Inadequate neuraxial anaesthesia during caesarean delivery: a survey of practitioners

BACKGROUND

We aimed to determine the knowledge, training, practices and attitudes of obstetric anaesthetic practitioners with regard to failed neuraxial anaesthesia for caesarean delivery.

METHOD

We performed a contemporaneous and representative survey in an innovative fashion. We conducted an international cross-sectional study of obstetric anaesthetic practitioners at the Annual Scientific Meeting of the Obstetric Anaesthetists' Association (OAA 2021). Validated survey questions were collected in real time using an audience response system.

RESULTS

Of the 426 participants who logged into the survey system, 356 provided responses (4173 responses to 13 questions, across all grades/seniority of practitioner). The number of responses to questions ranged from 81% to 61%. Survey responses suggest that it is routine for respondents to inform patients about the difference between pain and expected intra-operative sensations, (320/327, 97.9%) but less routine to inform patients of the risk of intra-operative pain (204/260, 78.5%), or the possibility of conversion to general anaesthesia. (290/309 93.8%). Only 30% of respondents reported the use of written guidelines for follow-up of patients who experience intra-operative pain under neuraxial anaesthesia, and only 23% reported formal training in management of intra-operative pain under neuraxial anaesthesia. Respondents felt that inadequate block duration, prolonged surgery, and patient anxiety were contributory factors to failed anaesthesia, and the contributory factors differed between grade/seniority of practitioner. Modalities used to test a block were cold, motor block and light touch, with approximately 65% of respondents routinely using three modalities.

CONCLUSIONS

Our study survey found that the consent process may not always be adequately comprehensive, and that standardised documentation and testing of the block and focused training may be beneficial to prevent patient dissatisfaction and the chance of litigation.

Education in obstetric anesthesiology: an international approach

Competency-based training and active teaching methods are increasingly becoming accepted and utilized in medical schools and hospitals, and obstetric anesthesiology training is expected to follow this process. This article summarizes current modalities of obstetric anesthesiology training in five countries from various parts of the world. Analysis of these curricula shows that implementation of new educational methods is variable, incomplete, and lacking in data related to patient outcomes. Research in assessments and practical applications are required to avoid wide ranges of educational strategies.

Neurodevelopmental outcomes after prenatal exposure to anaesthesia for maternal surgery: a propensity-score weighted bidirectional cohort study

Up to 1% of pregnant women undergo anaesthesia for non-obstetric surgery. This study investigated neurodevelopmental outcomes after prenatal anaesthesia for maternal surgery. A bidirectional cohort study of children born between 2001 and 2018 was performed: neurodevelopmental outcomes of children who had received prenatal anaesthesia for maternal surgery were prospectively compared with unexposed children, with exposure status being assessed retrospectively. Children exposed to anaesthesia for obstetric and fetal surgery were excluded. The primary outcome was the global executive composite of the behaviour rating inventory of executive function score. Our secondary outcomes were: total problems; internalising problems and externalising problems derived from the child behaviour checklist; psychiatric diagnoses; and learning disorders. In 90% of exposed children, there was a single mean (SD) antenatal anaesthesia exposure lasting 91(94) min. There was a broad spectrum of indications, with abdominal surgery being most frequent. Parents of 129 exposed (response rate 68%) and 453 unexposed (response rate 63%) children participated. There were no arguments for non-response bias. After propensity weighting, there were no statistically significant differences in primary outcome, with a weighted mean difference (95%CI) of exposed minus unexposed children of 1.9 (-0.4-4.2), p = 0.10; or any of the secondary outcomes. Sensitivity analyses confirmed the robustness. Exploratory analyses, however, showed significant differences in certain subgroups for the primary outcome, (e.g. for intra-abdominal surgery, exposure duration > 1 h) and some cognitive subdomains (e.g. working memory and attention). This bidirectional cohort study, the largest investigation on the subject to date, has found no evidence in the general population for an association between prenatal exposure to anaesthesia and impaired neurodevelopmental outcomes.

Financial toxicity in patients with advanced solid malignancies participating in early-phase clinical trials

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Background: Financial toxicity (FT) adversely influences patient quality of life and is a barrier to clinical trial enrollment. Early phase clinical trials (EPTs) primarily recruit patients with advanced malignancies who have received all standard therapy regimens and may thus have high levels of FT. We sought to assess baseline FT and its association with clinicodemographic factors in patients participating in early phase clinical trials. Methods: We conducted a study to assess baseline FT in English-speaking patients (pts) with advanced metastatic solid tumors who were participating in EPTs at the Yale Cancer Center (Yale) and the Tisch Cancer Institute at Mount Sinai (Sinai). Pts were consented after EPT consent and prior to day 1 of study treatment. Pts completed a clinical and demographic questionnaire as well as the 11-item validated Comprehensive Score for Financial Toxicity (COST) FT instrument. Primary endpoints included baseline FT and association with clinicodemographic variables. Statistical analysis was performed using two-sided T-tests and Pearson correlations for numeric data and Fisher’s Exact Test for categorical data. Multivariate analysis was performed using a linear regression model. Results: 138 pts enrolled in this study, of whom 132 completed the COST instrument (Yale, N = 84; Sinai, N = 48). Median age was 62 and 49.2% were male. 71.2% patients self-identified as White and 15.2% as Black; 7.2% identified as Hispanic. 32.6% reported an annual income of < $50,000. Insurance providers included private insurers (50%), Medicare (31.8%), Medicaid (10.6%), and Medicaid with Medicare supplemental (3.8%). 56.8% reported monthly out of pocket medical expenses of $100 or more. Median FT score was 22.5 out of a maximum score of 44 (mean 21.5). FT scores ≥ 22.5 in pts were associated with age < 65 (OR = 2.229, P = 0.04), being the household money manager (OR = 2.98, P = 0.02), and being the primary wage earner (OR = 3.12, P = 0.004). FT scores < 22.5 in pts was associated with retirement (OR = 0.15, P = 3.67e-05). In multivariate analysis, retirement was associated with FT score < 22.5 (OR = 0.18, P = 0.02). There was no statistically significant difference in FT scores between Yale and Sinai pts. However, Sinai pts were more racially diverse (p = 3.05e-05), had lower household income (P = 0.01), out of pocket expenses (P = 0.01), ED visits (P = 0.0075), and dependents (P = 0.004) and were less likely to have private insurance (P = 0.004). Conclusions: Pts with advanced cancers consenting to EPTs report significant baseline FT. Our study encompasses a diverse population from two large urban academic centers. Baseline FT was higher among pts < 65 years of age, primary wage earners, and those who managed household finances independently. Retirement was a protective factor, which may be explained by the life savings often required to retire. Ongoing work will compare baseline and 2 month FT in this patient population.

