Ear and hearing care programs for First Nations children: a scoping review

BACKGROUND

Ear and hearing care programs are critical to early detection and management of otitis media (or middle ear disease). Otitis media and associated hearing loss disproportionately impacts First Nations children. This affects speech and language development, social and cognitive development and, in turn, education and life outcomes. This scoping review aimed to better understand how ear and hearing care programs for First Nations children in high-income colonial-settler countries aimed to reduce the burden of otitis media and increase equitable access to care. Specifically, the review aimed to chart program strategies, map the focus of each program against 4 parts of a care pathway (prevention, detection, diagnosis/management, rehabilitation), and to identify the factors that indicated the longer-term sustainability and success of programs.

METHOD

A database search was conducted in March 2021 using Medline, Embase, Global Health, APA PsycInfo, CINAHL, Web of Science Core Collection, Scopus, and Academic Search Premier. Programs were eligible or inclusion if they had either been developed or run at any time between January 2010 to March 2021. Search terms encompassed terms such as First Nations children, ear and hearing care, and health programs, initiatives, campaigns, and services.

RESULTS

Twenty-seven articles met the criteria to be included in the review and described a total of twenty-one ear and hearing care programs. Programs employed strategies to: (i) connect patients to specialist services, (ii) improve cultural safety of services, and (iii) increase access to ear and hearing care services. However, program evaluation measures were limited to outputs or the evaluation of service-level outcome, rather than patient-based outcomes. Factors which contributed to program sustainability included funding and community involvement although these were limited in many cases.

CONCLUSION

The result of this study highlighted that programs primarily operate at two points along the care pathway-detection and diagnosis/management, presumably where the greatest need lies. Targeted strategies were used to address these, some which were limited in their approach. The success of many programs are evaluated as outputs, and many programs rely on funding sources which can potentially limit longer-term sustainability. Finally, the involvement of First Nations people and communities typically only occurred during implementation rather than across the development of the program. Future programs should be embedded within a connected system of care and tied to existing policies and funding streams to ensure long term viability. Programs should be governed and evaluated by First Nations communities to further ensure programs are sustainable and are designed to meet community needs.

Patellofemoral contact forces and knee gait mechanics 3 months after ACL reconstruction are associated with cartilage degradation 24 months after surgery

OBJECTIVE

Evaluate patellofemoral cartilage health, as assessed by quantitative magnetic resonance imaging (qMRI) T2 relaxation times, 24-months after ACL reconstruction (ACLR) and determine if they were associated with patellofemoral contact forces and knee mechanics during gait 3 months after surgery.

DESIGN

Thirty individuals completed motion analysis during overground walking at a self-selected speed 3 months after ACLR. An EMG-driven neuromusculoskeletal model was used to determine muscle forces, which were then used in a previously described model to estimate patellofemoral contact forces. Biomechanical variables of interest included peak patellofemoral contact force, peak knee flexion angle and moment, and walking speed. These same participants underwent a sagittal bilateral T2 mapping qMRI scan 24-months after surgery. T2 relaxation times were estimated for both patellar and trochlear cartilage. Paired t-tests were used to compare T2 relaxation times between limbs while Pearson correlations and linear regressions were utilized to assess the association between the biomechanical variables of interest and T2 relaxation times.

RESULTS

Prolonged involved limb trochlear T2 relaxation times (vs uninvolved) were present 24-months after surgery, indicating worse cartilage health. No differences were detected in patellar cartilage. Significant negative associations were present within the involved limb for all the biomechanical variables of interest 3 months after ACLR and trochlear T2 relaxation times at 24-months. No associations were found in patellar cartilage or within the uninvolved limb.

CONCLUSIONS

Altered involved limb trochlear cartilage health is present 24-months after ACLR and may be related to patellofemoral loading and other walking gait mechanics 3 months after surgery.

