Remotely delivered cognitive-behavioural and personalized exercise interventions to lessen the impact of fatigue: a qualitative evaluation

Objectives

Fatigue can be a disabling symptom of inflammatory rheumatic diseases. LIFT (Lessening the Impact of Fatigue in inflammatory rheumatic diseases: a randomized Trial) is a randomized trial of remotely delivered cognitive-behavioural approach or personalized exercise programme interventions, compared with usual care. The aim of this nested qualitative study was to evaluate participants’ experiences of taking part in the intervention, including their ideas about future service delivery.

Methods

Semi-structured telephone interviews were conducted with a subgroup of LIFT participants to discuss their views and experiences of the interventions.

Results

Forty-three participants (30 women) from six sites who had participated in the cognitive-behavioural approach (n = 22) or personalized exercise programme (n = 21) interventions took part. Five themes were identified in the thematic analysis. In the theme ‘not a miracle cure, but a way to better manage fatigue’, LIFT could not cure fatigue; however, most felt better able to manage after participating. Participants valued ‘building a therapeutic relationship’ with the same therapist throughout the intervention. In ‘structure, self-monitoring and being accountable’, participants liked the inclusion of goal-setting techniques and were motivated by reporting back to the therapist.

After taking part in the interventions, participants felt ‘better equipped to cope with fatigue’; more confident and empowered. Lastly, participants shared ideas for ‘a tailored programme delivered remotely’, including follow-up sessions, video calling, and group-based sessions for social support.

Conclusion

Many participants engaged with the LIFT interventions and reported benefits of taking part. This suggests an important future role for the remote delivery of fatigue self-management.

Habitat provision is a major driver of native bird communities in restored urban forests

Urbanization, and the drastic loss of habitat it entails, poses a major threat to global avian biodiversity. Ecological restoration of urban forests is therefore increasingly vital for native bird conservation, but control of invasive predators may also be needed to sustain native bird populations in cities where species invasions have been particularly severe.

We evaluated restoration success by investigating changes in native bird communities along a restoration chronosequence of 25 restored urban forests representing 72 years of forest development, which we compared to two target reference systems and a control system. We hypothesized that total species richness and relative abundance of native forest birds would increase with the age of restoration planting. We further hypothesized that relative abundance of rats, possums and cats would negatively impact native birds, while amount of native forest in the surrounding landscape would have a positive effect.

We used structural equation modelling (SEM) to investigate the relative influence of forest structure (complexity index, tree height, canopy openness, basal area, species richness and density), landscape attributes (patch area, perimeter length, landscape composition within three buffer zones, distance to the nearest road and water source) and invasive mammalian predator indices of relative abundance on total species richness and relative abundance of native forest birds.

Species richness increased with age of restoration planting, with community composition progressing towards that found in target reference systems. SEM revealed that years restored was a direct driver of bird species richness but an indirect driver of abundance, which was directly driven by canopy openness. Contrary to our predictions, invasive mammals had no significant effect on native bird species richness or abundance.

Our results demonstrate that provision and improvement of habitat quantity and quality through restoration is the vital first step to re‐establishing native forest bird communities in cities.

Dynamic Proximal Ulnar Osteotomy for the Treatment of Ununited Anconeal Process in 17 Dogs

A prospective study was made of 17 dogs with ununited anconeal process treated by osteotomy of the proximal ulna. The effect of the surgery on lameness was evaluated subjectively and the elbows were assessed radiographically for evidence of anconeal fusion and healing of the osteotomy. Whilst clinical outcome was generally good and complications infrequent, relatively few cases achieved anconeal fusion. These results do not compare well with the results of a previous study but this disparity may be due in part to differences in patient population and radiographic evaluation.

Further work is required to establish how best to achieve predictable anconeal fusion.

Proximal ulnar osteotomy was used to treat 17 dogs with ununited anconeal process. Clinical results were good but anconeal fusion was not achieved consistently. Further work is needed to determine how best to achieve predictable anconeal fusion.

Arthroscopic management of a lateral glenohumeral ligament rupture in two dogs

Tears to the lateral glenohumeral ligament appear to be uncommon in dogs. Two Labrador Retrievers were arthroscopically diagnosed with lateral glenohumeral ligament tears of the shoulder. Both cases failed to respond to conservative management. Surgical stabilisation of the lateral aspect of the shoulder joint was achieved using an arthroscopically placed suture using a hanging limb technique. Lameness resolved in both cases.