Airway management guidance for the endemic phase of COVID-19

It is now apparent that severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) and coronavirus disease 2019 (COVID‐19) will remain endemic for some time. Improved therapeutics and a vaccine may shorten this period, but both are far from certain. Plans must be put in place on the assumption that the virus and its disease will continue to affect the care of patients and the safety of staff. This will impact particularly on airway management due to the inherent risk to staff during such procedures. Research is needed to clarify the nature and risk of respiratory aerosol‐generating procedures. Improved knowledge of the dynamics of SARS‐CoV‐2 infection and immunity is also required. In the meantime, we describe the current status of airway management during the endemic phase of the COVID‐19 pandemic. Some controversies remain unresolved, but the safety of patients and staff remains paramount. Current evidence does not support or necessitate dramatic changes to choices for anaesthetic airway management. Theatre efficiency and training issues are a challenge that must be addressed, and new information may enable this.

Identifying clinically meaningful severity categories for PROMIS pediatric measures of anxiety, mobility, fatigue, and depressive symptoms in juvenile idiopathic arthritis and childhood-onset systemic lupus erythematosus

PURPOSE

A key limitation to widespread adoption of patient-reported outcome (PRO) measures is the lack of interpretability of scores. We aim to identify clinical severity thresholds to distinguish categories of no problems, mild, moderate, and severe along the PROMIS® Pediatric T-score metric for measures of anxiety, mobility, fatigue, and depressive symptoms for use in populations with juvenile idiopathic arthritis (JIA) and childhood-onset systemic lupus erythematosus (cSLE).

METHODS

We used a modified standard setting methodology from educational testing to identify clinical severity thresholds (clinical cut scores). Using item response theory-based parameters from PROMIS item banks, we developed a series of clinical vignettes that represented different severity or ability levels along the PROMIS Pediatric T-score metric. In stakeholder workshops, participants worked individually and together to reach consensus on clinical cut scores. Median cut-score placements were taken when consensus was not reached. Focus groups were recorded and qualitative analysis was conducted to identify decision-making processes.

RESULTS

Nine adolescents (age 13-17 years) with JIA (33% female) and their caregivers, five adolescents (age 14-16 years) with cSLE (100% female) and their caregivers, and 12 pediatric rheumatologists (75% female) participated in bookmarking workshops. Placement of thresholds for bookmarks was highly similar across stakeholder groups (differences from 0 to 5 points on the PROMIS t-score metric) for all but one bookmark placement.

CONCLUSION

This study resulted in clinical thresholds for severity categories for PROMIS Pediatric measures of anxiety, mobility, fatigue, and depressive symptoms, providing greater interpretability of scores in JIA and cSLE populations.

Patient deprivation and perceived scan burden negatively impact the quality of whole-body MRI

AIM

To evaluate the association between the image quality of cancer staging whole-body magnetic resonance imaging (WB-MRI) and patient demographics, distress, and perceived scan burden.

MATERIALS AND METHODS

A sample of patients recruited prospectively to multicentre trials comparing WB-MRI with standard scans for staging lung and colorectal cancer were invited to complete two questionnaires. The baseline questionnaire, administered at recruitment, collated data on demographics, distress and co-morbidity. The follow-up questionnaire, completed after staging investigations, measured perceived WB-MRI scan burden (scored 1 low to 7 high). WB-MRI anatomical coverage, and technical quality was graded by a radiographic technician and grading combined to categorise the scan as "optimal", "sub-optimal" or "degraded". A radiologist categorised 30 scans to test interobserver agreement. Data were analysed using the chi-square, Fisher's exact, t-tests, and multinomial regression.

RESULTS

One hundred and fourteen patients were included in the study (53 lung, 61 colorectal; average age 65.3 years, SD=11.8; 66 men [57.9%]). Overall, 45.6% (n=52), scans were classified as "optimal" quality, 39.5% (n=45) "sub-optimal", and 14.9% (n=17) as "degraded". In adjusted analyses, greater deprivation level and higher patient-reported scan burden were both associated with a higher likelihood of having a sub-optimal versus an optimal scan (odds ratio [OR]: 4.465, 95% confidence interval [CI]: 1.454 to 13.709, p=0.009; OR: 1.987, CI: 1.153 to 3.425, p=0.013, respectively). None of the variables predicted the likelihood of having a degraded scan.

CONCLUSIONS

Deprivation and patients' perceived experience of the WB-MRI are related to image quality. Tailored protocols and individualised patient management before and during WB-MRI may improve image quality.

