Enamel Caries Detection and Diagnosis: An Analysis of Systematic Reviews

Detection and diagnosis of caries-typically undertaken through a visual-tactile examination, often with supporting radiographic investigations-is commonly regarded as being broadly effective at detecting caries that has progressed into dentine and reached a threshold where restoration is necessary. With earlier detection comes an opportunity to stabilize disease or even remineralize the tooth surface, maximizing retention of tooth tissue and preventing a lifelong cycle of restoration. We undertook a formal comparative analysis of the diagnostic accuracy of different technologies to detect and inform the diagnosis of early caries using published Cochrane systematic reviews. Forming the basis of our comparative analysis were 5 Cochrane diagnostic test accuracy systematic reviews evaluating fluorescence, visual or visual-tactile classification systems, imaging, transillumination and optical coherence tomography, and electrical conductance or impedance technologies. Acceptable reference standards included histology, operative exploration, or enhanced visual assessment (with or without tooth separation) as appropriate. We conducted 2 analyses based on study design: a fully within-study, within-person analysis and a network meta-analysis based on direct and indirect comparisons. Nineteen studies provided data for the fully within-person analysis and 64 studies for the network meta-analysis. Of the 5 technologies evaluated, the greatest pairwise differences were observed in summary sensitivity points for imaging and all other technologies, but summary specificity points were broadly similar. For both analyses, the wide 95% prediction intervals indicated the uncertainty of future diagnostic accuracy across all technologies. The certainty of evidence was low, downgraded for study limitations, inconsistency, and indirectness. Summary estimates of diagnostic accuracy for most technologies indicate that the degree of certitude with which a decision is made regarding the presence or absence of disease may be enhanced with the use of such devices. However, given the broad prediction intervals, it is challenging to predict their accuracy in any future "real world" context.

Abstracts of published randomised controlled trials in Endodontics: Reporting quality and spin

AIMS

To assess the reporting quality of recently published randomised controlled trial (RCT) abstracts in Endodontics, to investigate factors associated with reporting quality, and to evaluate the existence and characteristics of spin. Spin refers to reporting strategies that distort study results and misguide readers.

METHODOLOGY

The PubMed database was searched to identify abstracts of RCTs in the field of Endodontics published during 2017 to 2018. Two authors assessed the reporting quality of each included abstract using the original 16-item CONSORT for Abstracts checklist, with the overall quality score (OQS, range: 0 to 16) being the primary outcome measure. For each individual item, a score of '1' was given if it was described adequately, and '0' if the description was inadequate. Linear regression analyses were conducted to identify factors associated with reporting quality. For the evaluation of spin, two authors selected parallel-group RCTs with a nonsignificant primary outcome from the included abstracts, and evaluated independently the existence and characteristics of spin among these abstracts.

RESULTS

A total of 162 abstracts were included for assessment of reporting, for which the mean OQS was 3.97 (SD, 1.30; 95 % CI, 3.77 to 4.17). According to multivariable analysis, origin from Europe (P=0.001) and reporting of the exact P value (P=0.020) were significantly associated with better reporting. Forty abstracts with statistically nonsignificant results for their primary outcome were included for spin evaluation, among which 34 (85.0%) had at least one type of spin. Thirty-two abstracts (94.1%) had spin in their conclusions section, and six abstracts (17.6%) had spin in the results section.

CONCLUSIONS

The reporting quality of RCT abstracts in Endodontics needs to be improved. The occurrence rate of spin in the sample of abstracts of RCTs in the field of Endodontics was high. Relevant stakeholders are recommended to be familiar with the CONSORT for Abstracts guideline and develop active strategies to ensure its implementation.

Clinical and laboratory characteristics in juvenile-onset systemic lupus erythematosus across age groups

Background

Systemic lupus erythematous (SLE) is a systemic autoimmune/inflammatory condition. Approximately 15–20% of patients develop symptoms before their 18th birthday and are diagnosed with juvenile-onset SLE (JSLE). Gender distribution, clinical presentation, disease courses and outcomes vary significantly between JSLE patients and individuals with adult-onset SLE. This study aimed to identify age-specific clinical and/or serological patterns in JSLE patients enrolled to the UK JSLE Cohort Study.

Methods

Patient records were accessed and grouped based on age at disease-onset: pre-pubertal (≤7 years), peri-pubertal (8–13 years) and adolescent (14–18 years). The presence of American College of Rheumatology (ACR) classification criteria, laboratory results, disease activity [British Isles Lupus Assessment Group (BILAG) and Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2 K) scores] and damage [Systemic Lupus International Collaborating Clinics (SLICC) damage index] were evaluated at diagnosis and last follow up.