Evaluation of Clinical Metrology Instrument in Dogs with Osteoarthritis

Background

In veterinary clinical pain studies, there is a paucity of data on test‐retest variability in Clinical Metrology Instruments (CMIs), and it is unknown whether CMIs should be administered using independent (respondents not permitted to see previous answers) or dependent (respondents shown previous answers) interviewing.

Objectives

To compare baseline variability in CMIs designed to assess pain in dogs with osteoarthritis, and compare CMI scores using independent (InD) and dependent interviewing (DI) for the Canine Brief Pain Inventory (CBPI) and the Client‐Specific Outcome Measures (CSOM).

Animals

Fifty‐one client‐owned dogs with radiographic evidence of osteoarthritis and associated pain.

Methods

Clinical Metrology Instruments data were collected during 2 randomized, double‐masked, placebo‐controlled, proof of principle pilot studies with parallel treatment groups. Enrolled dogs received either placebo or antinerve growth factor antibody (NV‐01).

Results

Agreement between baseline CMI scores was good (CBPI Pain P = .29, CBPI Interference P = .32, CSOM P = .036, LOAD P = .67, HCPI P = .27), being best for the LOAD (ICC = 0.89). CMI responses collected during independent and dependent interviewing were not statistically different (CBPI Pain P = .33, CBPI Interference P = .28, CSOM P = .42) and showed good agreement. Additionally, dependent interviewing resulted in increased treatment effect sizes.

Conclusions and Clinical Importance

There is little difference between independent and dependent interviewing, however, dependent interviewing resulted in increased treatment effect sizes. By using dependent interviewing, investigators could increase clinical trial power through minimal change to study design. Further research is warranted to investigate the use of dependent interviewing.

Molecular epidemiology of tuberculosis in England, 1998

SETTING

England.

OBJECTIVE

To investigate the proportion of tuberculosis (TB) cases attributable to recent transmission and factors associated with clustering.

DESIGN

Demographic, clinical and microbiological surveillance data were collated from all new culture-confirmed cases in 1998. Using insertion sequence (IS) 6110 restriction fragment length polymorphism (RFLP) typing, strains were classified as clustered (identical patterns) or unique and risk factors were determined using multivariable logistic regression.

RESULTS

RFLP patterns were available for 2265 of 3713 (61%) cases: 1808 had >or=5 IS6110 copies, while 372 cases were in 152 clusters, giving an estimated proportion due to recent transmission of 12.2%.Pulmonary disease (aOR 1.6; 95%CI 1.1-2.2), previous treatment (aOR 3.7; 2.2-6.5) and homelessness (aOR 5.5; 1.2-24.1) were independent risk factors for clustering. Fourteen per cent of patients of Indian subcontinent origin were clustered compared with 27% of white patients. Many clusters spanned ethnic groups (45%) and geographical regions (47%).

CONCLUSION

The calculated proportion of TB cases due to recent transmission is low.Adjusting for missed cases and study duration, it increases to 27.6%. Many cases may arise from reactivation or acquisition outside England. Transmission within England accounted for approximately one in four cases and occurred over wide geographic areas, between ethnic groups and among the homeless. Molecular epidemiology can inform local and national public health action.

Development of a commercial system to apply the Meat Standards Australia grading model to optimise the return on eating quality in a beef supply chain

A major trial was conducted to develop, test and demonstrate the application of Meat Standards Australia (MSA) research findings in a beef retailing environment. A new concept retail store was established whereby a mix of raw beef products and pre-cooked meals were merchandised under an eating quality grade defined by MSA palatability scores. Products were presented fully prepared within cooking method with pricing based on the predicted cooked results. Large price differentials were established between the three grades offered, with 5-star product priced at more than double the 3-star product. The principle of pricing being directly related to eating quality was extended from the retail store sales to fabrication and the purchase of source cattle from producers. This encouraged considerable innovation to optimise eating quality and returns, demonstrating the potential for truly transparent value-based pricing systems to achieve change. Novel systems were developed to break down and fabricate the carcass into ‘retail-ready’ product with extensive software development to trace the eating quality, value and location of individual cuts and products. Detailed feedback provided the producer with an accurate measure of value and sufficient data to evaluate possible alternative production strategies. Results at each level of the supply chain were encouraging with compound annual growth in sales exceeding 12% at retail level and continued innovation through fabrication and on-farm areas combining to improve eating quality and financial outcomes. It was demonstrated that the consumer focus delivered by MSA grades could be applied at a commercial level providing an opportunity to reposition beef as a contemporary consumer product and to implement a value-based system across all sectors.