[Treatment resistant depression: actuality and perspectives in 2017]

Major depressive disorder (MDD) affects 3 to 17 % of adults. 15 to 30 % of patients with MDD suffer from treatment resistant depression (TRD). No international consensus defines TRD. The most common definition is " MDD that is not enough improved after two successive and different classes of antidepressant treatments in appropriate dose and duration ". The appropriate dose corresponds to maximal dose accepted by scientific reports and clinical recommendations, while the appropriate duration is around 6 weeks. TRD is diagnosed after excluding a pseudoresistant depression, that is related to weak compliance or to somatic and psychiatric differential diagnosis. As well as in MDD, molecular, neuro-anatomical and metabolic disturbances are involved in TRD. A decreased cerebral plasticity induced by low level of Brain-Derived Neurotrophic Factor (BDNF) is also reported. Several authors describe that the cerebral atrophy and the dopaminoglutaminergic system disturbances are more severe in TRD than in MDD. In contrast to MDD treatment, TRD treatment is most often physical treatment. Electroconvulsive therapy (ECT) followed by a tricyclic antidepressant and/or lithium is the most effective treatment. Deep brain stimulation and vagal nerve stimulation reach also a high rate of remission but they are both very invasive technique. Repetitive transcranial magnetic stimulation in TRD seems to be effective in TRD but lower than ECT. There are two majors purposes for this review. First it may help the clinician to understand the TRD's complexity and also it details the kind of treatment useful to care it.

Chronic delivery of α-melanocyte-stimulating hormone in rat hypothalamus using albumin-alginate microparticles: effects on food intake and body weight

Chronic delivery of neuropeptides in the brain is a useful experimental approach to study their long-term effects on various biological parameters. In this work, we tested albumin-alginate microparticles, as a potential delivery system, to study if continuous release in the hypothalamus of α-melanocyte-stimulating hormone (α-MSH), an anorexigenic neuropeptide, may result in a long-term decrease in food intake and body weight. The 2-week release of α-MSH from peptide-loaded particles was confirmed by an in vitro assay. Then, daily food intake and body weight were studied for 18 days in rats injected bilaterally into the paraventricular hypothalamic nucleus with particles loaded or not with α-MSH. A decrease in body weight gain, persisting throughout the study, was found in rats injected with α-MSH-charged particles as compared with rats receiving non-charged particles and with rats injected with the same dose of α-MSH in solution. Food intake was significantly decreased for 3 days in rats receiving α-MSH-loaded particles and it was not followed by the feeding rebound effect which appears after food restriction. The presence of α-MSH-loaded particles in the hypothalamus was confirmed by immunohistochemistry. In conclusion, our study validates albumin-alginate microparticles as a new carrier system for long-term delivery of neuropeptides in the brain and demonstrates that chronic delivery of α-MSH in the hypothalamus results in a prolonged suppression of food intake and a decrease of body weight gain in rats.

The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors

We present the main findings of the 5th National Audit Project on accidental awareness during general anaesthesia. Incidences were estimated using reports of accidental awareness as the numerator, and a parallel national anaesthetic activity survey to provide denominator data. The incidence of certain/probable and possible accidental awareness cases was ~1:19 600 anaesthetics (95% CI 1:16 700-23 450). However, there was considerable variation across subtypes of techniques or subspecialties. The incidence with neuromuscular blockade was ~1:8200 (1:7030-9700), and without it was ~1:135 900 (1:78 600-299 000). The cases of accidental awareness during general anaesthesia reported to 5th National Audit Project were overwhelmingly cases of unintended awareness during neuromuscular blockade. The incidence of accidental awareness during caesarean section was ~1:670 (1:380-1300). Two thirds (82, 66%) of cases of accidental awareness experiences arose in the dynamic phases of anaesthesia, namely induction of and emergence from anaesthesia. During induction of anaesthesia, contributory factors included: use of thiopental; rapid sequence induction; obesity; difficult airway management; neuromuscular blockade; and interruptions of anaesthetic delivery during movement from anaesthetic room to theatre. During emergence from anaesthesia, residual paralysis was perceived by patients as accidental awareness, and commonly related to a failure to ensure full return of motor capacity. One third (43, 33%) of accidental awareness events arose during the maintenance phase of anaesthesia, most due to problems at induction or towards the end of anaesthesia. Factors increasing the risk of accidental awareness included: female sex; age (younger adults, but not children); obesity; anaesthetist seniority (junior trainees); previous awareness; out-of-hours operating; emergencies; type of surgery (obstetric, cardiac, thoracic); and use of neuromuscular blockade. The following factors were not risk factors for accidental awareness: ASA physical status; race; and use or omission of nitrous oxide. We recommend that an anaesthetic checklist, to be an integral part of the World Health Organization Safer Surgery checklist, is introduced as an aid to preventing accidental awareness. This paper is a shortened version describing the main findings from 5th National Audit Project - the full report can be found at http://www.nationalauditprojects.org.uk/NAP5_home#pt.

