can result in significant changes in innate immunity. In the natural environment, fish are exposed to multiple stressors simultaneously. Temperature change and/or chemical exposure as individual environmental stressors have been shown in various fish species to alter all aspects of the immune response. These same stressors have also been shown to alter plasma steroid levels in exposed fish. For this study, the effects of elevated temperature and nickel pollution on specific immune parameters of Japanese medaka (Oryzias latipes) were determined. Fish were exposed for 1, 7 or 14d to either: waterborne nickel (Ni) at the nominal concentration of 125ppb; a 5 degrees C (+/-0.5 degrees C) rapid increase in water temperature; or, both potential stressors in combination. Medaka maintained at room temperature (25 degrees C+/-1 degrees C) served as the controls. Altered function of the innate and adaptive arms of the immune response was evaluated by assessing kidney macrophage-mediated superoxide (O(2)(-)) production and splenic T-cell proliferation, respectively. Plasma cortisol levels were analysed in the same fish as a marker of the physiological stress response. While kidney cell number was unaffected by exposure of fish to either stressor alone or both factors in combination, spleen cellularity was decreased (compared to control fish) in medaka exposed for 1d to thermal stress in combination with Ni, and to a lesser extent to thermal stress alone. T-lymphocyte proliferation by medaka splenocytes was not affected by any exposure paradigm. Unstimulated intracellular O(2)(-) production by kidney phagocytes was significantly elevated (compared to control) in medaka exposed for 1d to either thermal stress alone or temperature change in combination with Ni; by 7d, only the stressor combination significantly increased baseline O(2)(-) production. Resting levels of extracellular O(2)(-) production was significantly reduced in fish maintained for 1d at the elevated temperature. Effects on phorbol 12-myristate 13 acetate (PMA)-stimulated intracellular and extracellular O(2)(-) production were less dramatic than those observed for resting phagocytes. Exposure of medaka to elevated temperature for 14d tended (p<0.06) to reduce PMA-stimulated intracellular O(2)(-) production (compared to the time-matched control). Although exposure of fish for 14d to elevated temperature only slightly reduced stimulated extracellular O(2)(-) production, exposure for the same duration to Ni alone significantly depressed oxyradical production by kidney phagocytes (compared to the time-matched controls). Decreased plasma cortisol levels were observed in fish exposed for 7d to either an elevated water temperature or Ni (compared to the time-matched control); by 14d of exposure, no significant treatment-induced effects on cortisol levels were observed. These findings add to the growing body of literature seeking to determine what effects, if any, exposure to multiple aquatic pollution-induced effects have upon fish health and the health of impacted ecosystems.

Severe pulmonary disease due to multisystemic eosinophilic epitheliotropic disease in a horse

Multisystemic eosinophilic epitheliotropic disease was diagnosed histologically in a 17-year-old Quarter Horse intact mare that was presented with a chronic history of respiratory distress. At necropsy, the lungs were poorly collapsed and the pulmonary parenchyma contained innumerable, discrete, spherical nodules in a miliary pattern. A few similar nodules were scattered in the liver and the renal lymph nodes. Histologically, these nodules consisted of fibrosing eosinophilic granulomas. Based on histologic findings and the absence of an etiologic agent, a diagnosis of multisystemic eosinophilic epitheliotropic disease was made.

Predictors of operative death after oesophagectomy for carcinoma

BACKGROUND

Oesophagectomy for carcinoma provides a chance of cure but carries significant risk. This study defined risk factors for death after oesophageal resection for malignant disease.

METHODS

Between 1990 and 2003, 773 oesophagectomies for oesophageal cancer were performed. Continuous variables were categorized into quartiles for analysis. Predictors of operative mortality were identified by univariate and multiple logistic regression analysis.

RESULTS

The operative mortality rate was 4.8 per cent (37 of 773). In univariate analysis, advanced age, reduced forced expiratory volume in 1 s (FEV1), reduced forced vital capacity, presence of diabetes and tumour located in the upper third of the oesophagus were associated with a higher mortality rate. Multivariate analysis identified age (highest relative to lowest quartile, odds ratio (OR) 4.87 (95 per cent confidence interval (c.i.) 1.35 to 17.55); P = 0.009), tumour position (upper third relative to other locations, OR 4.23 (95 per cent c.i. 1.06 to 16.86); P = 0.041) and FEV1 (lowest relative to highest quartile, OR 4.72 (95 per cent c.i. 1.01 to 21.99); P = 0.018) as independent predictors of death.

CONCLUSION

Advanced age, impaired preoperative respiratory function and a tumour high in the oesophagus are associated with a significantly increased risk of death after oesophagectomy for carcinoma.

New approaches to enhance the accuracy of the diagnosis of reflux disease

The accuracy of symptoms in diagnosing gastro-oesophageal reflux disease (GORD) is complicated by the lack of a gold standard test. Statistical techniques such as latent class and Bayesian analyses can estimate accuracy of symptoms without a gold standard. Both techniques require three independent diagnostic tests. Latent class analysis makes no assumptions about the performance of the tests. Bayesian analysis is useful when the accuracy of the other tests is known. These statistical techniques should be used in the future to validate GORD symptom questionnaires comparing them with endoscopy, oesophageal pH monitoring, and response to proton pump inhibitor therapy. Studies that evaluate GORD symptoms are usually done in secondary care. The prevalence of GORD in primary care will be lower and this reduces the positive predictive value of symptoms. There will be some bias in the type of patient referred for diagnosis and this usually decreases the specificity of symptom diagnosis.