799 FRAILTY MATTERS PROJECT

Introduction

Preventing and managing frailty is a new area for many community practitioners yet frailty specific education remains limited. We aimed to understand and strengthen the capability of District Nurses (DNs) in leading personalised care for older people with frailty.

Methods

We conducted a participatory action research (PAR) study with DNs in one Scottish NHS Board area. Phase 1 involved three focus groups (n = 17); one one-to-one interviews; and collection of baseline team dynamics questionnaires (n = 10). Evidence from phase 1 informed co-design of an educational framework, delivered in Phase 2 as a combined coaching and educational programme through small group learning, web based coaching and bite sized online education. Interactive sessions were supported by a person-centred coach and 2 older citizen ‘co-coaches’ to bring the experience of people affected by frailty. In Phase 3 we analysed participant feedback and assessed transferability to other disciplines and to health and care settings across the UK.

Results

At baseline, DNs did not perceive frailty as a long term condition. They identified a need for help to understand the concept of frailty and to build skills and confidence in delivering community interventions. Participants embraced the coaching and educational intervention and valued the opportunity for dialogue with peers and citizen co-coaches about what really matters to patients, families and professionals. Our survey of other disciplines and teams highlighted this educational programme is both relevant and transferable.

Conclusion

Through co-design we developed a contextually sensitive programme that makes sense of frailty in the reality of both community professionals and people living with frailty. Combining technical knowledge and relational skills-building with peer support and coaching helps prepare DNs to lead interprofessional teams caring for people living with frailty. The educational framework and combined coaching and educational package are highly applicable to interdisciplinary teams in other community settings.

0380 Association of Day-to-Day Variability in Rest-Activity Circadian Rhythm with Sleep Quality Among Law Enforcement Officers

Introduction

Poor sleep quality may be attributed to several occupational factors and has been linked to adverse health outcomes, including cardiovascular disease. Recent epidemiologic studies suggest rest-activity circadian rhythm (RAR) as a possible determinant of poor sleep quality. The focus of these studies has been on the magnitude of the parameters of RAR with little attention to the impact of their day-to-day fluctuation. We examined association of daily variation in parameters of RAR with sleep quality.

Methods

Participants (n=280) were officers from the Buffalo Cardio-metabolic Occupational Police Stress Study (2004-2009). Sleep quality was determined using the Pittsburgh Sleep Quality Index (PSQI). Participants wore wrist actigraph for a minimum of seven days. A cosine curve was fit to measure goodness of fit and estimate the mean values of the three parameters of RAR: Mesor, Amplitude, and Acrophase. Day-to-day variability of the parameters were assessed by fitting the cosine function separately for each day and computing the sample standard deviation across the days. Poisson regression models were conducted adjusting for demographic, lifestyle, and occupational factors.

Results

The prevalence of poor sleep quality was 50.3%. Poor sleep quality was 56% higher in officers with the largest day-to-day variability in Mesor (PR=1.56, 95%CI:1.11 - 2.19) compared to those with the lowest daily variation. Similar estimates were found for Amplitude (PR=1.42, 1.03 - 1.95), Acrophase (PR=1.86, 1.29 - 2.67), and measure of goodness of fit (PR=1.54, 1.13 - 2.11). On the other hand, mean values of RAR parameters were not significantly associated with poor sleep quality.

Conclusion

Results suggest larger daily variation in parameters of RAR is associated with a decrease in sleep quality. Given that day-to-day variation in RAR may increase the odds of poor sleep quality, future studies ought to address risk factors for higher daily fluctuations in RAR which could aid in developing intervention measures.

Support

CDC/NIOSH grant 1R01OH009640-01A1

0179 Poor Sleep Quality Increases Odds of On-Duty Injuries in Policing

Introduction

Shiftwork is inevitable in law enforcement. Officers are scheduled around-the-clock to protect and serve communities. Many police departments are also understaffed; consequentially, officers’ work schedules often include long work hours. Shift work and long work hours can result in sleep loss, poor sleep quality, and fatigue. In turn, these factors can impair police officers’ operational performance. We investigated whether sleep loss and poor sleep quality increase odds of on-duty injuries or disciplinary actions in policing.

Methods

Officers (n=113) that started their careers as police officers at the Buffalo Police Department between 1994–2001 were studied. Work and injury data were obtained for each officer starting with their hire date and continuing day-by-day for 15-years. Between 2004–2009, officers reported any disciplinary actions in the prior two years and their sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) and Survey Screen for Apnea. Data were analyzed using logistic regression with logit link functions (PROC GLIMMIX, SAS 9.4). Covariates included sex, ethnicity, experience, shift type, workload, and secondary employment.

Results

Seventy-four percent of officers had poor sleep quality (PSQI global score ≥ 5). Officers with poorer sleep quality had greater odds of injury (OR=1.3 [95% CI: 1.0–1.5], p=0.03). Officers’ sleep duration was not a significant predictor of injuries (OR=1.0 [95% CI: 0.3–3.2], p=0.96). Officers with sleep disturbances (OR=3.5 [95% CI: 1.0–11.8], p<0.05) and/or using sleep medications (OR=15.7 [95% CI: 2.8–89.3], p<0.01) had higher odds of injury. None of the variables were significant predictors of disciplinary actions.

Conclusion

Poor sleep quality was prevalent among the officers. The natures of the injuries were likely multi-factorial and complex. Notwithstanding, poor sleep quality was associated with higher odds of on-duty injuries. The source of officers’ sleep disturbances (e.g. shift work, insomnia, and/or policing-related stresses) remains to be determined.

