Scale-up of the Internet-based Professional Learning to help teachers promote Activity in Youth (iPLAY) intervention: a hybrid type 3 implementation-effectiveness trial

BACKGROUND

Whole-of-school programs have demonstrated success in improving student physical activity levels, but few have progressed beyond efficacy testing to implementation at-scale. The purpose of our study was to evaluate the scale-up of the 'Internet-based Professional Learning to help teachers promote Activity in Youth' (iPLAY) intervention in primary schools using the RE-AIM framework.

METHODS

We conducted a type 3 hybrid implementation-effectiveness study and collected data between April 2016 and June 2021, in New South Wales (NSW), Australia. RE-AIM was operationalised as: (i) Reach: Number and representativeness of students exposed to iPLAY; (ii) Effectiveness: Impact of iPLAY in a sub-sample of students (n = 5,959); (iii) Adoption: Number and representativeness of schools that received iPLAY; (iv) Implementation: Extent to which the three curricular and three non-curricular components of iPLAY were delivered as intended; (v) Maintenance: Extent to which iPLAY was sustained in schools. We conducted 43 semi-structured interviews with teachers (n = 14), leaders (n = 19), and principals (n = 10) from 18 schools (11 from urban and 7 from rural locations) to determine program maintenance.

RESULTS

Reach: iPLAY reached ~ 31,000 students from a variety of socio-economic strata (35% of students were in the bottom quartile, almost half in the middle two quartiles, and 20% in the top quartile).

EFFECTIVENESS

We observed small positive intervention effects for enjoyment of PE/sport (0.12 units, 95% CI: 0.05 to 0.20, d = 0.17), perceptions of need support from teachers (0.26 units, 95% CI: 0.16 to 0.53, d = 0.40), physical activity participation (0.28 units, 95% CI: 0.10 to 0.47, d = 0.14), and subjective well-being (0.82 units, 95% CI: 0.32 to 1.32, d = 0.12) at 24-months. Adoption: 115 schools received iPLAY.

IMPLEMENTATION

Most schools implemented the curricular (59%) and non-curricular (55%) strategies as intended. Maintenance: Based on our qualitative data, changes in teacher practices and school culture resulting from iPLAY were sustained.

CONCLUSIONS

iPLAY had extensive reach and adoption in NSW primary schools. Most of the schools implemented iPLAY as intended and effectiveness data suggest the positive effects observed in our cluster RCT were sustained when the intervention was delivered at-scale.

TRIAL REGISTRATION

ACTRN12621001132831.

Auditory performance after cochlear reimplantation

AIM

The aim of this study was to evaluate the impact of cochlear reimplantation (CR) on hearing performance in children and adults with severe to profound hearing loss.

MATERIAL AND METHODS

Retrospective observational study.

OBJECTIVES

The main objective of this study was to determine whether there was a difference in hearing performance before and after CR. Secondary objectives were to analyze reasons for CR; to assess correlations between auditory performance and complete electrode reinsertion during CR, age, gender, explantation-to-CR interval, and interval between first implantation and CR; and to assess difference in APCEI score and the French evaluation protocol for implanted patients before and after CR.

RESULTS

Comparison of speech perception scores before and after explantation-reimplantation showed no significant difference (P>0.005) at 1 year or at 2 years after CR. In 80% of cases, reimplantation was due to hard implant failure. In other cases, it was undertaken for soft failure (diminished performance but no abnormalities on integrity testing) (8%), medical reasons (6%), or undetermined reasons (6%). There was no significant correlation between auditory performance at 1 or 2 years and complete or incomplete reinsertion of electrodes, age, gender, explantation-to-CR interval, or interval between first implantation and CR (P>0.005). For the adult subgroup, the French evaluation protocol scores did not differ after reimplantation (P=0.62). Likewise, for the child sub-group, APCEI and CAP results did not deteriorate after reimplantation.

CONCLUSION

Reimplantation had no negative impact on hearing and speech perception, but provided performance equivalent to or better than after initial implantation.

