312 Foreign Bodies in the Urinary Tract - Can We Learn Something from the Pandemic?

Aim

We aim to quantify the morbidity and resource utilisation from patients presenting with foreign bodies in the urinary tract and analyse the effect of the coronavirus pandemic on the numbers. Often these patients have co-existing mental health issues, which necessitates coordinated multi-disciplinary care. It is important that patient care is assessed holistically, with assessment of whether changes in mental health care impact urological morbidity.

Method

We performed a 2-year, retrospective, single-institution study of patients requiring removal of foreign bodies from their urinary tract.

Results

There were 49 episodes of patients needing removal of foreign body; all were inpatients at the regional mental health hospital.8% of patient episodes presented with urinary sepsis. All patients had successful general anaesthetic, endoscopic removal of the foreign body from their urinary tract. There was significantly more episode’s pre-pandemic (38 episodes, mean 2.7 per month) than during the pandemic (11 episodes, mean 1.1 per month). During the pandemic, staffing levels within the mental health hospital have been increased to enable isolation procedures to be conducted when necessary. It was felt that the reduction in foreign body insertion episodes was a consequence of this. The resultant reduction in acute hospital admissions and procedures is estimated to have saved £400,256 per annum.

Conclusions

Patients presenting with a foreign body in the urinary tract utilize a considerable number of resources and are a source of morbidity. Urosepsis and retention are common sequelae. Reduced episodes during the pandemic have shown that increased staffing levels have a positive effect and could be cost-effective. It is imperative that this data is used to appropriately allocate resources to reduce patient morbidity.

21 One-Shot Tract Dilatation for Supine Percutaneous Nephrolithotomy (PCNL) in Obese Patients

Introduction

With the rising incidence of both obesity and urolithiasis, the need to perform stone surgery in high BMI patients is increasing. We analysed the safety and efficacy of the one-shot tract dilatation (OSD) technique in obese patients undergoing supine percutaneous nephrolithotomy (PCNL).

Method

Retrospective review of all supine PCNLs performed by a single surgeon between January 2014 and December 2020. Patient factors (age and BMI), stone complexity and procedural characteristics (tract size and dilatation technique) were collected. Outcomes included access success, length of stay, operating duration, and inpatient complications.

Results

Overall 104 supine PCNLs were performed in 93 patients. Forty-four had a BMI >/ =  30 kg/m2 with a median age of 53 years, median BMI 35.12 kg/m2 and median Guy’s stone score of 2. When initial puncture was successful (43 cases (98%)), tract dilatation was satisfactory on all occasions. Dilatation was performed using a balloon dilator (24Ch) in 12 cases and OSD in 31 cases (range 16Ch to 24Ch, median 22Ch). Median length of stay was lower when OSD used (1 day) versus balloon (2 days), P = 0.03. Median operating time using OSD was 98 minutes versus 120 minutes using balloon (P = 0.10). There was no significant difference in operative time or length of stay when using OSD compared with BMI < 30 kg/m2. There were two Clavien-Dindo Grade I and one Grade II complications in patients where OSD was used. No transfusions were required.

Conclusions

One shot dilatation is an effective and safe means of access in obese patients when performing a supine PCNL.

The impact of weather on the incidence of dark cutting in Australian feedlot cattle