Risk of anal furunculosis in German shepherd dogs is associated with the major histocompatibility complex

Anal furunculosis (AF) is a chronic, progressive inflammatory disease of the perianal tissues most frequently affecting middle-aged or older German Shepherd dogs (GSD). Because this breed accounts for over 80% of all reported cases, there is likely to be a genetic association with disease susceptibility. Although there are some similarities with perianal fistulation that occurs in human Crohn's disease, the aetiology and pathogenesis of AF are still poorly understood. Recent research has suggested an immune-mediated aetiology, and evidence for this has been further provided by clinical responses to the immunosuppressive drug cyclosporin. The aim of the current study was to investigate canine major histocompatibility complex immune response genes. Dog leucocyte antigen class II alleles and haplotypes were characterised by sequence-based typing of 107 GSD affected with AF and 196 breed-matched controls collected in the UK. A highly significant association of DLA-DRB1*00101 with the presence of AF was observed (OR = 5.01, CI = 2.7-9.3, P < 0.00000001). This association was confirmed in a second cohort of GSD collected in Finland. Homozygosity for this allele is associated with an earlier disease onset.

Monitoring tuberculosis treatment outcome: analysis of national surveillance data from a clinical perspective

BACKGROUND

In 1998, the World Health Organization (WHO) and the International Union Against Tuberculosis and Lung Disease (IUATLD) published recommendations standardising the evaluation of tuberculosis treatment outcome in Europe. These guidelines fail to account for clinically appropriate alterations in the management of patients.

OBJECTIVES

To evaluate tuberculosis treatment outcome in England, Wales and Northern Ireland by redefining the outcome criteria and investigate factors associated with unsuccessful treatment outcome 12 months after notification.

METHODS

This was a prospective analysis of a cohort of patients diagnosed in England, Wales and Northern Ireland and reported to the Enhanced Tuberculosis Surveillance system in 2001 and 2002. Proportions of success and failure were calculated based on a new set of criteria following discussion with clinicians treating tuberculosis cases. Logistic regression was used to study risk factors for unsuccessful treatment outcome.

RESULTS

13 048 cases were notified in the study period. Of the 2676 that were identified as new sputum smear positive pulmonary cases, 2209 (82.5%) had treatment outcome data reported. Using the WHO/IUATLD criteria, 76.8% were classified as successful. In contrast, applying the new criteria, the success rate was 87.5%. This rate exceeds the 85% success target set by the WHO. Risk factors for unsuccessful treatment outcome included male sex (OR 1.27; 95% CI 1.08 to 1.49), being elderly (p trend < 0.001), having pulmonary tuberculosis (OR 1.28; 95% CI 1.08 to 1.53) and having resistance to any antituberculosis drug (OR 1.90; 95% CI 1.44 to 2.52).

CONCLUSION

The proportion of tuberculosis cases with a successful treatment outcome exceeded the target of 85% success rate based on the modified outcome categories. Although the tuberculosis treatment outcome criteria set by WHO/IUATLD appear to be clear, they mix measures of process and outcome. Further refinement may be necessary in low incidence high income countries, especially those with a high mortality among the elderly.

Upregulation of heat shock protein 27 in metaplastic and neoplastic lesions of the endocervix

Heat shock proteins (hsps) are molecular chaperones that are known to play a pivotal role in regulating intracellular homeostasis. hsp27 may have diagnostic and prognostic values for different gynecological malignancies. A cross-sectional analytical study was conducted at the Department of Pathology, The University of Liverpool, Liverpool, UK. Included in the study were 80 cervical glandular lesions of various histologic types, representing tuboendometrial metaplasia/endometriosis (n = 19), cervical glandular intraepithelial neoplasia (n = 33), and invasive adenocarcinoma (n = 28). Paraffin-embedded sections were stained using a commercial mouse monoclonal anti-hsp27 antibody with prior pressure-cooking for antigen retrieval. Sections of 11 normal cervices were used as controls. The median percentage of cells expressing hsp27 in each group was calculated. Normal cervical glands showed minimal expression of hsp27 (median: 10%, interquartile ranges [IQ]: 5-15). Expression was significantly more widespread in tuboendometrial metaplasia/endometriosis (median: 35%, IQ: 15-80), cervical glandular intraepithelial neoplasia (median: 60%, IQ: 32-80), and invasive adenocarcinoma (median: 40%, IQ: 25-80) when compared with normal endocervix (P = 0.007, < 0.001, and 0.001, respectively). However, no significant difference in hsp27 protein expression was found between cervical glandular intraepithelial neoplasia and invasive adenocarcinoma. In invasive adenocarcinoma, hsp27 showed no correlation with tumor grade, lymph node involvement, and lymphovascular space invasion. Our data highlight early dysregulation of hsp27 expression in both metaplastic and neoplastic lesions of the cervix.