Determination of ultra-trace metal-protein interactions in co-formulated monoclonal antibody drug product by SEC-ICP-MS

Transition metals can be introduced in therapeutic protein drugs at various steps of the manufacturing process (e.g. manufacturing raw materials, formulation, storage), and can cause a variety of modifications on the protein. These modifications can potentially influence the efficacy, safety, and stability of the therapeutic protein, especially if critical quality attributes (CQAs) are affected. Therefore, it is meaningful to understand the interactions between proteins and metals that can occur during the manufacturing process, formulation, and storage of biotherapeutics. Here, we describe a novel strategy to differentiate between ultra-trace levels of transition metals (cobalt, chromium, copper, iron, and nickel) interacting with therapeutic proteins and free metal in solution in the drug formulation using size exclusion chromatography coupled to inductively coupled plasma mass spectrometry (SEC-ICP-MS). Two monoclonal antibodies (mAbs) were coformulated and stored up to nine days in a scaled down model to mimic metal exposure from manufacturing tanks. The samples containing the mAbs were first analyzed by ICP-MS for bulk metal analysis, then studied using SEC-ICP-MS to measure the extent of metal-protein interactions. The SEC separation was used to differentiate metal associated with the mAbs from free metal in solution. Relative quantitation of metal-protein interaction was then calculated using the relative peak areas of protein-associated metal to free metal in solution and weighting it to the total metal concentration in the mixture as measured by bulk metal analysis by ICP-MS. The SEC-ICP-MS method offers an informative means of measuring metal-protein interactions during drug development.

Perceived listening ability and hearing loss: Systematic review and qualitative meta-synthesis

BACKGROUND

Hearing loss (HL) can affect communication in complex ways. Understanding how adults with HL reflect on and conceptualise the way they listen (metacognition) is required if interventions, and the outcome measures used to evaluate them, are to address barriers to functional communication arising from HL.

OBJECTIVES

This study describes how adults with HL experience and report the processes, behaviours, and components of listening, as presented in published studies.

DESIGN

Systematic review and meta-synthesis of qualitative studies.

METHODS

Systematic searches identified English-language, peer-reviewed journal articles reporting the results of qualitative or mixed-methods studies of adults' with HL perceived listening abilities. Medline, PsychInfo, Web of Science, Embase, and Google Scholar were searched from inception to November 2021. Handsearching reference lists of included studies identified additional studies for inclusion. The Critical Appraisal Skills Programme (CASP) qualitative checklist was used to appraise studies' methodological quality. Data from included studies were analysed using thematic meta-synthesis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) Confidence in the Evidence from Reviews of QUALitative (CERQual) approach assessed confidence in the review findings. Two reviewers independently completed all screening and quality appraisal. Thematic meta-synthesis and GRADE CERQual assessment was completed by one reviewer and confirmed by a second reviewer. Discrepancies were resolved through discussion.

RESULTS

Data from 46 studies were included in the review. Thematic meta-synthesis identified six descriptive themes: 1) perceived listening ability; 2) external modifiers; 3) psychosocial impacts of hearing loss; 4) communication partner perspectives; 5) self-efficacy for listening; and 6) cognitive load. GRADE CERQual ratings for descriptive themes ranged from low to moderate confidence. Descriptive themes were related by analytic themes of liminality and reciprocity.

CONCLUSIONS

Adults with HL provide in-depth accounts of components and processes of listening, with studies reporting both cognitive and affective experiences consistent with theoretical models of metacognition. The findings will inform content generation for a hearing-specific patient-reported outcome measure of perceived listening ability in everyday communication.

Listening-Based Communication Ability in Adults With Hearing Loss: A Scoping Review of Existing Measures

Introduction

Hearing loss in adults has a pervasive impact on health and well-being. Its effects on everyday listening and communication can directly influence participation across multiple spheres of life. These impacts, however, remain poorly assessed within clinical settings. Whilst various tests and questionnaires that measure listening and communication abilities are available, there is a lack of consensus about which measures assess the factors that are most relevant to optimising auditory rehabilitation. This study aimed to map current measures used in published studies to evaluate listening skills needed for oral communication in adults with hearing loss.

Methods

A scoping review was conducted using systematic searches in Medline, EMBASE, Web of Science and Google Scholar to retrieve peer-reviewed articles that used one or more linguistic-based measure necessary to oral communication in adults with hearing loss. The range of measures identified and their frequency where charted in relation to auditory hierarchies, linguistic domains, health status domains, and associated neuropsychological and cognitive domains.

Results

9121 articles were identified and 2579 articles that reported on 6714 discrete measures were included for further analysis. The predominant linguistic-based measure reported was word or sentence identification in quiet (65.9%). In contrast, discourse-based measures were used in 2.7% of the articles included. Of the included studies, 36.6% used a self-reported instrument purporting to measures of listening for communication. Consistent with previous studies, a large number of self-reported measures were identified (n = 139), but 60.4% of these measures were used in only one study and 80.7% were cited five times or fewer.