This study conducted a retrospective analysis of historical Meat Standard Australia (MSA) carcass data in combination with Bureau of Meteorology (BOM) weather data, to evaluate the relationship between climatic conditions prior to feedlot departure on the incidence of dark cutting grain-fed beef. Data records for 2,795,754 carcasses from 17 commercial feedlots over a 6-year period were evaluated within this study. Carcasses were consigned to 16 abattoirs. Weather data from BOM were recorded at 30-min intervals and were obtained from weather stations with the closest proximity to each feedlot. These data were used to calculate the Temperature Humidity Index (THI). Climatic data were amalgamated into daily observations and a series of predictors including ambient temperature (T_A, °C), relative humidity (RH, %), wind speed (WS, m/s), rainfall (mm) and THI. In addition, lag interactions from 24 h out to 28 days prior to exiting the feedlot were generated. The incidence of dark cutting was determined as percentage per cohort with an ultimate pH > 5.7. Data were analysed using three models: model 1 included feedlot, abattoir, hormone growth promotant status and sex as fixed effects. Model 2 incorporated the fixed effects within model 1 and minimum, maximum and standard deviation (SD) of T_A and RH, daily range in T_A, average WS and rainfall as random effects. Model 3 incorporated minimum, maximum, range and SD of THI, average WS and rainfall as random effects in addition to the fixed effects of model 1. The incidence of dark cutting within feedlot had a 10.1% range in estimated means with the lowest incidence was observed at feedlot 17 (0%) and highest incidence at feedlot 10 (10.1%). The inclusion of the climatic variables in model 2 and model 3 accounted for an additional 0.1 to 0.2% of the incidence of dark cutting carcasses. Higher maximum T_A, RH and THI in the 3 to 28 days prior to consignment were all associated with an increased incidence of dark cutting (P < 0.05), but not in the 48 h preceding consignment (P > 0.05). Low minimum T_A and low THI were also associated with an increase the incidence of dark cutting across all lag periods (P < 0.05). Increased variation in THI and T_A in the 48 h prior to consignment increased dark cutting (P < 0.05) while increased standard deviation (SD) of temperature and THI range also increased dark cutting in the 14 and 28 day prior to feedlot exit (P < 0.05). Smaller minimum ranges in T_A in the 28 days prior to consignment also reduced dark cutting (P < 0.05). Climatic conditions accounted for a further 0.1 to 0.2% of the incidence of dark cutting, whereas animal management factors, feedlot and abattoir were able to account for 21% of dark cutting. These data suggest that climatic conditions appear to have an inherent role in the incidence of dark cutting, albeit a small impact. Regardless, understanding the influence of climatic conditions on dark cutting allows for the implementation of management strategies within the supply chain to further reduce the impact of climatic conditions on grain-fed cattle.

Embedded microcomputer-based force plate system validation when evaluating lameness severity differentiation under an induced synovitis model in lactating dairy cattle

Bovine lameness has relatively large negative economic and welfare implications on the U.S. dairy industry. Due to the ramifications, early lameness detection will aid in assisting dairy producers to mitigate downstream effects through early treatment. The objective of this study was to determine the minimum standing time required among 2-, 3-, 4-, 5-, and 10 min time intervals to obtain an accurate weight distribution estimate for each leg when attempting to detect lameness. An embedded microcomputer-based force plate system was developed to measure vertical forces from individual cow limb weight distribution to detect bovine lameness when utilizing an induced synovitis lameness model. The force plate has four quadrants, with each load cell quadrant measuring the force placed on it from a single limb. The force plate recorded weight (kg) every second from each load cell quadrant, after which, a 60 s moving average for weight distribution was calculated. A sequential study design was employed to evaluate non-lame and induced lameness to ensure time requirements were consistent. Prior to induction, the force plate system was used to measure weight distribution every second for 15 min. After lameness induction, additional 15 min increments were recorded every 24 h for seven days. Lameness was induced by injecting the left hind distal interphalangeal joint in three cows with amphotericin B, 12 h prior to the start of the study. Data were analyzed using a linear mixed effect that included the fixed effects of day relative to lameness induction, time period, foot and injected foot. Cow within replicate was included as a random effect. Cumulative minutes were assessed up to 15 min by comparing the least square rolling 60 s cumulative means expressed as a percentage of each animal's BW percentage placed on each leg for 2-, 3-, 4-, 5-, and 10 min intervals. Results indicate that the minimum time needed for accurate lameness detection in cows was 2 min.

567 The Ever-Present Costs of Cosmetic Surgery Tourism; A 5-Year Observational Study

Introduction

Cosmetic surgery tourism is an ever-growing industry. An increasing number of patients are presenting to NHS services with complications from their surgery. This study aims to evaluate the current presentation patterns for complications in cosmetic surgery tourism, as well as the financial burden to a single UK level one trauma centre in Birmingham, UK.

Method

Between 2015 and 2020, all patients presenting to the department of plastic surgery with complications of cosmetic surgery performed outside of the UK were included. A cost analysis was performed for each patient using published ‘National Schedule of NHS Costs.’

Results

A total of 26 patients presented to our hospital within the study period. 32 cosmetic procedures were undertaken, with the majority performed in Turkey (n = 14). Abdominoplasty was the most common procedure, followed by gluteal enhancement surgery. The total financial cost to our hospital from all cosmetic surgery-related complications was £152,946, with an average cost per patient of £5,882.54 (range £362 - £26,585).

Conclusions

Patients seek out medical tourism for multiple reasons. The costs displayed should predominantly be viewed as a reflection of the detrimental effect these complications can have on patients’ lives. Global governing bodies should focus efforts on educating patients and raising awareness on this ever-prevalent issue.