Support

CDC/NIOSH grant 1R01OH009640-01A1; NIJ grant 2005-FS-BX-0004

Validation of the Seegene RV15 multiplex PCR for the detection of influenza A subtypes and influenza B lineages during national influenza surveillance in hospitalized adults

Background. The Serious Outcomes Surveillance Network of the Canadian Immunization Research Network (CIRN SOS) has been performing active influenza surveillance since 2009 (ClinicalTrials.gov identifier: NCT01517191). Influenza A and B viruses are identified and characterized using real-time reverse-transcriptase polymerase chain reaction (RT-PCR), and multiplex testing has been performed on a subset of patients to identify other respiratory virus aetiologies. Since both methods can identify influenza A and B, a direct comparison was performed.Methods. Validated real-time RT-PCRs from the World Health Organization (WHO) to identify influenza A and B viruses, characterize influenza A viruses into the H1N1 or H3N2 subtypes and describe influenza B viruses belonging to the Yamagata or Victoria lineages. In a subset of patients, the Seeplex RV15 One-Step ACE Detection assay (RV15) kit was also used for the detection of other respiratory viruses.Results. In total, 1111 nasopharyngeal swabs were tested by RV15 and real-time RT-PCRs for influenza A and B identification and characterization. For influenza A, RV15 showed 98.0 % sensitivity, 100 % specificity and 99.7 % accuracy. The performance characteristics of RV15 were similar for influenza A subtypes H1N1 and H3N2. For influenza B, RV15 had 99.2 % sensitivity, 100 % specificity and 99.8 % accuracy, with similar assay performance being shown for both the Yamagata and Victoria lineages.Conclusions. Overall, the detection of circulating subtypes of influenza A and lineages of influenza B by RV15 was similar to detection by real-time RT-PCR. Multiplex testing with RV15 allows for a more comprehensive respiratory virus surveillance in hospitalized adults, without significantly compromising the reliability of influenza A or B virus detection.

The Relationship of Antiphospholipid Antibodies to Thromboembolic Disease in Systemic Lupus Erythematosus: A Cross-Sectional Study

In order to determine whether an association exists between antiphospholipid antibodies (APLA) and thromboembolic events in patients with systemic lupus erythematosus (SLE), we performed a cross-sectional study of consecutive unselected SLE patients. The occurrence of previous thromboembolic events was determined by investigators blinded to the APLA status of the patients by critical review of objective tests that had been performed at the time of symptomatic presentation and by performing venous Doppler ultrasound of the legs to elicit venous reflux as an indication of previous venous thrombosis. The presence of APLA was determined by coagulation assays for the lupus anticoagulant (LA) using five tests with well-defined control ranges and by ELISA assay for anticardiolipin antibodies (ACLA). These tests were measured on two separate occasions. The results of the study demonstrate a statistically significant association between persistently abnormal ACLA assays and thromboembolic events and a non-significant trend between persistently abnormal LA and thromboembolic events. Transient abnormalities of LA and ACLA were less strongly associated with thromboembolic events. We conclude that in patients with SLE, there is a significant association between thromboembolism and APLA.

A Low Molecular Weight Heparin Alters the Fetal Coagulation System in the Pregnant Sheep

Standard heparin and a LMWH, CY222 do not cross the placenta nor alter fetal coagulation when injected into the pregnant ewe. We found that another LMWH, Pharmuka-10169 (PK-10169) alters fetal coagulation without crossing the placenta in the pregnant sheep. To characterize this anticoagulant we measured the in vitro and in vivo effects of 125I-PK-10169 in maternal and fetal plasmas following administration of PK-10169 to the mother or fetus. The fetal anticoagulant activity was not neutralizable by protamine sulphate and was attributable to the inhibition of thrombin but not factor Xa. In vitro, the fetal anticoagulant activity had properties similar to dermatan sulphate : both catalyzed the inhibition of thrombin but not factor Xa by sheep plasma; and neither was neutralizable by protamine sulphate. These effects were due to the enhanced neutralization of thrombin by heparin cofactor II. We conclude that PK-10169 does not cross the placenta, but does induce the release of an endogenous dermatan sulphate-like substance which alters fetal coagulation.

Fibrin Clot Lysis by Thrombolytic Agents Is Impaired in Newborns due to a Low Plasminogen Concentration

Although thrombolytic drugs have been extensively used in adults, there is sparse information on their effectiveness in newborns whose fibrinolytic system differs significantly from adults. The purpose of this study was to determine if low plasma levels of plasminogen in cord plasma limited the therapeutic effectiveness of thrombolytic agents. Urokinase (UK), streptokinase (SK) and tissue plasminogen activator (TPA) were compared for their ability to lyse washed 125I-labelled adult or cord fibrin clots suspended in cord or adult plasma. 125I-labelled fibrin clots were prepared by recalcifying cord or adult plasma spiked with labelled fibrinogen and then placed into cord or adult plasma which contained either saline or differing amounts of a specific thrombolytic agent. After a 60 min incubation, the remaining 125I-fibrin in clots released 125I-fibrin fragments, and concentrations of fibrinogen, α2-antiplasmin, and plasminogen in the bathing plasma were measured and compared to starting values. Cord fibrin clots were more resistant than adult fibrin clots to all thrombolytic drugs tested (p <0.001). On average, the cord system retained 27% more 125I-fibrin in clots, and released 32% less 125I-fibrin fragments into plasma. Fibrinogenolysis was also decreased in cord plasmas compared to adult plasmas. The degree of fibrinolysis and fibrinogenolysis in cord plasma increased to adult values when plasminogen concentrations were increased in the bathing plasma. Thus, cord fibrin clots have an impaired response to thrombolytic agents secondary to low levels of plasminogen. We speculate that the clinical response of newborns to thrombolytic agents is also impaired and will not be enhanced by increasing doses of thrombolytic agents but may be enhanced by increasing the concentration of plasminogen.