5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors

We present the main findings of the 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia (AAGA). Incidences were estimated using reports of accidental awareness as the numerator, and a parallel national anaesthetic activity survey to provide denominator data. The incidence of certain/probable and possible accidental awareness cases was ~1:19,600 anaesthetics (95% confidence interval 1:16,700-23,450). However, there was considerable variation across subtypes of techniques or subspecialities. The incidence with neuromuscular block (NMB) was ~1:8200 (1:7030-9700), and without, it was ~1:135,900 (1:78,600-299,000). The cases of AAGA reported to NAP5 were overwhelmingly cases of unintended awareness during NMB. The incidence of accidental awareness during Caesarean section was ~1:670 (1:380-1300). Two-thirds (82, 66%) of cases of accidental awareness experiences arose in the dynamic phases of anaesthesia, namely induction of and emergence from anaesthesia. During induction of anaesthesia, contributory factors included: use of thiopental, rapid sequence induction, obesity, difficult airway management, NMB, and interruptions of anaesthetic delivery during movement from anaesthetic room to theatre. During emergence from anaesthesia, residual paralysis was perceived by patients as accidental awareness, and commonly related to a failure to ensure full return of motor capacity. One-third (43, 33%) of accidental awareness events arose during the maintenance phase of anaesthesia, mostly due to problems at induction or towards the end of anaesthesia. Factors increasing the risk of accidental awareness included: female sex, age (younger adults, but not children), obesity, anaesthetist seniority (junior trainees), previous awareness, out-of-hours operating, emergencies, type of surgery (obstetric, cardiac, thoracic), and use of NMB. The following factors were not risk factors for accidental awareness: ASA physical status, race, and use or omission of nitrous oxide. We recommend that an anaesthetic checklist, to be an integral part of the World Health Organization Safer Surgery checklist, is introduced as an aid to preventing accidental awareness. This paper is a shortened version describing the main findings from NAP5--the full report can be found at http://www.nationalauditprojects.org.uk/NAP5_home.

5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent, and medicolegal issues

The 5th National Audit Project (NAP5) of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland into accidental awareness during general anaesthesia (AAGA) yielded data related to psychological aspects from the patient, and the anaesthetist, perspectives; patients' experiences ranged from isolated auditory or tactile sensations to complete awareness. A striking finding was that 75% of experiences were for <5 min, yet 51% of patients [95% confidence interval (CI) 43-60%] experienced distress and 41% (95% CI 33-50%) suffered longer term adverse effect. Distress and longer term harm occurred across the full range of experiences but were particularly likely when the patient experienced paralysis (with or without pain). The patient's interpretation of what is happening at the time of the awareness seemed central to later impact; explanation and reassurance during suspected AAGA or at the time of report seemed beneficial. Quality of care before the event was judged good in 26%, poor in 39%, and mixed in 31%. Three-quarters of cases of AAGA (75%) were judged preventable. In 12%, AAGA care was judged good and the episode not preventable. The contributory and human factors in the genesis of the majority of cases of AAGA included medication, patient, and education/training. The findings have implications for national guidance, institutional organization, and individual practice. The incidence of 'accidental awareness' during sedation (~1:15,000) was similar to that during general anaesthesia (~1:19,000). The project raises significant issues about information giving and consent for both sedation and anaesthesia. We propose a novel approach to describing sedation from the patient's perspective which could be used in communication and consent. Eight (6%) of the patients had resorted to legal action (12, 11%, to formal complaint) at the time of reporting. NAP5 methodology provides a standardized template that might usefully inform the investigation of claims or serious incidents related to AAGA.

Community-based healthcare costs for children born low birthweight, preterm and/or small for gestational age: data from the Longitudinal Study of Australian Children

AIM

Children born low birthweight, preterm and/or small for gestational age (SGA) sustain substantially increased costs for hospital-based health care and additional educational support in the first few years of life. This is the first study internationally to investigate costs beyond hospital care, to community-based health care and prescription medicines across early and middle childhood with actual cost data, and to examine these costs according to the severity of perinatal risk.

METHOD

In the prospective Longitudinal Study of Australian Children, we followed two cohorts of children from age of 0 to 5 years (no increased perinatal risk, n = 3973; mild risk, n = 442; and moderate-to-high risk, n = 297), and from age of 4 to 9 years (no increased perinatal risk, n = 3629; mild risk, n = 465; and moderate-to-high risk, n = 361). Children were defined as mild risk if born 32-36 weeks, with birthweight 1500-2499 g, and/or SGA (<5-9th percentile), and moderate-to-high risk if born <32 weeks, birthweight <1500 g and/or extremely SGA (<5th percentile). Federal government expenditure (2011 $AUD) on healthcare attendances and prescription medication from birth to 9 years were calculated via data linkage to the Australian Medicare records.

RESULTS

Mean costs per child were A$362 higher (95% CI $156; 568) from 0 to 5 years and A$306 higher (95% CI $137; 475) from 4 to 9 years, for children with any compared with no increased perinatal risk (P < 0.001). At the population level, an additional A$32m was spent per year for children 0-9 years with any relative to no increased perinatal risk.

CONCLUSIONS

Perinatal risk is a major public health issue conferring considerable additional expense to community-based health care, most marked in the first year of life but persisting up to at least 10 years. Even without additionally considering burden, these findings add to the urgency of identifying effective mechanisms to reduce perinatal risk across its full spectrum.

Effects of pro-cholinergic treatment in patients suffering from spatial neglect

Spatial neglect is a neurological condition characterized by a breakdown of spatial cognition contralateral to hemispheric damage. Deficits in spatial attention toward the contralesional side are considered to be central to this syndrome. Brain lesions typically involve right fronto-parietal cortices mediating attentional functions and subcortical connections in underlying white matter. Convergent findings from neuroimaging and behavioral studies in both animals and humans suggest that the cholinergic system might also be critically implicated in selective attention by modulating cortical function via widespread projections from the basal forebrain. Here we asked whether deficits in spatial attention associated with neglect could partly result from a cholinergic deafferentation of cortical areas subserving attentional functions, and whether such disturbances could be alleviated by pro-cholinergic therapy. We examined the effect of a single-dose transdermal nicotine treatment on spatial neglect in 10 stroke patients in a double-blind placebo-controlled protocol, using a standardized battery of neglect tests. Nicotine-induced systematic improvement on cancellation tasks and facilitated orienting to single visual targets, but had no significant effect on other tests. These results support a global effect of nicotine on attention and arousal, but no effect on other spatial mechanisms impaired in neglect.