Results

A total of 418 JSLE patients were included in this study: 43 (10.3%) with pre-pubertal disease onset; 240 (57.4%) with peri-pubertal onset and 135 (32.3%) were diagnosed during adolescence. At diagnosis, adolescent JSLE patients presented with a higher number of ACR criteria when compared with pre-pubertal and peri-pubertal patients [pBILAG2004 scores: 9(4–20] vs. 7(3–13] vs. 7(3–14], respectively, p = 0.015] with increased activity in the following BILAG domains: mucocutaneous (p = 0.025), musculoskeletal (p = 0.029), renal (p = 0.027) and cardiorespiratory (p = 0.001). Furthermore, adolescent JSLE patients were more frequently ANA-positive (p = 0.034) and exhibited higher anti-dsDNA titres (p = 0.001). Pre-pubertal individuals less frequently presented with leukopenia (p = 0.002), thrombocytopenia (p = 0.004) or low complement (p = 0.002) when compared with other age groups. No differences were identified in disease activity (pBILAG2004 score), damage (SLICC damage index) and the number of ACR criteria fulfilled at last follow up.

Conclusions

Disease presentations and laboratory findings vary significantly between age groups within a national cohort of JSLE patients. Patients diagnosed during adolescence exhibit greater disease activity and “classic” autoantibody, immune cell and complement patterns when compared with younger patients. This supports the hypothesis that pathomechanisms may vary between patient age groups.

Development of a European Public Health Emergency Preparedness Training Toolkit

Background

In 2017, under the supervision of the European Centre for Disease Prevention and Control (ECDC), a list of competencies and knowledge and skill statements for EU professionals working in Public Health Emergency Preparedness (PHEP) systems were identified and integrated into a Competency Model. Building on these efforts, a PHEP competency-based training toolkit was developed, pilot tested and finalized with the goal of providing a standardized training resource for experts involved in response to cross-border threats to health.

Objectives

Led by the ECDC, an international research team drafted a preliminary version of a curriculum consisting of five modules, with a list of targeted competencies, learning objectives, reading and training methods including case studies and simulation exercises. In May 2018, the curriculum was pilot tested in a 3.5-day training course at the University of Bologna, Italy. The participants included 20 representatives from 8 EU Member States. An evaluation strategy, combining both quantitative and qualitative methods, was designed to assess the impact of the training on participants’ applied knowledge and competence.

Results

Overall, the participants’ feedback on the pilot course was positive, with scores from 4.0 to 4.8 out of 5 for all the items considered. Several suggestions were made both by the trainers and the trainees to enhance the effectiveness of the learning activities, and the curriculum was integrated into a training toolkit with more exercises, teaching materials and a guide for facilitators.

Conclusions

This European Public Health Emergency Preparedness Training Toolkit is the first EU competency-based toolkit intended to help Member States improve their response to public health emergencies through standardized training. Designed for individuals working in strategic positions at the national level, its general approach, modular structure and content are relevant and can be tailored to a wider range of professionals.

Key messages

To improve PHEP in the EU, competency-based curricula and standardized training programs and resources for health professionals are needed. By enhancing the overall public health professionals’ experience and competency, the European PHEP Training Toolkit represents a step towards strengthening preparedness and response systems in the EU.

2379Endothelial cell derived extracellular vesicles mediate immune cell deployment from the spleen and transcriptional programming following acute myocardial infarction

Background

Acute myocardial infarction (AMI) induces transcriptional activation of monocyte en route to the injured myocardium, possibly through interactions involving plasma liberated extracellular vesicles (EVs), which are enriched for proteins and microRNAs (miRNAs) post-AMI. Neutrophils are the first immune cells to arrive at sites of injury and mediate further damage to the ischaemic myocardium. Here, we describe neutrophil-deployment from the spleen in AMI and by endothelial cell (EC) derived-EVs.

Methods

Patients presenting AMI provided informed consent as part of the Oxford Acute Myocardial Infarction Study (OxAMI). Plasma EV were isolated by differential ultra-centrifugation (120,000g, 2 hours) followed by washing and characterised for: morphology using transmission electron microscopy (TEM), size and concentration profiling by Nanoparticle Tracking Analysis, EV markers (TSG101, ALIX, CD9, HSP70) by western blot, and miRNAs by RT-qPCR. Mouse and human EC were used in vitro to derive EC-EV under control conditions or after inflammatory stimulation with tumour necrosis factor-alpha (TNF-α) (10ng/mL) and from CRISPR-edited miRNA-126 knock-out ECs. EC-EVs were tail vein injected into wild-type mice or exposed to primary human peripheral blood neutrophils in vitro.