Antithrombotic Properties of Heparin in a Neonatal Piglet Model of Thrombin-Induced Thrombosis

The relative deficiency of antithrombin III (AT III) in neonatal plasma results in lower recovery of heparin in some assay systems. It is uncertain whether low AT III levels also limit the antithrombotic effects of heparin in this age group. We therefore compared the antithrombotic properties of heparin in mature pigs and newborn piglets, whose coagulation and inhibitor system closely resembles that of the human neonate. Animals were pretreated with saline, 10 or 25 U/kg heparin (n ≥16 per age group and dose). Following an injection of 100 U/kg thrombin, systemic 125I-fibrinogen consumption and local 125I-fibrinogen incorporation into jugular venous stasis thrombi were measured. Significantly more 125I-fibrinogen was consumed in piglets than in pigs systemically (p <0.0001), as well as within the occluded vein segment (p = 0.0112), largely because heparin was less effective in piglets than in pigs. This neonatal resistance to heparin could not be explained by lower heparin levels in the newborn animals. However, pretreatment with AT III concentrate significantly improved the antithrombotic properties of heparin in this age group (p <0.0001). We conclude that physiologically low AT III levels reduce the efficacy of heparin in neutralizing thrombin activity in newborn piglets. We speculate that AT III deficiency may also limit the antithrombotic properties of heparin in newborn infants with thrombotic disease.

Morphological and Biochemical Features Affecting the Antithrombotic Properties of the Aorta in Adult Rabbits and Rabbit Pups

We hypothesised that there are important physiologic differences in arterial wall structure and function with respect to antithrombotic activity in the very young (pre-puberty) compared to adults. Electron microscopy, gel electrophoresis, and activity assays were used to examine differences in aorta structure and function comparing prepubertal rabbits (pups) to adult rabbits. Differences in endothelial function, extracellular matrix structure, proteoglycan (PG) distribution and glycosaminoglycan (GAG) content and function were shown. In both intima and media, total PG, chondroitin sulfate (CS) PG and heparan sulfate (HS) PG content were significantly increased in pups compared to adult rabbits. These findings corresponded to increased concentrations by mass analyses of CS GAG and DS GAG in aortas from pups. There was also a significant increase in antithrombin activity in pups due to HS GAG. In conclusion, differences in both structure and antithrombin activity of aortas from pups compared to adult rabbits suggest that young arteries may have greater antithrombotic potential that is, at least in part, related to increased HS GAG.

Antivibration gloves: effects on vascular and sensorineural function, an animal model

Anti-vibration gloves have been used to block the transmission of vibration from powered hand tools to the user, and to protect users from the negative health consequences associated with exposure to vibration. However, there are conflicting reports as to the efficacy of gloves in protecting workers. The goal of this study was to use a characterized animal model of vibration-induced peripheral vascular and nerve injury to determine whether antivibration materials reduced or inhibited the effects of vibration on these physiological symptoms. Rats were exposed to 4 h of tail vibration at 125 Hz with an acceleration 49 m/s(2). The platform was either bare or covered with antivibrating glove material. Rats were tested for tactile sensitivity to applied pressure before and after vibration exposure. One day following the exposure, ventral tail arteries were assessed for sensitivity to vasodilating and vasoconstricting factors and nerves were examined histologically for early indicators of edema and inflammation. Ventral tail artery responses to an α2C-adrenoreceptor agonist were enhanced in arteries from vibration-exposed rats compared to controls, regardless of whether antivibration materials were used or not. Rats exposed to vibration were also less sensitive to pressure after exposure. These findings are consistent with experimental findings in humans suggesting that antivibration gloves may not provide protection against the adverse health consequences of vibration exposure in all conditions. Additional studies need to be done examining newer antivibration materials.

Interim estimates of 2013/14 influenza clinical severity and vaccine effectiveness in the prevention of laboratory-confirmed influenza-related hospitalisation, Canada, February 2014

Binary file ES_Abstracts_Final_ECDC.txt matches

Transcallosal resection of hypothalamic hamartoma for gelastic epilepsy

INTRODUCTION

Hypothalamic hamartomas (HHs) are commonly associated with severe epilepsy resistant to anticonvulsant therapy. Historically, surgical resection of HHs resulted in considerable morbidity.

DISCUSSION

Two series of patients who successfully underwent resection using a transcallosal approach have now been published; we report the first UK experience of this technique in a series of five patients with HHs and gelastic epilepsy resistant to anticonvulsant therapy. Patients were assessed pre- and postoperatively for seizure activity, endocrine function, ophthalmology, and neurocognitive function. Two patients had precocious puberty and all had evidence of developmental delay and behavioral problems. Postoperatively, all children experienced at least a 50% reduction in seizure frequency with abolition of major seizure types; one child remains seizure-free. One child developed a mild postoperative right hemiparesis and one developed transient diabetes insipidus.

CONCLUSION

There were no adverse developmental effects of surgery. Transcallosal resection of HHs ameliorates resistant epilepsy syndromes associated with HH.

Psychological treatment of post-traumatic stress disorder (PTSD)

BACKGROUND

Psychological interventions are widely used in the treatment of post-traumatic stress disorder (PTSD).

OBJECTIVES

To perform a systematic review of randomised controlled trials of all psychological treatments following the guidelines of The Cochrane Collaboration.

SEARCH STRATEGY

Systematic searches of computerised databases, hand search of the Journal of Traumatic Stress, searches of reference lists, known websites and discussion fora, and personal communication with key workers.

SELECTION CRITERIA

Types of studies - Any randomised controlled trial of a psychological treatment. Types of participants - Adults suffering from traumatic stress symptoms for three months or more. Types of interventions - Trauma-focused cognitive behavioural therapy/exposure therapy (TFCBT); stress management (SM); other therapies (supportive therapy, non-directive counselling, psychodynamic therapy and hypnotherapy); group cognitive behavioural therapy (group CBT); eye movement desensitisation and reprocessing (EMDR). Types of outcomes - Severity of clinician rated traumatic stress symptoms. Secondary measures included self-reported traumatic stress symptoms, depressive symptoms, anxiety symptoms, adverse effects and dropouts.

