A prospective bacterial whole-genome-sequencing-based surveillance programme for comprehensive early detection of healthcare-associated infection transmission in paediatric oncology patients

BACKGROUND

Bacterial whole-genome sequencing (WGS) and determination of genetic relatedness is an important tool for investigation of epidemiologically suspected outbreaks.

AIM

This prospective cohort study evaluated a comprehensive, prospective bacterial WGS-based surveillance programme for early detection of transmission of most bacterial pathogens among patients at a paediatric oncology hospital.

METHODS

Cultured bacterial isolates from clinical diagnostic specimens collected prospectively from both inpatient and outpatient encounters between January 2019 and December 2021 underwent routine WGS and core genome multi-locus sequence typing to determine isolates' relatedness. Previously collected isolates from January to December 2018 were retrospectively analysed for identification of prior or ongoing transmission. Multi-patient clusters were investigated to identify potential transmission events based on temporal and spatial epidemiological links and interventions were introduced.

FINDINGS

A total of 1497 bacterial isolates from 1025 patients underwent WGS. A total of 259 genetically related clusters were detected, of which 18 (6.9%) multi-patient clusters involving 38 (3.7%) patients were identified. Sixteen clusters involved two patients each, and two clusters involved three patients. Following investigation, epidemiologically plausible transmission links were identified in five (27.8%) multi-patient clusters. None of the multi-patient clusters were suspected by conventional epidemiological surveillance.

CONCLUSION

Bacterial WGS-based surveillance for early detection of hospital transmission detected several limited multi-patient clusters that were unrecognized by conventional epidemiological methods. Genomic surveillance helped efficiently focus interventions while reducing unnecessary investigations.

Behavior Sequence Analysis of Victims' Accounts of Intimate Partner Violence

Intimate partner violence (IPV) relates not only to physical forms of abuse, but also psychological, emotional, economic, and financial controlling behaviors. IPV is a dynamic, complex phenomenon that occurs over a relatively long period of time. While several measures of IPV exist, a method that can track the progression and escalation of such behaviors in relationships could offer more understanding and highlight key intervention points for individuals in such relationships. Behavior Sequence Analysis is used in the current research to map the chain and progression of behaviors in multiple real-world cases of IPV. Results indicate clear sequential clusters of behaviors such as physical and psychological abuse, and coercive controlling behaviors such as gaslighting, restricting movement, and removing freedoms. Overall, this research stands as a foundation framework to build a greater understanding of the processes and pathways of IPV, and offers workers in the field a novel method to assist with interviewing and intervening in such cases.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Beyond Diffusion Tensor MRI Methods for Improved Characterization of the Brain after Ischemic Stroke: A Review

Ischemic stroke is a worldwide problem, with 15 million people experiencing a stroke annually. MR imaging is a valuable tool for understanding and assessing brain changes after stroke and predicting recovery. Of particular interest is the use of diffusion MR imaging in the nonacute stage 1-30 days poststroke. Thousands of articles have been published on the use of diffusion MR imaging in stroke, including several recent articles reviewing the use of DTI for stroke. The goal of this work was to survey and put into context the recent use of diffusion MR imaging methods beyond DTI, including diffusional kurtosis, generalized fractional anisotropy, spherical harmonics methods, and neurite orientation and dispersion models, in patients poststroke. Early studies report that these types of beyond-DTI methods outperform DTI metrics either in being more sensitive to poststroke changes or by better predicting outcome motor scores. More and larger studies are needed to confirm the improved prediction of stroke recovery with the beyond-DTI methods.

The effect of pre-analytical variables on downstream application and data analysis of human endometrial biopsies

STUDY QUESTION

What are the effects of pre-analytical variables on the downstream analysis of patient-derived endometrial biopsies?

SUMMARY ANSWER

There are distinct differences in the protein levels of the master regulator of oxygen homeostasis, hypoxia-inducible factor-1-alpha (HIF1α), and the protein and mRNA levels of three related genes, carbonic anhydrase 9 (CA9), vascular endothelial growth factor A (VEGFA) and progesterone receptor (PR) in human endometrial biopsies, depending on the pre-analytical variables: disease status (cancer vs benign), timing of biopsy (pre- vs post-hysterectomy) and type of biopsy (pipelle vs full-thickness).

WHAT IS KNOWN ALREADY

Patient-derived biopsies are vital to endometrial research, but pre-analytical variables relating to their collection may affect downstream analysis, as is evident in other tissues.

STUDY DESIGN SIZE DURATION

A prospective observational study including patients undergoing hysterectomy for endometrial cancer (EC) or benign indications was conducted at a large tertiary gynaecological unit in the UK. Endometrial biopsies were obtained at different time points (pre- or post-hysterectomy) using either a pipelle endometrial sampler or as a full-thickness wedge biopsy.