Upregulation of heat shock protein 27 in metaplastic and neoplastic lesions of the endocervix

Heat shock proteins (hsps) are molecular chaperones that are known to play a pivotal role in regulating intracellular homeostasis. hsp27 may have diagnostic and prognostic values for different gynecological malignancies. A cross-sectional analytical study was conducted at the Department of Pathology, The University of Liverpool, Liverpool, UK. Included in the study were 80 cervical glandular lesions of various histologic types, representing tuboendometrial metaplasia/endometriosis (n = 19), cervical glandular intraepithelial neoplasia (n = 33), and invasive adenocarcinoma (n = 28). Paraffin-embedded sections were stained using a commercial mouse monoclonal anti-hsp27 antibody with prior pressure-cooking for antigen retrieval. Sections of 11 normal cervices were used as controls. The median percentage of cells expressing hsp27 in each group was calculated. Normal cervical glands showed minimal expression of hsp27 (median: 10%, interquartile ranges [IQ]: 5–15). Expression was significantly more widespread in tuboendometrial metaplasia/endometriosis (median: 35%, IQ: 15–80), cervical glandular intraepithelial neoplasia (median: 60%, IQ: 32–80), and invasive adenocarcinoma (median: 40%, IQ: 25–80) when compared with normal endocervix (P = 0.007, <0.001, and 0.001, respectively). However, no significant difference in hsp27 protein expression was found between cervical glandular intraepithelial neoplasia and invasive adenocarcinoma. In invasive adenocarcinoma, hsp27 showed no correlation with tumor grade, lymph node involvement, and lymphovascular space invasion. Our data highlight early dysregulation of hsp27 expression in both metaplastic and neoplastic lesions of the cervix.

A study of the variation in tuberculosis incidence and possible influential variables in Manchester, Liverpool, Birmingham and Cardiff in 1991-1995

SETTING AND OBJECTIVE

The reversal of the decline in United Kingdom tuberculosis rates has sparked a resurgence of interest in the epidemiology and prevention of tuberculosis in the UK. In this paper we quantify the primary factors explaining the variability in the electoral ward level relative risk of tuberculosis in Manchester, Liverpool, Birmingham and Cardiff.

DESIGN

Ecological analysis of the incidence of tuberculosis in 397 wards using hospital admissions data as a proxy for tuberculosis incidence. Admissions were evaluated from the financial years 1991/1992 to 1994/1995. Ward level covariates included measures of country of birth, ethnicity and various socio-economic measures.

RESULTS

Separate analyses were carried out for pulmonary and non-pulmonary tuberculosis. For pulmonary tuberculosis the final model included measures of the ward population born in India and Pakistan, overcrowded housing and not-owner-occupied housing. For non-pulmonary tuberculosis the covariates were ward population born in India and Pakistan, overcrowded housing and the proportion of households with no car.

CONCLUSIONS

The country of birth of the ward population is the single most influential explanatory factor in the variability of the ward rates for both pulmonary and non-pulmonary tuberculosis in these four cities. Measures of poverty are of secondary importance.

