Characterizing the mechanism of action for mRNA therapeutics for the treatment of propionic acidemia, methylmalonic acidemia, and phenylketonuria

Messenger RNA (mRNA) therapeutics delivered via lipid nanoparticles hold the potential to treat metabolic diseases caused by protein deficiency, including propionic acidemia (PA), methylmalonic acidemia (MMA), and phenylketonuria (PKU). Herein we report results from multiple independent preclinical studies of mRNA-3927 (an investigational treatment for PA), mRNA-3705 (an investigational treatment for MMA), and mRNA-3210 (an investigational treatment for PKU) in murine models of each disease. All 3 mRNA therapeutics exhibited pharmacokinetic/pharmacodynamic (PK/PD) responses in their respective murine model by driving mRNA, protein, and/or protein activity responses, as well as by decreasing levels of the relevant biomarker(s) when compared to control-treated animals. These preclinical data were then used to develop translational PK/PD models, which were scaled allometrically to humans to predict starting doses for first-in-human clinical studies for each disease. The predicted first-in-human doses for mRNA-3927, mRNA-3705, and mRNA-3210 were determined to be 0.3, 0.1, and 0.4 mg/kg, respectively.

The association between gut microbiome and growth in infants with cystic fibrosis

BACKGROUND

In cystic fibrosis (CF), pathophysiologic changes in the gastrointestinal tract lead to malnutrition and altered gut microbiome. Microbiome alterations have been linked to linear growth, gut inflammation and respiratory manifestations. Elucidating these gut microbiome alterations may provide insight into future nutritional management in CF.

METHODS

Infants were followed for 12-months at four sites in the United States (US-CF) and Australia (AUS-CF). 16S rRNA gene sequencing was performed on longitudinal stool samples. Associations between microbial abundance and age, antibiotic prophylaxis, malnutrition, and breast feeding were evaluated using generalized linear mixed models. Taxonomic and predictive functional features were compared between groups.

RESULTS

Infants with CF (N = 78) were enrolled as part of a larger study. AUS-CF infants had higher mean weight-for-age z-scores than US-CF infants (p = 0.02). A subset of participants (CF N = 40, non-CF disease controls N = 10) provided stool samples for microbiome analysis. AUS-CF infants had lower stool alpha diversity compared to US-CF infants (p < 0.001). AUS-CF infants had higher relative abundance of stool Proteobacteria compared to US-CF infants which was associated with antibiotic prophylaxis (p < 0.001). Malnutrition (weight-for-age <10th percentile) was associated with depleted Lactococcus (p < 0.001). Antibiotic prophylaxis (p = 0.002) and malnutrition (p = 0.012) were linked with predicted decreased activity of metabolic pathways responsible for short chain fatty acid processing.

CONCLUSIONS

In infants with CF, gut microbiome composition and diversity differed between the two continents. Gut microbial diversity was not linked to growth. The relationship between malnutrition and antibiotic prophylaxis with reduced SCFA fermentation could have implications for gut health and function and warrants additional investigation.

Increasing Enzyme Mannose-6-Phosphate Levels but Not Miglustat Coadministration Enhances the Efficacy of Enzyme Replacement Therapy in Pompe Mice

Pompe disease is a rare glycogen storage disorder caused by a deficiency in the lysosomal enzyme acid α-glucosidase, which leads to muscle weakness, cardiac and respiratory failure, and early mortality. Alglucosidase alfa, a recombinant human acid α-glucosidase, was the first approved treatment of Pompe disease, but its uptake into skeletal muscle via the cation-independent mannose-6-phosphate (M6P) receptor (CIMPR) is limited. Avalglucosidase alfa has received marketing authorization in several countries for infantile-onset and/or late-onset Pompe disease. This recently approved enzyme replacement therapy (ERT) was glycoengineered to maximize CIMPR binding through high-affinity interactions with ∼7 bis-M6P moieties. Recently, small molecules like the glucosylceramide synthase inhibitor miglustat were reported to increase the stability of recombinant human acid α-glucosidase, and it was suggested that an increased serum half-life would result in better glycogen clearance. Here, the effects of miglustat on alglucosidase alfa and avalglucosidase alfa stability, activity, and efficacy in Pompe mice were evaluated. Although miglustat increased the stability of both enzymes in fluorescent protein thermal shift assays and when incubated in neutral pH buffer over time, it reduced their enzymatic activity by ∼50%. Improvement in tissue glycogen clearance and transcriptional dysregulation in Pompe mice correlated with M6P levels but not with miglustat coadministration. These results further substantiate the crucial role of CIMPR binding in lysosomal targeting of ERTs. SIGNIFICANCE STATEMENT: This work describes important new insights into the treatment of Pompe disease using currently approved enzyme replacement therapies (ERTs) coadministered with miglustat. Although miglustat increased the stability of ERTs in vitro, there was no positive impact to glycogen clearance and transcriptional correction in Pompe mice. However, increasing mannose-6-phosphate levels resulted in increased cell uptake in vitro and increased glycogen clearance and transcriptional correction in Pompe mice, further underscoring the crucial role of cation-independent mannose-6-phosphate receptor-mediated lysosomal targeting for ERTs.