DATA COLLECTION AND ANALYSIS

Data were entered using Review Manager software. Quality assessments were performed. Data were analysed for summary effects using Review Manager 4.2.

MAIN RESULTS

Thirty-three studies were included in the review. With regards to reduction of clinician assessed PTSD symptoms measured immediately after treatment TFCBT did significantly better than waitlist/usual care (standardised mean difference (SMD) = -1.40; 95% CI, -1.89 to -0.91; 14 studies; n = 649). There was no significant difference between TFCBT and SM (SMD = -0.27; 95% CI, -0.71 to 0.16; 6 studies; n = 239). TFCBT did significantly better than other therapies (SMD = -0.81; 95% CI, -1.19 to -0.42; 3 studies; n = 120). Stress management did significantly better than waitlist/usual care (SMD = -1.14; 95% CI, -1.62 to -0.67; 3 studies; n = 86) and than other therapies (SMD = -1.22; 95% CI, -2.09 to -0.35; 1 study; n = 25). There was no significant difference between other therapies and waitlist/usual care control (SMD = -0.43; 95% CI, -0.90 to 0.04; 2 studies; n = 72). Group TFCBT was significantly better than waitlist/usual care (SMD = -0.72; 95% CI, -1.14 to -0.31). EMDR did significantly better than waitlist/usual care (SMD = -1.51; 95% CI, -1.87 to -1.15; 5 studies; n = 162). There was no significant difference between EMDR and TFCBT (SMD = 0.02; 95% CI, -0.28 to 0.31; 6 studies; n = 187). There was no significant difference between EMDR and SM (SMD = -0.35; 95% CI, -0.90 to 0.19; 2 studies; n = 53). EMDR did significantly better than other therapies (self-report) (SMD = -0.84; 95% CI, -1.21 to -0.47; 2 studies; n = 124).

AUTHORS' CONCLUSIONS

There was evidence individual TFCBT, EMDR, stress management and group TFCBT are effective in the treatment of PTSD. Other non-trauma focused psychological treatments did not reduce PTSD symptoms as significantly. There was some evidence that individual TFCBT and EMDR are superior to stress management in the treatment of PTSD at between 2 and 5 months following treatment, and also that TFCBT, EMDR and stress management were more effective than other therapies. There was insufficient evidence to determine whether psychological treatment is harmful. There was some evidence of greater drop-out in active treatment groups. The considerable unexplained heterogeneity observed in these comparisons, and the potential impact of publication bias on these data, suggest the need for caution in interpreting the results of this review.

The Environmental Stewardship System (ESS): a generic system for assuring rural environmental performance

The Environmental Stewardship System (ESS) is proposed as a generic assurance system for demonstrating environmental performance. It incorporates Environmental Management Systems (EMS) and is matched to natural resources management (NRM) and catchment targets. ESS is a framework for aligning and clarifying environmental objectives and targets across scales. It operates at the catchment and farm levels, interdependently, focusing on the main industries, mainstream farming methods and whole-farm business management. For farmers, it provides a staged pathway of increasing levels of performance and audit process that they can progress along, up to full ISO 14001. It is a modular system that is expandable to suit the particular operational needs of land managers, industries and catchment agencies. ESS is an inclusive framework for integrating various industry farm management improvement schemes and other management requirements. It is an auditable system to provide recognition to land managers who deliver environmental stewardship. The ESS was developed from the findings of the Murray–Darling Basin Commission’s Watermark Environmental Stewardship Project. By addressing the four major deficiencies in current arrangements for NRM delivery (the Stewardship Standard is poorly defined at the Murray–Darling Basin and at the local scales; reporting of outcomes is poorly aligned across scales; and auditing arrangements are not integrated) ESS has the potential to significantly improve the delivery of NRM within Australia, when the drivers for uptake are strong enough. In particular, it would reinforce and elaborate the Australian regional NRM delivery model at the subregional scale. The ESS provides a national framework for assured agricultural production and rural land management. It is in the public domain for others to draw from or adopt.

Techniques for preventing hypotension during spinal anaesthesia for caesarean section

BACKGROUND

Maternal hypotension, the most frequent complication of spinal anaesthesia for caesarean section, can be associated with severe nausea or vomiting which can pose serious risks to the mother (unconsciousness, pulmonary aspiration) and baby (hypoxia, acidosis and neurological injury).

OBJECTIVES

To assess the effects of prophylactic interventions for hypotension following spinal anaesthesia for caesarean section.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2005).

SELECTION CRITERIA

Randomised controlled trials comparing interventions to prevent hypotension with placebo or alternative treatment in women having spinal anaesthesia for caesarean section.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed eligibility and methodological quality of studies, and extracted data.

MAIN RESULTS

We included 75 trials (a total of 4624 women). Crystalloids were more effective than no fluids (relative risk (RR) 0.78, 95% confidence interval (CI) 0.60 to 1.00; one trial, 140 women, sequential analysis) and colloids were more effective than crystalloids (RR 0.68, 95% CI 0.52 to 0.89; 11 trials, 698 women) in preventing hypotension following spinal anaesthesia at caesarean section. No differences were detected for different doses, rates or methods of administering colloids or crystalloids. Ephedrine was significantly more effective than control (RR 0.51, 95% CI 0.33 to 0.78; seven trials, 470 women) or crystalloid (RR 0.70, 95% CI 0.50 to 0.96; four trials, 293 women) in preventing hypotension. No significant differences in hypotension were seen between ephedrine and phenylephrine (RR 0.95, 95% CI 0.37 to 2.44; three trials, 97 women) and phenylephrine was more effective than controls (RR 0.27, 95% CI 0.16 to 0.45; two trials, 110 women). High rates or doses of ephedrine may increase hypertension and tachycardia incidence. Lower limb compression was more effective than control (no leg compression) (RR 0.69, 95% CI 0.53 to 0.90; seven trials, 399 women) in preventing hypotension, although different methods of compression appeared to vary in their effectiveness. No other comparisons between different physical methods such as position were shown to be effective, but these trials were often small and thus underpowered to detect true effects should they exist.