Discussion

Current measures used in published studies to assess listening abilities relevant to oral communication target a narrow set of domains. Concepts of communicative interaction have limited representation in current measurement. The lack of measurement consensus and heterogeneity amongst the assessments limit comparisons across studies. Furthermore, extracted measures rarely consider the broader linguistic, cognitive and interactive elements of communication. Consequently, existing measures may have limited clinical application if assessing the listening-related skills required for communication in daily life, as experienced by adults with hearing loss.

Adults' with hearing loss perceived listening ability in daily communication: protocol for a systematic review and qualitative meta-synthesis

INTRODUCTION

Understanding how adults with hearing loss perceive their abilities when listening in daily communication situations is vital to understanding the functional listening challenges associated with hearing loss. The aim of this study is to explore how adults with hearing loss describe their own experiences of the processes, behaviours and components of listening in real-world communication through secondary analysis of published qualitative data.

METHODS AND ANALYSIS

A systematic review and thematic meta-synthesis of qualitative research studies and qualitative components of mixed-methods studies will be conducted. Studies published in English will be identified through searching Medline, PsychInfo, Web of Science, Embase and Google Scholar databases from inception to November 2021. Handsearching of the included studies' reference lists will be completed. Included articles will be assessed for methodological quality using the Critical Appraisal Skills checklist for qualitative studies. Thematic synthesis will proceed as follows: (1) line-by-line coding to label concepts present in the 'results' or 'findings' section(s) of the included studies; (2) grouping of similar codes into descriptive themes; (3) development of higher level analytic themes to develop a new interpretation of the included studies' findings. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) Confidence in the Evidence from Reviews of QUALitative (CerQUAL) research approach will be used to establish the degree of confidence that may be placed in synthesis findings and results will be reported alongside the synthesis. Two reviewers will independently undertake screening for eligibility, data extraction and quality appraisal, analysis and GRADE-CERQual assessments. Discrepancies will be resolved through discussion.

ETHICS AND DISSEMINATION

As secondary data analysis of the published literature, ethical approval is not required. The results will be disseminated in peer-reviewed journals, conference presentations and other research and clinical meetings. This protocol is registered with PROSPERO prospective database of systematic review.

PROSPERO REGISTRATION NUMBER

CRD42020213389.

Psychosocial morbidity in women with abnormal cervical cytology managed by cytological surveillance or initial colposcopy: longitudinal analysis from the TOMBOLA randomised trial

OBJECTIVE

To compare psychosocial outcomes (follow-up related worries and satisfaction with follow-up related information and support) over 30 months of two alternative management policies for women with low-grade abnormal cervical cytology.

METHODS

Women aged 20-59 years with low-grade cytological abnormalities detected in the National Health Service Cervical Screening Programme were randomised to cytological surveillance or initial colposcopy. A total of 3399 women who completed psychosocial questionnaires at recruitment were invited to complete questionnaires at 12, 18, 24 and 30 months. Linear mixed models were used to investigate differences between arms in the two psychosocial outcomes. Each outcome had a maximum score of 100, and higher scores represented higher psychosocial morbidity.

RESULTS

On average, over 30 months, women randomised to colposcopy scored 2.5 points (95%CI -3.6 to -1.3) lower for follow-up related worries than women randomised to cytological surveillance. Women in the colposcopy arm also scored significantly lower for follow-up related satisfaction with information and support (-2.4; -3.3 to -1.4) over 30 months. For both outcomes, the average difference between arms was greatest at 12th- and 18th-month time points. These differences remained when the analysis was stratified by post-school education.

CONCLUSIONS

Women with low-grade cytology, irrespective of their management, have substantial initial psychosocial morbidity that reduces over time. Implementation of newer screening strategies, which include surveillance, such as primary HPV screening, need to consider the information and support provided to women. © 2016 The Authors. Psycho-Oncology published by John Wiley & Sons Ltd.