PARTICIPANTS/MATERIALS SETTING METHODS

The changes in HIF1α, CA9, VEGFA and PR protein levels were measured by semi-quantitative analysis of immunostaining, and the expression levels of three genes (CA9, VEGFA and PR) were investigated by quantitative real-time PCR, in endometrial biopsies from 43 patients undergoing hysterectomy for EC (n = 22) or benign gynaecological indications (n = 21).

MAIN RESULTS AND THE ROLE OF CHANCE

An increase in HIF1α immunostaining was observed in EC versus benign endometrium (functionalis glands) obtained pre-hysterectomy (P < 0.001). An increase in CA9 immunostaining was observed in EC versus benign endometrial functionalis glands at both pre- and post-hysterectomy time points (P = 0.03 and P = 0.003, respectively). Compared with benign endometrial pipelle samples, EC samples demonstrated increased mRNA expression of CA9 (pre-hysterectomy P < 0.001, post-hysterectomy P = 0.008) and VEGFA (pre-hysterectomy P = 0.004, post-hysterectomy P = 0.002). In benign uteri, HIF1α immunoscores (functionalis glands, P = 0.03 and stroma, P = 0.009), VEGFA immunoscores (functionalis glands, P = 0.03 and stroma, P = 0.01) and VEGFA mRNA levels (P = 0.008) were increased in matched post-hysterectomy versus pre-hysterectomy samples. Similarly, in EC, an increase in VEGFA immunoscores (epithelial and stromal) and VEGFA mRNA expression was observed in the matched post-hysterectomy versus pre-hysterectomy biopsies (P = 0.008, P = 0.004 and P = 0.018, respectively). Full-thickness benign post-hysterectomy endometrial biopsies displayed increased VEGFA (P = 0.011) and PR (P = 0.006) mRNA expression compared with time-matched pipelle biopsies.

LARGE SCALE DATA

N/A.

LIMITATIONS REASONS FOR CAUTION

This descriptive study explores the effect of pre-analytical variables on the expression of four proteins and three hypoxia-related genes in a limited number of endometrial biopsies from patients with EC and benign controls. Due to the small number, it was not possible to investigate other potential variables such as menstrual cycle phase, region-specific differences within the endometrium, grade and stage of cancer, and surgical technicalities.

WIDER IMPLICATIONS OF THE FINDINGS

Careful consideration of the effects of these pre-analytical variables is essential when interpreting data relating to human endometrial biopsies. A standardized approach to endometrial tissue collection is essential to ensure accurate and clinically transferrable data.

STUDY FUNDING/COMPETING INTERESTS

The authors have no conflicts of interest to declare. The work included in this manuscript was funded by Wellbeing of Women project grants RG1073 and RG2137 (D.K.H.), Wellbeing of Women Entry-Level Scholarship ELS706 and Medical Research Council MR/V007238/1 (A.M./D.K.H.), Liverpool Women's Hospital Cancer Charity (M.A.) and University of Liverpool (L.B., L.R. and E.N.).

How decision-making about euthanasia for animals is taught to Australasian veterinary students

This study set out to explore how euthanasia decision-making for animals was taught to students in eight Australasian veterinary schools. A questionnaire-style interview guide was used by a representative at each university to interview educators. Educators were interviewed about their teaching of euthanasia decision-making for four categories of animals: livestock, equine, companion and avian/wildlife. Using thematic analysis, the terms provided by participants to describe how (mode of teaching) and what (specific content) they taught to students were categorised. Information about content was categorised into human-centred factors that influence decision-making, and animal-based indicators used to directly inform decision-making. All eight representatives reported some teaching relevant to euthanasia decision-making at their university for livestock, companion animal and avian/wildlife. One representative reported no such teaching for equid animals at their university. Observation of a euthanasia case was rarely reported as a teaching method. Five universities reported multiple modes of teaching relevant information, while two universities made use of modalities that could be described as opportunistic teaching (e.g., 'Discussion of clinical cases'). Factors taught at most universities included financial considerations, and that it is the owner's decision to make, while animal-based indicators taught included QoL/animal welfare, prognosis and behaviour change. Overall, most universities used a variety of methods to cover relevant material, usually including lectures and several other approaches for all animal types. However, because two universities relied on presentation of clinical cases, not all students at these veterinary schools will be exposed to make, or assist in making, euthanasia decisions.

A randomised controlled masked clinical trial of two treatments for osteoarthritis in dogs