Exhaled volatile organic compounds and lung microbiome in COPD: a pilot randomised controlled trial

Background

Breath analysis is a burgeoning field, with interest in volatile organic compounds (VOCs) as a noninvasive diagnostic tool or an outcome measure, but no randomised controlled trials (RCTs) have yet evaluated this technology in a clinical trial longitudinally. In a pilot RCT, our exploratory objectives were feasibility of measuring VOCs via multiple techniques, assessing relationships between VOCs and Haemophilus colonisation and whether CXCR2 antagonism with danirixin altered lung microbiome composition in individuals with COPD.

Method

43 participants had VOCs and sputum biomarkers evaluated. VOCs and induced sputum were collected after 6 h of fasting at screening and at days 1, 7 and 14. VOCs were analysed via gas chromatography mass spectrometry (GC-MS), field asymmetric ion mobility spectrometry (FAIMS) and eNose. The primary outcome for these analyses was the relationship between VOCs and Haemophilus abundance determined by 16S rRNA sequencing.

Results

A joint-effects model demonstrated a modest relationship between four exhaled VOCs and Haemophilus relative abundance (R²=0.55) measured only by GC-MS, but not as measured using gas chromtaography FAIMS or eNose. There was considerable variability in absolute quantities of individual VOCs longitudinally.

Conclusions

VOC measurement in clinical trials to identify subsets of COPD is feasible, but assessment of new VOC technologies must include concurrent GC-MS validation. Further work to standardise collection of VOCs and measuring a background or “housekeeper” VOC is required to understand and normalise individual VOC quantities.

VOC measurement in clinical trials to identify COPD subsets is feasible, but assessment of VOC technologies must include concurrent GC-MS validation. Further work to standardise collection of VOCs and measure a background or “housekeeper” VOC is required.https://bit.ly/3BNyKvS

[The evolution of child psychiatry emergencies: Results and reflections from a Nancy University Hospital study]

INTRODUCTION

Mental illness is one of the most common causes of disability, morbidity and mortality in childhood. According to the scientific literature, the prevalence of mental health disorders is an estimated 10% to 20% in the USA and similar results are found in France. Although primordial, outpatient care often appears insufficient with inequalities in its geographical distribution and its accessibility. These past decades have been marked by an increase in consultations for mental disorders in pediatric emergency departments. Is this trend indicative of a "defect" in the healthcare organization? Identifying the root causes of this inflation in psychiatric consultations seems of paramount importance in the improvement of healthcare policies. In France and worldwide, only a few studies deal with this subject. That is why we proposed to observe the evolution of the number of consultations for mental health reasons in the pediatric emergency department of Nancy University Hospital and to detail their characteristics.

MATERIALS AND METHODS

Ancillary comparative and retrospective study (2003-2013) on minors having received a child psychiatry consultation within the pediatric emergency department of Nancy University Hospital.

RESULTS

The number of consultations for mental health reasons increased by 119% (97 in 2003; 212 in 2013), while consultations for pediatrics reasons remained stable over the period studied. Consultations mainly dealt with females representing 55.6% of consultations in 2003 and 63.7% in 2013. Mean age of consultants was stable: 13.9 years (standard deviation=3.3 years) in 2003; 14.1 (2.5) years in 2013. Family structure witnessed a three-fold increase in the single-parent model. Regarding consultation motives, behavioral disorders were significantly more represented in 2013: 27.7% (RR=1.7; 95% CI 1.0-2.8; P<0.05) versus 16.5%. As far as diagnosis is concerned (ICD-10), emotional and behavioral disorders increased to 35.9% from 12.6% (RR=2.8; IC95% 1.6-5.1; P=0.0001).