A multi-country Salmonella Enteritidis phage type 14b outbreak associated with eggs from a German producer: ‘near real-time’ application of whole genome sequencing and food chain investigations, United Kingdom, May to September 2014

Binary file ES_Abstracts_Final_ECDC.txt matches

Feeding protein supplements in alfalfa hay-based lactation diets improves nutrient utilization, lactational performance, and feed efficiency of dairy cows

Due to the increasing cost of soybean meal and concerns of excess N being excreted into the environment, new protein supplements have been developed. Two products that have shown potential in increasing N utilization efficiency are slow-release urea (SRU; Optigen; Alltech Inc., Nicholasville, KY) and ruminal-escape protein derived from yeast (YMP; DEMP; Alltech Inc.). The objective of this study was to assess the effects of feeding these 2 supplements in alfalfa hay-based [45.7% of forage dietary dry matter (DM)] dairy diets on nutrient utilization, feed efficiency, and lactational performance of dairy cows. Twelve multiparous dairy cows were used in a triple 4 × 4 Latin square design with one square consisting of ruminally cannulated cows. Treatments included (1) control, (2) SRU-supplemented total mixed ration (SRUT), (3) YMP-supplemented total mixed ration (YMPT), and (4) SRU- and YMP-supplemented total mixed ration (SYT). The control consisted only of a mixture of soybean meal and canola meal in a 50:50 ratio. The SRU and the YMP were supplemented at 0.49 and 1.15% DM, respectively. The experiment consisted of 4 periods lasting 28 d each (21 d of adaptation and 7 d of sampling). Cows fed YMPT and SYT had decreased intake of DM, and all supplemented treatments had lower crude protein intake compared with those fed the control. Milk yield tended to have the greatest increase in YMPT compared with the control (41.1 vs. 39.7 kg/d) as well as a tendency for increased milk fat and protein yields. Feed efficiencies based on yields of milk, 3.5% fat-corrected milk, and energy-corrected milk increased at 10 to 16% due to protein supplementation. Cows fed protein supplements partitioned less energy toward body weight gain, but tended to partition more energy toward milk production. Efficiency of use of feed N to milk N increased by feeding SRUT and YMPT, and milk N-to-manure N ratio increased with YMPT. Overall results from this experiment indicate that replacing the mixture of soybean meal and canola meal with SRU and YMP in alfalfa hay-based dairy diets can be a good approach to improve nutrient utilization efficiencies in lactating dairy cows.

Four-month outbreak of invasive meningococcal disease caused by a rare serogroup B strain, identified through the use of molecular PorA subtyping, England, 2013

Molecular PorA subtyping provides information that increasingly requires the adaptation of standard public health approaches to outbreak management. We report an outbreak of a rare subtype of meningococcal infection not previously identified in the United Kingdom (UK). The outbreak occurred in the Warwickshire area in England between February and June 2013. Molecular subtyping allowed the identification of additional cases, prompting an enhanced public health response that included efforts to identify potential social networks that might benefit from chemoprophylaxis. It also prompted swabbing to define nasopharyngeal carriage in the focal nursery and helped explain the unusual epidemiological pattern. Without subtyping to identify a link, the additional cases would have been managed as sporadic cases in accordance with current UK guidance.

Effects of altering alfalfa hay quality when feeding steam-flaked versus high-moisture corn grain on ruminal fermentation and lactational performance of dairy cows