Results

Patients presenting with AMI (N=15) have significantly more plasma EV at time of injury vs a 6-month follow-up measurement (2.2-fold more, P=0.008). Plasma EVs at the time of AMI presentation correlate significantly with the extent of ischaemic injury (R=0.046, P=0.006) and plasma neutrophils (R=0.37, P=0.017). Experimental AMI in wild-type mice induced a significant increase in peripheral blood neutrophils and a simultaneous reduction in splenic-neutrophils, suggesting splenic-neutrophil deployment (P=0.004). Human plasma EV are enriched for vascular cell adhesion molecule-1 (VCAM-1) and EC-associated miR-126 post-AMI (Akbar et al 2017). miRNA-126-mRNA targets are significantly over represented when compared to neutrophil Gene Ontology terms for: degranulation (P<0.001), activation (P<0.001), chemotaxis (P=0.008) and migration (P=0.008). Human and mouse EC release more EV after inflammatory stimulation and show enrichment for miRNA-126. CRISPR-edited miRNA-126 deficient human EC express more VCAM-1 (P<0.001) and release more EC-EVs (P<0.001). EC-EV exposure to primary human neutrophils alters inflammatory gene expression (IL-6 (P<0.05), CCL7 (P<0.001) and CCL18 (P<0.001)). EC-EV tail vein injected into wild-type mice mobilise splenic-neutrophils to peripheral blood (P<0.001).

Conclusions

Neutrophil deployment from the spleen is a novel finding in acute injury and interactions with EC-EV may mediate their splenic liberation and transcriptional programming following AMI, en route to the injured myocardium. The splenic neutrophil reserve may be a novel therapeutic target in AMI to modulate the inflammatory response before recruitment of cells to sites of injury.

Acknowledgement/Funding

British Heart Foundation Project Grant and Centre for Research Excellence Awards (RE/13/1/30181), Nuffield Benefaction for Medicine and ISSF

Outcomes following mycophenolate mofetil versus cyclophosphamide induction treatment for proliferative juvenile-onset lupus nephritis

Background

Juvenile-onset systemic lupus erythematosus (JSLE) is more severe than adult-onset disease, including more lupus nephritis (LN). Despite differences in phenotype/pathogenesis, treatment is based upon adult trials. This study aimed to compare treatment response, damage accrual, time to inactive LN and subsequent flare, in JSLE LN patients treated with mycophenolate mofetil (MMF) versus intravenous cyclophosphamide (IVCYC).

Methods

UK JSLE Cohort Study participants, ≤16 years at diagnosis, with ≥4 American College of Rheumatology criteria for SLE, with class III or IV LN, were eligible. Mann–Whitney U tests, Fisher's exact test and Chi-squared tests were utilized for statistical analysis.

Results

Of the patients, 34/51 (67%) received MMF, and 17/51 (33%) received IVCYC. No significant differences were identified at 4–8 and 10–14 months post-renal biopsy and last follow-up, in terms of renal British Isles Lupus Assessment Grade scores, urine albumin/creatinine ratio, serum creatinine, ESR, anti-dsDNA antibody, C3 levels and patient/physician global scores. Standardized Damage Index scores did not differ between groups at 13 months or at last follow-up. Inactive LN was attained 262 (141–390) days after MMF treatment, and 151 (117–305) days following IVCYC ( p = 0.17). Time to renal flare was 451 (157–1266) days for MMF, and 343 (198–635) days for IVCYC ( p = 0.47).

Conclusion

This is the largest study to date investigating induction treatments for proliferative LN in children, demonstrating comparability of MMF and IVCYC.

Implementation of the cobas Liat influenza point-of-care test into an emergency department during a high-incidence season: a retrospective evaluation following real-world implementation

The cobas Liat influenza A/B and respiratory syncytial virus (RSV) assay (Liat) was used in the adult emergency department of a large London hospital from 21^st January 2018 to 14^th April 2018. Influenza was detected in 308 of 1027 (30%) samples tested; influenza A in 157 (15.3%), influenza B in 149 (14.5%) and RSV in 28 (2.7%). When compared against Fast Track Diagnostics Respiratory Pathogens 21 multiplex polymerase chain reaction and Cepheid Xpert Xpress Flu/RSV assay, Liat performance for the detection of influenza A or B was: sensitivity 85% [95% confidence interval (CI) 76–92)], specificity 98% (95% CI 97–99), negative predictive value 94% (95% CI 92–96) and positive predictive value 95% (95% CI 91–97).

Implementation of influenza point-of-care testing and patient cohorting during a high-incidence season: a retrospective analysis of impact on infection prevention and control and clinical outcomes

BACKGROUND

During high-incidence influenza seasons, a robust infection prevention and control policy is imperative to reduce nosocomial transmission of influenza.

AIM

To assess the impact of influenza point-of-care testing (POCT) in an emergency department (ED) and patient cohorting on an influenza ward on infection prevention and control and clinical outcomes.

METHODS

Influenza POCT was operational in the study ED from 21^st January 2018 and patient cohorting was operational on an influenza ward from 25^th January 2018. A retrospective 'before-after' analysis was performed with pre-intervention defined as 1^st November 2017 to 20^th January 2018 and post-intervention defined as 21^st January 2018 to 30^th April 2018. The primary outcome was the rate of hospital-acquired influenza. Secondary outcomes included antiviral prescription and length of stay. The length of time that inpatients remained influenza-positive was estimated by polymerase chain reaction (PCR).

