Isoniazid urine spectrophotometry for prediction of serum pharmacokinetics in adults with TB

BACKGROUND

Isoniazid (INH) is an important drug in many TB regimens, and unfavorable treatment outcomes can be caused by suboptimal pharmacokinetics. Dose adjustment can be personalized by measuring peak serum concentrations; however, the process involves cold-chain preservation and laboratory techniques such as liquid chromatography (LC)/mass spectrometry (MS), which are unavailable in many high-burden settings. Urine spectrophotometry could provide a low-cost alternative with simple sampling and quantification methods.

METHODS

We enrolled 56 adult patients on treatment for active TB. Serum was collected at 0, 1, 2, 4, 6, and 8 h for measurement of INH concentrations using validated LC-MS/MS methods. Urine was collected at 0-4, 4-8, and 8-24 h intervals, with INH concentrations measured using colorimetric methods.

RESULTS

The median peak serum concentration and total serum exposure over 24 h were 4.8 mg/L and 16.4 mg*hour/L, respectively. Area under the receiver operator characteristic curves for urine values predicting a subtherapeutic serum concentration (peak <3.0 mg/L) were as follows: 0-4 h interval (AUC 0.85, 95% CI 0.7-0.96), 0-8 h interval (AUC 0.85, 95% CI 0.71-0.96), and 0-24 h urine collection interval (AUC 0.84, 95% CI 0.68-0.96).

CONCLUSION

Urine spectrophotometry may improve feasibility of personalized dosing in high TB burden regions but requires further study of target attainment following dose adjustment based on a urine threshold.

Perinatal outcome of pregnancy complicated by twin anemia-polycythemia sequence: systematic review and meta-analysis

OBJECTIVE

To report the perinatal outcome of monochorionic diamniotic (MCDA) twin pregnancies complicated by twin anemia-polycythemia sequence (TAPS), according to the type of TAPS (spontaneous or postlaser) and the management option adopted.

METHODS

MEDLINE, EMBASE and The Cochrane Library databases were searched for studies reporting on the outcome of twin pregnancies complicated by TAPS. Inclusion criteria were non-anomalous MCDA twin pregnancies with a diagnosis of TAPS. The primary outcome was perinatal mortality; secondary outcomes were neonatal morbidity and preterm birth (PTB). The outcomes were stratified according to the type of TAPS (spontaneous or following laser treatment for twin-twin transfusion syndrome) and the management option adopted (expectant, laser surgery, intrauterine transfusion (IUT) or selective reduction (SR)). Random-effects meta-analysis of proportions was used to analyze the data.

RESULTS

Perinatal outcome was assessed according to whether TAPS occurred spontaneously or after laser treatment in 506 pregnancies (38 studies). Intrauterine death (IUD) occurred in 5.2% (95% CI, 3.6-7.1%) of twins with spontaneous TAPS and in 10.2% (95% CI, 7.4-13.3%) of those with postlaser TAPS, while the corresponding rates of neonatal death were 4.0% (95% CI, 2.6-5.7%) and 9.2% (95% CI, 6.6-12.3%), respectively. Severe neonatal morbidity occurred in 29.3% (95% CI, 25.6-33.1%) of twins after spontaneous TAPS and in 33.3% (95% CI, 17.4-51.8%) after postlaser TAPS, while the corresponding rates of severe neurological morbidity were 4.0% (95% CI, 3.5-5.7%) and 11.1% (95% CI, 6.2-17.2%), respectively. PTB complicated 86.3% (95% CI, 77.2-93.3%) of pregnancies with spontaneous TAPS and all cases with postlaser TAPS (100% (95% CI, 84.3-100%)). Iatrogenic PTB was more frequent than spontaneous PTB in both groups. Perinatal outcome was assessed according to the management option adopted in 417 pregnancies (21 studies). IUD occurred in 9.8% (95% CI, 4.3-17.1%) of twins managed expectantly and in 13.1% (95% CI, 9.2-17.6%), 12.1% (95% CI, 7.7-17.3%) and 7.6% (95% CI, 1.3-18.5%) of those treated with laser surgery, IUT and SR, respectively. Severe neonatal morbidity affected 27.3% (95% CI, 13.6-43.6%) of twins in the expectant-management group, 28.7% (95% CI, 22.7-35.1%) of those in the laser-surgery group, 38.2% (95% CI, 18.3-60.5%) of those in the IUT group and 23.3% (95% CI, 10.5-39.2%) of those in the SR group. PTB complicated 80.4% (95% CI, 59.8-94.8%), 73.4% (95% CI, 48.1-92.3%), 100% (95% CI, 76.5-100%) and 100% (95% CI, 39.8-100%) of pregnancies after expectant management, laser surgery, IUT and SR, respectively.