Randomized controlled trial comparison of analgesic drugs for control of pain associated with induced lameness in lactating dairy cattle

Both the economic loss and welfare implications of lameness affect the dairy industry. Currently no analgesic drugs are approved to alleviate lameness-associated pain in lactating dairy cattle in the United States. In this randomized controlled trial, 48 lactating Holsteins were enrolled to evaluate the effect of oral meloxicam and i.v. flunixin meglumine on induced lameness. Cows were allocated to 1 of 4 treatment groups (n = 12 per group): lameness and flunixin meglumine (LAME + FLU); lameness and meloxicam (LAME + MEL); lameness and placebo (LAME + PLBO); or sham induction and placebo (SHAM + PLBO). Six hours before treatment, arthritis-synovitis was induced in the distal interphalangeal joint with 20 mg of amphotericin B, whereas SHAM cows were given an intra-articular injection of an equal volume (4 mL) of isotonic saline. Cows in LAME + FLU received 2.2 mg/kg flunixin meglumine i.v. and whey protein placebo orally; LAME + MEL were administered 1 mg/kg meloxicam orally and 2 mL/45 kg sterile saline placebo i.v.; LAME + PLBO were administered 2 mL/45 kg sterile saline placebo i.v. and whey protein placebo orally; and SHAM + PLBO received 2 mL/45 kg sterile saline placebo i.v. and whey protein placebo orally. The initial treatment of MEL, FLU, or PLBO was identified as time 0 h and followed by a second dose 24 h later with data collection for 120 h. The methods used to assess analgesic efficacy were electronic pressure mat, visual lameness assessment, visual analog score, plasma cortisol concentration, plasma substance P concentration, mechanical nociception threshold, and infrared thermography imaging. Linear mixed effect modeling was the primary method of statistical analysis. Visual lameness scoring indicated a lower proportion of the FLU + LAME group was lame at the T2 h and T8 h time points in comparison to the positive controls, whereas MEL therapy resulted in a lower proportion of lame cows at the T8 h time point. Cortisol area under the effect curve was lower following FLU therapy compared with LAME + PBLO for the 0-2 h (LSM difference = 35.1 ng·h/mL, 95% CI: 6.8, 63.3 ng·h/mL), 2-8 h (LSM difference = 120.6 ng·h/mL, 95% CI: 77.2, 164.0 ng·h/mL), and 0-24 h (LSM difference = 226.0 ng·h/mL, 95% CI: 103.3, 348.8 ng·h/mL) time intervals. Following MEL therapy, cortisol area under the effect curve was lower than LAME + PLBO for both the 2 to 8 h (LSM difference = 93.6 ng·h/mL, 95% CI: 50.2, 137.0 ng·h/mL) and 0 to 24 h time intervals (LSM difference = 187.6 ng·h/mL, 95% CI: 64.9, 310.4 ng·h/mL). Analysis of data from other assessment modalities failed to discern biologically relevant differences between treatment groups. We conclude that meaningful differences were evident for visual lameness assessment and cortisol from MEL and FLU treatment versus the positive control. Further clinical research is needed toward development of a model that will create reproducible events that are more pronounced in severity and duration of lameness which can be validated as a substitute for naturally occurring lameness cases.

Factors predictive of an advanced stage of colorectal cancer at presentation - a bi-national study

AIM

Identifying elements associated with advanced colorectal cancer (CRC) stage may inform understanding of whether advanced disease is a corollary of access to healthcare or tumour biology and in turn allow the use of targeted screening and awareness programmes. The aim of this study was to identify factors that predict advanced stage of CRC at presentation in Australia and New Zealand.

METHOD

This was a cross-sectional registry study sourced from the prospectively maintained Binational Colorectal Cancer Audit database of Australia and New Zealand. The primary outcome was stage as defined by the TNM system with associations drawn to demographic and perioperative variables.

RESULTS

In total, 25 282 separate cancers were included. Univariate analysis found younger age, treatment at a public facility, increasing American Society of Anesthesiologists (ASA) grade, more distal tumours, and less recent year of surgery to all be associated with more advanced disease; sex and presentation at a rural vs urban hospital had no bearing on this outcome. Logistic regression identified younger age (< 60 years vs > 80 years: OR 1.96; 95% CI 1.80-2.14; P = 0.002), treatment at a public vs private hospital (OR 1.21; 95% CI 1.14-1.28; P < 0.001), increasing ASA grade (ASA4 vs ASA1: OR 1.37; 95% CI 1.17-1.59, P < 0.001) and more distal tumours (mid-low rectal vs right colon tumours: OR 1.52; 95% CI 1.41-1.64; P < 0.001) to be independent predictors of nodal or metastatic disease at presentation.