Systematic literature review of the epidemiology of glycogen storage disease type 1a

Glycogen storage disease (GSD) type 1a is an inherited autosomal recessive metabolic disease caused by a deficiency in glucose-6-phosphatase activity. The objectives of this research were to systematically review the published literature on the epidemiology of GSD 1a and to assess the performance of reported epidemiology measures in a simulation model. In this systematic literature review 2,539 record titles and abstracts were screened. Of these, only 11 studies contained relevant data on GSD 1a disease epidemiology. Reported disease frequency ranged from 0.085/100,000 to 10.3/100,000 newborns when considering all the GSD literature. When this was narrowed to GSD 1 and GSD 1a, the range was tightened to 0.25-3.02/100,000 and 0.085-4.9/100,000 newborns, respectively. Most of the identified studies counted the number of diagnoses in a defined period and related to the number of births in the same (Dx method) or different time period (DoB method). The simulation model results indicate that in most of the situations, the Dx method provides a closer estimate to the true disease incidence than the DoB method. Despite the scarcity of epidemiology data, the results of this systematic review strongly support that GSD 1a and its parent disease groups (GSD and GSD 1) are rare diseases.

The relationship between health-related quality of life, perceived social support, and social network size in African Americans with aphasia: a cross-sectional study

Stroke significantly impairs health-related quality of life (HRQL). Stroke survivors with aphasia (SWA) experience lower HRQL than stroke survivors without aphasia (SSA) as a result of poorer communication and social functioning. The extent to which aphasia influences HRQL in African-Americans and the components of social functioning that are most important to HRQL warrants further exploration.There were two main objectives of this paper. The first was to survey HRQL domains of communication, physical, mental/emotional, role, and social functioning in African American SWA and SSA. The second was to examine if social support and social network predicted HRQL in SWA.A total of 39 African American adults (62.4 ± 11.10) participated in this descriptive cross-sectional case control study. Patient-reported outcome measures were used to assess HRQL, perceived social support, and social network in SWA, SSA, and normal-aging healthy controls (NAH). Data analysis included an ANOVA and moderator regression to determine if social support or social network predicted HRQL in SWA.SWA reported a significantly lower overall HRQL (p = <.000) than NAH adults. Communication HRQL was the hallmark difference found between SWA and SSA (p = <.000). Social support and social network were relatively similar among all three groups. However, social support and social network did not predict HRQL in SWA.Findings from this study suggest that social HRQL continues to be significantly lower in SWA; however, social support and social network factors do not drive differences among African-Americans. Moreover, communication HRQL remains the hallmark difference between SWA and SSA.

"Spontaneous" late recovery from stuttering: Dimensions of reported techniques and causal attributions

PURPOSE

(1) To survey the employed techniques and the reasons/occasions which adults who had recovered from stuttering after age 11 without previous treatment reported as causal to overcome stuttering, (2) to investigate whether the techniques and causal attributions can be reduced to coherent (inherently consistent) dimensions, and (3) whether these dimensions reflect common therapy components.

METHODS

124 recovered persons from 8 countries responded by SurveyMonkey or paper-and-pencil to rating scale questions about 49 possible techniques and 15 causal attributions.

RESULTS

A Principal Component Analysis of 110 questionnaires identified 6 components (dimensions) for self-assisted techniques (Speech Restructuring; Relaxed/Monitored Speech; Elocution; Stage Performance; Sought Speech Demands; Reassurance; 63.7% variance explained), and 3 components of perceived causal attributions of recovery (Life Change, Attitude Change, Social Support; 58.0% variance explained).