CONCLUSIONS

In France, as well as in other western countries, the number of visits in pediatric emergency departments for mental health reasons more than doubled over a 10-year span. This growth mostly concerned externalizing disorders as a motive for consultation. Causes for this increase are multifactorial and closely related to the prevalence of psychiatric disorders in children. Some studies showed that economic factors played a major role on mental illness during such a downturn as the financial crisis of 2007-2008. Unemployment caused by economic crises can weaken pediatric caregivers and therefore their patients. Evolution of family structure and value also explains this trend. These past decades, the two-parent model, relevant till the 1960s, has evolved to a point where single parents are more quickly overwhelmed. Family values are now focused on consensus rather than duty and hedonism has become a central value. Women are more involved in the working world which became for all a performance field. Several studies have shown that social settings where competitiveness is the norm breed externalized disorders in children by advocating short-term efficiency. Moreover, the widespread use of screens in households as well as early exposure impact the psychomotor development, decrease the amount of sleep and may be responsible for the occurrence of many psychiatric disorders. There are some epidemiological reasons too. In 1971, Omran introduced a concept called "epidemiological transition" explaining how mental health issues appeared in the limelight through to the decline of infectious and cardiovascular diseases. This phenomenon has already occurred in western countries which could explain the increase in the prevalence of psychiatric disorders. In Africa, there is evidence it may have already started. Beyond all these considerations, the increase in consultations for mental disorders in pediatric emergency departments can be explained by a change in care consumption habits. Going straight to the local emergency department, accessible on a 24/7 basis, is easier than waiting for an outpatient appointment and is also free for the have-nots lacking proper insurance coverage. Scarce resources in ambulatory care may also explain the increased recourse to emergency services. Several reports have shown a lack of child psychiatrists and their uneven geographical distribution. For example, in the US only a third of children with mental disorders receive proper care, a lack which doubled between 1997 and 2010. Despite the reason for this trend, it is important to propose a better fitting of the healthcare system to the population needs, and to improve prevention and early identification. All these changes require further collective reflection.

[Interest and difficulties in setting up pharmaceutical reconciliations for patients with dressings for complex wounds]

OBJECTIVES

The management of wounds is a commonplace activity in a patient's healthcare pathway. The involvement of the pharmacist in the management of complex dressings can help strengthen the continuity of this care thanks to the pharmaceutical reconciliation. The objective of this study was to improve the quality of information transmitted between the city and the hospital regarding complex wound dressings.

METHODS

This is a prospective study consisting of two groups in three services (medicine, diabetology, vascular surgery): the control group corresponded to a classic patient care and in the intervention group, the pharmacists performed dressing reconciliations. A follow-up of the patients after coming back home was realized with healthcare professionals of city involved.

RESULTS

Twenty patients were included in the control group and 19 in the intervention group. Entry conciliation has improved the quality and quantity of information on wounds transmitted between the city and the hospital. Exit conciliation has increased from 60 to 100% wound and dressing output prescriptions. One hundred percent of nurses surveyed were satisfied with the patients care.

CONCLUSIONS

Reconciliation would improve information transmitted between the city and the hospital and avoid a break in the continuity of complex wounds cares. However, the time dedicated and the adhesion of the care services were difficulties encountered. This study is the first highlighting the interest of medical device reconciliation and could allow reconciliation extension toward other medical devices.

Screen for modulators of atonal homolog 1 gene expression using notch pathway-relevant gene transcription based cellular assays

Atonal homolog 1 (Atoh1) is a basic helix-loop-helix 9 (bHLH) transcription factor acting downstream of Notch and is required for the differentiation of sensory hair cells in the inner ear and the specification of secretory cells during the intestinal crypt cell regeneration. Motivated by the observations that the upregulation of Atoh1 gene expression, through genetic manipulation or pharmacological inhibition of Notch signaling (e.g. γ-secretase inhibitors, GSIs), induces ectopic hair cell growth in the cochlea of the inner ear and partially restores hearing after injuries in experimental models, we decided to identify small molecule modulators of the Notch-Atoh1 pathway, which could potentially regenerate hair cells. However, the lack of cellular models of the inner ear has precluded the screening and characterization of such modulators. Here we report using a colon cancer cell line LS-174T, which displays Notch inhibition-dependent Atoh1 expression as a surrogate cellular model to screen for inducers of Atoh1 expression. We designed an Atoh1 promoter-driven luciferase assay to screen a target-annotated library of ~6000 compounds. We further developed a medium throughput, real-time quantitative RT-PCR assay measuring the endogenous Atoh1 gene expression to confirm the hits and eliminate false positives from the reporter-based screen. This strategy allowed us to successfully recover GSIs of known chemotypes. This LS-174T cell-based assay directly measures Atoh1 gene expression induced through Notch-Hes1 inhibition, and therefore offers an opportunity to identify novel cellular modulators along the Notch-Atoh1 pathway.