Ozone exposure thresholds and foliar injury on forest plants in Switzerland

Canton Ticino in southern Switzerland is exposed to some of the highest concentrations of tropospheric ozone in Europe. During recent field surveys in Canton Ticino, foliar symptoms identical to those caused by ozone have been documented on native tree and shrub species. In Europe, the critical ozone level for forest trees has been defined at an AOT40 of 10 ppm.h O3 (10 ppm.h accumulated exposure of ozone over a threshold of 40 ppb) during daylight hours over a six-month growing season. The objective of this study was to determine the amount of ambient ozone required to induce visible foliar symptoms on various forest plant species in southern Switzerland. Species were grown within eight open-top chambers and four open plots at the Vivaio Lattecaldo Cantonal Forest Nursery in Ticino, Switzerland. Species differed significantly in terms of the ppb.h exposures needed to cause visible symptoms. The most to least symptomatic species grown within open-plots in this study rank as Prunus serotina, Salix viminalis, Vibrnum lantana, Rhamnus cathartica, Betula pendula, Rumex obtusifolius, Sambucus racemosa, Morus nigra, Prunus avium, Fraxinus excelsior, Rhamnus frangula, Alnus viridis, Fagus sylvatica and Acer pseudoplatanus. Similar rankings were obtained in the non-filtered chamber plots. The ranking of species sensitivity closely follows AOT values for the occurrence of initial symptoms and symptom progression across the remainder of the exposure season. Species that first showed evidence of foliar injury also demonstrated the most sensitivity throughout the growing season, with symptoms rapidly advancing over ca. 25-30% of the total plant leaf surfaces by the end of the observation period. Conversely, those species that developed symptoms later in the season had far less total injury to plant foliage by the end of the observation period (1.5 to < 5% total leaf area injured). The current European ambient ozone standard may be insufficient to protect native plant species from visible foliar injury, and many more native species may be sensitive to ozone-induced foliar injury than are currently known.

Holocene isostasy and relative sea-level changes on the east coast of England

Analysis of sea-level data from the east coast of England identifies local-scale and regional scale factors to explain spatial and temporal variations in the altitude of Holocene sea-level index points. The isostatic effect of the glacial rebound process, including both the ice (glacio-isostatic) and water (hydro-isostatic) load contributions, explains regionalscale differences between eight areas: c. 20 m range at 8 cal. ka bp and by 4 cal. ka bp relative sea-level in Northumberland was above present, whereas in areas to the south relative sea level has been below present throughout the Holocene. Estimates for pre-industrial relative sea-level change range from 1.04 ± 0.12 mm a−1 in the Fenland to −1.30 ± 0.68 mm a−1 (i.e. sea-level fall) in north Northumberland, although this may overestimate the current rate of sea-level fall. Isostatic effects will produce similar relative differences in rates of sea-level change through the twenty-first century. The data agree closely with the patterns predicted by glacio- and hydro-isostatic models, but small systematic differences along the east coast await testing against new ice models. Local scale processes identified include differential isostatic effects within the Humber Estuary and the Fenland, tide range changes during the Holocene, and the effects of sediment consolidation. These processes help explain the variation in altitude between sea-level reconstructions derived from index points taken from basal peats and those from peats intercalated within thick sequences of Holocene sediments.

Modelling western North Sea palaeogeographies and tidal changes during the Holocene

Analysis of cores collected from Late Devensian (Weichselian) and Holocene sediments on the floor of the North Sea provides evidence of the transgression of freshwater environments during relative sea-level rise. Although many cores show truncated sequences, examples from the Dogger Bank, Well Bank and 5 km offshore of north Norfolk reveal transitional sequences and reliable indicators of past shoreline positions. Together with radiocarbon-dated sea-level index points collected from the Holocene sediments of the estuaries and coastal lowlands of eastern England these data enable the development and testing of models of the palaeogeographies of coastlines in the western North Sea and models of tidal range changes through the Holocene epoch. Geophysical models that incorporate ice-sheet reconstructions, earth rheology, eustasy, and glacio- and hydroisostasy provide predictions of sea-level relative to the present for the last 10 ka at 1-ka intervals. These predictions, added to a model of present-day bathymetry, produce palaeogeographic reconstructions for each time period. The palaeogeographic maps reveal the transgression of the North Sea continental shelf. Key stages include a western embayment off northeast England as early as 10 kabp; the evolution of a large tidal embayment between eastern England and the Dogger Bank before 9 kabpwith connection to the English Channel prior to 8 kabp; and Dogger Bank as an island at high tide by 7.5 kabpand totally submerged by 6 kabp. Analysis of core data shows that coastal and saltmarsh environments could adapt to rapid rates of sea-level rise and coastline retreat. After 6 kabpthe major changes in palaeogeography occurred inland of the present coast of eastern England. The palaeogeographic models provide the coastline positions and bathymetries for modelling tidal ranges at each 1-ka interval. A nested hierarchy of models, from the scale of the northeast Atlantic to the east coast of England, uses 26 tidal harmonics to reconstruct tidal regimes. Predictions consistently show tidal ranges smaller than present in the early Holocene, with only minor changes since 6 kabp. Recalibration of previously available sea-level index points using the model results rather than present tidal-range parameters increases the difference between observations and predictions of relative sea-levels from the glacio-hydro-isostatic models and reinforces the need to search for better ice-sheet reconstructions.