AUTHORS' CONCLUSIONS

While interventions such as colloids, ephedrine, phenylephrine or lower leg compression can reduce the incidence of hypotension, none have been shown to eliminate the need to treat maternal hypotension during spinal anaesthesia for caesarean section. No conclusions can be drawn regarding rare adverse effects due to the relatively small numbers of women studied.

First Report of Alternaria Brown Spot of Citrus Caused by Alternaria alternata in Peru

Alternaria brown spot, caused by Alternaria alternata (Fr.) Keissler, causes leaf, twig, and fruit lesions and reduces yield and fruit quality of many tangerines (Citrus reticulata Blanco) and their hybrids (3). In 2003, characteristic symptoms of brown spot were observed on young leaves and fruit of 'Minneola' tangelo in the Satipo Province of Peru. In 2004, the disease was discovered in the provinces of Chanchamayo, Leoncio Prado, and La Convención in the Junin, Huanuco, and Cusco regions, respectively, as well as in the Apurimac and the Ene valleys. In 2005, it was confirmed in the province of Oxapampa in the Pasco Region. Brown-to-black lesions surrounded by yellow halos and veinal necrosis were observed on young leaves, often causing abscission of young shoots and twig dieback. Light brown, circular lesions were observed on fruit, and when severe, resulted in premature abscission. Isolations from infected leaves and twigs were made on potato dextrose agar (PDA) with 10 μg/ml of benomyl. Colonies that developed after 5 days at 27°C were olive brown-to-black and produced small, muriform, pigmented conidia typical of A. alternata. On PDA without benomyl, gray colonies with conidia typical of Colletotrichum gloeosporioides were recovered frequently. Inoculation of three detached young shoots of 'Minneola' by spraying with a suspension of 10⁵ conidia/ml of A. alternata produced leaf and twig symptoms characteristic of the disease after 48 h and confirmed pathogenicity of three isolates. Symptoms were not observed on control leaves sprayed with water nor on an equal number of leaves inoculated with a suspension of 10⁵ conidia/ml of C. gloeosporioides. Reisolation of A. alternata from diseased tissue fulfilled Koch's postulates. DNA was extracted from 17 isolates and a partial endopolygalacturonase gene was amplified and sequenced (2). Sequences of all 17 isolates were identical, and in BLAST searches of the NCBI database, the closest matches were A. alternata accession nos. AY295023.1, AY295022.1, and AY295021.1 with 100, 99.8, and 99.8% sequence similarity, respectively. Phylogenetic analyses revealed that all isolates from Peru clustered with brown spot isolates from Israel, Turkey, South Africa, and Australia (1). These results, along with morphological characterization and pathogenicity tests, confirm the identity of the fungus as the tangerine pathotype of A. alternata. The disease has significantly reduced yield and the commercial value of fruit and may be a limiting factor for the production of susceptible cultivars in those areas of Peru. References: (1) T. L. Peever et al. Phytopathology 92:794, 2002. (2) T. L. Peever et al. Mycologia 96:119, 2004, (3) L.W. Timmer et al. Pages 19-21 in: Compendium of Citrus Diseases. 2nd ed. L. W. Timmer et al eds. The American Phytopathological Society, St. Paul, MN, 2000.

Psychological treatment of post-traumatic stress disorder (PTSD)

BACKGROUND

Psychological interventions are widely used in the treatment of post-traumatic stress disorder (PTSD).

OBJECTIVES

To perform a systematic review of randomised controlled trials of all psychological treatments except eye movement desensitisation and reprocessing following the guidelines of the Cochrane Collaboration.

SEARCH STRATEGY

Systematic searches of computerised databases, hand search of the Journal of Traumatic Stress, searches of reference lists, known websites and discussion fora, and personal communication with key workers.

SELECTION CRITERIA

Types of studies - Any randomised controlled trial of a psychological treatment. Types of participants - Adults suffering from traumatic stress symptoms for three months or more. Types of interventions - Trauma-focused cognitive behavioural therapy/exposure therapy (TFCBT); stress management (SM); other therapies (supportive therapy, non-directive counselling, psychodynamic therapy and hypnotherapy); group cognitive behavioural therapy (group CBT). Types of outcomes - Severity of clinician rated traumatic stress symptoms. Secondary measures included self-reported traumatic stress symptoms, depressive symptoms, anxiety symptoms, adverse effects and dropouts.

DATA COLLECTION AND ANALYSIS

Data was entered using the Review Management software. Quality assessments were performed. The data were analysed for summary effects using the RevMan 4.2 programme.

MAIN RESULTS

Twenty-nine studies were included in the review. With regards to reduction of clinician assessed PTSD symptoms TFCBT did significantly better than waitlist/usual care (standardised mean difference (SMD) = -1.36; 95% CI, -1.88 to -0.84; 13 studies; n = 609). There was no significant difference between TFCBT and SM (SMD = -0.27; 95% CI, -0.71 to 0.16; 6 studies; n = 239). TFCBT did significantly better than other therapies (SMD = -0.81; 95% CI, -1.19 to -0.42; 3 studies; n = 120). Stress management did significantly better than waitlist/usual care (SMD = -1.14; 95% CI, -1.62 to -0.67; 3 studies; n = 86) and than other therapies (SMD = -1.22; 95% CI, -2.09 to -0.35; 1 study; n = 25). There was no significant difference between other therapies and waitlist/usual care control (SMD = -0.43; 95% CI, -0.90 to 0.04; 2 studies; n = 72). Group TFCBT was significantly better than waitlist/usual care (SMD = -0.72; 95% CI, -1.14 to -0.31).