Cardiotoxicity as a Result of 5-Fluorouracil Therapy

We report the case of a patient bearing a sigmoid colon carcinoma, stage IV, who after 11 months of antiblastic therapy, having completed a dose of 81,000 mg of 5-FU and CCNU, suffered a myocardial infarct. We attribute this compication to 5-FU. Due to the fact that the coronary angiogram did not confirm the arteriosclerotic nature of the lesion, we suggest that it could have been caused by an endoarteritis, resulting from an immuno-allergic or toxic cumulative process.

Inflammatory cell distribution in colon mucosa as a new tool for diagnosis of irritable bowel syndrome: A promising pilot study

BACKGROUND

Currently, there are no histological criteria to diagnose irritable bowel syndrome (IBS). Our aims were (i) to examine the distribution of inflammatory cells in the colon of healthy and IBS subjects and (ii) to find histological diagnosis criteria for IBS.

METHODS

Colonic biopsies were taken from four distinct regions of the colon from 20 controls (HC) and 11 patients with IBS (4 with constipation (IBS-C) and 7 with diarrhea (IBS-D) and embedded in paraffin. Macrophages, mast cells, eosinophils, and T lymphocytes were immunostained and positive cells counted.

KEY RESULTS

In both HC and IBS patients, global cellularity decreased from the cecum to the rectum (P < .01) which is attributed to reduced number of macrophages (P < .05) and eosinophils (P < .001) but not T cells. Mast cells were reduced in IBS (P < .05) but not in HC, particularly in IBS-D (P < .05). Results showed higher number of macrophages in the left colon of IBS subjects than HC (P < .05).

CONCLUSION & INFERENCES

Here we report a decreasing gradient of immune cells from the cecum to the rectum of the human colon. Although global cellularity cannot be used to distinguish between IBS and HC, closer analysis of macrophages and mast cells may be useful markers to confirm IBS histologically and to differentiate between IBS-C and IBS-D when clinical presentation alternates between constipation and diarrhoea. This pilot study remains to be confirmed with greater number of patients.

Rapid Mobilization Reveals a Highly Engraftable Hematopoietic Stem Cell

Hematopoietic stem cell transplantation is a potential curative therapy for malignant and nonmalignant diseases. Improving the efficiency of stem cell collection and the quality of the cells acquired can broaden the donor pool and improve patient outcomes. We developed a rapid stem cell mobilization regimen utilizing a unique CXCR2 agonist, GROβ, and the CXCR4 antagonist AMD3100. A single injection of both agents resulted in stem cell mobilization peaking within 15 min that was equivalent in magnitude to a standard multi-day regimen of granulocyte colony-stimulating factor (G-CSF). Mechanistic studies determined that rapid mobilization results from synergistic signaling on neutrophils, resulting in enhanced MMP-9 release, and unexpectedly revealed genetic polymorphisms in MMP-9 that alter activity. This mobilization regimen results in preferential trafficking of stem cells that demonstrate a higher engraftment efficiency than those mobilized by G-CSF. Our studies suggest a potential new strategy for the rapid collection of an improved hematopoietic graft.

Circulating endothelial progenitors in vascular repair

Endothelial Colony Forming Cells (ECFCs) are obtained in culture from Circulating Endothelial Progenitor Cells. They display all characteristics of endothelial cells and they display stem cells features. Cord blood-derived ECFCs (CB-ECFCs) have a high clonogenic and proliferative potentials, and exhibit vascular repair capabilities useful for the treatment of ischemic diseases. However, the link between immaturity and functional properties of CB-ECFCs is still poorly defined. We showed that these cells have a high clonogenic potential and are capable to be efficiently reprogrammed into induced pluripotent stem cells. Moreover, we analyzed the expression of a broad panel of genes involved in embryonic stem cell properties. We define a novel stem cell transcriptional signature for CB-ECFCs fora better characterization and stratification according to their stem cell profile. We then improved the yield of CB-ECFC production for obtaining cells more functional in fewer passages. We used Glycosaminoglycans (GAG), components from the extracellular matrix which potentiate heparin binding growth factor activities. GAG mimetics were designed, having the capacity to increase the yield of ECFC during the isolation process, to increase the number of colonies, improve adhesion, proliferation, migration and self-renewal. GAG mimetics have thus great interest for vascular regeneration in combination with ECFC. Our results show that CB-ECFC are immature cells harboring specific functions such as formation of colonies, proliferation and formation of vascular structures in vitro and in vivo.