CONCLUSION

Younger age, increasing ASA grade, more distal tumours, and treatment at a public rather than private facility are independently associated with the presence of nodal or distant CRC metastases at diagnosis.

Refocusing cancer multidisciplinary team meetings in the United Kingdom: comparing urology with other specialties

INTRODUCTION

Multidisciplinary team (MDT) meetings have been the gold standard of cancer care in the UK since the 1990s. We aimed to identify the views of urology cancer MDT members in the UK on improving the functioning of meetings and compare them with those of other specialties to manage the increasing demand on healthcare resources and enhance the care of complex cancer cases.

METHODS

We analysed data from 2 national surveys distributed by Cancer Research UK focusing on the views of 2,294 and 1,258 MDT members about cancer MDT meetings.

FINDINGS

Most breast, colorectal, lung and urology cancer MDT members felt meetings could be improved in the following areas: time for meeting preparation in job plans, streamlining of patients, auditing meeting decisions and prioritising complex cases. Most urology respondents (87%) agreed some patients could be managed outside a full MDT discussion, but this was lower for other specialties (lung 78%, breast 75%, colorectal 64%).

CONCLUSIONS

To facilitate decisions on which patients require discussion in an MDT meeting, factors adding to case complexity across all tumour types were identified, including rare tumour type, cognitive impairment and previous treatment failure. This study confirms that urology MDT members are supportive of changing from reviewing all new cancer diagnoses to discussing complex cases but managing others with a more protocolised pathway. The mechanisms for how to do this and how to ensure the safety of patients require further clarification.

Comparative Pharmacokinetics of Meloxicam Between Healthy Post-partum vs. Mid-lactation Dairy Cattle

Lactating dairy cattle are at risk for various painful conditions throughout their life, such as lameness, parturition, mastitis, and metabolic disorders. These conditions necessitate adequate methods of analgesia to address welfare concerns through efficacious pain mitigation. As no method of analgesia has been approved for lactating dairy cattle, to date, research is necessary to determine effective pain management strategies for dairy cattle. In both the European Union and Canada, meloxicam has been approved for use in lactating dairy cattle as a methodology for pain control. The objective of this study was to characterize the pharmacokinetics of meloxicam administered orally and intravenously to lactating dairy cattle in the post-partum vs. mid-lactation period. In this parallel study design, 12 healthy, lactating Holsteins were enrolled within 24 h of freshening and randomly allocated to intravenous (0.2 mg/kg) or oral (1.0 mg/kg) meloxicam administration treatment groups. They were matched based on parity to 12, healthy cows that were considered mid-lactation [>150 days-in-milk (DIM)] to receive the same treatment. Based on meloxicam formulation, sampling times varied and plasma was collection via jugular venipuncture for 6 days. Plasma drug concentrations were evaluated using liquid chromatography coupled with mass spectroscopy and pharmacokinetic properties were evaluated using non-compartmental (i.e., statistical moments) analysis. Results indicated a decreased systemic clearance of meloxicam in post-partum relative to mid-lactation cows, which resulted in a longer half-life and increased total exposure independent of mode of administration. These results suggest a need for dose adjustments based on stage in lactation and further assessment of the impact of days-in-milk on milk withholding period.

Short communication: Determination of the milk pharmacokinetics and depletion of milk residues of flunixin following transdermal administration to lactating Holstein cows

Flunixin is a nonsteroidal anti-inflammatory drug and the most commonly prescribed analgesic in cattle in the United States. Recently, the US Food and Drug Administration (FDA) approved a transdermal formulation of flunixin for control of pyrexia associated with bovine respiratory disease and the control of pain associated with foot rot. The transdermal formulation is not currently approved for use in lactating dairy cattle in the United States, but extra-label use in dairy cattle is permissible under US regulations. The objectives of this study were to determine the pharmacokinetics in milk of dairy cows treated with transdermal flunixin and determine an appropriate withdrawal time for milk. Ten lactating Holstein cows were enrolled into the study in mid lactation. Following treatment, cows were milked 3 times per day through 144 h. Milk samples were collected for drug analysis using ultra-high-pressure liquid chromatography coupled with a triple quadrupole mass spectrometer. The geometric mean maximum concentration for flunixin in milk was 0.010 μg/mL and was 0.061 μg/mL for the active metabolite, 5-hydroxyflunixin. The geometric mean terminal half-life was 20.71 h for flunixin and 22.62 h for 5-hydroxyflunixin. Calculations to approximate a withdrawal time in milk following transdermal flunixin administration were accomplished using a statistical tolerance limit procedure. This analysis indicated that it would be prudent to observe a withdrawal period of 96 h following the last treatment. This is more than twice as long as the labeled withdrawal period of 36 h following use of the injectable formulation. The withdrawal period suggested by this work should be applied carefully, as this study was not conducted under the full quality control practices required by the US FDA for a full drug approval study. Caution should be taken when applying this withdrawal time to diseased animals, animals that are milked with different milking frequencies, and those in different stages of production as these have all been shown to affect drug depletion from milk.

