What is the existing evidence base for adult medical Same Day Emergency Care in UK NHS hospitals? A scoping review

Introduction

This scoping review focuses on acute medical Same Day Emergency Care (SDEC), as medical patients represent a significant proportion of emergency admissions in the NHS.

Methods

This scoping review has been conducted in accordance with the JBI methodology and as detailed in the published scoping review protocol.

Results

Identified papers included two observational cohort studies, four audits, four review articles, two opinion pieces, a paper on potential future developments, three policy documents, one strategy paper and a position statement. Key themes were extrapolated and discussed in a narrative.

Conclusions

The scarcity of literature in relation to the quality, safety, and effectiveness of SDEC highlights the need for further study. Therefore, there is a pressing need for SDEC specific research within the UK.

What is the existing evidence base for adult medical same day emergency care in UK NHS hospitals? A scoping review protocol

OBJECTIVES

Same day emergency care (SDEC) is a new model of care, which has emerged over the past 5 years, building on prior ambulatory care services. The National Health Service (NHS) England National Strategy for SDEC suggests SDEC can meet local health needs by providing alternatives to emergency department attendance or hospital admission, for people with an urgent healthcare need, beyond the limited scope of an urgent treatment centre. This review focuses on acute medical SDEC, as medical patients represent a significant proportion of emergency admissions. The planned scoping review aims to map the existing evidence base.

METHODS AND ANALYSIS

This is a protocol for a scoping review to be conducted in accordance with the format of the Joanna Briggs Institute (JBI) methodology for scoping reviews. The databases to be searched will include EMBASE, MEDLINE and CINAHL, via EBSCOhost. Sources of unpublished studies, policies and grey literature will include Google Scholar, the Cochrane Library, TRIP database, ProQuest Dissertations and Theses Open, and the Health Management Information Consortium. Papers relating to acute medicine adult patients attending NHS SDEC services in the UK will be included. International papers will be excluded, as will those over 5 years old, and those where full text is not available. The results of the search and study inclusion/exclusion process will be reported and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram. Data will be extracted from papers included in the scoping review by two reviewers, using a JBI data extraction tool. Any differences of opinion will be discussed until consensus is reached. If needed, a third reviewer will be asked to join the review team to achieve consensus. Data and themes extracted will be summarised and presented in tables. A narrative thematic summary will accompany the presented results, describing how the results relate to the review objective. Literature gaps will be identified and recommendations for future research made.

ETHICS AND DISSEMINATION

There is no requirement for ethical approval for this scoping review. On completion, it will be published in a peer-reviewed academic journal and presented at a conference.

Defence Medical Services' REBOA training course

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

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

BACKGROUND & AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND AND OBJECTIVES

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

METHOD

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

RESULTS

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

DISCUSSION

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

Biological variation of cardiac troponins in chronic kidney disease

Background

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

Methods and results

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

Conclusions

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

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

Introduction

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

Methods

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

Results

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

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

Conclusions

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

Electronic supplementary material

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

Systematic review of prehospital haemostatic dressings

Introduction

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

Methods

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

Results

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

Conclusions

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

Developing clinical reasoning and effective communication skills in advanced practice

Clinical reasoning and effective communication are fundamental skills for nurses working at an advanced level of practice. Clinical reasoning processes are designed to enable the nurse to establish the nature of a patient's presenting condition before focusing on problem-solving techniques that can guide the appropriate course of treatment. This article explores the concept of clinical reasoning in advanced practice and outlines the various approaches that nurses can take. It also details the role of effective communication in advanced practice. A case study is used to demonstrate the specific stages involved in clinical reasoning.

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

Background

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

Methods

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

Results

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

Conclusion

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Nurse practitioner consultations in primary health care: an observational interaction analysis of social interactions and consultation outcomes

OBJECTIVE

To determine the discrete nature of social interactions occurring in nurse practitioner consultations and investigate the relationship between consultation social interaction styles (biomedical and patient-centred) and the outcomes of patient satisfaction, patient enablement, and consultation time lengths.