DISCUSSION

Two components for self-assisted techniques (Speech Restructuring; Elocution) reflect treatment methods. Another component (Relaxed/Monitored Speech) consists mainly of items that reflect a common, non-professional understanding of effective management of stuttering. The components of the various perceived reasons for recovery reflect differing implicit theories of causes for recovery from stuttering. These theories are considered susceptible to various biases. This identification of components of reported techniques and of causal attributions is novel compared to previous studies who just list techniques and attributions.

CONCLUSION

The identified dimensions of self-assisted techniques and causal attributions to reduce stuttering as extracted from self-reports of a large, international sample of recovered formerly stuttering adults may guide the application of behavioral stuttering therapies.

mRNA Therapy Improves Metabolic and Behavioral Abnormalities in a Murine Model of Citrin Deficiency

Citrin deficiency is an autosomal recessive disorder caused by loss-of-function mutations in SLC25A13, encoding the liver-specific mitochondrial aspartate/glutamate transporter. It has a broad spectrum of clinical phenotypes, including life-threatening neurological complications. Conventional protein replacement therapy is not an option for these patients because of drug delivery hurdles, and current gene therapy approaches (e.g., AAV) have been hampered by immunogenicity and genotoxicity. Although dietary approaches have shown some benefits in managing citrin deficiency, the only curative treatment option for these patients is liver transplantation, which is high-risk and associated with long-term complications because of chronic immunosuppression. To develop a new class of therapy for citrin deficiency, codon-optimized mRNA encoding human citrin (hCitrin) was encapsulated in lipid nanoparticles (LNPs). We demonstrate the efficacy of hCitrin-mRNA-LNP therapy in cultured human cells and in a murine model of citrin deficiency that resembles the human condition. Of note, intravenous (i.v.) administration of the hCitrin-mRNA resulted in a significant reduction in (1) hepatic citrulline and blood ammonia levels following oral sucrose challenge and (2) sucrose aversion, hallmarks of hCitrin deficiency. In conclusion, mRNA-LNP therapy could have a significant therapeutic effect on the treatment of citrin deficiency and other mitochondrial enzymopathies with limited treatment options.

The Impact of Social Media on Communication Sciences and Disorders: A Need for Examination and Research

Purpose

Peer-reviewed research is the typical pathway for research to be implemented into clinical practice. However, the Internet, digital technology, and social media have introduced significant changes for how this information is shared, publicized, evaluated, and utilized. Some of these changes are positive, such as rapid distribution of needed information, whereas others are negative, such as widespread dissemination and influence of fake news and misinformation. The purpose of this editorial is to provide a brief look at how these negative changes have affected the helping professions.

Conclusion

In view of the wide-ranging challenges and influences described here, this editorial is a call for action to our researchers, educators, and clinicians to examine how social media has impacted the scientific practice of communication sciences and disorders. It concludes with a series of questions and examples for how this examination might unfold.

Critical Thinking Is a Noble Endeavor-A Response to Paul's Question: An Invited Essay

Paul (2018a, 2018b) discussed the concept of critical thinking in a series of American Annals of the Deaf editorials examining how critical thinking might serve as a "springboard" to deep knowledge or wisdom and wondering if critical thinking should be viewed as a noble endeavor or hopeless cause. Paul explored three questions in which he considered (a) types of critical thinkers, (b) teaching and evaluating critical thinking, and (c) empathy's role in critical thinking. Responding to Paul, the author focuses on the same questions by summarizing Paul's view, then following with his own. He also explores the question What is critical thinking? Mostly, the author's views resemble Paul's, but he elaborates on places where he thinks gaps or possible misunderstandings exist. The author concludes that critical thinking is indeed a noble endeavor because it is not just what you think that matters, but how you think.

A Randomized Controlled Trial of Knifelight and Open Carpal Tunnel Release

A randomized controlled trial was done to compare the results of carpal tunnel decompression using the standard open approach and the Knifelight® technique. Twenty-six patients with bilateral carpal tunnel syndrome requiring operation were selected for the study and the operative technique was randomized for the first hand. Six weeks later, the second hand was operated upon using the alternate technique. There was little difference between the two techniques with regard to time taken to return to work, return of grip strength, symptom relief, complications, incidence of pillar pain and patient preference. However, the incidence of scar tenderness was significantly lower with the Knifelight® technique.