This experiment was performed to test a hypothesis that nutritive benefits of feeding high-moisture corn (HMC) would be different when fed with different qualities of alfalfa hay (AH) due to associative effects on ruminal fermentation and nutrient utilization efficiency. Eight multiparous lactating Holstein cows were used; 4 were surgically fitted with ruminal cannulas. Days in milk averaged 184 ± 10.7 at the start of the experiment. The experiment was performed in a duplicate 4 × 4 Latin square design. Within each square, cows were randomly assigned to a sequence of 4 diets during each of the four 21-d periods (14 d of treatment adaptation and 7 d of data collection and sampling). A 2 × 2 factorial arrangement was used; fair-quality AH [FAH; 39.6% neutral detergent fiber (NDF) and 17.9% crude protein (CP)] or high-quality AH (HAH; 33.6% NDF and 21.9% CP) was combined with steam-flaked corn (SFC) or HMC to form 4 treatments: FAH with SFC, FAH with HMC, HAH with SFC, and HAH with HMC. The AH was fed at 32% dry matter (DM) content, whereas SFC or HMC was included at 17% DM content. Quality of AH did not affect DM intake, whereas feeding HMC decreased DM intake, regardless of quality of AH. Digestibility of DM was greater for cows fed HAH compared with those fed FAH (70.1 vs. 67.6%). Digestibility of NDF increased by feeding HMC (67.6 vs. 58.4%), but not by quality of AH. Under FAH, starch digestibility decreased by feeding HMC compared with SFC (85.7 vs. 95.0%), but it was similar under HAH, resulting in an interaction between quality of AH and type of corn grain (CG). Feeding different qualities of AH did not affect milk yield; however, feeding HMC decreased milk yield in FAH diet, causing an AH × CG interaction. Efficiency of milk yield/DM intake was improved due to feeding HMC, regardless of the quality of the AH. In addition, dietary N utilization for milk N tended to increase by feeding HMC, but it was not influenced by quality of AH. Yield of microbial protein increased by feeding HAH diets compared with FAH diets, whereas feeding the HMC diet increased microbial protein yield under the HAH diet, leading to an interaction between and AH and CG. Overall results in this experiment indicate that feeding HMC in AH-based diets improved feed efficiency as well as N utilization efficiency, regardless of quality of AH.

Guidelines for the public health management of typhoid and paratyphoid in England: practice guidelines from the National Typhoid and Paratyphoid Reference Group

OBJECTIVES

The Typhoid and Paratyphoid Reference Group (TPRG) was convened by the Health Protection Agency (HPA) and the Chartered Institute of Environmental Health (CIEH) to revise guidelines for public health management of enteric fever. This paper presents the new guidelines for England and their rationale.

METHODS

Methods include literature reviews including grey literature such as audit data and case studies; analysis of enhanced surveillance data from England, Wales and Northern Ireland; review of clearance and screening schedules in use in other non-endemic areas; and expert consensus.

RESULTS

The evidence and principles underpinning the new guidance are summarised. Significant changes from previous guidance include: • Algorithms to guide risk assessment and management, based on risk group and travel history; • Outline of investigation of non-travel cases; • Simplified microbiological clearance schedules for cases and contacts; • Targeted co-traveller screening and a "warn and inform" approach for contacts; • Management of convalescent and chronic carriers.

CONCLUSIONS

The guidelines were launched in February 2012. Feedback has been positive: the guidelines are reported to be clear, systematic, practical and risk-based. An evaluation of the guidelines is outlined and will add to the evidence base. There is potential for simplification and consistency between international guidelines.

The role of human papillomavirus testing in the management of women with low-grade abnormalities: multicentre randomised controlled trial

OBJECTIVE

To assess the value of a single human papillomavirus (HPV) test in making decisions on management of women with cervical cytology showing borderline nuclear abnormality (BNA) or mild dyskaryosis. In particular, to determine whether information on high-risk (hr) HPV status would be valuable in the choice between (1) cytological surveillance versus immediate referral to colposcopy, and (2) at colposcopy, between biopsy and recall versus immediate large loop excision of the transformation zone (LLETZ).

DESIGN

Multicentre individually randomised controlled trial, nested within the NHS Cervical Screening Programmes, investigating the value of HPV testing by testing for interactions between HPV status and (1) cytological surveillance versus colposcopy, and (2) biopsy and recall versus immediate LLETZ. Setting Grampian, Tayside and Nottingham. Population Women (n = 4439), aged 20-59 years, with a cytology test showing borderline nuclear abnormalities or mild dyskaryosis during October 1999 to October 2002.

METHODS

High-risk HPV status was determined at recruitment using the polymerase chain reaction assay with the GP5+/6+ general primer system. The results of this HPV testing were not disclosed to either the participating women or to those involved in their management. Women were randomised to either (1) 6-monthly cytological screening in primary care or (2) referral for colposcopy. Human papillomavirus status was used to stratify both randomisations. All women were followed for 3 years, concluding with an invitation to an exit appointment at which colposcopic examination was undertaken. In addition, in women who were randomised to initial colposcopy and underwent colposcopy, the association between hrHPV status and presence of cervical intraepithelial neoplasia (CIN) grade 2 or more severe disease (henceforth CIN2 or worse) was examined.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive and negative predictive values of the HPV test for predicting CIN2 or worse and the implications for the choice of management between cytological surveillance and immediate referral for colposcopy.