FINDINGS

There were 654 inpatients with confirmed influenza during the 2017/18 influenza season: 223 pre- and 431 post-intervention. Post-intervention, there were fewer cases of hospital-acquired influenza per day (0.66 vs 0.95, P < 0.0001), median length of stay was shorter (5.5 vs 7.5 days, P = 0.005) and antiviral prescription was more frequent (80% vs 64.1%, P < 0.0001). Cohorting released 779 single rooms for use elsewhere in the trust. The fixed probability of being PCR-negative by the next day (P) was 0.14 [95% confidence interval (CI) 0.12-0.16] for immunocompetent patients. This implies that half of immunocompetent patients are PCR-negative by five days post-diagnosis (95% CI 5-6).

CONCLUSION

Influenza POCT in an ED and patient cohorting on an influenza ward were associated with reduced nosocomial transmission of influenza and improved patient flow. A policy of retesting immunocompetent patients five days post-diagnosis could allow half of these patients to come out of respiratory isolation earlier.

Assessing the Quality of Models of the Ambient Solar Wind

In this paper we present an assessment of the status of models of the global Solar Wind in the inner heliosphere. We limit our discussion to the class of models designed to provide solar wind forecasts, excluding those designed for the purpose of testing physical processes in idealized configurations. In addition, we limit our discussion to modeling of the 'ambient' wind in the absence of coronal mass ejections. In this assessment we cover use of the models both in forecast mode and as tools for scientific research. We present a brief history of the development of these models, discussing the range of physical approximations in use. We discuss the limitations of the data inputs available to these models and its impact on their quality. We also discuss current model development trends.

Probabilistic Solar Wind and Geomagnetic Forecasting Using an Analogue Ensemble or "Similar Day" Approach

Effective space-weather prediction and mitigation requires accurate forecasting of near-Earth solar-wind conditions. Numerical magnetohydrodynamic models of the solar wind, driven by remote solar observations, are gaining skill at forecasting the large-scale solar-wind features that give rise to near-Earth variations over days and weeks. There remains a need for accurate short-term (hours to days) solar-wind forecasts, however. In this study we investigate the analogue ensemble (AnEn), or "similar day", approach that was developed for atmospheric weather forecasting. The central premise of the AnEn is that past variations that are analogous or similar to current conditions can be used to provide a good estimate of future variations. By considering an ensemble of past analogues, the AnEn forecast is inherently probabilistic and provides a measure of the forecast uncertainty. We show that forecasts of solar-wind speed can be improved by considering both speed and density when determining past analogues, whereas forecasts of the out-of-ecliptic magnetic field [ B N ] are improved by also considering the in-ecliptic magnetic-field components. In general, the best forecasts are found by considering only the previous 6 - 12 hours of observations. Using these parameters, the AnEn provides a valuable probabilistic forecast for solar-wind speed, density, and in-ecliptic magnetic field over lead times from a few hours to around four days. For B N , which is central to space-weather disturbance, the AnEn only provides a valuable forecast out to around six to seven hours. As the inherent predictability of this parameter is low, this is still likely a marked improvement over other forecast methods. We also investigate the use of the AnEn in forecasting geomagnetic indices Dst and Kp. The AnEn provides a valuable probabilistic forecast of both indices out to around four days. We outline a number of future improvements to AnEn forecasts of near-Earth solar-wind and geomagnetic conditions.

Evaluation of the ACR and SLICC classification criteria in juvenile-onset systemic lupus erythematosus: a longitudinal analysis

Objectives The Systemic Lupus International Collaborating Clinics (SLICC) group proposed revised classification criteria for systemic lupus erythematosus (SLICC-2012 criteria). This study aimed to compare these criteria with the well-established American College of Rheumatology classification criteria (ACR-1997 criteria) in a national cohort of juvenile-onset systemic lupus erythematosus (JSLE) patients and evaluate how patients' classification criteria evolved over time. Methods Data from patients in the UK JSLE Cohort Study with a senior clinician diagnosis of probable evolving, or definite JSLE, were analyzed. Patients were assessed using both classification criteria within 1 year of diagnosis and at latest follow up (following a minimum 12-month follow-up period). Results A total of 226 patients were included. The SLICC-2012 was more sensitive than ACR-1997 at diagnosis (92.9% versus 84.1% p < 0.001) and after follow up (100% versus 92.0% p < 0.001). Most patients meeting the SLICC-2012 criteria and not the ACR-1997 met more than one additional criterion on the SLICC-2012. Conclusions The SLICC-2012 was better able to classify patients with JSLE than the ACR-1997 and did so at an earlier stage in their disease course. SLICC-2012 should be considered for classification of JSLE patients in observational studies and clinical trial eligibility.