CONCLUSIONS

The present meta-analysis provides pooled estimates of the risks of perinatal mortality, neonatal morbidity and PTB in twin pregnancies complicated by TAPS, stratified by the type of TAPS and the management option adopted. Although a direct comparison could not be performed, the results from this systematic review suggest that spontaneous TAPS may have a better prognosis than postlaser TAPS. No differences in terms of mortality and morbidity were observed when comparing different management options for TAPS, although these findings should be interpreted with caution in view of the limitations of the included studies. Individualized prenatal management, taking into account the severity of TAPS and gestational age, is currently the recommended strategy. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Twin chorionicity-specific population birth-weight charts adjusted for estimated fetal weight

OBJECTIVES

To construct chorionicity-specific birth-weight reference charts for dichorionic diamniotic (DCDA) and monochorionic diamniotic (MCDA) twin pregnancies, incorporating estimated-fetal-weight (EFW) data in order to adjust for the relationship between suboptimal growth and preterm delivery. An additional aim was to determine if the inclusion of complicated twin pregnancies impacts on the reference charts produced.

METHODS

The inclusion criteria for this retrospective cohort study were twin pregnancy of known DCDA or MCDA chorionicity, known pregnancy outcome, last ultrasound scan within 14 days before birth and delivery between 25 and 38 weeks' gestation (Analysis A). An analysis was also conducted excluding pregnancies with complications recorded (Analysis B). Previously published twin EFW reference ranges were used in the analysis. A joint statistical model for EFW and observed birth weight for each pregnancy was created in order to estimate population birth-weight reference ranges corresponding to the distribution expected if all pregnancies delivered at any given gestational age. It was not assumed that the median EFW was equal to birth weight for any given gestational age. The models were fitted using a Bayesian approach.

RESULTS

We retrieved data on 1664 twin pregnancies, of which 707 DCDA and 241 MCDA pregnancies met the inclusion criteria. In Analysis A, the estimated population median birth weight was similar to the median EFW at around 27 weeks' gestation but fell below the EFW values with increasing gestation, being 156 g lower in both DCDA and MCDA pregnancies at 35 weeks; this finding was confirmed by direct comparison of the last EFW and birth-weight values in each pregnancy. When the analysis was repeated after excluding complicated twin pregnancies (Analysis B), compared with Analysis A, there was very little difference in the median birth-weight results obtained across gestation. The largest absolute difference between Analyses A and B for DCDA twins was at 31, 32 and 33 weeks, with a 9-g lower median birth weight in Analysis A compared with Analysis B. The largest absolute difference for MCDA twins was greater than that for DCDA twins, with a 21-g lower median birth weight at 25 weeks in Analysis A compared with Analysis B.

CONCLUSIONS

We have established population chorionicity-specific birth-weight reference charts for DCDA and MCDA twin pregnancies, corresponding to the range expected were all pregnancies to deliver at any given gestational age. In this population of twins, the median birth weight was consistently lower than that reported for singletons, and there was variation in the median birth weight at different gestational ages according to chorionicity. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. - Legal Statement: This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Consensus diagnostic criteria and monitoring of twin anemia-polycythemia sequence: Delphi procedure

OBJECTIVES

Twin anemia-polycythemia sequence (TAPS) is associated with increased perinatal morbidity and mortality. Inconsistencies in the diagnostic criteria for TAPS exist, which hinder the ability to establish robust evidence-based management or monitoring protocols. The main aim of this study was to determine, by expert consensus using a Delphi procedure, the key diagnostic features and optimal monitoring approach for TAPS.

METHODS

A Delphi process was conducted among an international panel of experts on TAPS. Panel members were provided with a list of literature-based parameters for diagnosing and monitoring TAPS. They were asked to rate the importance of the parameters on a five-point Likert scale. Consensus was sought to determine the cut-off values for accepted parameters, as well as parameters used in the monitoring of and assessment of outcome in twin pregnancy complicated by TAPS.

RESULTS

A total of 132 experts were approached. Fifty experts joined the first round, of whom 33 (66%) completed all three rounds. There was agreement that the monitoring interval for the development of TAPS should be every 2 weeks and that the severity should be assessed antenatally using a classification system based on middle cerebral artery (MCA) peak systolic velocity (PSV), but there was no agreement on the gestational age at which to start monitoring. Once the diagnosis of TAPS is made, monitoring should be scheduled weekly. For the antenatal diagnosis of TAPS, the combination of MCA-PSV ≥ 1.5 MoM in the anemic twin and ≤ 0.8 MoM in the polycythemic twin was agreed. Alternatively, MCA-PSV discordance ≥ 1 MoM can be used to diagnose TAPS. Postnatally, hemoglobin difference ≥ 8 g/dL and intertwin reticulocyte ratio ≥ 1.7 were agreed criteria for diagnosis of TAPS. There was no agreement on the cut-off of MCA-PSV or its discordance for prenatal intervention. The panel agreed on prioritizing perinatal and long-term survival outcomes in follow-up studies.

CONCLUSIONS

Consensus-based diagnostic features of TAPS, as well as cut-off values for the parameters involved, were agreed upon by a panel of experts. Future studies are needed to validate these diagnostic features before they can be used in clinical trials of interventions. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Core outcome set for studies investigating management of selective fetal growth restriction in twins

OBJECTIVE

Selective fetal growth restriction (sFGR) occurs in monochorionic twin pregnancies when unequal placental sharing leads to restriction in the growth of just one twin. Management options include laser separation of the fetal circulations, selective reduction or expectant management, but what constitutes the best treatment is not yet known. New trials in this area are urgently needed but, in this rare and complex group, maximizing the relevance and utility of clinical research design and outputs is paramount. A core outcome set ensures standardized outcome collection and reporting in future research. The objective of this study was to develop a core outcome set for studies evaluating treatments for sFGR in monochorionic twins.