RESULTS

There were no significant interactions between management and HPV status. Hence, in women with mild dyskaryosis or BNA who are HPV positive, there is no advantage of (1) immediate colposcopy over cytological surveillance (P = 0.76) or (2) immediate LLETZ over biopsy and recall (P = 0.27). The sensitivity of HPV testing for detection of CIN2 or worse was 75.2% (95% CI 68.8-81.0%) among women with mild dyskaryosis and 69.9% (95% CI 61.7-77.3%) among those with BNA. Specificity was higher in those with BNA (71.3%; 95% CI 68.5-74.1%) than in those with mild dyskaryosis (46.9%; 95% CI 42.2-51.6%). Sensitivity decreased with increasing age whereas specificity increased. The negative predictive value was high, particularly among women with BNA (94.5%; 95% CI 92.9-96.0%). Across all ages, 22% of women who had CIN2 or worse were HPV negative. Conversely, 40% of those who were HPV positive did not have CIN. HPV was a much more reliable predictor in women aged over 40 years.

CONCLUSIONS

We conclude that in younger women with low-grade cytological abnormalities, a single HPV test would not be useful in determining who should be referred for colposcopy or the most effective management at colposcopy. In women over 40, a negative HPV test could be used to rule out further investigation.

An exploration of the causes of tuberculosis stigma in an urban district in Ghana

SETTING

Shama Ahanta East Metropolitan District, Ghana.

OBJECTIVES

To explore tuberculosis (TB) stigma and to elucidate how it operates in community settings and within the health care system to affect case finding and treatment adherence.

DESIGN

Individual interviews and focus groups with TB patients, health care workers and community members.

RESULT

Ten causes of TB stigma emerged from the data: fear of infection, physical frailty, association with human immunodeficiency virus/acquired immune-deficiency syndrome, perceived causes and spread of TB, outdated societal beliefs and practices about TB, public health practice and discourse, health staff's own fear of TB, self-stigmatisation by TB patients, judgement, blaming and shaming TB patients, and past experiences with TB. Fear of infection was identified as the main cause of TB stigma, with an element of fear recognised in all the other nine causes, named the 'moderating elements'. The moderating elements enhance the fear of infection, and fear of infection enhances the moderating elements.

CONCLUSION

The fear attached to TB underlies the beliefs, attitudes, actions and behaviours of the whole community when interacting with patients. These findings will be used to advocate for complete integration of TB services into the general health care system and involvement of community members in TB services in the district.

Lifestyle and socio-demographic factors associated with high-risk HPV infection in UK women

The world age-standardised prevalence of high-risk HPV (hrHPV) infection among 5038 UK women aged 20–59 years, with a low-grade smear during 1999–2002, assessed for eligibility for TOMBOLA (Trial Of Management of Borderline and Other Low-grade Abnormal smears) was 34.2%. High-risk HPV prevalence decreased with increasing age, from 61% at ages 20–24 years to 14–15% in those over 50 years. The age-standardised prevalence was 15.1, 30.7 and 52.7%, respectively, in women with a current normal, borderline nuclear abnormalities (BNA) and mild smear. In overall multivariate analyses, tertiary education, previous pregnancy and childbirth were associated with reduced hrHPV infection risk. Risk of infection was increased in non-white women, women not married/cohabiting, hormonal contraceptives users and current smokers. In stratified analyses, current smear status and age remained associated with hrHPV infection. Data of this type are relevant to the debate on human papillomavirus (HPV) testing in screening and development of HPV vaccination programmes.

Pilot study in the development of an interactive multimedia learning environment for sexual health interventions: a focus group approach

In the UK there are high rates of sexually transmitted infections and unintended pregnancies amongst young people. There is limited and contradictory evidence that current sexual health education interventions are effective or that they improve access to appropriate sexual health services. This paper describes the outcome of focus group work with young people that was undertaken to inform the design of an Interactive Multimedia Learning Environment that incorporates message framing, intended for use in sexual health promotion. The focus group work addressed sexual attitudes, behaviour, risk perception, and knowledge of sexual health and sexual health services in Nottingham. The results provided new insights into young peoples' sexual behaviour, and their diversity of knowledge and beliefs. Common themes expressed regarding sexual health services included concerns about confidentiality, lack of confidence to access services and fear of the unknown. The results showed that while the adolescents are reasonably knowledgeable about infection, they do not know as much about the relevant services to treat it. This work emphasizes the need for user involvement throughout the design and development of a sexual health intervention, and will form the basis of the next part of the project.