A rare case of sinus of valsalva-right atrial fistula secondary to an abscess perforation from underlying aortic valve endocarditis

Sinus of Valsalva-right atrial fistulas are abnormal connections between the aorta and the right atrium, and present challenging surgical conditions. An extremely rare etiology of aorto-right atrial fistula is infective endocarditis. This case report presents a 21 year old Caucasian female patient who had native aortic valve Staphylococcus aureus endocarditis complicated by sinus of Valsalva abscess perforation associated with an acute heart block, an aorto-right atrial fistula, severe heart failure, and cardiogenic shock. She underwent emergent aortic valve replacement and complex sinus of Valsalva fistula pericardial patch reconstruction and repair. This case report further explores the advantages and disadvantages of different valves for different patient populations, and evaluates the patient’s prosthesis mismatch and effective orifice area.

Clinical value of circulating endothelial cells and of soluble CD146 levels in patients undergoing surgery for non-small cell lung cancer

Background:

Previous studies indicate that endothelial injury, as demonstrated by the presence of circulating endothelial cells (CECs), may predict clinical outcome in cancer patients. In addition, soluble CD146 (sCD146) may reflect activation of angiogenesis. However, no study has investigated their combined clinical value in patients undergoing resection for non-small cell lung cancer (NSCLC).

Methods:

Data were collected from preoperative blood samples from 74 patients who underwent resection for NSCLC. Circulating endothelial cells were defined, using the CellSearch Assay, as CD146+CD105+CD45−DAPI+. In parallel, sCD146 was quantified using an ELISA immunoassay. These experiments were also performed on a group of 20 patients with small-cell lung cancer, 60 healthy individuals and 23 patients with chronic obstructive pulmonary disease.

Results:

The CEC count and the plasma level of sCD146 were significantly higher in NSCLC patients than in the sub-groups of controls (P<0.001). Moreover, an increased CEC count was associated with higher levels of sCD146 (P=0.010). Both high CEC count and high sCD146 plasma level at baseline significantly correlated with shorter progression-free survival (P<0.001, respectively) and overall survival (P=0.005; P=0.009) of NSCLC patients.

Conclusions:

The present study provides supportive evidence to show that both a high CEC count and a high sCD146 level at baseline correlate with poor prognosis and may be useful for the prediction of clinical outcome in patients undergoing surgery for NSCLC.

Long-term follow-up after biliary stent placement for postcholecystectomy bile duct strictures: a multicenter study

BACKGROUND AND STUDY AIMS

Endoscopic stenting is a recognized treatment of postcholecystectomy biliary strictures. Large multicenter reports of its long-term efficacy are lacking. Our aim was to analyze the long-term outcomes after stenting in this patient population, based on a large experience from several centers in France.

METHODS

Members of the French Society of Digestive Endoscopy were asked to identify patients treated for a common bile duct postcholecystectomy stricture. Patients with successful stenting and follow-up after removal of stent(s) were subsequently included and analyzed. Main outcome measures were long-term success of endoscopic stenting and related predictors for recurrence (after one stenting period) or failure (at the end of follow-up).

RESULTS

A total of 96 patients were eligible for inclusion. The mean number of stents inserted at the same time was 1.9±0.89 (range 1-4). Stent-related morbidity was 22.9% (n=22). The median duration of stenting was 12 months (range 2-96 months). After a mean follow-up of 6.4±3.8 years (range 0-20.3 years) the overall success rate was 66.7% (n=64) after one period of stenting and 82.3% (n=79) after additional treatments. The mean time to recurrence was 19.7±36.6 months. The most significant independent predictor of both recurrence and failure was a pathological cholangiography at the time of stent removal.

CONCLUSION

Endoscopic stenting helps to avoid surgery in more than 80% of patients bearing postcholecystectomy common bile duct strictures. However, a persistent anomaly on cholangiography at the time of stent removal is a strong predictor of recurrence and may lead to consideration of surgery.

THE STANDARDIZATION OF ANTIPNEUMOCOCCIC SERUM TYPES I AND II

1. The mouse protection test used for the standardization of anti-pneumococcic serum Type I and II is very unreliable. 2. The specific polysaccharide precipitation test can be used to establish the comparative value of a test serum to a standardized serum. 3. The polysaccharide used for such tests does not have to be of the highest purity.