The product 4CYTE™ Canine (Interpath Pty Ltd., Ballarat, Victoria, Australia) contains four active ingredients: three marine-derived ingredients and Epiitalis®, which is extracted from the seed of the plant Biota orientalis. Carprofen is a non-steroidal anti-inflammatory drug (NSAID) licensed for the treatment of osteoarthritis in dogs and is the active ingredient in several licensed products. This study aimed to compare the efficacy of 4CYTE Canine with carprofen for the treatment of pain from osteoarthritis. The trial was a randomised, masked, parallel group trial in dogs with naturally occurring osteoarthritis. Sixty-nine dogs with body weight of between 10 and 50 kg were enrolled in the study, of which 66 (95.7%) completed the study. The 4CYTE Canine was administered at 60 mg active/kg daily and carprofen at 2-4 mg/kg daily, with a loading dose of up to 4 mg/kg on the first day. The trial duration was 28 days. The primary outcome was defined as improvement in Owner Lameness Score at Day 28 compared with Day 0. Other outcomes measured included Veterinary Lameness Scores and the Owner Mobility Scores. At Day 28, 14 of 29 (48.3%) dogs that received 4CYTE Canine and 13 of 37 (35.1%) dogs that received carprofen had improved. The 4CYTE Canine was found to be non-inferior to carprofen at Day 14 for the Owner Mobility Score and at Day 28 for all three outcomes. This response pattern suggests that improvement in response to 4CYTE Canine continued between Days 14 and 28. These results support the conclusion that 4CYTE Canine is not inferior to carprofen by end-point clinical efficacy.

An Electronically Delivered Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure With Reduced Ejection Fraction: The EPIC-HF Trial

BACKGROUND

Major gaps exist in the routine initiation and dose up-titration of guideline-directed medical therapies (GDMT) for patients with heart failure with reduced ejection fraction. Without novel approaches to improve prescribing, the cumulative benefits of heart failure with reduced ejection fraction treatment will be largely unrealized. Direct-to-consumer marketing and shared decision making reflect a culture where patients are increasingly involved in treatment choices, creating opportunities for prescribing interventions that engage patients.

METHODS

The EPIC-HF (Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction) trial randomized patients with heart failure with reduced ejection fraction from a diverse health system to usual care versus patient activation tools-a 3-minute video and 1-page checklist-delivered electronically 1 week before, 3 days before, and 24 hours before a cardiology clinic visit. The tools encouraged patients to work collaboratively with their clinicians to "make one positive change" in heart failure with reduced ejection fraction prescribing. The primary endpoint was the percentage of patients with GDMT medication initiations and dose intensifications from immediately preceding the cardiology clinic visit to 30 days after, compared with usual care during the same period.

RESULTS

EPIC-HF enrolled 306 patients, 290 of whom attended a clinic visit during the study period: 145 were sent the patient activation tools and 145 were controls. The median age of patients was 65 years; 29% were female, 11% were Black, 7% were Hispanic, and the median ejection fraction was 32%. Preclinic data revealed significant GDMT opportunities, with no patients on target doses of β-blocker, sacubitril/valsartan, and mineralocorticoid receptor antagonists. From immediately preceding the cardiology clinic visit to 30 days after, 49.0% in the intervention and 29.7% in the control experienced an initiation or intensification of their GDMT (P=0.001). The majority of these changes were made at the clinician encounter itself and involved dose uptitrations. There were no deaths and no significant differences in hospitalization or emergency department visits at 30 days between groups.

CONCLUSIONS

A patient activation tool delivered electronically before a cardiology clinic visit improved clinician intensification of GDMT. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03334188.

An Electronically delivered, Patient-activation tool for Intensification of medications for Chronic Heart Failure with reduced ejection fraction: Rationale and design of the EPIC-HF trial

BACKGROUND

Heart failure with reduced ejection fraction (HFrEF) benefits from initiation and intensification of multiple pharmacotherapies. Unfortunately, there are major gaps in the routine use of these drugs. Without novel approaches to improve prescribing, the cumulative benefits of HFrEF treatment will be largely unrealized. Direct-to-consumer marketing and shared decision making reflect a culture where patients are increasingly involved in treatment choices, creating opportunities for prescribing interventions that engage patients.

HYPOTHESIS

Encouraging patients to engage providers in HFrEF prescribing decisions will improve the use of guideline-directed medical therapies.

DESIGN

The Electronically delivered, Patient-activation tool for Intensification of Chronic medications for Heart Failure with reduced ejection fraction (EPIC-HF) trial randomizes patients with HFrEF to usual care versus patient-activation tools-a 3-minute video and 1-page checklist-delivered prior to cardiology clinic visits that encourage patients to work collaboratively with their clinicians to intensify HFrEF prescribing. The study assesses the effectiveness of the EPIC-HF intervention to improve guideline-directed medical therapy in the month after its delivery while using an implementation design to also understand the reach, adoption, implementation, and maintenance of this approach within the context of real-world care delivery. Study enrollment was completed in January 2020, with a total 305 patients. Baseline data revealed significant opportunities, with <1% of patients on optimal HFrEF medical therapy.

SUMMARY

The EPIC-HF trial assesses the implementation, effectiveness, and safety of patient engagement in HFrEF prescribing decisions. If successful, the tool can be easily disseminated and may inform similar interventions for other chronic conditions.

How management of grief associated with ending the life of an animal is taught to Australasian veterinary students

OBJECTIVE

Veterinarians have an important role in supporting and understanding their clients' grief. Veterinary schools have a duty to teach students how best to manage grief - both that of the students/future veterinarians and the clients. This study explores how grief management, associated with ending the life of an animal, was taught to students in eight Australasian veterinary schools.