Decreased morbidity and use of hospital services in English HIV-infected individuals with increased uptake of anti-retroviral therapy 1996-1997. National Prospective Monitoring System Steering Group

OBJECTIVE

To investigate the relationship between changing morbidity patterns, the use of hospital services by HIV-infected patients and the uptake of antiretroviral therapy (ART) in England.

DESIGN

Prospective serial cross-sectional analyses based on data collected through the National Prospective Monitoring System (NPMS), a multi-centre prospective monitoring system.

SETTING

HIV-infected patients seen in 10 clinics, five London and five non-London, during the three semesters, 1 January 1996 to 30 June 1997.

MAIN OUTCOME MEASURES

The mean use of hospital services per patient-year, mean new HIV-related opportunistic illnesses per 1000 patient-years and percentage uptake of ART.

RESULTS

The use of inpatient services changed particularly among AIDS patients. The mean number of inpatient days for AIDS patients decreased from 19.7 [95% confidence interval (CI) 13.7-25.7] in 1996 to 11.2 (95% CI 6.1-15.6) per patient-year in 1997. Concurrently the number of new AIDS-defining events decreased significantly from 567 (95% CI 529-607) to 203 (95% CI 183-225) per 1000 patient-years. The overall uptake of ART increased significantly from 33% (95% CI 31-35%) to 50% (95% CI 48-52%), and a switch from mono or dual to triple therapy or quadruple or more therapy was observed. However, by mid-1997 only 29% (95% CI 26-32%) of asymptomatic patients and 51% (95% CI 49-54%) of patients with symptomatic non-AIDS were on ART, compared with 69% (95% CI 66-71%) of AIDS patients.

CONCLUSION

The observed reduction in new AIDS-defining events has led to a reduction in the need for inpatient hospital care and has been associated with an increased uptake of ART, including a switch to triple therapy. All of these factors are likely to have contributed to the observed reduction in mortality among English AIDS patients. As the overall uptake of ART remained relatively low in English centres further improvements can be anticipated. However, the medium to long-term effects of these treatment regimens will need to be closely monitored.

The use and cost of HIV service provision in England in 1996. National Prospective Monitoring System (NPMS) Steering Group and NPMS Working Party on Costs

OBJECTIVE

The aim of the study was to measure the use and estimate the cost of HIV service provision in England.

DESIGN AND SETTING

Standardised activity and case-severity data were collected prospectively in 10 English HIV clinics (5 London and 5 non-London sites) for the periods 1 January 1996 to 30 June 1996 and 1 July 1996 to 31 December 1996 and linked to unit cost data. In total, 5440 patients with HIV infection attended during the first 6 months and 5708 during the second 6 months in 1996.

MAIN OUTCOME MEASURES AND RESULTS

The mean number of inpatient days per patient-year for patients with AIDS was 19.7 [95% confidence interval (CI): 13.7 to 25.7] for January to June and 20.8 (95% CI: 15.3 to 26.4) for July to December 1996. The mean number of outpatient visits for asymptomatic patients with HIV infection was 14.8 (95% CI: 11.9 to 17.6) and 13.3 (95% CI: 10.8 to 15.7) for the respective periods and 16.1 (95% CI: 13.21 to 18.97) and 15.7 (95% CI: 11.2 to 20.2), respectively, for patients with symptomatic non-AIDS (i.e. symptomatic patients with HIV infection but without AIDS-defining conditions). Substantial centre-to-centre variation was observed, suggesting that many clinics can continue the shift from an inpatient- to an outpatient-based service. Cost estimates per patient-year for HIV service provision for 1996 varied from 4695 Pounds (95% CI: 3769 Pounds to 5648 Pounds) for asymptomatic patients, to 7605 Pounds (95% CI: 6273 Pounds to 8909 Pounds) for symptomatic non-AIDS patients to 20,358 Pounds (95% CI: 17,681 Pounds to 23,206 Pounds) for patients with AIDS.