METHODS

An international steering group of clinicians, researchers and patients with experience of sFGR was established to oversee the process of development of a core outcome set for studies investigating the management of sFGR. Outcomes reported in the literature were identified through a systematic review and informed the design of a three-round Delphi survey. Clinicians, researchers, and patients and family representatives participated in the survey. Outcomes were scored on a Likert scale from 1 (limited importance for making a decision) to 9 (critical for making a decision). Consensus was defined a priori as a Likert score of ≥ 8 in the third round of the Delphi survey. Participants were then invited to take part in an international meeting of stakeholders in which the modified nominal group technique was used to consider the consensus outcomes and agree on a final core outcome set.

RESULTS

Ninety-six outcomes were identified from 39 studies in the systematic review. One hundred and three participants from 23 countries completed the first round of the Delphi survey, of whom 88 completed all three rounds. Twenty-nine outcomes met the a priori criteria for consensus and, along with six additional outcomes, were prioritized in a consensus development meeting, using the modified nominal group technique. Twenty-five stakeholders participated in this meeting, including researchers (n = 3), fetal medicine specialists (n = 3), obstetricians (n = 2), neonatologists (n = 3), midwives (n = 4), parents and family members (n = 6), patient group representatives (n = 3), and a sonographer. Eleven core outcomes were agreed upon. These were live birth, gestational age at birth, birth weight, intertwin birth-weight discordance, death of surviving twin after death of cotwin, loss during pregnancy or before final hospital discharge, parental stress, procedure-related adverse maternal outcome, length of neonatal stay in hospital, neurological abnormality on postnatal imaging and childhood disability.

CONCLUSIONS

This core outcome set for studies investigating the management of sFGR represents the consensus of a large and diverse group of international collaborators. Use of these outcomes in future trials should help to increase the clinical relevance of research on this condition. Consensus agreement on core outcome definitions and measures is now required. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Electronic Cigarette Advertising Impacts Adversely on Smoking Behaviour Within a London Student Cohort: A Cross-Sectional Structured Survey

Introduction

In contrast to tobacco smoking, electronic cigarette (“vaping”) advertisement had been approved in the United Kingdom (UK) in January 2013. Currently, there are an estimated 3.2 million UK e-cigarette users. The impact of e-cigarette advertisement on tobacco use has not been studied in detail. We hypothesised that e-cigarette advertisement impacts on conventional smoking behaviour.

Methods

A cross-sectional structured survey assessed the impact of e-cigarette advertising on the perceived social acceptability of cigarette and e-cigarette smoking and on using either cigarettes or e-cigarettes (on a scale of 1 to 5/‘not at all’ to ‘a lot’). The survey was administered between January to March 2015 to London university students, before and after viewing 5 UK adverts including a TV commercial.

Results

Data were collected from 106 participants (22 ± 2 years, 66% male), comprising cigarette smokers (32%), non-smokers (54%) and ex-smokers (14%). This included vapers (16%), non-vapers (77%) and ex-vapers (7%). After viewing the adverts, smokers (2.6 ± 1.0 vs. 3.8 ± 1.1, p = 0.001) and non-smokers (3.2 ± 0.7 vs. 3.7 ± 0.8, p = 0.007) felt smoking was more socially acceptable, compared to before viewing them. Participants were more likely to try both e-cigarettes (1.90 ± 1.03 to 3.09 ± 1.11, p < 0.001) and conventional cigarettes (1.73 ± 0.83 to 2.27 ± 1.13, p < 0.001) after viewing the adverts compared to before. Vapers were less likely to smoke both an e-cigarette, and a conventional cigarette after viewing the adverts.

Conclusion

E-cigarette advertising encourages both e-cigarette and conventional cigarette use in young smokers and non-smokers. The adverts increase the social acceptability of smoking without regarding the importance of public health campaigns that champion smoking cessation.

Electronic supplementary material

The online version of this article (10.1007/s00408-019-00262-z) contains supplementary material, which is available to authorized users.

Core outcome set for research studies evaluating treatments for twin-twin transfusion syndrome

OBJECTIVE

To develop, using a Delphi procedure and a nominal group technique, a core outcome set (COS) for studies evaluating treatments for twin-twin transfusion syndrome (TTTS), which should assist in standardizing outcome selection, collection and reporting in future research studies.

METHODS

An international steering group comprising healthcare professionals, researchers and patients with experience of TTTS guided the development of this COS. Potential core outcomes, identified through a comprehensive literature review and supplemented by outcomes suggested by the steering group, were entered into a three-round Delphi survey. Healthcare professionals, researchers, and patients or relatives of patients who had experienced TTTS were invited to participate. Consensus was defined a priori using the 15%/70% definition of the Core Outcome Measures in Effectiveness Trials (COMET) initiative. The modified nominal group technique was used to evaluate the consensus outcomes in a face-to-face consultation meeting and identify the final COS.