METHODS

A questionnaire-style interview guide was used by a representative at each university to conduct structured interviews with educators in a snowball sampling approach. Educators were interviewed about the teaching of grief management for four categories of animals: livestock, equine, companion and avian/wildlife. The terms used by participants to describe what they taught were grouped into common themes. Teaching was defined by individual participants and included structured and unstructured approaches. The stage in the degree (preclinical or clinical years) that grief management was taught in the veterinary curriculum and by whom (e.g. clinicians or psychologists) is also described.

RESULTS

Grief management was taught more in preclinical than clinical years. However, due to how grief was characterised, much of this teaching was general 'nonspecific' teaching that included all categories of animals. Client grief was taught more generically, whereas, grief of veterinarians was taught using specific examples given by clinicians.

CONCLUSION

A more robust end-of-life (EoL) management curriculum that includes all aspects of grief management is likely to increase job satisfaction, client happiness and professional satisfaction.

Who's challenging who training for staff empathy towards adults with challenging behaviour: cluster randomised controlled trial

BACKGROUND

One in five adults with intellectual disabilities (ID) known to services display challenging behaviours (CBs), and these individuals are at risk for restrictive practices and poor care. Staff attitudes may contribute to the development and/or maintenance of CBs. We investigated the effectiveness of co-produced Who's Challenging Who? training delivered by people with ID to staff.

METHOD

This study involved a cluster randomised controlled trial (RCT) of Who's Challenging Who? training with follow-up at six and 20 weeks post-randomisation.

PARTICIPANTS

two staff from each of 118 residential care settings for adults with ID at least one of whom displayed aggressive CB.

PRIMARY OUTCOME

Self-reported Staff Empathy for people with Challenging Behaviour Questionnaire.

ANALYSIS

intention to treat of all randomised settings. ISCRTN registration: ISRCTN53763600.

RESULTS

118 residential settings (including 236 staff) were randomised to either receive training (59 settings) or to receive training after a delay (59 settings). The primary analysis included data from 121 staff in 76 settings (51% of staff, 64% of settings). The adjusted mean difference on the transformed (cubed) Staff Empathy for people with Challenging Behaviour Questionnaire score at the primary end point was 1073.2 (95% CI: -938.1 to 3084.5, P = 0.296) in favour of the intervention group (effect size Cohen's d = .19).

CONCLUSIONS

This is the first large-scale RCT of a co-produced training course delivered by people with ID. Findings indicated a small positive (but statistically non-significant) effect on increased staff empathy at 20 weeks, and small to moderate effects for staff reported secondary outcomes in favour of the intervention group.

All-ceramic crown preparations: An alternative technique

BACKGROUND

The aim of this study was to compare the crown preparation dimensions produced from two different techniques of preparation for posterior all-ceramic crowns.

METHODS

Twenty-four fourth year dental students undertook a course of advanced simulation training involving education in an alternative technique of preparation for a 36 all-ceramic crown. Crown preparations performed using the traditional technique were compared with an alternative technique for total occlusal convergence (TOC) and reduction difference (RD) using digital scanning and comparative software.

RESULTS

Groups that spent the most time performing the alternative technique produced crown preparations with significantly lower buccolingual (BL) TOC. The training resulted in crown preparations that were closer to ideal TOC and RD measurements.

CONCLUSIONS

The alternative technique of crown preparation for a posterior all-ceramic crown showed initial promise in creating a less buccolingually tapered and more ideally occlusally reduced crown preparation.

Australian oral health case notes: assessment of forensic relevance and adherence to recording guidelines

BACKGROUND

Dental case notes record clinical diagnoses and treatments, as well as providing continuity of patient care. They are also used for dento-legal litigation and forensic purposes. Maintaining accurate and comprehensive dental patient records is a dental worker's ethical and legal obligation.

METHODS

Australian registered specialist forensic odontologists were surveyed to determine the relevance of recorded case note items for dental identification. A dental case notes sample was assessed for adherence with odontologist nominated forensic value and compiled professional record keeping guidelines of forensic relevance. Frequency of item recording, confidence interval, examiner agreement and statistical significance were determined.

RESULTS

Broad agreement existed between forensic odontologists as to which recorded dental items have most forensic relevance. Inclusion frequency of these items in sampled case notes varied widely (e.g. single area radiographic view present in 75%, CI = 65.65-82.50; completed odontogram in 56%, CI = 46.23-65.33). Recording of information specified by professional record keeping guidelines also varied, although overall inclusion was higher than for forensically desired items (e.g. patient's full name in 99%, CI = 94.01 - >99.99; named treating practitioner in 23%, CI = 15.78-32.31).

CONCLUSIONS

Many sampled dental case notes lacked details identified as being valuable by forensic specialists and as specified by professional record keeping guidelines.