Image analysis of skin scaling using D-Squame samplers: comparison with clinical scoring and use for assessing moisturizer efficacy

The severity of scaling disorders can be evaluated objectively using the D-Squame technique coupled with image analysis. The parameters of scaling derived using this approach need to be clinically relevant and should have greater discrimination than visual grading. Improvements to an existing method that fulfil these requirements are presented. Three scaling parameters were calculated using image analysis of digitized video-captured images of obliquely lit D-Squame samples. These parameters were compared to clinical scores of scaling made by five observers from photographs of the same areas sampled with D-Squame. In addition, two clinical studies were carried out to assess moisturizer effects on different degrees of xerosis, and to compare two different moisturizer preparations. The three scaling parameters gave correlation coefficients, r, between 0.6 and 0.75 when compared with global clinical scores of scaling. Significant reductions in all parameters were observed with 2 weeks of moisturizer use on lower leg skin with marked xerosis compared to an untreated control. The same moisturizer had a similar effect on milder xerosis of the forearm, and showed a greater decrease than a moisturizer with lower glycerol content. Increases in skin hydration, as measured with a corneometer, were also seen in both clinical studies, and corresponded well with D-Squame results. Differences in the degrees of scaling between these two anatomical sites were also detected with this technique. In a previous publication, the same technique was shown to be repeatable and reproducible; in the current article its correlation with clinical observations of scaling or flaking skin has been demonstrated.

[Congenital cyst and fistula of the face and neck]

The authors propose an update on cervicofacial congenital cysts and fistulas' symptomatology. Embryological data, epidemiology and clinical manifestations are described. A reminder of the therapeutic principles is proposed as well as the evolution of these congenital pathologies, which may or may not involve the branchial system. branchial.

Establishing Quality Assurance Criteria for Serial Dilution Operations on Liquid-Handling Equipment

Since the advent of high-throughput screening (HTS) in the early 1990s, parallel multichannel liquid handlers have become a mainstay in every drug discovery setting. Although several peer-reviewed publications have discussed methods and criteria for stamping multiwell copies, there is very little information about establishing a standard operating procedure (SOP) for standard (microliter-level) serial dilutions of compounds used in dose-response experiments. The authors discuss the 4 main criteria any serial dilution process must pass (accuracy, precision, fold dilution, and outliers) and the process for establishing thresholds for all of these values in a compound management or biological screening laboratory. The thresholds need to be both low enough to be acceptable from a biological potency variability perspective and high enough to allow the instruments to pass the quality assurance (QA) analysis on a regular basis. In this article, the authors suggest suitable thresholds arrived at by a variety of methods, including trend analysis of QA data, survey questionnaire from the main stakeholders (screening scientists, chemists), and published criteria for single-shot stamping. A mathematical analysis of the effect of threshold values on estimated XC50s was performed to ensure that the variability introduced by the serial dilution step is within acceptable overall variability limits.

Linking Pneumocystis jiroveci sulfamethoxazole resistance to the alleles of the DHPS gene using functional complementation in Saccharomyces cerevisiae

Curative and prophylactic therapy for Pneumocystis jiroveci pneumonia relies mainly on cotrimoxazole, an association of trimethoprim and sulfamethoxazole (SMX). SMX inhibits the folic acid pathway through competition with para-aminobenzoic acid (pABA), one of the two substrates of the dihydropteroate synthase (DHPS), a key enzyme in de novo folic acid synthesis. The most frequent non-synonymous single nucleotide polymorphisms (SNPs) in P. jiroveci DHPS are seen at positions 165 and 171, the combination leading to four possible different genetic alleles. A number of reports correlate prophylaxis failure and mutation in the P. jiroveci DHPS but, because of the impossibility of reliably cultivating P. jiroveci, the link between DHPS mutation(s) and SMX susceptibility is not definitively proven. To circumvent this limitation, the yeast Saccharomyces cerevisiae was used as a model. The introduction of the P. jiroveci DHPS gene, with or without point mutations, directly amplified from a clinical specimen and cloned in a centromeric plasmid into a DHPS-deleted yeast strain, allowed a fully effective complementation. However, in the presence of SMX at concentrations >250 mg/L, yeasts complemented with the double mutated allele showed a lower susceptibility compared with strains complemented with either a single mutated allele or wild-type alleles. These results confirm the need for prospective study of pneumocystosis, including systematic determination of the DHPS genotype, to clarify further the impact of mutations on clinical outcome. Additionally, the S. cerevisiae model proves to be useful for the study of still uninvestigated biological properties of P. jiroveci.