AUTHORS' CONCLUSIONS

There was evidence that individual TFCBT, stress management and group TFCBT are effective in the treatment of PTSD. Other non-trauma focused psychological treatments did not reduce PTSD symptoms as significantly. There was some evidence that individual TFCBT is superior to stress management in the treatment of PTSD at between 2 and 5 months following treatment, and also that TFCBT was also more effective than other therapies. There was insufficient evidence to determine whether psychological treatment is harmful. There was some evidence of greater drop-out in active treatment groups.

The use of glyceryl trinitrate ointment with EMLA cream for i.v. cannulation in children undergoing routine surgery

This prospective randomized controlled double-blind trial was performed to investigate whether glyceryl trinitrate (GTN) ointment, applied ten minutes after the removal of a eutectic mixture of local anaesthetic cream, lignocaine/ prilocaine (EMLA), influences site selection for intravenous cannulation in children. Eighty children aged between five and 15 years, having general surgery as day patients, received EMLA cream on both hands for 90 minutes prior to transfer to the theatre suite. Acting as their own controls, the children received GTN on one hand, and placebo on the other, after removal of the EMLA cream and ten minutes prior to the insertion of an intravenous cannula. The application of GTN or placebo to left or right hand was blinded and randomized. At induction, the hand with the visually best quality veins was selected and cannulated. The primary outcome was selection between the EMLA/GTN hand and EMLA/placebo hand. The selection having been made, the number of attempts at cannulation, ease of insertion and pain scores (VAS) for cannulation were also recorded. The choice of hand was positively influenced by the use of GTN, with the GTN hand chosen in 51 of 72 (70%) children who completed the protocol (P = 0.001). The findings of this study suggest that the application of GTN after EMLA removal may be clinically useful in aiding cannulation in children.

Image-guided acoustic therapy

The potential role of therapeutic ultrasound in medicine is promising. Currently, medical devices are being developed that utilize high-intensity focused ultrasound as a noninvasive method to treat tumors and to stop bleeding (hemostasis). The primary advantage of ultrasound that lends the technique so readily to use in noninvasive therapy is its ability to penetrate deep into the body and deliver to a specific site thermal or mechanical energy with submillimeter accuracy. Realizing the full potential of acoustic therapy, however, requires precise targeting and monitoring. Fortunately, several imaging modalities can be utilized for this purpose, thus leading to the concept of image-guided acoustic therapy. This article presents a review of high-intensity focused ultrasound therapy, including its mechanisms of action, the imaging modalities used for guidance and monitoring, some current applications, and the requirements and technology associated with this exciting and promising field.

Blood-compatible biomaterials by surface coating with a novel antithrombin-heparin covalent complex

Covalent antithrombin-heparin complex (ATH) was covalently grafted to a polycarbonate urethane (Corethane) endoluminal graft (a kind gift of Corvita Corporation) after being activated using 0.3% m/m NaOCl in 0.15 M phosphate pH 6.0. ATH graft density (1.98 x 10(-7) mol/m2) was 6 times the maximum amount of unfractionated heparin (UFH) that could be bound to polycarbonate urethane surfaces. Surface-bound ATH could be stored in sterile 0.15 M NaCl at 4 degrees C for at least 2 months with good antithrombotic activity before being implanted into rabbits. Analysis of ATH-coated tubing showed that it contained significant direct thrombin inhibitory activity. In vivo testing in a rabbit model was compared to non-activated non-coated surfaces, activated-non-coated surfaces, hirudin-coated surfaces and antithrombin (AT)-coated surfaces. The weight of the clot generated in the ATH-coated graft tubing was significantly less than the weight of the clot generated within the hirudin-coated graft (p = 0.03 with a 1-tailed Student's t test). The anticoagulant nature of ATH grafts in vivo was shown to be due to bound ATH because boththe AT-coated surfaces and non-coated but activated surfaces showed similar thromboresistant efficacy to that of untreated material (ANOVA; p < 0.05). Apart from the direct antithrombin activity that contributed to much of the prolonged patency in vivo, surface-bound ATH likely catalyzed AT inhibition of thrombin, as evidenced by a significant number of 125I-AT binding sites (> or = 1.5 x 10(-8) mol/m2). Thus, ATH appears to be a good candidate for coating cardiovascular devices, such as endoluminal grafts, with high levels of substitution and significant long-term blood-compatibility.

Techniques for preventing hypotension during spinal anaesthesia for caesarean section

BACKGROUND

Maternal hypotension is the most frequent complication of spinal anaesthesia for caesarean section. Most workers define hypotension as a maternal systolic blood pressure below 70-80% of baseline recordings and/or an absolute value of < 90 - 100mmHg. Hypotension is often associated with nausea and vomiting and, if severe, poses serious risks to mother (unconsciousness, pulmonary aspiration) and baby (hypoxia, acidosis and neurological injury). Several strategies are currently used to prevent or minimise hypotension but there is no established ideal technique.

OBJECTIVES

To assess the relative efficacy and side effects of prophylactic interventions for hypotension following spinal anaesthesia for caesarean section.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group Trials Register (January 2002) and the Cochrane Controlled Trials Register (Cochrane Library, Issue 4, 2001).

SELECTION CRITERIA

All published or unpublished randomised controlled trials comparing interventions to prevent hypotension with placebo or alternative treatment in women having spinal anaesthesia for caesarean section.

DATA COLLECTION AND ANALYSIS

Trials identified from searching are assessed for inclusion by the same two reviewers independently. Studies are excluded from review where: hypotension is not an outcome measure or clearly defined prior to administering a rescue treatment; randomisation is unsatisfactory; the spinal anaesthetic technique or dose of local anaesthetic is not controlled-for; and the intervention is implemented in response to a fall in blood pressure rather than for prevention. Review Manager software is used for calculation of the treatment effect, represented by relative risks and proportional and absolute risk reductions.