Perceptions of registered nurses in four state health insititutions on continuing formal education

This study investigated registered nurses in four selected state health institutions' perceptions with regard to continuing formal education. The relevance of continuing formal education is being emphasised globally by the increasing quest for quality assurance and quality management systems within an ethos of continuous improvement. According to Tlholoe (2006:5), it is important to be committed to continual learning, as people's knowledge become less relevant because skills gained early in a career are insufficient to avoid costly mistakes made through ignorance. Continuing formal education in nursing is a key element to the maintenance of quality in health care delivery. The study described: registered nurses' views on continuing formal education. Registered nurses' perceived barriers to continuing formal education. A quantitative descriptive survey design was chosen using a questionnaire for data collection. The sample consisted of 40 registered nurses working at four state health institutions in the Western Cape Province, South Africa. Convenience sampling was selected to include registered nurses who were on duty on the days during which the researcher visited the health institutions to distribute the questionnaires. The questionnaire contained mainly closed-ended and a few open-ended questions. Content validity of the instrument was ensured by doing a thorough literature review before construction of items and a pretest. Reliability was established by the pretest and providing the same information to all respondents before completion of the questionnaires. The ethical considerations of informed consent, anonymity and confidentiality were adhered to and consent to conduct the study was obtained from relevant authorities. Descriptive statistics, based on calculations using the Microsoft (MS) Excel (for Windows 2000) programme, were used to summarise and describe the research results. The research results indicated that most registered nurses perceive continuing formal education as beneficial to their personal and professional growth and that it could lead towards improving the quality of patient/client care, but barriers exist which prevent or deter them from undertaking continuing formal education programmes. The main structural barriers included lack of funding and lack of coherent staff development planning and physical barriers including job and family responsibilities.

Rapid Optical Imaging of Breast Tumor Margins: Final Results from a 100-Patient Clinical Study

Background: Increasing attention has been given to the surgical margin status in primary breast conserving therapy (BCT) due to reports which indicate that 20-70% of patients undergoing BCT must undergo multiple surgeries for complete tumor resection. For the past 4 years, our multidisciplinary group has been working to address this clinical need via the development of an optically-based intraoperative breast tumor margin assessment device. This device, based on diffuse reflectance spectroscopy, is sensitive to biochemical and morphological changes associated with cancer and has a sensing depth of 1-2 mm which is compatible with widely used criteria for cancer-free margins. The device is capable of surveying the entire specimen surface intraoperatively in imaging mode. Here we report the results of a non-significant-risk study of the device in over 100 patients at Duke University Medical Center.Materials and Methods: Under an institutionally-approved protocol, we tested our device on consented patients undergoing a partial mastectomy at DukeUniversity Medical Center for invasive or in situ malignancies. Optical spectral images of tumor margins were recorded within 20 minutes of excision and converted into tissue compositional parameter maps that reflect the vascular density, fat content and cell density in the tissue. The pathologic status of the imaged margins was collected from standard post-operative surgical pathology reports. Intraoperative frozen section and touch prep analysis was not performed on these specimens. Margins were considered positive if residual malignancy was found within 2 mm of the tissue surface.Results and Discussion: BCT specimens from 121 patients have been imaged with the optical device. One to four margins were imaged on each BCT specimen. Data from 112 patients were retained for analysis (51 negative margins, and 47 margins containing cancer within 1mm). Images of negative margins from patients with at least one positive margin (9 patients) elsewhere on the specimen were excluded from analysis due to the potential for presence of margin positivity that was not identified pathologically. For each margin, a set of 8 tissue composition maps were generated, from which a set of 36 image-descriptive variables were obtained. Wilcoxon rank-sum tests were used to determine which of the variables best separated negative from positive margins. A predictive model was developed using conditional inference trees to identify the optimal partitions from all 36 image-descriptive variables. The model selected variables related to the light scattering properties, total hemoglobin content, and β-carotene content of the underlying tissue, which are related to tissue density and morphology, vascular volume, and fat content, respectively. This model resulted in a sensitivity of 80% for detecting cancer at the margin, a sensitivity of 73% for detecting residual disease within 1mm of the margin, and a specificity of 65%. These results are promising and a prospective validation trial of the device is under development.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5017.

Cognitive-behavioural therapy for adolescents with bulimic symptomatology: the acceptability and effectiveness of internet-based delivery

BACKGROUND

The evidence base for the treatment of adolescents with bulimia nervosa (BN) is limited.

AIMS

To assess the feasibility, acceptability, and clinical outcomes of a web-based cognitive-behavioural (CBT) intervention for adolescents with bulimic symptomatology.

METHOD

101 participants were recruited from eating disorders clinics or from beat, a UK-wide eating disorders charity. The programme consisted of online CBT sessions ('Overcoming Bulimia Online'), peer support via message boards, and email support from a clinician. Participants' bulimic symptomatology and service utilisation were assessed by interview at baseline and at three and six months. Participants' views of the treatment package were also determined.

RESULTS

There were significant improvements in eating disorder symptoms and service contacts from baseline to three months, which were maintained at six months. Participants' views of the intervention were positive.

CONCLUSIONS

The intervention has the potential for use as a first step in the treatment of adolescents with bulimic symptomatology.