Lateral weight transference exercises following acute stroke: a preliminary study of clinical effectiveness

Objectives: To evaluate a training programme aimed at improving lateral weight transference in patients following acute stroke to determine main treatment effects, if any, to inform the design of future studies.

Design: A single-blind randomized controlled trial.

Setting: The Stroke Unit at The James Cook University Hospital, Middlesbrough, UK.

Subjects: Thirty-five patients with an acute stroke.

Interventions: All subjects received their usual care, including physiotherapy. The treatment group (n / 17) received 12 additional therapy sessions (over four weeks) comprising exercises aimed at improving lateral weight transference in sitting delivered by trained physiotherapy assistants.

Main outcome measures: Measures of dynamic reaching, sitting and standing, and static standing balance were undertaken by a blind independent observer.

Results: Specific measures of weight displacement in standing and reaching, and timed standing up and sitting down did not detect any differences over time regardless of group. Neither were there any significant changes over time, except for sway during static standing (p B=0.01) and time to return to their original position during dynamic reaching (p / 0.01).

Conclusions: A training programme aimed at improving lateral weight transference did not appear to enhance the rehabilitation of acute stroke patients. Improvements observed in postural control in standing and sitting may be attributable to usual care or natural recovery.

Preparing Our Future Helping Professionals to Become Critical Thinkers: A Tutorial

Critical thinking is increasingly recognized as an essential knowledge and skill for the helping professions. Yet, our pedagogical literature has provided infrequent guidance on how instructors can help students to understand what “critical thinking” means or how it might contribute to their professional lives. Therefore, the purpose of this tutorial is to provide guidelines on how instructors might teach future practitioners to become critical thinkers. The main topics address an instructional definition of critical thinking, the basic knowledge and skills that comprise critical thinking, a broad view of instructional approaches, and a summary of developmental milestones of adult critical thinkers. Specific teaching strategies from instructors who have hands-on experience with guiding their students to become critical thinkers are included.

Combined low-dose contrast-enhanced MR angiography and perfusion for acute ischemic stroke at 3T: A more efficient stroke protocol

BACKGROUND AND PURPOSE

There is need to improve image acquisition speed for MR imaging in evaluation of patients with acute ischemic stroke. The purpose of this study was to evaluate the feasibility of a 3T MR stroke protocol that combines low-dose contrast-enhanced MRA and dynamic susceptibility contrast perfusion, without additional contrast.

METHODS

Thirty patients with acute stroke who underwent 3T MR imaging followed by DSA were retrospectively enrolled. TOF-MRA of the neck and brain and 3D contrast-enhanced MRA of the craniocervical arteries were obtained. A total of 0.1 mmol/kg of gadolinium was used for both contrast-enhanced MRA (0.05 mmol/kg) and dynamic susceptibility contrast perfusion (0.05 mmol/kg) (referred to as half-dose). An age-matched control stroke population underwent TOF-MRA and full-dose (0.1 mmol/kg) dynamic susceptibility contrast perfusion. The cervicocranial arteries were divided into 25 segments. Degree of arterial stenosis on contrast-enhanced MRA and TOF-MRA was compared with DSA. Time-to-maximum maps (>6 seconds) were evaluated for image quality and hypoperfusion. Quantitative analysis of arterial input function curves, SNR, and maximum T2* effects were compared between half- and full-dose groups.

RESULTS

The intermodality agreements (k) for arterial stenosis were 0.89 for DSA/contrast-enhanced MRA and 0.63 for DSA/TOF-MRA. Detection specificity of >50% arterial stenosis was lower for TOF-MRA (89%) versus contrast-enhanced MRA (97%) as the result of overestimation of 10% (39/410) of segments by TOF-MRA. The DWI-perfusion mismatch was identified in both groups with high interobserver agreement (r = 1). There was no significant difference between full width at half maximum of the arterial input function curves (P = .14) or the SNR values (0.6) between the half-dose and full-dose groups.

CONCLUSIONS

In patients with acute stroke, combined low-dose contrast-enhanced MRA and dynamic susceptibility contrast perfusion at 3T is feasible and results in significant scan time and contrast dose reductions.