Primary healthcare costs associated with sleep problems up to age 7 years: Australian population-based study

OBJECTIVES

In Australian 0-7-year olds with and without sleep problems, to compare (1) type and costs to government of non-hospital healthcare services and prescription medication in each year of age and (2) the cumulative costs according to persistence of the sleep problem.

DESIGN

Cross-sectional and longitudinal data from a longitudinal population study.

SETTING

Data from two cohorts participating in the first two waves of the nationally representative Longitudinal Study of Australian Children.

PARTICIPANTS

Baby cohort at ages 0-1 and 2-3 (n=5107, 4606) and Kindergarten cohort at ages 4-5 and 6-7 (n=4983, 4460).

MEASUREMENTS

Federal Government expenditure on healthcare attendances and prescription medication from birth to 8 years, calculated via linkage to Australian Medicare data, were compared according to parent report of child sleep problems at each of the surveys.

RESULTS

At both waves and in both cohorts, over 92% of children had both sleep and Medicare data. The average additional healthcare costs for children with sleep problems ranged from $141 (age 5) to $43 (age 7), falling to $98 (age 5) to $18 (age 7) per child per annum once family socioeconomic position, child gender, global health and special healthcare needs were taken into account. This equates to an estimated additional $27.5 million (95% CI $9.2 to $46.8 million) cost to the Australian federal government every year for all children aged between 0 and 7 years. In both cohorts, costs were higher for persistent than transient sleep problems.

CONCLUSIONS

Higher healthcare costs were sustained by infants and children with sleep problems. This supports ongoing economic evaluations of early prevention and intervention services for sleep problems considering impacts not only on the child and family but also on the healthcare system.

Disease activity return during natalizumab treatment interruption in patients with multiple sclerosis

BACKGROUND

Due to a heightened risk of progressive multifocal leukoencephalopathy (PML) with increased natalizumab exposure, some physicians interrupt treatment of patients with multiple sclerosis (MS) despite a lack of data regarding the safety of treatment interruption, the rate and severity of MS disease activity return after treatment interruption, or alternative treatment strategies.

OBJECTIVES

To determine the effects of natalizumab treatment interruption on clinical and MRI measures of disease activity in relapsing patients with MS.

METHODS

Clinical relapses and gadolinium-enhanced (Gd+) lesions were analyzed over an 8-month period in patients from the AFFIRM, SENTINEL, and GLANCE studies of natalizumab, and their respective safety extension studies, following the voluntary suspension of natalizumab dosing that occurred in February 2005.

RESULTS

Relapses were analyzed in 1,866 patients, and Gd+ lesions were analyzed in 341 patients. Annualized relapse rates and Gd+ lesions both increased shortly after natalizumab interruption and peaked between 4 and 7 months. A consistent return of disease activity was observed regardless of overall natalizumab exposure, whether or not patients received alternative MS therapies, and in patients with highly active MS disease. A rebound of relapse or Gd+ lesion activity, beyond placebo-treated levels from the clinical studies, was not observed in any of the analyses conducted.

CONCLUSIONS

Following interruption of natalizumab treatment, MS disease activity returned in a pattern that was consistent with known pharmacokinetic and pharmacodynamic properties of natalizumab, and did not show evidence of rebound.

State-level differences in the oral health of Australian preschool and early primary school-age children

BACKGROUND

This study compares oral health outcomes and behaviours for young Australian children by residential state or territory to determine whether state differences arise from individual exposures to risk factors.

METHODS

Cross-sectional data for 4606 2-3 year olds and 4464 6-7 year olds were obtained from the Longitudinal Study of Australian Children. Outcome measures were parent-reports of children's caries experience, frequency of toothbrushing and dental services use.

RESULTS

For 2-3 year olds, children from the Australian Capital Territory were less likely to have parent-reported caries than children from other states, and more likely to brush their teeth twice daily and to have used dental services. For 6-7 year olds, optimal outcomes were observed in New South Wales for lowest caries experience, Western Australia for highest toothbrushing, and South Australia for highest dental services use. Adjustments for socio-demographic predictors did not eliminate state differences in oral health.

CONCLUSIONS

  Large state differences in the oral health of young children persisted after adjustment for individual socio-demographic determinants, suggesting these arise from variations in the systems to promote and care for children's oral health. Several states would benefit from a stronger emphasis on oral health promotion in young children, and disparities from a young age suggest the need for better engagement of early childhood professionals in oral health promotion.

Randomised double-blind, placebo-controlled trial of the effects of the 'party pills' BZP/TFMPP alone and in combination with alcohol

The objective of this study was to determine the clinical effects of party pills containing benzylpiperazine (BZP) and trifluoromethylphenylpiperazine (TFMPP) when taken alone and in combination with alcohol. The study was a randomised, double-blind, placebo-controlled trial conducted in a hospital-based clinic in Wellington, New Zealand. Thirty-five volunteers who had previously used party pills containing BZP were included in this trial. Participants received one of the following four treatments: 300 mg/74 mg BZP/TFMPP and placebo, 300 mg/74 mg BZP/TFMPP and 57.6 g (6 units) alcohol, placebo and 57.6 g (6 units) alcohol and double placebo. The primary outcome variable was a measure of driving performance, the standard deviation of lateral position (SDLP) measured at 6.5 h. Secondary measures included adverse events, cardiovascular effects, psychological function and delayed effects on sleep. The study was stopped early, after 35 of the planned 64 subjects had undertaken testing, because of severe adverse events that occurred in four of 10 BZP/TFMPP-only subjects, three of seven combined BZP/TFMPP and alcohol subjects, none of the 6 placebo subjects, and none of the 12 alcohol-only subjects. The overall rate of severe adverse events (defined as causing considerable interference with usual activity and/or rated by subject as severe) in those receiving BZP/TFMPP was seven of 17 (41.2%, 95% CI 18.4-67.1). The severe events included agitation, anxiety, hallucinations, vomiting, insomnia and migraine. BZP/TFMPP significantly improved the driving performance, decreasing SDLP at -4.2 cm (95% CI -6.8 to -1.6, P = 0.002). The effect of alcohol was to increase SDLP: 2.3 cm (95% CI -0.3 to 4.9, P = 0.08). BZP/TFMPP also resulted in increased heart rate and blood pressure and in difficulty in getting to sleep. BZP/TFMPP alone or with alcohol carries a significant risk of severe adverse events when taken in similar doses to those recommended by manufacturers.