Identification of nanometre-sized ultra-high molecular weight polyethylene wear particles in samples retrieved in vivo

Nanometre-sized particles of ultra-high molecular weight polyethylene have been identified in the lubricants retrieved from hip simulators. Tissue samples were taken from seven failed Charnley total hip replacements, digested using strong alkali and analysed using high-resolution field emission gun-scanning electron microscopy to determine whether nanometre-sized particles of polyethylene debris were generated in vivo. A randomised method of analysis was used to quantify and characterise all the polyethylene particles isolated. We isolated nanometre-sized particles from the retrieved tissue samples. The smallest identified was 30 nm and the majority were in the 0.1 microm to 0.99 microm size range. Particles in the 1.0 microm to 9.99 microm size range represented the highest proportion of the wear volume of the tissue samples, with 35% to 98% of the total wear volume comprised of particles of this size. The number of nanometre-sized particles isolated from the tissues accounted for only a small proportion of the total wear volume. Further work is required to assess the biological response to nanometre-sized polyethylene particles.

Epigenetic influences may explain dental differences in monozygotic twin pairs

BACKGROUND

Comparisons between monozygotic (MZ) co-twins have tended to focus on the similarities between their dentitions rather than differences. The aim of this study was to determine the prevalence of discordant expression for simple hypodontia and supernumerary teeth in MZ twin pairs and to explain how phenotypic differences might occur despite their similar genotypes.

METHODS

Records of 278 pairs of MZ twins, including dental casts and radiographs, were examined and the prevalences of discordant expression for missing upper lateral incisors (ULI) or second premolars (PM2), and of mesiodentes, were determined. Zygosities were confirmed by comparisons of blood markers and DNA.

RESULTS

There was evidence of at least one missing ULI or PM2 in 24 of the 278 MZ pairs (8.6 per cent), with 21 of these 24 pairs (87.5 per cent) showing discordant expression. Nine of the 278 MZ pairs (3.2 per cent) displayed evidence of mesiodentes, with eight of these nine pairs (88.9 per cent) being discordant.

CONCLUSION

Our findings show that differences in the expression of missing or extra teeth occur often between MZ co-twins whose genetic make-up predisposes them to simple hypodontia or mesiodentes. We postulate that minor variations in epigenetic events during odontogenesis may account for these distinct differences.

Microbial contamination of hospital bed handsets

BACKGROUND

Hospital bed handsets, including nurse call equipment and television controls, have been found to contain biologic material and may be contaminated with microbes.

OBJECTIVE

The aim of this study was to assess the microbial contamination of hospital bed handsets.

METHODS

Hospital bed handsets were removed from 115 randomly chosen rooms in a suburban hospital. The handsets were transported to the laboratory in a sterile fashion and opened using a sterile technique, and cultures were obtained from both the anterior and posterior surfaces of the units.

RESULTS

The cultures of 12 units (10.4%) revealed no microorganisms. One hundred three units (89.6%) had cultures that grew microorganisms. Of the handsets that were found to contain microorganisms, 48 units (46.6%) had only 1 microorganism, and 55 units (53.4%) had multiple organisms, including 33 units (32.0%) with 2 microorganisms, 21 units (20.4%) with 3 microorganisms, and 1 unit (1.0%) with 4 microorganisms. The microorganisms identified included 90 isolates (87.4%) of coagulase-negative staphylococcus, 51 isolates (49.5%) of bacillus species, 13 isolates (12.6%) of fungal species, 8 isolates (7.8%) of nonhemolytic streptococcus species, 7 isolates (6.8%) of alpha-hemolytic streptococcus species, 1 isolate (1.0%) of Staphylococcus aureus, and 1 isolate (1.0%) of methicillin-resistant Staphylococcus aureus.

CONCLUSION

Hospital bed handsets were found to have a high incidence of contamination with bacteria and fungus and were found to contain organisms that are known to be the etiologic agents in nosocomial infections. Because of the frequency and duration of contact between hospital patients and hospital bed handsets, existing infection control measures should be studied that could reduce the level of contamination of such handsets or that could isolate the handsets from the patient.

Lipid and hormonal profile of Panamanian women during the menstrual cycle

Forty-one women of reproductive age were included in the study, to establish the variation of serum lipids during the menstrual cycle and simultaneously, to determine the physiological fluctuation of FSH, LH, prolactin (PRL), progesterone (P4) and estradiol (E2) concentration in serum, during the menstrual cycle. A significant decrease of total serum cholesterol (165.29 +/- 3.6 mg/dl) and triglycerides (108.99 +/- 9.65) occurred during the luteal phase, as compared with the follicular phase (176.16 +/- 3.51, 108.99 +/- 9.65). Changes were not observed with HDL-cholesterol during the cycle. On the other hand, FSH showed an initial rise (mean 5 IU/l) followed by a surge (10 IU/l) and a progressive fall toward the midcycle. In contrast LH secretion showed a steady increase with a maximal concentration at surge (32.1 IU/l). PRL mean value was observed, with a discrete increase after day 13 of the menstrual cycle, that was more noticeable at the end of the cycle. Forty-eight hours after the FSH and LH midcycle surge, elevation of progesterone was observed, with maximal concentration occurring on day 24 (23 nmol/l) and later on progesterone levels fell rapidly. Thirty-six to 24 h before the surge of LH and FSH at midcycle was observed the peak serum concentration of estradiol (1300 pmol/l) followed by a progressive fall. Changes in the concentration of serum lipids during the menstrual cycle are presumably due to a direct or indirect effect of physiological fluctuation of sex hormones.