The intersection of online social networking with medical professionalism

AIM

To measure the frequency and content of online social networking among medical students and residents.

METHODS

Using the online network Facebook, we evaluated online profiles of all medical students (n = 501) and residents (n = 312) at the University of Florida, Gainesville. Objective measures included the existence of a profile, whether it was made private, and any personally identifiable information. Subjective outcomes included photographic content, affiliated social groups, and personal information not generally disclosed in a doctor-patient encounter.

RESULTS

Social networking with Facebook is common among medical trainees, with 44.5% having an account. Medical students used it frequently (64.3%) and residents less frequently (12.8%, p < .0001). The majority of accounts (83.3%) listed at least 1 form of personally identifiable information, only a third (37.5%) were made private, and some accounts displayed potentially unprofessional material. There was a significant decline in utilization of Facebook as trainees approached medical or residency graduation (first year as referent, years 3 and 4, p < .05).

DISCUSSION

While social networking in medical trainees is common in the current culture of emerging professionals, a majority of users allow anyone to view their profile. With a significant proportion having subjectively inappropriate content, ACGME competencies in professionalism must include instruction on the intersection of personal and professional identities.

The efficacy and safety of duodenal stenting: a prospective multicenter study

BACKGROUND AND STUDY AIMS

Duodenal stenting has become a popular treatment in cases of malignant stenosis. However, a prospective evaluation of the efficacy and morbidity of this procedure has not been performed. A prospective multicenter study of duodenal stenting was conducted by the Société Française d'Endoscopie Digestive (SFED).

PATIENTS AND METHODS

A total of 51 patients were selected (mean age 72), the majority (69%) having pancreatic adenocarcinoma. Palliative treatment was chosen because of irresectability (61.2%), inoperability (18.4%), or both (20.4 %). Enteral Wallstent prostheses were used, and the patients were followed up on day 3, after 1 month, and then every month, with weight measurement, and symptomatic and laboratory evaluation.

RESULTS

One prosthesis was sufficient in 46 patients. Stent positioning and deployment were correct in 50/51 patients (98%). Twenty patients also underwent biliary stenting in addition to the duodenal stenting. On day 3, 43 patients (84%) were able to tolerate soft solids or a full diet. Six complications were attributed to stenting: three intestinal hemorrhages, two cases of peritonitis due to bowel perforation, and one case of septicemia, and these led to five deaths (mortality 9.8%). Stent dysfunction was observed in 12 cases (23.5%) after a mean delay of 75 days, comprising 11-malignant obstructions and one migration: a new stent was inserted inside the first one and was effective in eight cases; and no treatment was given in the other four patients because of their clinical state. The median survival was 71.5 days.

CONCLUSIONS

Palliative endoscopic treatment of malignant duodenal stenosis using metallic prostheses is highly feasible, even with associated biliary stenting. Symptomatic improvement is fast. However, the mortality and the obstruction rate are high, suggesting that a prospective trial comparing this treatment with surgery is still required.

Patients with sporadic duodenal adenoma are a high-risk group for advanced colorectal neoplasia: results of a case-control study

AIM

To evaluate colorectal cancer risk among patients with sporadic duodenal neoplasia using a case-control protocol.

METHODS

Cases were 35 patients referred for the management of sporadic duodenal adenoma and who underwent colonoscopy. Colonoscopy findings among cases were compared with those from a control group matched for age and sex (two controls per case) without duodenal adenoma. Colonoscopy findings were categorized as adenoma, advanced adenoma, cancer or advanced neoplasia. The two groups were compared using the chi-squared test. Odds ratio and 95% confidence intervals were calculated.

RESULTS

Colorectal adenoma was present in 31% of cases vs. 24% of controls, advanced neoplasia in 29% vs. 4%, advanced adenoma in 23% vs. 3% and adenocarcinoma in 6% vs. 1%. The relative risks of advanced colorectal adenoma and advanced colorectal neoplasia in cases were 10.1 (95% CI: 1.8-100.1, P = 0.003) and 8.9 (95% CI: 2.1-53.3, P = 0.001), respectively.