RESULTS

One hundred and three participants, from 29 countries, participated in the three-round Delphi survey. Of those, 88 completed all three rounds. Twenty-two consensus outcomes were identified through the Delphi procedure and entered into the modified nominal group technique. The consensus meeting was attended by 11 healthcare professionals, two researchers and three patients; 12 core outcomes were prioritized for inclusion in the COS. Fetal core outcomes included live birth, pregnancy loss (including miscarriage, stillbirth, termination of pregnancy and neonatal mortality), subsequent death of a cotwin following single-twin demise at the time of treatment, recurrence of TTTS, twin anemia-polycythemia sequence and amniotic band syndrome. Neonatal core outcomes included gestational age at delivery, birth weight, brain injury syndromes and ischemic limb injury. Maternal core outcomes included maternal mortality and admission to Level-2 or -3 care setting. One aspirational outcome, neurodevelopment at 18-24 months of age, was also prioritized.

CONCLUSIONS

Implementing the COS for TTTS within future research studies could make a substantial contribution to advancing the usefulness of research in TTTS. Standardized definitions and measurement instruments are now required for individual core outcomes. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Consensus definition and essential reporting parameters of selective fetal growth restriction in twin pregnancy: a Delphi procedure

OBJECTIVES

Twin pregnancy complicated by selective fetal growth restriction (sFGR) is associated with increased perinatal mortality and morbidity. Inconsistencies in the diagnostic criteria for sFGR employed in existing studies hinder the ability to compare or combine their findings. It is therefore challenging to establish robust evidence-based management or monitoring pathways for these pregnancies. The main aim of this study was to determine, by expert consensus using a Delphi procedure, the key diagnostic features of and the essential reporting parameters in sFGR.

METHODS

A Delphi process was conducted among an international panel of experts in sFGR in twin pregnancy. Panel members were provided with a list of literature-based parameters for diagnosing sFGR and were asked to rate their importance on a five-point Likert scale. Parameters were described as solitary (sufficient to diagnose sFGR, even if all other parameters are normal) or contributory (those that require other abnormal parameter(s) to be present for the diagnosis of sFGR). Consensus was sought to determine the cut-off values for accepted parameters, as well as parameters used in the monitoring, management and assessment of outcome of twin pregnancy complicated by sFGR. The questions were presented in two separate categories according to chorionicity.

RESULTS

A total of 72 experts were approached, of whom 60 agreed to participate and entered the first round; 48 (80%) completed all four rounds. For the definition of sFGR irrespective of chorionicity, one solitary parameter (estimated fetal weight (EFW) of one twin < 3^rd centile) was agreed. For monochorionic twin pregnancy, at least two out of four contributory parameters (EFW of one twin < 10^th centile, abdominal circumference of one twin < 10^th centile, EFW discordance of ≥ 25%, and umbilical artery pulsatility index of the smaller twin > 95^th centile) were agreed. For sFGR in dichorionic twin pregnancy, at least two out of three contributory parameters (EFW of one twin < 10^th centile, EFW discordance of ≥ 25%, and umbilical artery pulsatility index of the smaller twin > 95^th centile) were agreed.

CONCLUSIONS

Consensus-based diagnostic features of sFGR in both monochorionic and dichorionic twin pregnancies, as well as cut-off values for the parameters involved, were agreed upon by a panel of experts. Future studies are needed to validate these diagnostic features before they can be used in clinical trials of interventions. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Owner reported diseases of working equids in central Ethiopia

REASONS FOR PERFORMING STUDY

Working horses, donkeys and mules suffer from numerous diseases and clinical problems. However, there is little information on what owners perceive as important health concerns in their working animals.

OBJECTIVES

To identify and prioritise with owners the diseases and other health concerns in working equids in central Ethiopia using participatory methodologies.

STUDY DESIGN

Participatory situation analysis (PSA).

METHODS

The study was conducted with carthorse- and donkey-owners in 16 sites in central Ethiopia. Multiple participatory methodologies were utilised, including ranking, matrices and focus group discussions. Owners' perceptions on frequency, importance, morbidity and mortality of volunteered diseases and the clinical signs that owners attributed to each disease were obtained; information regarding the impact of these diseases and health concerns was also sought.

RESULTS

A total of 40 separate disease and health problems were volunteered by carthorse- and donkey-owners. Horse-owners volunteered a musculoskeletal syndrome (with the local name 'bird', clinical signs suggest possible disease pathologies including equine exertional rhabdomyolysis), colic and epizootic lymphangitis most frequently, whereas donkey-owners volunteered sarcoids, nasal discharge and wounds to occur most frequently. One problem (coughing) was volunteered frequently by both horse- and donkey-owners. Owners demonstrated knowledge of differing manifestations and severity of these problems, which resulted in differing impacts on the working ability of the animal.

CONCLUSIONS

Although many of the diseases and clinical signs had been previously reported, this study also identified some previously unreported priorities such as rabies in donkeys, an unidentified musculoskeletal syndrome in horses and respiratory signs in both horses and donkeys. The information gathered during this participatory study with owners may be used to inform future veterinary and educational programme interventions, as well as identify future research priorities.

Simulations of ceria nanoparticles

Atomistic computer simulations, using classical potential models, have been used to model ceria nanoparticles (NPs) with diameters of approximately 1 and 2 nm. Lattice expansion is observed in the stoichiometric 1 nm NP, consistent with experiment, indicating that reduction is not the primary driver for such expansion. Furthermore, on reduction, the 1 nm NP is found to distort significantly, offering a possible explanation for its reduced oxygen storage capacity compared to the 2 nm NP. Point defect calculations on the 2 nm NP indicate that while doping with La is energetically favourable, Fe incorporation is not.