Global solar wind variations over the last four centuries

The most recent "grand minimum" of solar activity, the Maunder minimum (MM, 1650-1710), is of great interest both for understanding the solar dynamo and providing insight into possible future heliospheric conditions. Here, we use nearly 30 years of output from a data-constrained magnetohydrodynamic model of the solar corona to calibrate heliospheric reconstructions based solely on sunspot observations. Using these empirical relations, we produce the first quantitative estimate of global solar wind variations over the last 400 years. Relative to the modern era, the MM shows a factor 2 reduction in near-Earth heliospheric magnetic field strength and solar wind speed, and up to a factor 4 increase in solar wind Mach number. Thus solar wind energy input into the Earth's magnetosphere was reduced, resulting in a more Jupiter-like system, in agreement with the dearth of auroral reports from the time. The global heliosphere was both smaller and more symmetric under MM conditions, which has implications for the interpretation of cosmogenic radionuclide data and resulting total solar irradiance estimates during grand minima.

Factors Affecting the Geo-effectiveness of Shocks and Sheaths at 1 AU

We identify all fast-mode forward shocks, whose sheath regions resulted in a moderate (56 cases) or intense (38 cases) geomagnetic storm during 18.5 years from January 1997 to June 2015. We study their main properties, interplanetary causes and geo-effects. We find that half (49/94) such shocks are associated with interacting coronal mass ejections (CMEs), as they are either shocks propagating into a preceding CME (35 cases) or a shock propagating into the sheath region of a preceding shock (14 cases). About half (22/45) of the shocks driven by isolated transients and which have geo-effective sheaths compress pre-existing southward B_z . Most of the remaining sheaths appear to have planar structures with southward magnetic fields, including some with planar structures consistent with field line draping ahead of the magnetic ejecta. A typical (median) geo-effective shock-sheath structure drives a geomagnetic storm with peak Dst of -88 nT, pushes the subsolar magnetopause location to 6.3 R_E, i.e. below geosynchronous orbit and is associated with substorms with a peak AL-index of -1350 nT. There are some important differences between sheaths associated with CME-CME interaction (stronger storms) and those associated with isolated CMEs (stronger compression of the magnetosphere). We detail six case studies of different types of geo-effective shock-sheaths, as well as two events for which there was no geomagnetic storm but other magnetospheric effects. Finally, we discuss our results in terms of space weather forecasting, and potential effects on Earth's radiation belts.

Macrosomia and haemodynamic instability may represent risk factors for subcutaneous fat necrosis in asphyxiated newborns treated with hypothermia

AIM

To identify additional risk factors other than asphyxia and hypothermia in newborns developing subcutaneous fat necrosis (SCFN).

METHODS

We conducted a prospective cohort study of all term asphyxiated newborns treated with hypothermia from 2008 to 2015. The presence and location of SCFN were recorded at the time of discharge or at follow-up visits. To identify the risk factors for developing SCFN, we compared the perinatal characteristics of those newborns who developed SCFN with those who did not.

RESULTS

The newborns developing SCFN had significantly higher birthweights compared with those newborns who did not develop SCFN. Among the newborns with a birthweight equal or superior to the 90th percentile, those who developed SCFN had a significantly higher use of inotropic support and higher maximum troponin levels during their initial hospitalisation.

CONCLUSION

A higher birthweight represented an independent risk factor for developing SCFN in asphyxiated newborns treated with hypothermia. When macrosomia is present, other risk factors related to haemodynamic instability during the initial hospitalisation may also increase the risk of developing SCFN.

Developing the radiation protection safety culture in the UK

In the UK, as elsewhere, there is potential to improve how radiological challenges are addressed through improvement in, or development of, a strong radiation protection (RP) safety culture. In preliminary work in the UK, two areas have been identified as having a strong influence on UK society: the healthcare and nuclear industry sectors. Each has specific challenges, but with many overlapping common factors. Other sectors will benefit from further consideration.In order to make meaningful comparisons between these two principal sectors, this paper is primarily concerned with cultural aspects of RP in the working environment and occupational exposures rather than patient doses.The healthcare sector delivers a large collective dose to patients each year, particularly for diagnostic purposes, which continues to increase. Although patient dose is not the focus, it must be recognised that collective patient dose is inevitably linked to collective occupational exposure, especially in interventional procedures.The nuclear industry faces major challenges as work moves from operations to decommissioning on many sites. This involves restarting work in the plants responsible for the much higher radiation doses of the 1960/70s, but also performing tasks that are considerably more difficult and hazardous than those original performed in these plants.Factors which influence RP safety culture in the workplace are examined, and proposals are considered for a series of actions that may lead to an improvement in RP culture with an associated reduction in dose in many work areas. These actions include methods to improve knowledge and awareness of radiation safety, plus ways to influence management and colleagues in the workplace. The exchange of knowledge about safety culture between the nuclear industry and medical areas may act to develop RP culture in both sectors, and have a wider impact in other sectors where exposures to ionising radiations can occur.