Strategies for Neoglycan conjugation to human acid α-glucosidase

Engineering proteins for selective tissue targeting can improve therapeutic efficacy and reduce undesired side effects. The relatively high dose of recombinant human acid α-glucosidase (rhGAA) required for enzyme replacement therapy of Pompe disease may be attributed to less than optimal muscle uptake via the cation-independent mannose 6-phosphate receptor (CI-MPR). To improve muscle targeting, Zhu et al. (1) conjugated periodate oxidized rhGAA with bis mannose 6-phosphate bearing synthetic glycans and achieved 5-fold greater potency in a murine Pompe efficacy model. In the current study, we systematically evaluated multiple strategies for conjugation based on a structural homology model of GAA. Glycan derivatives containing succinimide, hydrazide, and aminooxy linkers targeting free cysteine, lysines, and N-linked glycosylation sites on rhGAA were prepared and evaluated in vitro and in vivo. A novel conjugation method using enzymatic oxidation was developed to eliminate side oxidation of methionine. Conjugates derived from periodate oxidized rhGAA still displayed the greatest potency in the murine Pompe model. The efficiency of conjugation and its effect on catalytic activity were consistent with predictions based on the structural model and supported its use in guiding selection of appropriate chemistries.

Critical thinking: knowledge and skills for evidence-based practice

PURPOSE

I respond to Kamhi's (2011) conclusion in his article "Balancing Certainty and Uncertainty in Clinical Practice" that rational or critical thinking is an essential complement to evidence-based practice (EBP).

METHOD

I expand on Kamhi's conclusion and briefly describe what clinicians might need to know to think critically within an EBP profession. Specifically, I suggest how critical thinking is relevant to EBP, broadly summarize the relevant skills, indicate the importance of thinking dispositions, and outline the various ways our thinking can go wrong.

CONCLUSION

I finish the commentary by suggesting that critical thinking skills should be considered a required outcome of our professional training programs.

Combined inhibition of DNA methylation and histone acetylation enhances gene re-expression and drug sensitivity in vivo

Histone deacetylation and DNA methylation have a central role in the control of gene expression in tumours, including transcriptional repression of tumour suppressor genes and genes involved in sensitivity to chemotherapy. Treatment of cisplatin-resistant cell lines with an inhibitor of DNA methyltransferases, 2-deoxy-5′azacytidine (decitabine), results in partial reversal of DNA methylation, re-expression of epigenetically silenced genes including hMLH1 and sensitisation to cisplatin both in vitro and in vivo. We have investigated whether the combination of decitabine and a clinically relevant inhibitor of histone deacetylase activity (belinostat, PXD101) can further increase the re-expression of genes epigenetically silenced by DNA methylation and enhance chemo-sensitisation in vivo at well-tolerated doses. The cisplatin-resistant human ovarian cell line A2780/cp70 has the hMLH1 gene methylated and is resistant to cisplatin both in vitro and when grown as a xenograft in mice. Treatment of A2780/cp70 with decitabine and belinostat results in a marked increase in expression of epigenetically silenced MLH1 and MAGE-A1 both in vitro and in vivo when compared with decitabine alone. The combination greatly enhanced the effects of decitabine alone on the cisplatin sensitivity of xenografts. As the dose of decitabine that can be given to patients and hence the maximum pharmacodynamic effect as a demethylating agent is limited by toxicity and eventual re-methylation of genes, we suggest that the combination of decitabine and belinostat could have a role in the efficacy of chemotherapy in tumours that have acquired drug resistance due to DNA methylation and gene silencing.

Large and massive tears of the rotator cuff

The aim of this study was to determine the functional outcome and rate of re-tears following mini-open repair of symptomatic large and massive tears of the rotator cuff using a two-row technique.

The 24 patients included in the study were assessed prospectively before and at a mean of 27 months (18 to 53) after surgery using the Constant and the Oxford Shoulder scores. Ultrasound examination was carried out at follow-up to determine the integrity of the repair. Patient satisfaction was assessed using a simple questionnaire.

The mean Constant score improved significantly from 36 before to 68 after operation (p < 0.0001) and the mean Oxford Shoulder score from 39 to 20 (p < 0.0001). Four of the 24 patients (17%) had a re-tear diagnosed by ultrasound. A total of 21 patients (87.5%) were satisfied with the outcome of their surgery. The repair remained intact in 20 patients (83%). However, the small number of re-tears (four patients) in the study did not allow sufficient analysis to show a difference in outcome in relation to the integrity of the repair.