The management and welfare of working animals: identifying problems, seeking solutions and anticipating the future

Working animals, mainly equids, camelids and bovids, are draught animals that perform transport and traction activities. In developed countries technological development has resulted in animal power being minimised, however, in developing countries most agricultural operations are still being conducted by animals, and animal welfare is a major concern. Inadequate knowledge and inappropriate attitudes and practices regarding the management and welfare of working animals are the main contributory factors to welfare problems. The paper highlights the situation of working animals in developing countries, especially those of equids in Africa and Asia and bullocks in India, which are examined as examples. There is much room for improvement in the welfare of working animals, via the provision of basic veterinary care, technical advice on health and husbandry, including foot care, improved design and maintenance of harnesses and other equipment, and the development of appropriate policies and legislation. The paper discusses the role of the World Organisation for Animal Health in addressing these issues.

A new perspective on family involvement in chronic pain management programmes

OBJECTIVES

The aim of this study was to investigate how those with pain, and their significant others, perceive the involvement of significant others in a multidisciplinary chronic pain management programme.

METHODS

Semi-structured telephone interviews were conducted with eight people who had attended a Family Day as part of a three-week multidisciplinary chronic pain management programme in Auckland, New Zealand. Four of the participants had pain and four were significant others. Follow-up interviews were conducted with seven of the participants up to one year after their initial interview. Conventional content analysis was used to analyse collected data.

RESULTS

Participants viewed the involvement of significant others to be important because managing pain necessitates 'being on the same page' and significant others also needed an opportunity to access support and information.

CONCLUSION

The involvement of significant others in programmes is perceived to be important but must be a balance between what is feasible for significant others and beneficial for all. Further research into when and how significant others are included within programmes is urgently required.

Diabetes and cancer: two diseases with obesity as a common risk factor

There is a growing body of evidence to support a connection between diabetes (predominantly type 2), obesity and cancer. Multiple meta-analyses of epidemiological data show that people with diabetes are at increased risk of developing many different types of cancers, along with an increased risk of cancer mortality. Several pathophysiological mechanisms for this relationship have been postulated, including insulin resistance and hyperinsulinaemia, enhanced inflammatory processes, dysregulation of sex hormone production and hyperglycaemia. In addition to these potential mechanisms, a number of common risk factors, including obesity, may be behind the association between diabetes and cancer. Indeed, obesity is associated with an increased risk of cancer and diabetes. Abdominal adiposity has been shown to play a role in creating a systemic pro-inflammatory environment, which could result in the development of both diabetes and cancer. Here, we examine the relationship between diabetes, obesity and cancer, and investigate the potential underlying causes of increased cancer risk in individuals with diabetes. Current treatment recommendations for reducing the overall disease burden are also explored and possible areas for future research are considered.

Disposition of firocoxib in equine plasma after an oral loading dose and a multiple dose regimen

The objective of this study was to determine if a single loading dose (LD), 3× the label dose of firocoxib oral paste, followed by nine maintenance doses at the current label dose achieves and maintains near steady state concentrations. Six healthy, adult mares were administered 0.3mg/kg of firocoxib on Day 0, and 0.1 mg/kg 24 h later on Day 1, and at 24 h intervals from Day 2 to Day 9, for a total of 10 doses. Blood samples were collected throughout the study. The mean firocoxib maximum plasma concentration and standard deviation was 199±97 ng/mL, 175±44 ng/mL and 183±50 ng/mL after the LD, and first and last maintenance doses, respectively. The minimum mean concentration (C(min)) increased from 100±23 ng/mL after the LD to 132±38 ng/mL at Day 7. Then, the C(min) remained constant until Day 9. The average concentration at steady state (C(avg)) was 150±45 ng/mL, which compares well to the C(avg) (130±36 ng/mL) reported after multiple daily doses at 0.1 mg/kg. The administration of the single LD allowed achievement of the average steady state drug concentrations faster than a multi-dose regimen without a loading dose. After the LD, firocoxib at 0.1 mg/kg every 24 h was able to maintain a relatively constant average drug concentration which should produce less variability in onset of action and efficacy.

Ocular disease in working horses in Ethiopia: a cross-sectional study

Ocular disease is a frequent finding in working horses. This study aimed to estimate the prevalence and types of ocular pathology, and explore risk factors potentially associated with disease within a population of working horses in Ethiopia. In total, 1049 horses were selected from horses attending clinics run by the Society for Protection of Animals Abroad (SPANA). Each had an ophthalmic examination conducted under field conditions using a pen-torch. All owners completed a short questionnaire. The prevalence of ocular abnormalities was 23.5 per cent (95 per cent confidence interval (CI) 18.0 per cent to 30.1 per cent) and the percentage of horses with an abnormality in at least one eye was 43 per cent (95 per cent CI 28.7 per cent to 58.4 per cent), although this varied between towns. Mild eye pathology and end-stage disease with irreversible pathology were most common. There were significantly more eye abnormalities in the right eye compared with the left, and older horses were more likely to have ocular pathology. Only 55.1 per cent of owners had noticed there was an ocular abnormality present, and only 2.2 per cent had received any previous treatment for eye disease. Only 1.9 per cent presented to the clinic because of an eye problem. There appears to be either a lack of owner awareness, or a low perception of the importance of eye disease among owners.