PSI-4 Comparison of analgesics for control of lameness-associated pain in lactating dairy cattle

Both the economic loss and welfare implications of lameness vastly impact the dairy industry. There is a need for effective modalities of analgesia to minimize welfare concerns regarding lameness associated pain in lactating dairy cattle. To date, there are no labeled products with pain control indications available for lactating dairy cattle in the United States. Non-steroidal anti-inflammatory drugs (NSAIDs), like meloxicam and flunixin meglumine, are commonly used by veterinarians for pain management. Data is limited as to their efficacy in lameness-associated pain management. The overarching goal of this study was to compare the analgesic effects of flunixin meglumine (IV) and meloxicam (PO) in lactating dairy cattle with experimentally induced lameness via intra-articular injection of amphotericin B. We hypothesized that lameness would improve under meloxicam treatment compared to flunixin meglumine or no treatment control. A double blinded, randomized controlled trial involving positive and negative controls created the framework to assess efficacy parameters. Parameters included pressure algometry, pressure mat analysis, lameness score, infrared thermography imaging, substance P, and cortisol concentrations of 48 lactating Holstein cows across a six-day time period. Intra-articular injection with amphotericin B resulted in mild transient lameness. Results indicated statistically significant treatment by time effects for several parameters. Visual lameness scores showed flunixin meglumine was equally effective to meloxicam and both more effective than the positive control (P < 0.0001). Flunixin meglumine administered animals displayed lower cortisol levels to that of meloxicam treated cows and both more effective than the positive control (P = 0.0008). The cows treated with meloxicam withstood a greater force created by mechanical nociception threshold than cows administered flunixin meglumine and both more effective than the positive control (P = 0.0008). The impact of NSAID use as a therapeutic treatment of lameness is insurmountable in combatting welfare concerns in the dairy industry.

Impact of specialist management on survival from radiation-associated angiosarcoma of the breast

BACKGROUND

Radiation-associated angiosarcoma of the breast (RAAS) is a rare complication of adjuvant radiotherapy associated with poor survival. The British Sarcoma Group guidelines recommend that all angiosarcomas are referred to a sarcoma multidisciplinary team, although there is no recommendation that patients are managed within a sarcoma service. The aims of this study were to compare survival, complete excision rates and local recurrence rates of patients managed within a sarcoma service and those managed within local hospitals.

METHODS

All patients with RAAS referred to a regional sarcoma service between 1998 and 2015 were identified from prospective databases. Patient records, and radiology, pathology and operation notes were reviewed retrospectively.

RESULTS

Thirty-six patients were operated on with curative intent; 26 were managed by the sarcoma service (of whom 21 underwent radical excision of the irradiated field followed by chest wall reconstruction) and ten were managed locally. Median age was 69·5 (range 43-85) years. Disease-specific survival was significantly longer in patients managed by the sarcoma service than in those managed locally: median 91·1 (range 69·2-113·0) versus 48·8 (18·6-79·1) months respectively (P = 0·012). Overall survival rates were similar (P = 0·112). There was no difference in complete excision rate (18 of 26 in sarcoma service versus 5 of 10 in local services; P = 0·456), although the local recurrence rate was significantly lower among patients managed by the sarcoma service (9 of 26 versus 8 of 10; P = 0·015).

CONCLUSION

Specialist management of RAAS leads to fewer local recurrences and improved disease-specific survival. Early referral and management within specialist units is recommended.

Genetic tools to study juvenile hormone action in Drosophila

The insect juvenile hormone receptor is a basic helix-loop-helix (bHLH), Per-Arnt-Sim (PAS) domain protein, a novel type of hormone receptor. In higher flies like Drosophila, the ancestral receptor germ cell-expressed (gce) gene has duplicated to yield the paralog Methoprene-tolerant (Met). These paralogous receptors share redundant function during development but play unique roles in adults. Some aspects of JH function apparently require one receptor or the other. To provide a foundation for studying JH receptor function, we have recapitulated endogenous JH receptor expression with single cell resolution. Using Bacteria Artificial Chromosome (BAC) recombineering and a transgenic knock-in, we have generated a spatiotemporal expressional atlas of Met and gce throughout development. We demonstrate JH receptor expression in known JH target tissues, in which temporal expression corresponds with periods of hormone sensitivity. Larval expression largely supports the notion of functional redundancy. Furthermore, we provide the neuroanatomical distribution of JH receptors in both the larval and adult central nervous system, which will serve as a platform for future studies regarding JH action on insect behavior.