Detection of meticillin-resistant staphylococcus aureus (MRSA) colonization in newborn infants using real-time polymerase chain reaction (PCR)

OBJECTIVE

Meticillin-resistant staphylococcus aureus (MRSA) colonization on neonatal units is a common and important clinical problem. Effectiveness of polymerase chain reaction (PCR) for detecting MRSA nasal colonization of infants was evaluated and compared to culture-based methods. The effect of skin decolonization in affected infants was studied.

METHODS

Paired nasal swabs were collected from infants in our neonatal unit over a 12-month period (September 2007-2008). Colonization with MRSA was determined with a commercially available PCR method and compared to culture.

RESULTS

A total of 696 paired nasal swabs were taken. Three infants were colonized at the beginning and were included. There were positive PCRs in 12 infants. Five infants cultured MRSA from a nasal swab at the same time. No infants were culture-positive when PCR was negative (sensitivity 100%, specificity 99% compared to culture). PCR results were available within 24 h. Five infants were PCR+ and isolated meticillin-sensitive Staphylococcus aureus. This organism gave a false-positive PCR result. Two infants transferred in on broad-spectrum antibiotics were PCR+ and negative by culture. Decolonization led to negative nasal PCR and culture in 4/5 infants to discharge.

CONCLUSIONS

PCR methods are sensitive and specific for detection of MRSA colonization in newborn infants of all gestations with results 1-2 days before culture.

Brachiocephalic vein stenosis in association with ipsilateral hyperdynamic brachio-basilic fistula causing ipsilateral facial swelling and contralateral papillodema and visual loss. A case report

A 69-year-old hypertensive woman with a hyperdynamic, left brachio-basilic dialysis fistula presented with a long history of throbbing in her head, swelling of the left side of the face and two months of right visual loss with gross swelling of the right optic disc. Tight stenosis of left brachiocephalic vein was found to be causing retrograde flow into the left jugular vein which normalised after dilatation and stenting with resolution of the papillodema.

Continuing utilisation of specialised health services in extremely preterm infants

OBJECTIVE

To compare healthcare use from neonatal discharge to 18 months corrected age (CA) of two groups of extremely preterm neonates (23-25 vs 26-28 weeks).

DESIGN

Cohort study.

PATIENTS

Infants born at < or =28 weeks and admitted in three hospital centres in Quebec, Canada (n=254).

MAIN OUTCOME MEASURES

Neurodevelopmental outcomes and healthcare use from neonatal discharge to 18 months CA.

RESULTS

Re-hospitalisation rates occurred in 57% of children born at 23-25 weeks and in 49% of those born at 26-28 weeks. In these two age groups, by 18 months, 61% vs 59% were followed in physical or occupational therapy, 29% vs 17% were enrolled in a long-term rehabilitation program, 38% vs 28% used prescribed medication, and 59% vs 33% required medical assistive devices, respectively. Risk of re-hospitalisation was related to bronchopulmonary dysplasia (BPD), severe brain injury, use of home oxygen or an apnoea monitor and older age at neonatal discharge. Multiple births, BPD, severe brain injury, older age at neonatal discharge and single parenthood were associated with risk of using out-patient health services above average (>2 services).

CONCLUSION

Extremely preterm children are frequently re-hospitalised during infancy and use a substantial amount of healthcare resources. These results highlight the importance of resource allocation to preterm infants for medical and rehabilitation services after discharge from the neonatal intensive care unit.

Dynamical reconnection and stability constraints on cortical network architecture

Stability under dynamical changes to network connectivity is invoked alongside previous criteria to constrain brain network architecture. A new hierarchical network is introduced that satisfies all these constraints, unlike more commonly studied regular, random, and small-world networks. It is shown that hierarchical networks can simultaneously have high clustering, short path lengths, and low wiring costs, while being robustly stable under large scale reconnection of substructures.

A phase II clinical trial of gemcitabine and split dose cisplatin in advanced non-small cell lung cancer in an outpatient setting

In response to increasing pressure on inpatient services and a meta-analysis indicating that cisplatin (C) is superior to carboplatin, we report a phase II trial of gemcitabine (G) and split-dose C in advanced non-small cell lung cancer (NSCLC) in an outpatient setting. Patients with stage IIIB/IV NSCLC received: G/C 1250/40 mg/m(2); G and C were given on day (d) 1 and d8 in a 21d cycle. Patients with performance status 0-2, adequate bone marrow function and calculated glomerular filtration rate (GFR) >50 ml/min were eligible. Forty-two patients were enrolled: 25 male; median age 62 (range 37-78) years. There were 26 patients (62%) with stage IV disease. One hundred and thirty-eight cycles of chemotherapy were delivered. Chemotherapy was well tolerated, allowing maintenance of planned dose intensity (DI) with mean dose delivered of 780.1 mg/m(2) (93%) and 25.6 mg/m(2) (96%) for G and C, respectively. The overall response rate was 43%. Median survival was 12.5 months with a median follow-up of 13.5 months. One year survival rate was 51%. G plus C both given on d1 and d8 (q21d) is a very active, well tolerated and convenient outpatient schedule, which maintains DI.