Serotonergic polymorphisms and psychotic disorders in populations from North Spain

There is strong biological evidence relating alterations in the serotonergic system with mental disorders. These alterations may be originated at the DNA level by sequence mutations that alter the functioning of serotonin receptors and transporter. To test this hypothesis we investigated three genetic variants of the 5-HT2A receptor (-1438G/A, 102T/C and His452Tyr) and two variants of the serotonin transporter (a VNTR in the second intron and a 44 bp insertion/delition in the promoter region of the gene) in a clinical sample recruited in a human isolate and in surrounding areas in Northern Spain (N = 257) and in ethnically matched controls (N = 334). No clear association was found between 5-HT2A variants and psychosis. However, marginal associations were observed between the 5-HTT LPR and VNTR variants and psychosis (P < or = 0.05) indicating a minor contribution to psychosis of genetic alterations in this gene.

The value of twins in dental research

Due to recent advances in molecular genetics, studies of twins will continue to provide important insights into how genetic and environmental factors contribute to variation in human physical and behavioural traits and disorders. This review emphasizes that biometrical genetic studies of twins are particularly valuable in complementing and directing molecular approaches to facilitate the detection of quantitative trait loci. It also describes several other research models involving twins, apart from the traditional comparison of similarities in monozygotic (identical) and dizygotic (non-identical) pairs, that have the potential to provide new information in the future. Current knowledge about the genetic bases of common dental problems is summarized and future directions in dental research involving twins are outlined.

Molar intercuspal dimensions: genetic input to phenotypic variation

Molecular studies indicate that epigenetic events are important in determining how the internal enamel epithelium folds during odontogenesis. Since this process of folding leads to the subsequent arrangement of cusps on molar teeth, we hypothesized that intercuspal distances of human molar teeth would display greater phenotypic variation but lower heritabilities than overall crown diameters. Intercuspal distances and maximum crown diameters were recorded from digitized images of dental casts in 100 monozygotic and 74 dizygotic twin pairs. Intercuspal distances displayed less sexual dimorphism in mean values but greater relative variability and fluctuating asymmetry than overall crown measures. Correlations between intercuspal distances and overall crown measures were low. Models incorporating only environmental effects accounted for observed variation in several intercuspal measures. For those intercuspal variables displaying significant additive genetic variance, estimates of heritability ranged from 43 to 79%, whereas those for overall crown size were higher generally, ranging from 60 to 82%. Our finding of high phenotypic variation in intercuspal distances with only moderate genetic contribution is consistent with substantial epigenetic influence on the progressive folding of the internal enamel epithelium, following formation of the primary and secondary enamel knots.

Undergraduate student experience in dental service delivery in rural South Australia: an analysis of costs and benefits

BACKGROUND

Rural experience for dental students can provide valuable clinical education, change attitudes to rural practice, and make a valuable contribution to clinical service provision. The aim of this paper is to assess the costs and benefits of service delivery by students through rural training programmes.

METHODS

Groups of two students worked in the public dental clinics in adjacent rural centres where there had been long-term difficulties in recruiting staff. The costs and benefits of the programme were assessed by the impact on waiting lists, the total cost per patient of a course of care and by the marginal cost of adding service provision by students to existing arrangements.

RESULTS

The total costs of emergency and complete treatment provided by students were greater than the costs of treatment provided by public-sector dentists but less than the costs of private providers treating public patients. However, the value of services were greater when care was provided by students or private providers and the marginal cost of students providing services was 50-70 per cent of the cost of care provided by public dentists.

CONCLUSION

This assessment suggests that the service benefits achieved compliment the primary objective of influencing the attitude of students to rural practice.

Accelerating flap maturation by vascular endothelium growth factorin a rat tube flap model

The effect of exogenous vascular endothelium growth factor (VEGF) on the survival of the distal skin paddle with early pedicle division was studied in a rat tubed pedicle flap model. In part I, tubed pedicle skin flaps were created on the backs of 14 rats. The pedicle was divided after an interval of 3, 4, 5 or 7 days, and the survival area of each distal skin paddle was measured 5 days after the pedicle was divided. The percentages of survival were 0, 24.9%, 89.9% and 100%, respectively. In part II, tube flaps were created in 20 rats. In the experimental group, 2 ml of VEGF (50 microg ml(-1)) was injected into the recipient bed during tube flap creation in each rat. In the control group, 2 ml of saline was given. The tubed pedicle was divided 4 days after creation. The mean survival area of the distal skin paddle in the group treated with VEGF was 7.32 +/- 1.36 cm(2) (80.91%) at 5 days after pedicle division, which was of statistical significance when compared with the survival in the control group of 2.70 +/- 1.89 cm(2) (27.9%). The histology showed angiogenesis at the skin paddle-recipient bed interface following VEGF injection. These results demonstrate that the subcutaneous administration of VEGF into the recipient bed of the tube flap transfer can induce angiogenes is at the junction between the donor and the recipient bed, and improve skin paddle survival with early pedicle division.