Longitudinal study of CTX-M ESBL-producing E. coli strains on a UK dairy farm

The aim of this study was to investigate the bacterial strains and farm environment that may contribute to the persistence of ESBL-producing E. coli on a single UK dairy farm. A longitudinal study was conducted comprising 6 visits, between August and October 2010, followed by a further visit at approximately 69weeks after the initial visit. Faecal and environmental samples were collected from different parts of the farm. The persistence and extent of faecal shedding of ESBL E. coli by individual calves was also determined. Twenty two different PFGE types were identified. Four of these were persistent during the study period and were associated with serotypes: O98, O55, O141 and O33. The counts suggest that shedding in calf faeces was an important factor for the persistence of strains, and the data will be useful for parameterising mathematical models of the spread and persistence of ESBL strains within a dairy farm.

Characterization of the metabolic phenotype of chronically activated lymphocytes

Activated lymphocytes proliferate, secrete cytokines, and can make antibodies. Normally activated B and T cells meet the bioenergetic demand for these processes by up-regulating aerobic glycolysis. In contrast, several lines of evidence suggest that pathogenic lymphocytes in autoimmune diseases like lupus meet ATP demands through oxidative phosphorylation. Using (13)C-glucose as a stable tracer, we found that splenocytes from mice with lupus derive the same fraction of lactate from glucose as control animals, suggesting comparable levels of glycolysis and non-oxidative ATP production. However, lupus splenocytes increase glucose oxidation by 40% over healthy control animals. The ratio between pentose phosphate cycle (PPC) activity and glycolysis is the same for each group, indicating that increased glucose oxidation is due to increased activity of the TCA cycle in lupus splenocytes. Repetitive stimulation of cultured human T cells was used to model chronic lymphocyte activation, a phenotype associated with lupus. Chronically activated T cells rely primarily on oxidative metabolism for ATP synthesis suggesting that chronic antigen stimulation may be the basis for the metabolic findings observed in lupus mice. Identification of disease-related bioenergetic phenotypes should contribute to new diagnostic and therapeutic strategies for immune diseases.

Psychological interventions for postnatal depression: cluster randomised trial and economic evaluation. The PoNDER trial

OBJECTIVES

To investigate outcomes for postnatal women attributed to special training for health visitors (HVs) in systematically identifying postnatal depression and delivering psychologically informed interventions, and to establish the cost-effectiveness of the intervention.

DESIGN

A pragmatic randomised cluster trial with clusters allocated to experimental HV training arms or control, with an 18-month follow-up.

SETTING

GP practices in the former Trent Regional Health Authority.

PARTICIPANTS

Women registered with participating GP practices who became 36 weeks pregnant during the recruitment phase of the trial, had a live baby and were on a collaborating HV's caseload for 4 months postnatally.

INTERVENTION

HV training in the assessment of postnatal women, combined with either cognitive behavioural approach (CBA) or person-centred approach (PCA) sessions for eligible women, plus the option of a selective serotonin reuptake inhibitor if indicated.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of at-risk women with a 6-month Edinburgh Postnatal Depression Scale (EPDS) score > or = 12. The primary comparison was between at-risk women in the combined clusters randomised to HV training and women in practices randomised to provide HV usual care. The secondary comparison was to determine any differences between the proportions of women with a 6-month EPDS score > or = 12 in the CBA and PCA groups.