Can UK healthcare workers remotely support medical education in the developing world?: Focus group evaluation

Objectives

To evaluate the feasibility of providing regular, live, text-based teaching to medical students and junior doctors in Somaliland using a dedicated case-based medical education website (www.MedicineAfrica.com).

Design

Review of MedicineAfrica database for details of teaching sessions held in Somaliland from December 2008-October 2010 and evaluation of user experiences through focus groups.

Setting

King's College Hospital, London, UK and Ahmoud University, Borama, Somaliland.

Participants

Final year medical students, newly graduated interns and second year interns at Ahmoud University, Borama, Somaliland.

Main outcome measures

Qualitative and quantitative user rating of online case-based tutorials in the context of pre-existing educational opportunities available to them.

Results

Regular online teaching sessions are received enthusiastically by students and junior doctors and are reported to improve their clinical practice.

Conclusions

Despite technological limitations in Somaliland, a live text-based teaching service can be delivered effectively and streamlined with local curricula. This represents an alternative to traditional static teaching methodologies currently used in international medical education.

A cluster-randomised controlled trial to compare the effectiveness of different knowledge-transfer interventions for rural working equid users in Ethiopia

There have been few studies evaluating the efficacy of knowledge-transfer methods for livestock owners in developing countries, and to the authors' knowledge no published work is available that evaluates the effect of knowledge-transfer interventions on the education of working equid users. A cluster-randomised controlled trial (c-RCT) was used to evaluate and compare the effectiveness of three knowledge-transfer interventions on knowledge-change about equid health amongst rural Ethiopian working equid users. Groups were exposed to either; an audio programme, a village meeting or a diagrammatic handout, all of which addressed identical learning objectives, and were compared to a control group which received no intervention. Thirty-two villages were randomly selected and interventions randomly assigned. All participants in a village received the same intervention. Knowledge levels were assessed by questionnaire administration. Data analysis included comparison of baseline data between intervention groups followed by multilevel linear regression models (allowing for clustering of individuals within village) to evaluate the change in knowledge between the different knowledge-transfer interventions. A total of 516 randomly selected participants completed the pre-intervention questionnaire, 504 of whom undertook the post-dissemination questionnaire, a follow up response rate of 98%. All interventions significantly improved the overall 'change in knowledge' score on the questionnaire compared to the control, with the diagrammatic handout (coefficient (coef) 9.5, S.E.=0.6) and the village meeting (coef 9.7, S.E.=0.6) having a significantly greater impact than the audio programme (coef 4.8, S.E.=0.6). Covariates that were different at baseline, and which were also significant in the final model, were age and pre-intervention score. Although they had a minimal effect on the intervention coefficients there was a significant interaction between age and intervention. This study should aid the design of education materials for adult learning for working equid users and other groups in developing countries.

Undergraduate research. Genomics Education Partnership

The Genomics Education Partnership offers an inclusive model for undergraduate research experiences incorporated into the academic year science curriculum, with students pooling their work to contribute to international data bases.

Undergraduate research. Genomics Education Partnership

The Genomics Education Partnership offers an inclusive model for undergraduate research experiences incorporated into the academic year science curriculum, with students pooling their work to contribute to international data bases.

Pilot study of an outpatient-based approach for advanced lymphoma using vinorelbine, gemcitabine and filgrastim

BACKGROUND

Vinorelbine and gemcitabine have demonstrable single-agent activity against lymphoma, show differing toxicity profiles and can be given in an outpatient setting.

AIMS

We have evaluated the feasibility of an outpatient-based combination of vinorelbine and gemcitabine with filgrastim support (VGF) in patients with advanced lymphoma.

METHODS

An open-label, single-arm study of 40 consecutive patients with relapsed (n = 24) or refractory (n = 16) lymphoma was undertaken. The median number of prior regimens was three (range 1-11) and 12 had undergone prior stem cell transplantation. Patients received vinorelbine 25 mg/m(2) and gemcitabine 1000 mg/m(2) on days 1 and 8 of each 21-day cycle. Patients showing no response after two cycles (early response) were offered alternative therapy. Responding patients received two more cycles. Primary end-points were the early and overall response rates.

RESULTS

One hundred and sixteen cycles of therapy were delivered. Hospital admissions were required following 27 treatment cycles (24%), predominantly following cycle 1. Febrile neutropenia followed 6% of cycles. The early and overall response rates on an intention-to-treat basis were 60 and 53%, respectively. Responses for peripheral T-cell lymphoma and Hodgkin lymphoma were particularly encouraging, 70 and 75%, respectively. With a median follow up of 34 months overall survival for the entire cohort at 2 years is 50%. Furthermore, for the 23 patients who did not receive high-dose consolidative therapy 2-year survival was 35%.

CONCLUSIONS

Vinorelbine and gemcitabine with filgrastim support can be safely delivered in an outpatient setting and shows clinically meaningful activity against a range of advanced lymphoma subtypes.