Controlled clinical trial of two weight reducing diets in a NHS hospital dietetic outpatient clinic - a pilot study

BACKGROUND

Outpatient dietary weight reduction for obesity is unsatisfactory. The objective of this study was to compare the efficacy of an energy prescription diet with usual care (a healthy eating diet) in adult overweight patients referred to a NHS hospital dietetic outpatient clinic, in terms of weight change over 12 weeks.

METHODS

Controlled clinical trial (systematic allocation).

RESULTS

Of the 53 patients who attended their first appointment, 27 completed the trial. Mean weight loss (kg) after 12 weeks was 4.2 (sd 3.8) on the energy prescription diet (n = 16) and 6.0 (sd 2.8) on the healthy eating diet (n = 11).

CONCLUSIONS

Patients on a weight reducing diet based on energy prescription or healthy eating lost, on average, clinically significant amounts of body weight by 12 weeks. Mean weight loss was greater by about 50% in the healthy eating group and supports the development of a larger trial to estimate true effect.

The knee skyline radiograph: its usefulness in the diagnosis of patello-femoral osteoarthritis

The aim of this study was to determine the usefulness of the skyline radiograph in the diagnosis of patellofemoral osteoarthritis. Additionally, we wanted to assess the usefulness of patello-femoral crepitus as a clinical sign of this condition. Seventy-seven patients scheduled to undergo knee surgery had standard antero-posterior, lateral and skyline X-rays of their affected knee. The presence of clinical patello-femoral crepitus was also documented preoperatively. At the operation, their patellofemoral joints were graded into two groups according to the presence or absence of osteoarthritis. The lateral and skyline view X-rays as well as patello-femoral crepitus were compared individually against the operative findings. The skyline view had a sensitivity of 79% and a specificity of 80%. The lateral view had a sensitivity of 82% and specificity of 65%. Patello-femoral crepitus as a sign had a sensitivity of 89% and a specificity of 82%. There was no statistically significant difference between the two radiological views in terms of sensitivity and specificity in the diagnosis of patellofemoral osteoarthritis. Hence, we cannot recommend the skyline view as a routine radiological investigation in all cases of suspected patellofemoral osteoarthritis.

Independent associations between weight status and disability in adults: Results from the health survey for England

OBJECTIVES

While direct links between obesity and some illnesses are well-established, there is a relative paucity of research on associations between obesity and disabilities. The aim of this study was to test for significant associations between overweight and obesity and the presence of a wide range of disabling conditions in adults, controlling for sex, age, education, social class, income, cigarette smoking status and alcohol consumption.

STUDY DESIGN

Data were extracted from the Health Survey for England (2001); a cross-sectional survey of the community-dwelling population. In total, 8613 adult participants were included in the analysis.

METHODS

Multivariate logistic regression was employed to test whether the odds of having a range of disabling conditions are higher in the overweight and obese populations compared with those in the ideal weight range.

RESULTS

The risk of nearly all disabling conditions tested was elevated in the obese and morbidly obese groups. Of great importance for public health, the risks of musculoskeletal illness, arthritis and rheumatism, and personal care disability were significantly elevated, even in those in the overweight category (currently about half of the adult population living in the UK).

CONCLUSIONS

Obesity is independently associated with a range of disabling conditions in adults. The present study highlights the need for further research into the mechanisms by which these associations occur.

Science and pseudoscience in communication disorders: criteria and applications

PURPOSE

The purpose of this tutorial is to describe 10 criteria that may help clinicians distinguish between scientific and pseudoscientific treatment claims. The criteria are illustrated, first for considering whether to use a newly developed treatment and second for attempting to understand arguments about controversial treatments.

METHOD

Pseudoscience refers to claims that appear to be based on the scientific method but are not. Ten criteria for distinguishing between scientific and pseudoscientific treatment claims are described. These criteria are illustrated by using them to assess a current treatment for stuttering, the SpeechEasy device. The authors read the available literature about the device and developed a consensus set of decisions about the 10 criteria. To minimize any bias, a second set of independent judges evaluated a sample of the same literature. The criteria are also illustrated by using them to assess controversies surrounding 2 treatment approaches: Fast ForWord and facilitated communication.