MAIN RESULTS

Twenty-five trials (1477 women) meet our inclusion criteria. Four of fifteen interventions reviewed reduce the incidence of hypotension under spinal anaesthesia for caesarean section: (1) crystalloid versus control, relative risk (RR) 0.78 (95% confidence interval (CI) 0.63, 0.98); (2) pre-emptive colloid administration versus crystalloid, RR 0.54 (95% CI 0.37, 0.78); (3) ephedrine versus control, RR 0.69 (95% CI 0.57, 0.84); and (4) lower limb compression versus control, RR 0.70 (95% CI 0.59, 0.83). Ephedrine is associated with dose-related maternal hypertension and tachycardia, and fetal acidosis of uncertain clinical significance.

REVIEWER'S CONCLUSIONS

No intervention reliably prevents hypotension during spinal anaesthesia for caesarean section. No conclusions are drawn regarding rare adverse effects of interventions due to their probable low incidence and the small numbers of women studied. Further trials are recommended, in particular assessing a combination of the beneficial interventions, ie colloid or crystalloid preloading, ephedrine administration and leg compression with bandages, stockings or inflatable boots.

Safety and outcomes of thrombolysis with tissue plasminogen activator for treatment of intravascular thrombosis in children

OBJECTIVES

In this study, we tried to determine the safety and outcomes of thrombolysis with tissue plasminogen activator of intravascular thrombus.

STUDY DESIGN

Eighty consecutive children were treated between 1985 and 1999 in a tertiary care setting in a retrospective case series. There were 65 arterial thrombi (56 after cardiac catheterization) and 15 venous thrombi treated with tPA at an average dose of tPA of 0.5 mg/kg/hour for a median duration of 6 hours.

RESULTS

Clot resolution was complete in 65% of children, partial in 20%, and there was no effect in 15%. There were major complications in 40%, minor complications in 30%, and no complications in 30%. Two patients had cerebral ischemia secondary to hypotension because of profound bleeding, with intracranial hemorrhage in 2 additional patients. Clot resolution was not related to patient age or weight, dose, and duration of tPA therapy and fibrinogen levels. However, complications were more likely in patients who weighed less, had a longer duration of therapy, a greater decrease in fibrinogen levels, and who failed to have resolution of their clot.

CONCLUSIONS

tPA therapy can be effective in the thrombolysis of intravascular thrombus in children, but is associated with a low margin of safety and an unknown risk-benefit ratio.

Structuring prescribing data into traffic-light categories; a tool for evaluating treatment quality in primary care

BACKGROUND

Prescribing feedback based on aggregated data alone does not give the information needed to improve treatment quality.

OBJECTIVES

Our aim was to develop a new method, or tool, of presenting prescribing feedback which, combined with guideline recommendations, makes it possible for doctors to judge their own prescribing as good or bad.

METHODS

Asthma was chosen as a disease model, as treatment recommendations are readily available published as national and international guidelines. Four mean daily dosage intervals of inhaled short-acting beta-agonists and four mean daily dosage intervals of inhaled steroids were combined into a 4 x 4 matrix. This matrix of 16 combined dosage boxes was presented to 68 Norwegian GPs participating in peer review groups. As a first step, the GPs in the groups reached consensus on what they considered to be appropriate and inappropriate combined dosage intervals of these drugs based on national guideline recommendations and their joint clinical experience. Accordingly, traffic-light colours, green and red, were assigned to the combined dosage boxes in the matrix. Treatments in boxes difficult to judge were coloured yellow. During a 1-year period prior to the consensus meetings, the dispensed inhaled short-acting beta-agonists and inhaled steroids of each of the doctors' patients were recorded at the local pharmacies. As a second step in developing the new method, the number of patients treated within each of the coloured boxes was presented to the GPs in the peer review groups. These combined presentations provided an overview to the whole group, and individually to each GP, of how many patients were actually given appropriate or inappropriate treatment according to their own agreed upon standard.

RESULTS

The GPs categorized 34% of 1122 evaluated patients receiving inhaled short-acting beta-agonists or inhaled steroids as treated inappropriately during the 1-year registration period. Appropriate treatment was given to 47% of the patients, and in 19% of the cases the treatment was difficult to evaluate.

CONCLUSIONS

A method has been developed enabling GPs to categorize prescribing information into good (green), bad (red) and difficult to judge (yellow) treatment qualities, based on guideline recommendations and clinical experience. The actual prescribing data for each GP were labelled according to the same colour scheme, thus revealing to each GP his or her own actual prescribing compared with their own treatment standard, yielding information and motivation for quality improvement efforts.

Cerebral sinovenous thrombosis in children

BACKGROUND

Cerebral sinovenous thrombosis in children is a serious disorder, and information is needed about its prevention and treatment.

METHODS

The Canadian Pediatric Ischemic Stroke Registry was initiated in 1992 at the 16 pediatric tertiary care centers in Canada. Children (newborn to 18 years of age) with symptoms and radiographic confirmation of sinovenous thrombosis were included.

RESULTS

During the first six years of the registry, 160 consecutive children with sinovenous thrombosis were enrolled, and the incidence of the disorder was 0.67 cases per 100,000 children per year. Neonates were most commonly affected. Fifty-eight percent of the children had seizures, 76 percent had diffuse neurologic signs, and 42 percent had focal neurologic signs. Risk factors included head and neck disorders (in 29 percent), acute systemic illnesses (in 54 percent), chronic systemic diseases (in 36 percent), and prothrombotic states (in 41 percent). Venous infarcts occurred in 41 percent of the children. Fifty-three percent of the children received antithrombotic agents. Neurologic deficits were present in 38 percent of the children, and 8 percent died; half the deaths were due to sinovenous thrombosis. Predictors of adverse neurologic outcomes were seizures at presentation and venous infarcts.

CONCLUSIONS

Sinovenous thrombosis in children affects primarily neonates and results in neurologic impairment or death in approximately half the cases. The occurrence of venous infarcts or seizures portends a poor outcome.