Effectiveness of infliximab in the treatment of refractory juvenile dermatomyositis with calcinosis

OBJECTIVES

Some juvenile dermatomyositis (JDM) patients have a disease course which is refractory to multiple drug treatments. Prolonged disease activity is associated with increased mortality and morbidity. TNF-alpha has been identified in high levels in JDM patients who have a long disease course and calcinosis. We assessed the response of five refractory JDM patients to the anti-TNF-alpha monoclonal antibody, infliximab.

METHODS

For all five patients intravenous infliximab was initially given at a dose of 3 mg/kg. Further doses were then given at weeks 2, 6 and every 8 weeks thereafter. The dose and frequency were tailored in accordance with clinical response. Clinical and laboratory data were collected prospectively.

RESULTS

We report results between 8 and 30 months after starting infliximab. Improvements were seen in all five patients as shown by positive changes in physician visual analogue scale (VAS), Childhood Myositis Assessment Score (CMAS), Childhood Health Assessment Questionnaire (CHAQ), joint range of movement and, in some, regression of calcinosis and skin signs. There were no major side effects observed with addition of infliximab to the therapeutic regime.

CONCLUSIONS

Major clinical benefit was demonstrated after the initiation of infliximab in all five cases of refractory JDM.

Weight loss, dietary advice and statin therapy in non-alcoholic fatty liver disease: a retrospective study

BACKGROUND

Studies have shown that weight loss can have a favourable effect upon non-alcoholic fatty liver disease (NAFLD). However, the most effective means of achieving weight loss and safety profile of lipid-lowering drugs in the presence of NAFLD is unknown.

AIM

To investigate the effect of dietary advice and lipid-lowering drugs, particularly statins, on patients with NAFLD and dyslipidaemia.

DESIGN

Observational records based study.

METHODS

We studied 71 patients with NAFLD and dyslipidaemia diagnosed and treated between 1996 and 2002 at University Hospital Lewisham. Some were referred to a dietician for weight loss advice as part of their management. After treatment all patients were assessed for changes in weight, serum alanine transaminase (ALT) and serum lipids including serum cholesterol, serum high density lipoprotein (HDL) and serum triglycerides.

RESULTS

Thirty-seven male and 34 female patients with NAFLD and dyslipidaemia were followed up for a mean period of 440 +/- 374 days (median 335). Regression analysis revealed a significant association between changes in weight and changes in serum ALT (p < 0.039). Dietary advice failed to reduce body weight but significantly lowered the serum cholesterol to HDL ratio (p = 0.05). Only 15.4% of patients taking statins experienced a rise in serum ALT > or = 40 U/l, and in each case the rise was transient, returning near baseline or below without discontinuation of statin treatment.

CONCLUSIONS

Weight loss appears to improve NAFLD, and dietary advice and lipid-lowering drugs may be beneficial for patients with NAFLD and dyslipidaemia even if weight loss is not achieved. Statins appear to be safe and efficacious in this group.

Internal iliac artery pseudoaneurysm following renal transplant biopsy successfully treated with endovascular stenting and thrombosis: a case report

A 49-year-old man underwent living donor renal transplantation in November 2005. The transplant renal artery was anastomosed to the right internal iliac artery with an end-to-end anastomosis. The patient achieved immediate graft function and the allograft was normally perfused. Seven weeks later, renal allograft function deteriorated with a serum creatinine level increased to 244 micromol/L. An ultrasound scan revealed adequate perfusion to the kidney and the absence of hydronephrosis. A transplant biopsy revealed Banff IB rejection, which was treated with high-dose prednisolone. Following biopsy, the patient's renal function rapidly deteriorated with a serum creatinine level increased to 627 micromol/L, requiring hemodialysis. A computed tomography (CT) angiogram demonstrated a 6-cm diameter pseudoaneurysm arising from the internal iliac artery with absence of kidney perfusion. The aneurysm was accessed percutaneously with a 4-F catheter and 1000 U of human thrombin injected, resulting in partial thrombosis of the pseudoaneurysm. A balloon expandable covered metal stent was then placed across the site of the transplant renal artery anastomosis, resulting in successful occlusion of the aneurysm. Intrarenal blood flow was established by dilating 2 intrarenal branches with 3-mm diameter balloons. The serum creatinine level started to decrease within 24 hours of the procedure and renal function improved rapidly to a level achieved immediately after transplantation. Three months later the patient had a well-functioning allograft with a serum creatinine level of 176 micromol/L, follow-up CT scan demonstrated good perfusion of the transplanted kidney with no further change in the pseudoaneurysm. At 12 months follow-up the patient remains with a well-functioning allograft.