Intra-operative sentinel lymph node metastasis detection by “one-step nucleic acid amplification (OSNA)”: results of the french multicentric study

Abstract #1004

Background: Sentinel node (SLN) biopsy is widely used as a staging procedure in early breast cancer. usual procedures for intra-operative assessment have a low sensitivity and lead to reoperations for axillary dissection when the SLN is metastatic. The semi-automated OSNA test is based on a short sample preparation step and subsequent rapid amplification of CK19 mRNA. Results are available within 30 - 40 minutes. The OSNA method was developed to accurately detect metastases (≥ 0.2mm) in an intra-operative setting. The objective of this study was to evaluate diagnostic performance of OSNA in comparison to intensive histological examination.&#x2028; Methods: A total of 509 fresh SLN (234 patients) were cut into four slices. Two alternate slices were analysed by OSNA, the remaining ones were cut at 200µm intervals. On each level, Haematoxylin & Eosin and immunohistochemical staining (CK19 and AE1/AE3) were performed. In case of discordant results, the lysates of samples were subjected to QRT-PCR and Western Blot (Discordant Case Investigation, DCI) in order to detect whether the discordances were caused by tissue allocation bias (TAB): localisation of tumour deposits in only one slice due to the study design.&#x2028; Results: results were concordant for 202/234 patients (33 positive and 169 negative). 17/32 discordant cases were due to TAB. 2 cases were ininterpretable due to procedure errors. For remaining discordant cases, 2 were histology + / OSNA - and 11 were histology - / OSNA + (8 of them had CK 19 expression levels close to the cutoff). The sensitivity was 94.30% and specificity 93.90%. The overall concordance rate was 93.96%.&#x2028; Conclusion: OSNA is a rapid and accurate tool for intra-operative assessment of SLN and could reduce the reoperation rate for secondary axillary dissection when the SLN is metastatic.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1004.

Is there a way to measure implementation of integration in different countries? The case of the PRISMA implementation qualitative methodology

Introduction

The PRISMA implementation research has used an innovative tool: the penetration rate of integrated model in the system. The experimentation in France of the PRISMA adopts and adapts this methodology.

Aims and objective

This measurement relates to the functions of the 6 tools and mechanisms of the model: coordination boards, single entry point, case-management, single assessment instrument, individualised services plan and information system. In contrast with Quebec, no public policy in France incites to move towards this model of integration. In addition, in the French system the construction of coordination boards is complex because there is as much as ten supervision authorities and about fifteen organisation managers involved in each experimental site.

Methods of adaptation of the tool in France

The measurement was not only the absence, partial existence or existence of the 6 components but takes into account the appropriation process for each one, the administrative time and the new definition of thresholds to reach as compared to the model.

Results

This research tool presents two advantages. The measurement scale enables also the partners to appropriate the function of each model component and more precisely the global model of the integration. Actors do not feel evaluated but accompanied.

Comparison of bacterial colonization rates of antiseptic impregnated and pure polymer central venous catheters in the critically ill

A study was performed on critically ill patients to evaluate the rate of colonization and catheter-related sepsis using antiseptic bonded (Arrowguard Arrow International) versus smooth pure polymer (Infectguard MedexMedical Ltd) central venous catheters. Two hundred and thirty-two catheters were inserted into 181 patients. Indications for removal included local or systemic infection, the catheter was no longer required and patient death. No statistical difference in colonization rate was found between the two types of catheter.

Transplantation of fetal liver tissue suspension into the spleens of adult syngenic rats: effects of different cytotoxins on cytochrome P450 isoforms expression and on glycogen content