METHODS

A case study-based observational interaction analysis of verbal social interactions, arising from 30 primary health care nurse practitioner consultations, linked with questionnaire measures of patient satisfaction and enablement.

RESULTS

A significant majority of observed social interactions used patient-centred communication styles (P=0.005), with neither nurse practitioners nor patients or carers being significantly more verbally dominant. Nurse practitioners guided the sequence of consultation interaction sequences, but patients actively participated through interactions such as asking questions. Usage of either patient-centred or biomedical interaction styles were not significantly associated with increased levels of patient satisfaction or patient enablement. The median consultation time length of 10.1 min (quartiles 8.2, 13.7) was not significantly extended by high levels of patient-centred interactions being used in the observed consultations.

CONCLUSION

High usage levels of patient-centred interaction styles are not necessarily contingent upon having longer consultation times available, and clinicians can encourage patients to use participatory interactions, whilst still then retaining overall guidance of the phased sequences of consultations, and not concurrently extending consultation time lengths. This study adds to the body of nurse practitioner consultation communication research by providing a more detailed understanding of the nature of social interactions occurring in nurse practitioner consultations, linked to the outcomes of patient satisfaction and enablement.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Collaborative communication: learning from advanced clinical practice patient consultations

Advanced nurse practitioners, and nurses aspiring to this role, are required to understand how to communicate effectively and on a collaborative basis with patients and carers during consultations, with the aim of enhancing patient outcomes such as improved patient satisfaction, ability to self-manage healthcare needs and adherence to care plans. This article explores collaborative communication in consultations and how best to achieve this, using the author's doctoral observational research based on the findings of a mixed methods observational study of communication in advanced clinical practice patient consultations.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

A comparative study on the clinical decision-making processes of nurse practitioners vs. medical doctors using scenarios in a secondary care environment

AIM

To investigate the decision-making skills of secondary care nurse practitioners compared with those of medical doctors.

BACKGROUND

A literature review was conducted, searching for articles published from 1990 - 2012. The review found that nurse practitioners are key to the modernization of the National Health Service. Studies have shown that compared with doctors, nurse practitioners can be efficient and cost-effective in consultations.

DESIGN

Qualitative research design.

METHODS

The information processing theory and think aloud approach were used to understand the cognitive processes of 10 participants (5 doctors and 5 nurse practitioners). One nurse practitioner was paired with one doctor from the same speciality and they were compared using a structured scenario-based interview. To ensure that all critical and relevant cues were covered by the individual participating in the scenario, a reference model was used to measure the degree of successful diagnosis, management and treatment. This study was conducted from May 2012 - January 2013.

RESULTS

The data were processed for 5 months, from July to November 2012. The two groups of practitioners differed in the number of cue acquisitions obtained in the scenarios. In our study, nurse practitioners took 3 minutes longer to complete the scenarios.

CONCLUSION

This study suggests that nurse practitioner consultations are comparable to those of medical doctors in a secondary care environment in terms of correct diagnoses and therapeutic treatments. The information processing theory highlighted that both groups of professionals had similar models for decision-making processes.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

REPORT

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

DISCUSSION

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

Treating knee pain: history taking and accurate diagnoses

Prompt and effective diagnosis and treatment for common knee problems depend on practitioners' ability to distinguish between traumatic and inflammatory knee conditions. This article aims to enable practitioners to make accurate assessments, carry out knee examinations and undertake selected special tests as necessary before discharging or referring patients.

Lumps, bumps and vasculitis

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

History taking and clinical examination of the shoulder

Prompt and effective diagnosis and treatment for common shoulder problems depends on the ability of practitioners to distinguish between traumatic and non-traumatic shoulder conditions. This article aims to enable practitioners to make accurate assessments and carry out shoulder examinations, including the undertaking of selected special tests, before discharging or referring patients.

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

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

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

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