CONCLUSIONS

The relative risk of advanced colorectal adenoma and advanced neoplasia in cases was nine- to 10-fold that among controls. Patients with sporadic duodenal adenoma represent a high-risk group for advanced colorectal neoplasia and should therefore undergo complete colonoscopy.

Hospital injury rates in relation to socioeconomic status and working conditions

OBJECTIVES

To describe the risk of work injury by socioeconomic status (SES) in hospital workers, and to assess whether SES gradient in injury risk is explained by differences in psychosocial, ergonomic or organisational factors at work.

METHODS

Workforce rosters and Occupational Safety and Health Administration injury logs for a 5-year period were obtained from two hospitals in Massachusetts. Job titles were classified into five SES strata on the basis of educational requirements and responsibilities: administrators, professionals, semiprofessionals, skilled and semiskilled workers. 13 selected psychosocial, ergonomic and organisational exposures were assigned to the hospital jobs through the national O*NET database. Rates of injury were analysed as frequency records using the Poisson regression, with job title as the unit of analysis. The risk of injury was modelled using SES alone, each exposure variable alone and then each exposure variable in combination with SES.

RESULTS

An overall annual injury rate of 7.2 per 100 full-time workers was estimated for the two hospitals combined. All SES strata except professionals showed a significant excess risk of injury compared with the highest SES category (administrators); the risk was highest among semiskilled workers (RR 5.3, p<0.001), followed by nurses (RR 3.7, p<0.001), semiprofessionals (RR 2.9, p = 0.006) and skilled workers (RR 2.6, p = 0.01). The risk of injury was significantly associated with each exposure considered except pause frequency. When workplace exposures were introduced in the regression model together with SES, four remained significant predictors of the risk of injury (decision latitude, supervisor support, force exertion and temperature extremes), whereas the RR related to SES was strongly reduced in all strata, except professionals.

CONCLUSIONS

A strong gradient in the risk of injury by SES was reported in a sample population of hospital workers, which was greatly attenuated by adjusting for psychosocial and ergonomic workplace exposures, indicating that a large proportion of that gradient can be explained by differences in working conditions.

Chronic ischemic gastritis: case report of a difficult diagnosis and review of the literature

Chronic ischemic gastritis is an unusual entity that is rarely distinguished from other forms of intestinal ischemia. On the basis of a case encountered and a subsequent review of the literature, the main features of this rare condition are described here. A better understanding and awareness of the disease should improve the diagnosis and ultimately also the prognosis.

[Endoscopic treatment of Barrett's oesophagus]

Aims of the treatment of Barrett's oesophagus (BO) are disappearance of symptoms and inflammatory complications of gastro-oesophageal reflux disease (GORD), prevention of occurrence of dysplasia and adenocarcinoma, and early treatment of high-grade dysplasia (HGD) and adenocarcinoma. Anti-secretory treatment with proton-pump inhibitors (PPI) must result in disappearance of both symptoms and oesophagitis. The only correction of symptoms, as well as normalization of pHmetry, are not considered as adequate criteria for efficiency of treatment. It has not been demonstrated that treatment with PPI prevented occurrence of dysplasia and adenocarcinoma so the only BO is not an indication for treatment with PPI, which results in only partial regression of height and/or surface of BO. Endoscopic ablation of BO, combined with PPI, allows complete regression of intestinal metaplasia in about 50% of cases. Photodynamic therapy (PDT) seems the best technique for treatment of HGD and mucosal adenocarcinoma. This treatment is not indicated in case of low-grade dysplasia, since its benefit on survival is less clear than for HGD. Endoscopic treatment does not suppress the need for prolonged endoscopic follow-up since BO recurs in approximately one third of patients. For HGD isolated or associated with mucosal adenocarcinoma (proven by endoscopic ultrasound), endoscopic treatment can consist in mucosectomy or ablation with PDT or plasma argon coagulation (PAC) of these lesions if localized, possibly followed by complete ablation of BO by PAC, and always associated with an efficient treatment of GORD by PPI or anti-reflux surgery. Submucosal adenocarcinomas must be treated by oesophagectomy if allowed by the general condition of the patient.