Adverse events associated with methicillin-resistant Staphylococcus aureus in a nursing home

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) generates concern in nursing homes. Restrictive isolation precautions may be applied for indefinite periods. Adverse events driving these concerns include transmission and infection.

METHODS

The 721-bed Wisconsin Veterans Home in King performs approximately 645 cultures annually. The site, severity, and number of MRSA infections were determined for 69 months. Pulsed-field gel electrophoresis was performed on all initial isolates, followed by a statistical cluster analysis looking for evidence of transmission.

RESULTS

Sixty-seven MRSA infections were identified (1.6 per 100 residents per year); many were polymicrobial, and it was difficult to determine the proportionate role of MRSA in morbidity or mortality. There was an episode of rapidly fatal MRSA septicemia in which empiric antibiotic therapy was ineffective. Twenty-one genetic strains were encountered. Statistical analysis identified 13 clusters of genetically identical strains clustered in time and space (P<.05).

CONCLUSIONS

Infections with MRSA were identified at relatively low rates; however, the etiology of many serious nursing home infections is not determined, especially pneumonia. Statistical analysis revealed clustering and evidence of transmission. Nursing home practitioners should consider MRSA when applying empiric treatment to serious infections. We recommend a program including (1) judicious use of antibiotics, including topical agents, to reduce selection of resistant organisms; (2) obtaining and tracking cultures of infectious secretions to diagnose MRSA infections and focus antibiotic therapy; (3) universal standard secretion precautions because any resident could be a carrier; and (4) a detailed assessment and care plan for the carrier that maximizes containment of secretions and independence in activities. However, basic hygiene cannot be maintained in communal areas by some residents without restriction of activities of daily living.

Ganciclovir pharmacokinetics and cytokine dynamics in renal transplant recipients with cytomegalovirus infection

Ganciclovir is considered to be the first-line treatment for cytomegalovirus (CMV) in renal transplant recipients. This infection is also associated with elevations of specific plasma cytokines post-transplantation. To investigate daily cytokine response to therapy and ganciclovir pharmacokinetics, 4 transplant recipients (3 males, 1 female) with stable renal allograft function diagnosed with CMV infection were enrolled less than 4 months post-transplant. A creatinine clearance (ClCr) was generated by the Cockroft-Gault (C-G) equation (range: 42.3-68.5 mL/min) to determine ganciclovir dosing. Blood samples were collected for ganciclovir and cytokine [including interleukin (IL)-1beta, IL-2, IL-3, IL-4, IL-6, IL-8, IL-10, TNF-alpha, GM-CSF, and interferon (IFN)-gamma analyses after 7 d of intravenous (i.v.) ganciclovir (dosage range: 165-400 mg daily) therapy and again after 7 d of oral (p.o.) ganciclovir (dosage range: 1000 mg, 2-3 times daily) therapy. Pharmacokinetic ganciclovir was described with a two-compartment model. Total clearance of ganciclovir was consistently greater than ClCr, suggesting tubular secretion. Peak concentrations for i.v. ganciclovir averaged 8.39+/-1.87 microg/mL with minimum concentrations of 0.48+/-0.35 microg/mL. Plasma concentrations were lower but more sustained during a p.o. dosing interval (max=2.12+/-0.58 microg/mL, min=1.15+/-0.34 microg/mL). IL-6, IL-8, IL-10, and TNF-alpha were detectable at multiple times during the study periods while the remainder of the cytokines were only intermittently detectable. Average concentrations (i.v. versus p.o. study period) for TNF-alpha were 40.1+/-17.5 versus 22.1+/-11.2 pg/mL, for IL-8 were 17.1+/-15.6 versus 4.12+/-2.59 pg/mL, and for IL-10 were 7.39+/-5.54 versus 2.64+/-1.06 pg/mL. Concentrations were similar for IL-6 during both studies (9.39+/-5.42 versus 14.7+/-14.8 pg/mL). TNF-alpha, IL-8, and IFN-gamma appeared to correlate with CMV antigenemia. Further investigation of ganciclovir disposition and changes in plasma cytokines in renal transplant recipients during CMV infection may provide insight into variable antiviral responses in renal transplant recipients.

Pharmacodynamic-mediated reduction of temozolomide tumor concentrations by the angiogenesis inhibitor TNP-470