RESULTS

HVs in 101 clusters in 29 primary care trusts collaborated in the study. From 7649 eligible women 4084 (53.4%) consented to take part: 17.3% (595/3449) of women who returned a 6-week questionnaire had a 6-week EPDS score > or = 12 and were at-risk women; 70.3% (418/595) of at-risk women had a 6-month EPDS score available. In total, 45.6% (67/147) of control group (CG) at-risk women had a 6-month EPDS score > or = 12 versus 33.9% (93/271) of intervention group (IG) women (p = 0.036). A total of 32.9% (46/140) of at-risk women in the CBA group versus 35.1% (46/131) in the PCA group had a 6-month EPDS score > or = 12 (p = 0.74). The CG mean 6-month EPDS score for at-risk women was 11.3 (SD 5.8) versus 9.2 (SD 5.4) for the IG (p = 0.002) and this remained statistically significant after adjusting for 6-week variables (p = 0.001). In total, 16.4% (150/914) of all women in the CG had a 6-month EPDS score > or = 12 compared with 11.7% (205/1745) in the IG (p = 0.003). The CG mean 6-month EPDS score for all women was 6.4 (SD 5.2) compared with 5.5 (SD 4.7) for the IG (p < 0.001). The economic analysis results showed a consistent pattern of psychological approaches being cost-effective at funding levels used by the National Institute for Health and Clinical Excellence.

CONCLUSIONS

HV training was effective compared with HV usual care in reducing the proportion of at-risk women with a 6-month EPDS score > or = 12, with a wide confidence interval for the estimated intervention effect, suggesting that the true treatment effect may be small. The effect remained for 1 year. The economic evaluation demonstrated that the HV intervention was highly likely to be cost-effective compared with the control. There was no difference in outcomes between the CBA and the PCA groups.

Antimicrobial drug resistance of Salmonella and Escherichia coli isolates from cattle feces, hides, and carcasses

To determine patterns of cross-contamination and antibiotic susceptibility of microorganisms commonly associated with cattle, 60 cattle shipped to a commercial abattoir (20 in each of three separate trial periods) were followed through processing. Samples for bacterial isolation were collected from the feces and hides immediately before shipping, from the hides at the abattoir after exsanguination, and from the carcasses before evisceration and in the cooler. Samples were cultured for Salmonella and non-type-specific Escherichia coli. Salmonella was identified in 33.9% (n = 20) of the fecal samples and on 37.3% (n = 22) of the hides before shipment. At the abattoir, the proportion of hides from which Salmonella was isolated increased (P < 0.001) to 84.2% (48 hides). Nonspecific E. coli and Salmonella were recovered from 40.4 and 8.3% of preevisceration carcass samples, respectively. No Salmonella or nonspecific E. coli were recovered from hotbox carcass samples. Isolates were tested for antimicrobial drug susceptibility. For nonspecific E. coli, 80.3% (n = 270) of the isolates were resistant to at least one antimicrobial drug. For Salmonella, 97% (n = 101) of the isolates were resistant to at least one antimicrobial drug; however, only 4.0% were resistant to two or more. The most common resistance was to sulfamethoxazole. These results indicate that the presence of microorganisms resistant to antimicrobial drugs is common in cattle and beef. Further studies are needed to identify the sources and causes of this drug resistance.

Estimation of the relative risk of developing clinical scrapie: the role of prion protein (PrP) genotype and selection bias

Prion protein (PrP) genotype data from statutory confirmed cases and from three non-case datasets have been used to calculate the odds ratio (or) for the development of clinical scrapie for an individual sheep of a given PrP genotype, compared with one possessing the "wild-type" ARQ/ARQ genotype. Logistic regression has been used to estimate the ors, and a multiple-test procedure has been used to evaluate the statistical significance of each comparison. The results are similar to those observed in other studies: the VRQ/VRQ genotype has or point estimates greater than 20; the ARQ/VRQ and ARH/VRQ genotypes have or point estimates between 5 and 20; AHQ/VRQ between 0.03 and 0.1; ARR/VRQ 0.4 and 0.5; all the other PrP genotypes, excluding ARR/ARR, ARR/ARH and AHQ/ARH for which no clinical cases have been recorded have or point estimates of less than 0.3. The estimates derived from each dataset are comparable, but not identical. This can be explained by plausible biases inherent in the sampling of the non-case populations.

Frequencies of PrP genotypes in 38 breeds of sheep sampled in the National Scrapie Plan for Great Britain

Between October 2001 and January 2003 the prion protein (PrP) genotypes of over 250,000 sheep were determined through the operation of the National Scrapie Plan (NSP); the results for 38 breeds were analysed to provide an estimate of the underlying PrP genotype distribution of the British sheep population. Although there was marked variability among the genotype profiles of the different breeds, several trends emerged. A comparison of the allele frequencies demonstrated that the breeds could be grouped into three categories: breeds dominated by ARR and ARQ in which the frequency of ARR exceeded the frequency of ARQ; breeds dominated by ARR and ARQ in which the frequency of ARQ exceeded the frequency of ARR; and breeds with significant levels of either AHQ, ARH or VRQ. Hill breeds were more likely to have a lower proportion of animals at low risk of scrapie (NSP type 1) and a higher proportion of animals at an intermediate risk of scrapie (NSP type 3) than other breeds. Most breeds had a small proportion of animals at high risk of scrapie (NSP type 5). The frequency of ARR/VRQ (NSP type 4) was variable.