Oropharyngeal dysphagia in juvenile dermatomyositis (JDM): an evaluation of videofluoroscopy swallow study (VFSS) changes in relation to clinical symptoms and objective muscle scores

OBJECTIVE

To determine if objective, validated scores of muscle weakness and function [manual muscle testing (MMT), childhood myositis assessment scale (CMAS)] or scores of general disease activity or function [childhood health assessment questionnaire and physician global assessment of disease activity visual analogue scale (VAS)], can predict children at risk of swallow abnormalities in juvenile dermatomyositis (JDM) measured by videofluoroscopic swallow studies (VFSS).

METHODS

Patients were referred for speech and language dysphagia assessment upon diagnosis of JDM or flare of disease. VFSS was used to document a swallow score indicating severity of swallow dysfunction. Clinical symptoms, examination findings and objective scores of disease activity were analysed. Any correlation was looked for using chi-squared Fisher exact test and linear regression models.

RESULTS

Fourteen patients with inflammatory myopathy (age 2-16 years) had clinical assessments and VFSS. VFSS was abnormal in 11 children (79%). Only two children were asymptomatic at assessment, but both had swallow dysfunction, including aspiration, on VFSS. In contrast, three of the symptomatic children had a normal VFSS. No relationship was found between objective disease severity scores and VFSS swallow score.

CONCLUSIONS

This study failed to show any correlation between swallow score and objective measures of muscle strength and function (MMT/CMAS) or general disease activity and function [physician VAS/childhood health assessment questionnaire (CHAQ)]. In the absence of a more accurate assessment method to determine which children with active JDM are most at risk of swallow dysfunction and aspiration, all children with active dermatomyositis should be referred for speech and language assessment and VFSS.

A growing burden: the pathogenesis, investigation and management of non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is the most common hepatic disorder in western countries, and its incidence is increasing. This review outlines the significant health burden posed by NAFLD and discusses what is presently known about its pathogenesis, including the roles of the metabolic syndrome, obesity, insulin resistance, hepatic steatosis, reactive oxygen species, inflammatory cytokines and adipocytokines. The way in which NAFLD is clinically diagnosed is described, and areas of uncertainty surrounding its investigation are identified, before discussing the relative merits of the limited treatment options available and looking ahead to potential therapeutic strategies for the future.

CT colonography: interpretative performance in a non-academic environment

AIM

To investigate interpretative accuracy and reporting time for radiologists performing computed tomography (CT) colonography in day-to-day non-academic clinical practice.

MATERIALS AND METHODS

Thirteen radiologists from seven centres, who were reporting CT colonography in non-academic daily clinical practice, interpreted a dataset of 15 colonoscopically validated cases in a controlled environment. Ten cases had either a cancer or polyp >10mm; one case had a medium polyp and four were normal. Correct case categorization and interpretation times were compared using analysis of variance to aggregated results obtained from both experienced observers and observers recently trained using 50 cases, working in an academic environment. The effect of experience was determined using Spearman's rank correlation.

RESULTS

Individual accuracy was highly variable, range 53% (95% CI 27-79%) to 93% (95% CI 68-100%). Mean accuracy overall was significantly inferior to experienced radiologists (mean 75 versus 88%, p=0.04) but not significantly different from recently trained radiologists (p=0.48). Interpretation time was not significantly different to experienced readers (mean 12.4 min versus 11.7, p=0.74), but shorter than recently trained radiologists (p=0.05). There was a significant, positive, linear correlation between prior experience and accuracy (p<0.001) with no plateau.

CONCLUSION

Accuracy for sub-specialist radiologists working in a non-academic environment is, on average, equivalent to radiologists trained using 50 cases. However, there is wide variability in individual performance, which generally falls short of the average performance suggested by meta-analysis of published data. Experience improves accuracy, but alone is insufficient to determine competence.

Frequency and impact of extracolonic findings detected at computed tomographic colonography in a symptomatic population

Background

Extracolonic findings are frequently recognized alongside colonic pathology at computed tomographic colonography (CTC). This study assessed the clinical impact of extracolonic findings in a symptomatic population at high risk of colorectal cancer.

Methods

CTC was performed in a consecutive cohort of patients assessed in a fast-track colorectal cancer clinic as being at high risk of colorectal cancer. A review of CTC findings and case notes was undertaken. Patients with extracolonic findings were followed up for at least 12 months.

Results

Thirty-one (13·8 per cent) of 225 patients investigated by CTC had colorectal cancer. Extracolonic findings were identified in 81 (53·3 per cent) of 152 patients with normal or non-neoplastic bowel findings, compared with 27 (37 per cent) of 73 patients with colorectal neoplasia (P = 0·025). Twenty-four patients (10·7 per cent) with extracolonic findings underwent further investigation or treatment. The median duration of investigation was 19·5 weeks. Seventy-five clinical events were recorded, including 14 surgical procedures.

Conclusion

A prospective cost–benefit analysis of diagnostic CTC should be performed before it is established as a first-line investigation for colonic symptoms.