Syngenic fetal liver tissue suspensions were transplanted into the spleens of adult male Fisher 344 inbred rats. Four months after surgery, transplant recipients and age matched control rats were treated with different cytotoxins (allyl alcohol [AAL], bromobenzene [BBZ], carbon tetrachloride [CCl4], or thioacetamide [TAA]) or the respective solvents 24 or 48 hours before sacrifice. Effects of the cytotoxins on the expression of three cytochrome P450 (P450) isoforms, 1A1, 2B1 and 3A2, within spleens and livers were assessed by immunohistochemistry. Additionally, effects on glycogen content within the hepatocytes were examined. In the livers AAL caused small lesions and fatty degeneration of hepatocytes only in some periportal areas. BBZ led to a perivenous necrosis of single cells only, whereas CCl4 and TAA caused complete necrosis of the centrilobular parenchyma. Treatment with each of the four cytotoxins led to necrosis and fatty degeneration of single or groups of hepatocytes within the intrasplenic transplants. This effect was most pronounced with CCl4 and TAA. The orthotopic livers of both solvent treated transplant recipients and control rats displayed only in few lobules a slight P450 1A1, but in all lobules a strong P450 2B1 and 3A2 expression, all mainly located in the hepatocytes around the central veins. AAL administration led to an increase in the P450 2B1 expression in the perivenous hepatocytes, whereas the staining for P450 1A1 was not affected and that for P450 3A2 in the periportal areas was even decreased. BBZ administration caused a P450 1A1 expression in the periportal hepatocytes but a decrease in this staining of the perivenous cells. The number of hepatocytes positively stained for P450 2B1 and 3A2 in the perivenous and intermediate zones was diminished in comparison to the livers of solvent treated rats. TAA and, more pronounced, CCl4 administration caused a strong reduction in the expression of all three P450 isoforms. Spleens of control rats displayed almost no P450 isoforms expression, independent of the treatment with the cytotoxins. Similar to adult liver, the hepatocytes in the transplant containing spleens showed nearly no P450 1A1, but a noticeable P450 2B1 and 3A2 expression. No staining was observed within the bile duct cells of the intrasplenic transplants. AAL administration slightly reduced the P450 2B1 and 3A2 expression in the transplants. BBZ and, much more pronounced, CCl4 and TAA treatment diminished the staining for all three P450 isoforms. AAL administration led to a marked decrease in the glycogen content of the hepatocytes of the periportal zones of the liver lobules, whereas after BBZ, CCl4 and TAA treatment a strong perivenous reduction in the glycogen content was seen. Similarly, within the intrasplenic transplants a remarkable decline in the glycogen content of the hepatocytes was caused by the treatment with each of the four cytotoxins. Especially after AAL and BBZ treatment the glycogen depletion within both livers and transplants was much more pronounced than the effects on morphology or P450 isoforms expression. It can be concluded that the effects of cytotoxins like AAL, BBZ, CCl4 or TAA seen in normal orthotopic liver are exerted in a similar way also in intrasplenic liver cell transplants.

Transplantation of fetal liver tissue suspension into the spleens of adult syngenic rats: effects of various mitogens and cytotoxins on cytochrome P450 (P450) isoforms expression and on P450 mediated monooxygenase functions

Syngenic fetal liver tissue suspensions were transplanted into the spleens of adult male Fisher 344 inbred rats. Four months after surgery, transplant recipients and age matched control rats were treated with various mitogens (fluorene [FEN], fluorenone [FON] and 2-acetylaminofluorene [AAF]) or cytotoxins (allyl alcohol [AAL], bromobenzene [BBZ] and carbon tetrachloride [CCl4]) or the respective solvents 24 or 48 hours before sacrifice. The expression of three cytochrome P450 (P450) isoforms, 1A1, 2B1 and 3A2, within spleens and livers was assessed by immunohistochemistry and P450 mediated monooxygenase functions in spleen and liver 9000 g supernatants by the model reactions ethoxyresorufin O-deethylation (EROD), ethoxycoumarin O-deethylation (ECOD), and ethylmorphine N-demethylation (EMND). The orthotopic livers of both solvent treated transplant recipients and control rats displayed only in few lobules a slight P450 1A1, but in all lobules a moderate P450 2B1 and 3A2 expression, all mainly located in the hepatocytes around the central veins. Correspondingly, regular EROD, ECOD and EMND activities were observed. Each of the three mitogens increased the P450 1A1 expression in the hepatocytes of the perivenous zones of the liver lobules. FON administration caused an additional P450 1A1 immunostaining in the periportal areas, and AAF treatment a P450 1A1 expression in bile duct epithelia. Also the staining for P450 2B1 and 3A2 in the hepatocytes of the perivenous and intermediate zones of the liver lobules was intensified after treatment with any of the mitogens. The three model reactions were significantly increased within the livers after FEN and FON administration, whereas after AAF treatment only ECOD was enhanced, EROD remained unaffected and EMND was decreased. The cytotoxin AAL caused small lesions and fatty degeneration of hepatocytes only in some periportal areas. BBZ only produced a perivenous necrosis of single cells, whereas CCl4 caused complete necrosis of the centrilobular parenchyma. Immunohistochemically, AAL administration led to an increase in the P450 2B1 expression in the perivenous hepatocytes, whereas the staining for P450 1A1 was not affected and that for P450 3A2 was even decreased in the periportal areas. Due to AAL treatment EROD and EMND activities were not affected and ECOD activity was increased. BBZ administration caused a P450 1A1 expression in the periportal hepatocytes but a decrease in this staining of the perivenous cells. The number of hepatocytes positively stained for P450 2B1 and 3A2 in the perivenous and intermediate zones was diminished in comparison to the livers of solvent treated rats. After BBZ treatment, EROD and EMND activities were decreased, ECOD activity was not affected. CCl4 administration caused a strong reduction in the expression of all three P450 isoforms and in the activity of all three model reactions. Spleens of control rats displayed almost no P450 isoforms expression and P450 mediated monooxygenase functions, without as well as after treatment with the mitogens or cytotoxins. Similar to adult liver, the hepatocytes in the transplant containing spleens showed nearly no P450 1A1, but a noticeable P450 2B1 and 3A2 expression. No staining was observed within the bile duct cells of the intrasplenic transplants.

Transplantation of fetal liver tissue suspension into the spleens of adult syngenic rats: effects of beta-naphthoflavone, phenobarbital and dexamethasone on cytochrome P450 isoforms expression and on glycogen storage