A study of occlusal variation in the primary dentition of Australian twins and singletons

In this study, we quantified the extent of variation in different occlusal features of Australian children of European descent with complete primary dentitions, but no permanent teeth present in the mouth. The study group consisted of 412 individuals, aged between 3 and 7 years, including 70 monozygous (MZ) twin pairs, 68 same-sexed dizygous (DZ) twin pairs, 11 opposite-sexed DZ twin pairs, and 114 singletons. Occlusal traits, including inter-dental spacing, incisal overbite and overjet, arch breadth and arch depth, were obtained directly from dental casts or indirectly from photocopies or impressions of the casts. Descriptive statistics summarised the data and indicated that distributions were similar to those published for other populations. Univariate genetic analysis, using the structural equation modelling package Mx, was carried out on the quantitative data using the normal assumptions of the twin model. Genetic modelling indicated that a model incorporating additive genetic (A) and unique environmental variation (E) was the most parsimonious for interdental spacing, overbite, overjet and arch dimensions. Estimates of heritability for interdental spacing ranged from 0.62 to 0.81. Estimates for overbite and overjet were 0.53 and 0.28, respectively, and estimates for arch dimensions ranged from 0.69 to 0.89. These results indicated a moderate to relatively high genetic contribution to observed variation.

Vascular grafts in the rat model: an anatomic study

Vascular grafts in animal models have been used extensively in the microsurgical laboratory, and the rat offers an excellent source of graft to meet these needs. In this study, we compiled a list of vessels that were previously identified in experimental literature for use as vascular grafts in the rat model. We then dissected and measured both arterial and venous grafts taken from these sites in 12 adult rats. The surgical procedure for approaching each vascular graft was recorded. The diameter and harvestable length, the start and end points, and the number of branches of the graft were tabulated. We believe that these data will provide valuable insight applicable to the use of the rat vascular graft in microsurgical research and training.

Quantification of nerve tension after nerve repair: correlations with nerve defects and nerve regeneration

This study tested the validity of a quantitative in vitro nerve-tension-measuring technique, by correlating the tension measurements with functional and morphologic assessments of nerve regeneration. Initially, harvested nerves were used in vitro to determine a K value for lateral displacement in this tissue. Next, this value was used to calculate the tension of nerve repair, following 0-, 3-, 6-, and 9-mm resections of nerves in groups of rats. After quantifying the nerve tensions following excision and repair, the authors determined a sciatic function index to evaluate functional recovery and axon diameter in the animals. Functional recovery was significantly impaired in animals with elevated measurable tension (9.04 +/- 0.74 g in a 6-mm defect, 27.76 +/- 8.86 g in a 9-mm defect), compared to animals with no or 3-mm excision and measured tension of 3.3 +/- 1.09 g or less. Increased tension was also associated with a significant decrease in axon diameter. This study succeeded, therefore, in quantitatively relating the elements of measured nerve tension, nerve gaps, functional nerve recovery, and morphologic regeneration. Quantification of nerve tension by lateral displacement in vivo offers a possible solution to clinical management of nerve gaps, when the choice between primary repair and nerve grafting is not a clear one.

Studies leading to the identification of ZD1839 (IRESSA): an orally active, selective epidermal growth factor receptor tyrosine kinase inhibitor targeted to the treatment of cancer

This paper describes the development of the epidermal growth factor receptor tyrosine kinase inhibitor ZD1839 from a lead series of 4-anilinoquinazoline compounds. ZD1839 has suitable properties for use as a clinically effective drug and shows activity against human tumours. In particular, the use of pharmacokinetic data in the development of ZD1839 is discussed.

Treatment of facial angiofibromas of tuberous sclerosis by shave excision and dermabrasion in a dark-skinned patient

Tuberous sclerosis is an inherited disease expressed clinically by the triad of mental retardation, seizures, and tuberous lesions. Facial angiofibromas, a common manifestation of tuberous sclerosis, can cause considerable cosmetic disfigurement, emotional distress, obstruction of vision, and hemorrhage. Treatment by shave excision, as the first step to remove the larger nodules, followed by dermabrasion, to smooth and sculpt the final surface, has been recommended as the most effective form of therapy. However, this method of treatment raises the question of risk for development of hypopigmentation in susceptible patients. The authors present their treatment of angiofibromas with shave excision and dermabrasion in a dark-skinned patient.