A Quality Improvement Project to Reduce Falls and Improve Medication Management

This paper describes the implementation of a medication management model within a medical-center based home health agency. The model was integrated into the agency's quality improvement falls prevention program and was selected in part because it directly addressed two medication-related accreditation standards for home health care agencies. During a five-month period, a staff pharmacist conducted medication reviews for 228 HHA patients who met the program's inclusion criteria. Thirty-three percent of these patients required some type of follow-up to resolve potential medication-related problems. By far, falls were the most common reason for referral, with 71 patients, or 30% of all participating patients, referred to the pharmacist due to a recent fall. From a quality improvement standpoint, the program met and even exceeded expectations in that it enabled staff to identify a serious threat to patient safety-medication-related problems, especially falls--and gave them the tools to resolve these potential problems.

Community-acquired Legionnaires' disease in Nottingham--too many cases?

The aim of this study was to compare the incidence of community-acquired Legionnaires' Disease in Nottingham with England and Wales and to explore reasons for any difference observed. Based on data from the National Surveillance Scheme for Legionnaires' Disease (1980-1999), the rate of infection in England and Wales was 1.3 per million/year compared with 6.6 per million/ year in Nottingham. Domestic water samples were obtained from 41 (95%) of 43 Nottingham cases between 1997 and 2000. In 16 (39%) cases, Legionella sp. were cultured in significant quantities. Proximity to a cooling tower was examined using a 1:4 case-controlled analysis. No significant difference in the mean distance between place of residence to the nearest cooling tower was noted (cases 2.7 km vs. controls 2.3 km; P = 0.5). These data suggest that Nottingham does have a higher rate of legionella infection compared to national figures and that home water systems are a source.

Genetic analysis of capsular status of meningococcal carrier isolates

The meningococcal capsule is the primary virulence factor with systemic isolates requiring full expression of the capsule but with capability to down-regulate the capsule in order to invade. The meningococcal capsular operon is composed of a number of genes that are involved in capsular synthesis and transport. Differences in capsular synthesis genes may allow discrimination between meningococcal serogroups whereas absence of genes for either synthesis or transport imply that the meningococcus is unencapsulated. Although mechanisms such as slipped-strand mispairing and acquisition of insertion sequences have been demonstrated to be involved in regulation of capsular expression, few studies have addressed the mechanisms of capsular expression in carrier isolates. Following a community-based intervention programme for an outbreak of meningococcal disease, we collected meningococcal carrier isolates from the intervention area and control areas. We undertook genetic analysis of the capsular operon and the mechanisms of capsular regulation, together with an investigation of the potential of capsular genes to identify the genogroup of non-serogroupable isolates. Use of the siaD gene allowed the discrimination of 30/89 (34%) non-serogroupable isolates into B, C, W135 and Y with a siaA gene PCR permitting the characterization of a further 6 isolates whose capsules contained sialic acid. Slipped-strand mispairing was evident in only 4 of 13 genogroupable B isolates and the insertion sequence IS1301 was found in 2 of 36 siaA-positive isolates. Of 51 non-genogroupable isolates 25 (49%) were shown to be ctrA negative. There was a higher percentage of ctrA-positive isolates (P<0.001) amongst meningococcal strains obtained from those sampled in non-intervention schools than those sampled at intervention schools. The ctrA-negative isolates warrant further investigation of their genotypic organization since such avirulent strains may be important in conferring natural protection against invasive disease. We found that after mass antibiotic prophylaxis, recolonization occurs preferentially with non-pathogenic meningococcal strains. This as implications for assessment of the benefits of mass antibiotic and vaccination programmes for outbreak control. Previously expressed concerns of increased risk due to removal of protective ora may have been overstated.

Topical L-arginine gel lowers resting anal pressure: possible treatment for anal fissure

PURPOSE

Exogenous nitric oxide donors, such as glyceryl trinitrate, have been used as treatment for anal fissures; however, headaches develop in 60 percent of patients. Nitric oxide produced from the cellular metabolism of L-arginine mediates relaxation of the internal anal sphincter. This study investigated whether topical L-arginine gel reduces maximum anal resting pressure in volunteers.