In the present study, the effect of beta-naphthoflavone (BNF), phenobarbital (PB) and dexamethasone (DEX) on the expression of three cytochrome P450 (P450) isoforms, 1A1, 2B1 and 3A2, and on glycogen storage was investigated in intrasplenic liver cell explants in comparison to adult liver. Fetal liver tissue suspensions were transplanted into the spleens of adult male syngenic Fisher inbred rats. Four months after surgery, transplant recipients and age matched controls were orally treated with BNF (1 x 50 mg/kg body weight (b.wt.)), PB (1 x 50 mg/kg b.wt.), DEX (for 3 days 4 mg/kg b.wt. per day), or the respective solvents (dimethylsulfoxide or 0.9% NaCl). The animals were sacrificed 24 (BNF, DEX) or 48 (PB) hours after the last treatment. The livers of both solvent treated transplant recipients and control rats displayed only in few liver lobules a slight P450 1A1, but in all lobules a strong P450 2B1 and 3A2 expression, which was all mainly located in the hepatocytes around the central veins (zone III, according to Rappaport). After BNF administration a P450 1A1 expression was induced in the hepatocytes of the peripheral regions of the liver lobules (zone I, according to Rappaport), whereas the staining of the hepatocytes around the central veins disappeared. Also the staining for P450 2B1 in the hepatocytes of zone III became slightly more pronounced. Following PB treatment the P450 1A1 expression in the hepatocytes of the central regions (zone III), as seen in few lobules after solvent treatment only, was reduced, whereas the staining for P450 2B1 and 3A2 was more pronounced in the hepatocytes of the intermedial and central regions of the liver lobules (zone II and III). DEX treatment diminished P450 1A1 and 2B1 expression within the livers of both transplant recipients and control rats. In contrast, the staining for P450 3A2 was enhanced in all regions of the liver lobules. Transplantation of fetal liver tissue suspensions into the spleens did not influence the inducibility of P450 isoforms expression within the respective livers of the animals. Spleens of control rats displayed no P450 isoforms expression without as well as with induction. In the explant containing spleens, however, similar to normal liver, the transplanted hepatocytes displayed nearly no P450 1A1, but a strong P450 2B1 and 3A2 expression. After BNF treatment a staining for P450 1A1 was induced and also the P450 2B1 expression was slightly more pronounced. PB treatment caused an increase in the staining for P450 2B1 and 3A2 and DEX administration for P450 3A2 within the transplanted hepatocytes. Additionally, after DEX treatment some bile ducts of the explants displayed a slight staining for P450 1A1, 2B1 and 3A2. All hepatocytes within the livers of both solvent treated transplant recipients and control rats displayed a slightly PAS-positive cytoplasma and, in most cases, homogeneously distributed, fine-grained, strongly PAS-stained granules indicating glycogen storage. No regional variance in the glycogen content of the hepatocytes was seen within the liver lobules, but there was a marked difference between the individual hepatocytes of the same lobular region in the extent of glycogen accumulation. The hepatocytes within the explants displayed the same type of glycogen storage as did the adult liver cells. BNF treatment did not display any effect on the glycogen accumulation in livers and intrasplenic liver cell explants. After PB administration, only in livers, but not in the transplants, the glycogen content in the hepatocytes around the central veins was slightly reduced. DEX treatment lead to an excessive storage of fat within the hepatocytes of both livers and spleens. Thus, the glycogen was displaced, leading to a "spoke-wheel" like pattern of glycogen storage. Additionally, within the hepatocytes of both livers and liver cell explants a higher amount of glycogen seemed to be stored and the granules appeared to be more coarse-grained. (ABSTRACT

Developmental expression of cytochrome P450 isoforms after transplantation of fetal liver tissue suspension into the spleens of adult syngenic rats

In the present study, the developmental expression of three cytochrome P450 (P450) isoforms, 1A1, 2B1 and 3A2, and the ability to store glycogen was investigated in intrasplenic liver cell explants in comparison to adult and fetal liver. Fetal liver tissue suspensions were transplanted into the spleens of adult male syngenic Fisher inbred rats. Animals were sacrificed at 3 days, 1, 2, 4 weeks, 2, 4, 6 months and 1 year after transplantation. Spleens and livers of transplant recipients were compared to those of sham operated and control rats. Three days after transplantation little bulks of hepatocytes and only few bile ducts were seen in the red pulp of the transplant containing spleens. A massive hypertrophy and proliferation of bile ducts and also an augmentation in the number of hepatocytes were observed 4 weeks after transplantation. One month later, however, the bile ducts had become more and more atrophic, while instead the number of hepatocytes continuously increased. One year after surgery large masses of hepatocytes with apparent cord structure and only few but well preserved bile ducts were seen. Within the livers of adult rats, P450 1A1 was only slightly expressed by some hepatocytes around the central veins. P450 2B1 and 3A2 isoforms expression was much stronger, but also predominantly located in the hepatocytes of the central zone of the liver lobule. Hepatocytes of fetal livers displayed a moderate P450 1A1 expression. In some cells also a very mild staining for P450 2B1 and 3A2 was observed. Within the hepatocytes of the intrasplenic liver cell explants P450 1A1 was still expressed 3 days after transplantation, disappeared at 1 week after surgery, but reappeared at 4 weeks after transplantation. After 2, 4 and 6 months no staining for P450 1A1 was detectable any more. One year after transplantation again a slight P450 1A1 expression appeared. With P450 2B1 and 3A2 a mild to moderate expression was seen already at 3 days after transplantation. Four weeks after surgery nearly all of the hepatocytes were stained for P450 2B1 and 3A2, but there were marked differences between the individual cells in the extent of the expression of these two P450 subtypes, like it was also the case with normal adult liver. Within hepatocytes of the fetal livers strongly stained glycogen granules were seen, which, in comparison to adult livers, were rather coarse-grained. Three days after transplantation the glycogen granules in the transplanted hepatocytes were still coarse-grained, but from 1 week after transplantation on, they became more and more fine-grained. As it was also the case with normal adult liver cells, there were marked differences between the individual transplanted hepatocytes in their glycogen content. These results demonstrate that transplanted liver cells originating from syngenic fetal liver tissue suspensions can survive in host organs like the spleen for at least 1 year. They proliferate, differentiate, are able to store glycogen, and express different P450 isoforms, like normal adult liver cells.