CONCLUSIONS

Different combinations of antiretroviral therapy affect the cost estimates of HIV service provision differently. Anticipated reduction in inpatient-related activity through the increased use of combination antiretroviral therapy will further shift service provision from an inpatient- to outpatient-based service and reduce costs per patient-year. The extent and duration of such effects are currently unknown. The long term effects of combination treatment on the morbidity and mortality patterns of individuals infected with HIV are also currently unknown, as are their implications on the use and cost of HIV service provision. Multicentre databases like the National Prospective Monitoring System (NPMS) will provide healthcare professionals with information to improve existing services and anticipate the impact of new developments.

Variation in IgG1 heavy chain allotype does not contribute to differences in biological activity of two human anti-Rhesus (D) monoclonal antibodies

BACKGROUND

Pooled human anti-Rhesus D antiserum is currently administered for the prevention of RhD alloimmunization. Increased demand, and decreased supply, of donated pooled antiserum has led to the investigation of the suitability of human monoclonal anti-RhD antibodies for use in its place. However, it is unclear which biological properties of monoclonal antibodies are important for function in RhD-positive foetal red cell clearance and the prevention of alloimmunization. Various antibodies behave differently in a number of in vitro assays of biological function.

OBJECTIVES

To compare the function and structure of two human anti-RhD IgG1 monoclonal antibodies which differ in their ability to promote red cell lysis in vitro. In particular to examine whether the functional differences correlate to differences in the IgG1 heavy chain constant region (allotype).

STUDY DESIGN

We report here the cloning, characterization and re-expression in stable myeloma cell transformants of cDNAs coding for two such antibodies, secreted by the heterohybridoma cell lines ESD-1 (THERAD 03) and LHM 70/45.3 (THERAD 06). The cDNAs were then recombined to exchange portions of the Fc encoding regions and the recombinant antibodies were assayed in vitro to determine RhD-positive red cell-dependent activity.

RESULTS

Recombinant THERAD 03 and 06 antibodies behaved identically to the parent antibodies. The 'inactive' THERAD 06 did not have biological activity reconstituted by exchange with the THERAD 03 Fc regions, nor was THERAD 03 activity abolished by the reciprocal Fc region exchange.

CONCLUSIONS

Human monoclonal anti-RhD antibodies can be cloned and re-expressed in stable cell lines, and exhibit identical properties to the parent antibodies. Differences in biological activity cannot be attributed to differences in IgG1 heavy chain allotype.

Ultrasound evaluation of blunt abdominal trauma: program implementation, initial experience, and learning curve

OBJECTIVE

Although sonographic screening for blunt abdominal trauma is gaining acceptance, standards for implementation, training, credentialing, and quality control remain to be established.

DESIGN

This prospective study examines a Level I trauma service experience with the de novo establishment of a trauma ultrasound (US) program credentialed through the Department of Surgery under the auspices of Continuous Quality Improvement.

MATERIALS AND METHODS

All trauma surgeons attended a combined didactic and "hands on" 8-hour trauma US course. Abdominal sonography was subsequently performed on patients with potential blunt abdominal trauma followed by a standard diagnostic evaluation, which included computed tomographic scan, diagnostic peritoneal lavage, or observation.

MEASUREMENTS AND MAIN RESULTS

Three hundred patients were studied over a 4-month period. They averaged 35 years of age with an average injury severity score of 12. The time required to perform the US examination averaged less than 3 minutes. Standard diagnostic evaluation included computed tomographic scan (21%), diagnostic peritoneal lavage (45%), and observation (34%). US examinations resulted in 277 true negatives, 17 true positives, two false positives, and four false negatives for a sensitivity of 81.0%, a specificity of 99.3%, and an accuracy of 98.0%. Annualized cost savings with the use of US evaluation versus standard diagnostic evaluation would amount to over $100,000.00.

CONCLUSIONS

This experience with the de novo implementation of a trauma US program suggests that the training and credentialing requirements in this study are sufficient to provide surgeon ultrasonographers with acceptable competence in US diagnosis of blunt abdominal trauma.

The Diabetes Care Support Service for general practitioners in Auckland

AIMS

Diabetic complications can often be prevented by timely detection and intervention. Optimising diabetes care requires effective monitoring of risk factors at both practice and district level. We describe a novel method which combines district monitoring of diabetes with enhanced diabetes care by individual general practitioners.

METHODS

All general practitioners in south and west Auckland (n = 291) were invited to join the Diabetes Care Support Service (DCSS). This involved the identification of all diabetic patients within the practice and the completion of an audit from with key measures of diabetes and its care.