METHOD

In a two-center study, volunteers received a single topical dose of L-arginine or placebo (Aquagel ). Anal manometry was performed for two hours after application of 400 mg of L-arginine gel or placebo gel to the anal verge in 25 volunteers. Side effects were recorded after single application and also after repeated dosing for three days.

RESULTS

L-Arginine reduced maximum anal resting pressure by 46 percent from a median of 65 cm of water to a minimal value of 35 cm of water ( P< 0.001, Wilcoxon's signed-rank test). The difference between L-arginine and placebo using repeated-measures testing was significant at P< 0.005. No side effects occurred with either gel; in particular, no episodes of headache were recorded.

CONCLUSION

Topical L-arginine gel significantly lowers maximum anal resting pressure; its onset of action is rapid, and duration is at least two hours ( P< 0.01). L-arginine may have therapeutic potential, but further evaluation is needed before it can be used as a possible alternative treatment for chronic anal fissure.

Relationship of Campylobacter toxigenicity in vitro to the development of postinfectious irritable bowel syndrome

Campylobacter enteritis is associated with a significant risk of developing irritable bowel syndrome, but the mechanism is unknown. This study ascertained bowel symptoms in 93 patients 3 months after Campylobacter jejuni enteritis infection. The infecting organisms were cultured, and the effects of culture supernatants on toxin-sensitive epithelial cell monolayers (HEp-2, Green monkey kidney epithelial [Vero], and CHO-K1) were investigated. In all, 50, 43, and 41 of the isolates showed toxigenic effects on HEp-2, CHO-K1, and Vero cells, respectively. Persistently changed bowel habit was reported by 9 of 50 persons with HEp-2 toxin-positive infections but by only 2 of 43 with isolates negative for toxin (chi2=4.0; P<.05). Toxicity to HEp-2 and Vero cells was associated with significantly increased numbers of days with loose stools 6 months after C. jejuni enteritis infection (both, P<.05). Thus, long-term symptoms that occur Campylobacter infection are significantly associated with bacterial toxicity.

Survey of neonatal hepatitis B vaccination in Leicestershire

Some 121,390 live and still births were recorded in Leicestershire between June 1986 and May 1995. All mothers were offered antenatal screening for hepatitis B and 161 were positive for hepatitis B surface antigen. Examination of case notes from 113 mother and baby pairs identified 70 infants who fulfilled criteria for vaccination in place at the time, 47 of whom (67%) had received the three doses of hepatitis B vaccine then recommended for prevention of neonatal infection.

A novel DEAD-box RNA helicase exhibits high sequence conservation from yeast to humans

We have identified a novel Drosophila protein, DBP80, that exhibits significant similarity to mouse mDEAD5, yeast TIF1/2, and mammalian eIF-4A. DBP80 is a member of a subclass of DEAD-box proteins that contains a distinct domain, PX(I/R)ILLKR(E/D)EETLEGIKQ(F/Y)(F/Y), in addition to the seven canonical helicase domains.

A framework for managing risk

Supervision aims to maintain standards, thereby reducing clinical risk. Katrina Neal warns that supervision records could be used in a court of law, so should not be written simply to let off steam.

Mixed genogroup SRSV infections among a party of canoeists exposed to contaminated recreational water

Samples of faeces collected from a party of canoeists involved in a gastroenteritis outbreak were examined by electron microscopy and RT-PCR for evidence of infection with SRSVs. A broadly reactive primer pair was used to detect SRSVs followed by application of genogroup-specific primers to SRSV-positive specimens. Exposure data were collected by means of a questionnaire. SRSVs were detected in 1/4 specimens examined by EM and 3/4 by RT-PCR. Genogrouping, and sequencing of PCR products revealed two distinct strains: a genogroup I strain, related to the Desert Shield virus, and a genogroup II strain, related to the Lordsdale virus to be associated with the outbreak. Exposure data indicated that capsising and eating food before getting changed were associated with an increased risk of gastroenteritis and was consistent with infection following the consumption of contaminated water. This study confirms the greater sensitivity of RT-PCR for the diagnosis of SRSV infections and its utility, when incorporating genogroup-specific primers, in establishing more complex epidemiological data.