The use of alteplase to restore patency of central venous lines in pediatric patients: a cohort study

We evaluated the efficacy and safety of alteplase to restore central venous line (CVL) patency in a consecutive cohort study. A uniform, weight-dependent protocol for alteplase administration was established prospectively. For children < or =10 kg, a dose of 0.5 mg was used; for children >10 kg, doses of 1 to 2 mg were used. The alteplase remained instilled for 1 to 4 hours or overnight. Retrospective data accrual found that 25 children received alteplase for a total of 34 courses; 29 (85%) of the 34 courses of alteplase completely restored CVL patency. Alteplase appears to be a safe and effective thrombolytic agent for CVL patency restoration in children.

Chickenpox and stroke in childhood: a study of frequency and causation

BACKGROUND AND PURPOSE

The purpose of this study was to determine whether infection with varicella is causal for arterial ischemic stroke (AIS) in children.

METHODS

First, a prospective cohort study was conducted in young children (aged 6 months to 10 years) with AIS at 2 institutions (cohort study). The presence of varicella infection <12 months before AIS was determined and compared with the published frequency of varicella infection in the healthy pediatric population. The clinical and radiographic features of AIS were compared between the varicella and nonvaricella study cohorts. Second, a literature search of varicella-associated AIS was conducted, and the clinical and radiographic features were compared with the study nonvaricella cohort.

RESULTS

In the cohort study, 22 (31%) of 70 consecutive children with AIS had a varicella infection in the preceding year compared with 9% in the healthy population. Children in the varicella cohort were more likely to have basal ganglia infarcts (P<0.001), abnormal cerebral vascular imaging (P<0.05), and recurrent AIS or transient ischemic attacks (P<0.05) than those in the nonvaricella cohort. The pooled literature analysis of 51 cases of varicella-associated AIS showed similar findings to the varicella cohort.

CONCLUSION

In young children with AIS, there is a 3-fold increase in preceding varicella infection compared with published population rates, and varicella-associated AIS accounts for nearly one third of childhood AIS. Varicella-associated AIS has characteristic features, including a 2-fold increase in recurrent AIS and transient ischemic attacks. Varicella is an important risk factor for childhood AIS.

Treatment of vitamin K deficiency in cystic fibrosis: Effectiveness of a daily fat-soluble vitamin combination

OBJECTIVE

Patients with cystic fibrosis (CF) and pancreatic insufficiency (PI) commonly have vitamin K deficiency, and those with CF-associated liver disease (CFLD) have universal vitamin K deficiency. We evaluated the effectiveness of an oral fat-soluble vitamin combination (ADEKs) to treat patients with vitamin K deficiency.

STUDY DESIGN

Patients with PI and CF (mean age, 15 years; range, 0.6 to 46 years) including 6 with advanced CFLD were prospectively enrolled in a study of a fat-soluble vitamin combination taken on a daily basis. None had received vitamin K supplementation for at least 4 months before the study. Fat-soluble vitamin combination supplementation was given for a minimum of 4 months; the mean vitamin K intake was 0.18 mg/d (SD = 0.1, range, 0 to 0.3). The primary outcome was change in plasma PIVKA-II (prothrombin in vitamin K absence).

RESULTS

Before supplementation 58 (81%) of 72 patients had abnormal PIVKA-II levels (>2.9 ng/mL). After supplementation 29 (40%) had abnormal PIVKA-II levels (P =.001). All 6 patients with advanced CFLD had abnormal PIVKA-II levels (median, range of 20.8, 5.5 to 55 ng/mL) before treatment, which corrected to normal in 50% (4.1, 2.1 to 65 ng/mL). Four patients, 2 with CFLD, had a prolonged prothrombin time (>13.5 seconds) at both time periods.

CONCLUSIONS

An oral fat-soluble vitamin combination with a modest amount of vitamin K can, as a daily supplement, improve the PIVKA-II levels in patients with PI and CF.

Improving doctors' prescribing behaviour through reflection on guidelines and prescription feedback: a randomised controlled study

BACKGROUND

It is difficult to put research findings into clinical practice by either guidelines or prescription feedback.

AIM

To study the effect on the quality of prescribing by a combined intervention of providing individual feedback and deriving quality criteria using guideline recommendations in peer review groups.

METHODS

199 general practitioners in 32 groups were randomised to participate in peer review meetings related to either asthma or urinary tract infections. The dispensing by the participating doctors of antiasthmatic drugs and antibiotics during the year before the intervention period provided the basis for prescription feedback. The intervention feedback was designed to describe the treatment given in relation to recommendations in the national guidelines. In each group the doctors agreed on quality criteria for their own treatment of the corresponding diseases based on these recommendations. Comparison of their prescription feedback with their own quality criteria gave each doctor the proportion of acceptable and unacceptable treatments.

MAIN OUTCOME MEASURE

Difference in the prescribing behaviour between the year before and the year after the intervention.

RESULTS

Before intervention the mean proportions of acceptably treated asthma patients in the asthma group and urinary tract infection (control) group were 28% and 27%, respectively. The mean proportion of acceptably treated patients in the asthma group was increased by 6% relative to the control group; this difference was statistically significant. The mean proportions of acceptable treatments of urinary tract infection before intervention in the urinary tract infection group and asthma (control) group were 12% for both groups which increased by 13% in the urinary tract infection group relative to the control group. Relative to the mean pre-intervention values this represented an improvement in treatment of 21% in the asthma group and 108% in the urinary tract infection group.

CONCLUSIONS

Deriving quality criteria of prescribing by discussing guideline recommendations gave the doctors a basis for judging their treatment of individual patients as acceptable or unacceptable. Presented with feedback on their own prescribing, they learned what they did right and wrong. This provided a foundation for improvement and the process thus instigated resulted in the doctors providing better quality patient care.