RESULTS

Audit was completed for 217 (75%) of general practitioners and 4611 diabetic patients: 39% of general practitioners completed their own audit. The proportion of completed patient assessments ranged between 35% (foot pulses) and 89% (blood pressure). The process was found to be helpful by 88% of general practitioners (who commented).

CONCLUSION

The DCSS is a seamless, service-orientated approach to the delivery of diabetes care by primary and secondary services and is likely to improve care district-wide and identify the need for further interventions. Subsequent audit passes will allow the demonstration and monitoring of any changes that occur, as well as the demonstration of its feasibility and acceptability on an ongoing basis.

A strategy to reduce laxative use among older people

Institutions can be places of routine and unquestioned practice in the administration of medications. In one mixed ward of psychogeriatric patients constipation was a common problem for which laxatives were routinely given. In this particular ward, many of the patients were receiving up to five different laxatives a day either orally or rectally. Dementia and being bed or chair-bound greatly increased the risk of chronic constipation. Excessive laxative use is another cause of chronic constipation. A review of practice and a decision implement a new approach was prompted by the arrival of new ward managers. The use of laxatives was stopped almost entirely and a new dietary regime was started. This article outlines how the changes were implemented.

Approaches to maximizing stable expression of alpha 1-antitrypsin in transformed CHO cells

A variety of approaches to maximizing the production of recombinant human alpha 1-antitrypsin (AAT) in Chinese hamster ovary (CHO) cells have been investigated. The highly active and inducible human cytomegalovirus immediate early (IE) promoter/enhancer was used to drive transcription of a recombinant AAT gene in transiently transfected and stably transformed CHO cells. The AAT gene was modified to incorporate highly efficient 3'RNA processing signals from the herpes simplex virus type 2 IE gene 5, and optimal translational initiation signals were created by site-directed mutagenesis. The effect of flanking the recombinant gene with matrix attachment regions was investigated. Combinations of these modifications allowed secretion of up to 44 micrograms AAT/ml per day by cell lines growing in serum-rich medium. This could be increased to up to 100 micrograms AAT/ml per day upon chemical induction of expression by propionate, butyrate or hexamethylene bisacetamide. Cell lines adapted to grow in protein-free medium produced less AAT but still responded to chemical induction to secrete up to 14 micrograms/ml per day of readily purified AAT.

Retained intraocular foreign body simulating choroidal melanoma. A report of two cases

Many different lesions can be difficult to distinguish from malignant melanomas of the choroid. With the use of modern diagnostic facilities the misdiagnosis rate has been greatly reduced. In a recent report from the Collaborative Ocular Melanoma Study Group the incidence of misdiagnosis was only 0.48%. The presence of a retained intraocular foreign body presenting as a raised pigmented choroidal mass similar to a uveal melanoma is rare. We report two cases in which retained intraocular foreign bodies presented clinically as raised pigmented intraocular lesions. Retained intraocular foreign bodies should be considered in the differential diagnosis of ocular tumours, especially if there are any atypical features.

Triplet state EPR of reaction centers from the His(L173)→Leu (L173) mutant of Rhodobacter sphaeroides which contains a heterodimer primary donor

Electron paramagnetic resonance (EPR) spectroscopy has been used to examine the triplet states in reaction centers of Rhodobacter sphaeroides which have undergone a genetic modification affecting the primary donor. Reaction centers containing the His(L173)→Leu(L173) substitution in the amino acid sequence have a primary donor which consists of a BChl-BPh heterodimer. The triplets formed in this heterodimer reaction center were compared with those formed in the wild-type reaction center which contains the BChl-BChl homodimer. Both reaction centers transfer triplet energy to the carotenoid under illumination at liquid nitrogen temperatures (∼90 K). However, the intensity of the carotenoid triplet signal is significantly decreased in the Leu(L173) mutant compared with the wild-type reaction center. At 12 K, in wild-type reaction centers only the primary donor triplet is observed. The Leu(L173) mutant exhibits a signal similar to that observed by Bylina et al. (1990) in His(M200)→Leu(M200) mutant reaction centers from Rb. capsulatus. The values of the zero-field splitting parameters of this triplet are discussed within the context of various models for the primary donor triplet state. No alteration in the ability of the carotenoid to quench the primary donor triplet state results from mutations at these sites.