CONCLUSIONS

Clinicians are increasingly being held responsible for the evidence base that supports their practice. The power of these 10 criteria lies in their ability to help clinicians focus their attention on the credibility of that base and to guide their decisions for recommending or using a treatment.

Glove perforation and contamination in primary total hip arthroplasty

We conducted a randomised, controlled trial to determine whether changing gloves at specified intervals can reduce the incidence of glove perforation and contamination in total hip arthroplasty. A total of 50 patients were included in the study. In the study group (25 patients), gloves were changed at 20-minute intervals or prior to cementation. In the control group (25 patients), gloves were changed prior to cementation. In addition, gloves were changed in both groups whenever there was a visible puncture. Only outer gloves were investigated.

Contamination was tested by impression of gloved fingers on blood agar and culture plates were subsequently incubated at 37°C for 48 hours. The number of colonies and types of organisms were recorded. Glove perforation was assessed using the water test. The incidence of perforation and contamination was significantly lower in the study group compared with the control group. Changing gloves at regular intervals is an effective way to decrease the incidence of glove perforation and bacterial contamination during total hip arthroplasty.

Predictors of outcome after percutaneous treatment for cardiogenic shock

OBJECTIVES

To determine predictors of outcome after percutaneous coronary intervention (PCI) in patients with cardiogenic shock complicating acute myocardial infarction.

METHODS

Retrospective analysis of a cohort of 113 patients undergoing emergency coronary angiography and attempted PCI for cardiogenic shock complicating acute myocardial infarction in a regional cardiothoracic unit.

RESULTS

In-hospital mortality was 51% (58 patients). Adverse outcome was associated with previous myocardial infarction, age over 70 years, cardiogenic shock complicating failure to respond to thrombolytic treatment (failed thrombolysis), and multivessel coronary artery disease. Multivariate logistic regression analysis showed that the first three factors were independent predictors of in-hospital death with odds ratios of 5.21 (95% confidence interval (CI) 1.85 to 14.69), 4.02 (95% CI 1.14 to 14.12), and 3.78 (95% CI 1.43 to 9.96), respectively.

CONCLUSION

About 50% of patients with cardiogenic shock undergoing a strategy of urgent coronary angiography and PCI survive to hospital discharge. Survivors do well in the subsequent six months. Emergency PCI for cardiogenic shock reduces mortality from an expected 80% to about 50%. Clinical features can help determine which patients are most likely to gain from urgent coronary angiography and attempted PCI. Alternative strategies are needed to improve the outcome of patients who fare badly.

Sanders classification of fractures of the os calcis

Our study was undertaken to assess the inter- and intra-observer variability of the classification system of Sanders for calcaneal fractures. Five consultant orthopaedic surgeons with different subspecialty interests classified CT scans of 28 calcaneal fractures using this classification system. After six months, they reclassified the scans.

Kappa statistics were used to analyse the two groups. The interobserver variability of the classification system was 0.32 (95% confidence interval (CI) 0.26 to 0.38). The subclasses were then combined and assessment of agreement between the general classes as a whole gave a kappa value of 0.33 (95% CI 0.25 to 0.41). The mean kappa value for intra-observer variability of the classification system was 0.42 (95% CI 0.22 to 0.62). When the subclasses were combined, it was 0.45 (95% CI 0.21 to 0.65).

Our results show that, despite its popularity, the classification system of Sanders has only fair agreement among users.

Impairment on a simulated gambling task in long-term abstinent alcoholics

BACKGROUND

Recent research indicates that currently active or recently detoxified substance abusers make more disadvantageous decisions on a simulated gambling task (SGT). This study expands on the current literature by using the SGT to examine decision making in long-term abstinent alcoholics (mean of 6.6 years' abstinence) who do not have antisocial personality disorder or a history of conduct disorder.

METHODS

A total of 102 subjects (58 controls and 44 abstinent alcoholics) were tested on the SGT, in which subjects choose cards from 4 different decks that vary in terms of the magnitude of the immediate win (large or small) and the magnitude of long-term loss (large or small). The association of SGT performance with alcohol use variables, with the number of externalizing symptoms, and with personality measures of social deviance was examined.