The angiogenic phenotype is associated with increased tumor neovascularization and a state of vascular hyperpermeability to macromolecules. Angiogenesis inhibitors could reverse these processes, resulting in tumor capillaries that have normal membrane permeability. It was proposed that the switch from a hyperpermeable to a normal permeable state could have the untoward effect of decreasing tumor concentrations of anticancer drugs coadministered with angiogenesis inhibitors. The current investigation evaluated a potential drug interaction between the angiogenesis inhibitor O-(N-chloroacetyl-carbamoyl)-fumagillol (TNP-470) and the alkylating agent temozolomide (TMZ), in xenograft models that differentially expressed vascular endothelial growth factor (VEGF), a driving force for angiogenesis. Nude rats bearing either s.c. low VEGF (V-) or high VEGF (V+) or intracerebral V+ gliomas were administered either a multiple-dose regimen of TNP-470 or vehicle control. One day after the last dose of vehicle or TNP-470, a steady-state dosing regimen of TMZ was administered with subsequent collection and high-performance liquid chromatography analysis of plasma and either tumor homogenate or tumor microdialysis steady-state TMZ concentrations, and in some cases [5-(3-methyltriazen-1-yl)imidazole-4-carboximide] MTIC, its active metabolite. Microvessel density (MVD) was quantitated by image analysis using an anti-CD31 method. Statistical analyses of pharmacokinetic and pharmacodynamic end points in the control and TNP-470 treatment groups were completed by nonparametric tests. In both the s.c. and intracerebral V+ models, TNP-470 treatment produced significant reductions in TMZ tumor concentrations and tumor:plasma concentration ratios compared with control, being reduced an average of 25% and 50% in the s.c. and intracerebral tumors, respectively. MTIC concentrations in V+ s.c. tumors also were reduced by 50% in the presence of TNP-470. Consistent with the lower extent of neovascularization in the V- tumors, TMZ and MTIC tumor concentrations were not different in TNP-470 and control treatment groups in s.c. tumors. MVD was reduced by TNP-470 compared with vehicle control in the V+ tumors, but was unaltered in V- tumors, attesting to the use of MVD as a pharmacodynamic end point and the effectiveness of TNP-470 as an angiogenesis inhibitor. Angiogenesis inhibitor's pharmacodynamic actions on tumor angiogenesis can produce a reduction in tumor concentrations of coadministered anticancer agents. It is increasingly important to understand the pharmacokinetic and pharmacodynamic behavior of each class of drug so that optimal dosing regimens can be designed.

ASW: a gene with conserved avian W-linkage and female specific expression in chick embryonic gonad

Vertebrates exhibit a variety of sex determining mechanisms which fall broadly into two classes: environmental or genetic. In birds and mammals sex is determined by a genetic mechanism. In mammals males are the heterogametic sex (XY) with the Y chromosome acting as a dominant determiner of sex due to the action of the testis-determining factor, SRY. In birds females are the heterogametic sex (ZW); however, it is not known whether the W chromosome carries a dominant ovary-determining gene, or whether Z chromosome dosage determines sex. Using an experimental approach, which assumes only that the sex-determining event in birds is accompanied by sex-specific changes in gene expression, we have identified a novel gene, ASW (Avian Sex-specific W-linked). The putative protein for ASW is related to the HIT (histidine triad) family of proteins. ASW shows female-specific expression in genital ridges and maps to the chicken W chromosome. In addition, we show that, with the exception of ratites, ASW is linked to the W chromosome in each of 17 bird species from nine different families of the class Aves.

Evaluating prevention programs with the Results Mapping evaluation tool: a case study of a youth substance abuse prevention program

The harmful effects of alcohol and other drug abuse are widespread. Our health care, social service, education and legal systems are strained under the impact of substance abuse, not to mention the economic costs associated with substance abuse. Consequently, effective strategies which prevent substance abuse must be identified and replicated. Yet, user-friendly and cost-effective evaluation tools for community-based substance abuse prevention programs are rare. A recently developed tool that has promise to overcome some of the barriers which exist when evaluating prevention programs is 'Results Mapping'. Results Mapping documents and aims to quantify the contributions of a program to future outcomes of its target population with the intention of making data meaningful at the program and funding agency level. This case study was conducted to assess the feasibility of implementing the Results Mapping evaluation tool for community-based prevention programs. The study assessed qualitatively how well Results Mapping worked for one community-based substance abuse prevention program, as well as how much time and funding it took to implement this new tool. Results suggested that Results Mapping may be a valuable documentation, planning and learning tool, but funding agencies should be cautious about using Results Mapping scores to determine funding allocations.

Spinal cord lesions in Bangladesh: an epidemiological study 1994 - 1995

OBJECTIVES

Spinal Cord Lesions are a major public health problem in Bangladesh. This epidemiological study was undertaken in order to identify the causes of spinal cord lesions and thus to allow prevention and control programs to be developed.

MATERIALS AND METHODS

The records of 247 patients with spinal cord lesions admitted to The Centre for the Rehabilitation of the Paralysed (CRP), Savar, Dhaka from January 1994 to June 1995 were reviewed retrospectively. Comparisons were made with the reports of studies from other countries, both developing and developed.

RESULTS

The most common cause of traumatic lesions was a fall from a height followed by falling when carrying a heavy weight on the head and road traffic accidents. Most of the patients were between 20 - 40 years old and the overall age group ranged from 10 - 70 years. The male:female ratio was 7.5 : 1.0. Among the traumatic spinal cord lesions, 60% were paraplegics and 40% tetraplegics. Among the non-traumatic spinal cord lesions cases 84% were paraplegics and 16% tetraplegics. The leading cause of death resulted from respiratory complications and these deaths occurred in the very early period of admission.

CONCLUSION

From the results it can be deduced that the high incidence of spinal cord lesion as a result from falls from a height, and from falling when carrying a heavy weight on the head, can be explained by the mainly agricultural based economy of Bangladesh. The most common age group (10 - 40 years) of patients reflects the socio-economic conditions of Bangladesh. The male:female ratio (7.5 : 1.0) of patients with a spinal cord lesion is due to the socio-economic status and to the traditional culture of the society.