RESULTS

Compared with controls, long-term abstinent alcohol-dependent subjects had more externalizing symptoms, had personality profiles associated with a proneness to social deviance, and made more disadvantageous decisions on the SGT. The magnitude of disadvantageous decision making was associated with the duration of peak alcohol use but was associated with only one measure (low socialization) of socially deviant personality traits.

CONCLUSIONS

The results suggest that alcoholics can achieve long-term abstinence despite persistent deficits in decision making and abnormal personality profiles. The decision-making deficits either may be the result of long-term alcoholism or may reflect a factor predisposing to alcoholism that persists with abstinence. The possibility is raised that alcoholics who cannot achieve long-term abstinence are even more impaired on their decision making and have more abnormal personality profiles than the abstinent alcoholics studied here.

"Roadblocks" revisited: neural change, stuttering treatment, and recovery from stuttering

In light of emerging findings concerning untreated recovery and neural plasticity, this paper re-examines the viability of an NIH conference recommendation [Cooper, J. A. (1990). Research directions in stuttering: Consensus and conflict. In Cooper, J. A. (Ed.), Research needs in stuttering: Roadblocks and future directions (pp. 98-100). Rockville, MD: American Speech-Language-Hearing Association.] that adults who have recovered from stuttering might inform our understanding of the nature and treatment of persistent stuttering. It is suggested that those who have recovered could constitute a behavioral, cognitive, and neurophysiologic benchmark for evaluating stuttering treatment for adolescents and adults, while helping to identify the limits of recovery from a persistent disorder. This possibility seems especially promising because of findings from recent studies investigating untreated recovery during childhood and adulthood, the emerging evidence concerning neural plasticity and reorganization, and reports of neural system changes during stuttering treatment. Potential obstacles to applying findings from unassisted recovery to treatment do exist, but the benefits of attempts to fully understand stuttering certainly outweigh the difficulties.

EDUCATIONAL OBJECTIVES

After completing this activity, the learner will be able to: (1) describe two complexities involved in determining whether recovery from stuttering was assisted or unassisted; (2) discuss the implications for stuttering research of two neural plasticity research findings from areas other than stuttering; and (3) evaluate the possible implications for stuttering treatment of a coordinated research program that addresses behavioral, cognitive, and neurological characteristics of assisted and unassisted recovery from stuttering.

Unassisted recovery from stuttering: self-perceptions of current speech behavior, attitudes, and feelings

The purpose of this study was to investigate the nature of recovery from stuttering based on the experiences of adults who recovered without treatment. Using a semi-structured, open-ended interview format, 15 speakers verified as persons who recovered without treatment were asked to describe their status as everyday speakers. Seven speakers reported that they no longer stuttered and eight reported that they still stuttered on occasion. Interview material was coded and analyzed by the investigators and checked by independent judges. Results suggested that complete recovery was possible for speakers who reported that they no longer stuttered; whereas, those who still stuttered occasionally appeared to no longer be handicapped by stuttering, but required some vigilance to maintain their relatively fluent speech.

EDUCATIONAL OBJECTIVES

After completing this activity, the learner will be able to: (1) describe the relevance of self-report data for evaluating the nature of recovery from stuttering without treatment; (2) describe the differences in self-perception concerning the nature of recovery for those who no longer have any tendency to stutter compared to those who still have an occasional tendency to stutter; and (3) suggest the possible implications for understanding the nature of recovery from persistent stuttering based on investigations of late recovery without treatment.

Controlled clinical trial of two weight reducing diets in a NHS hospital dietetic outpatient clinic - a pilot study

BACKGROUND

Outpatient dietary weight reduction for obesity is unsatisfactory. The objective of this study was to compare the efficacy of an energy prescription diet with usual care (a healthy eating diet) in adult overweight patients referred to a NHS hospital dietetic outpatient clinic, in terms of weight change over 12 weeks.

METHODS

Controlled clinical trial (systematic allocation).

RESULTS

Of the 53 patients who attended their first appointment, 27 completed the trial. Mean weight loss (kg) after 12 weeks was 4.2 (sd 3.8) on the energy prescription diet (n = 16) and 6.0 (sd 2.8) on the healthy eating diet (n = 11).

CONCLUSIONS

Patients on a weight reducing diet based on energy prescription or healthy eating lost, on average, clinically significant amounts of body weight by 12 weeks. Mean weight loss was greater by about 50% in the healthy eating group and supports the development of a larger trial to estimate true effect [corrected].