PrP genotypes of rare breeds of sheep in Great Britain

In total 31,669 blood samples were collected from 1187 flocks of 27 rare breeds of sheep in the UK, and their genotype profiles at the prion protein locus were determined. The frequencies of the five alleles varied widely among the breeds and some had only two of the alleles and others had all five; the average was three. The average allele frequencies across all 27 breeds were 49.7 per cent for ARR, 4.4 per cent for AHQ, 2.7 per cent for ARH, 37.4 per cent for ARQ and 5.8 per cent for VRQ. The highest frequencies for each allele were 90.7 per cent for ARR in the Leicester Longwool, 24.7 per cent for AHQ in the Hebridean, 68.7 per cent for ARH in the Manx Loghtan, 98.7 per cent for ARQ in the North Ronaldsay and 28.4 per cent for VRQ in the Boreray. All 27 breeds had the ARR allele, 21 had AHQ, 11 had ARH, 26 had ARQ and 20 had VRQ.

Seasonal variation in muscle glycogen in beef steers

Dark-cutting in beef carcasses is a quality and economic problem for the grass-fed beef industry in Australia, with ~10% of carcasses graded as dark-cutting. Dark-cutting results from low muscle glycogen levels at the time of slaughter. An experiment was designed to examine the relationship between season and muscle glycogen levels for cattle at pasture. Sixty steers were allocated to 2 stocking rate treatments, low and high (1.5 and 2.5 steers/ha, respectively) with 3 replicates for each treatment and grazed in 6 separate paddocks. Monthly samples of the M. semimembranosus (SM) and M. semitendinosus (ST) were taken by biopsy from all cattle and analysed for glycogen and lactate content. Significant differences in muscle glycogen were found between seasons. Average muscle glycogen levels for autumn, winter, spring and summer were 1.24, 1.00, 1.15 and 0.82 mg/g SM and 0.85, 0.91, 1.05 and 0.76 mg/g ST, respectively. The seasonal effects on muscle glycogen were not influenced by stocking rate, but it is postulated that they were influenced by nutrition, with the peak in muscle glycogen level generally coinciding with the peak in pasture quantity and quality in spring.

The prevention of schizophrenia: what interventions are safe and effective?

Obstetric complications appear to increase the risk of developing schizophrenia, and post-World War II improvements in obstetric care may have contributed to a decline in the incidence of the illness in the developed world. Educating providers and consumers of psychiatric and obstetric services about the risk of obstetric complications in increasing the risk of schizophrenia could bring about a further small decrease in the incidence of the illness, safely and at low cost. On the other hand, attempts to prevent the occurrence of schizophrenia by treating people who manifest high-risk indicators prior to the development of the illness have a low probability of success and a high probability of unintended negative consequences. Early intervention with people who have developed the full schizophrenia syndrome is likely to have few negative effects and may yield benefits, although it is not yet clear that it will.

Effects of exposure to event 176 Bacillus thuringiensis corn pollen on monarch and black swallowtail caterpillars under field conditions

The widespread planting of corn genetically modified to produce Bacillus thuringiensis endotoxin has led to speculation that pollen from these fields might adversely affect nearby nontarget lepidopterans. A previous study of Bt corn engineered with Monsanto event 810 failed to detect an effect of pollen exposure on the black swallowtail, Papilio polyxenes, in either the field or the laboratory. Here, we report results of a field study investigating the impact of exposure to pollen from a Bt corn hybrid containing Novartis event 176 on two species of Lepidoptera, black swallowtails and monarch butterflies, Danaus plexippus. Nearly half of the 600 monarch larvae died within the first 24 h; this and subsequent mortality was not associated with proximity to Bt corn and may have been due in part to predation. Survivorship of black swallowtails was much higher than that of the monarchs and was also independent of proximity to the transgenic corn. However, despite five rainfall events that removed much of the pollen from the leaves of their host plants during the experiment, we observed a significant reduction in growth rates of black swallowtail larvae that was likely caused by pollen exposure. These results suggest that Bt corn incorporating event 176 can have adverse sublethal effects on black swallowtails in the field and underscore the importance of event selection in reducing environmental impacts of transgenic plants.

Subjective and objective dimensions of quality of life in psychiatric patients: a factor analytical approach: The South Verona Outcome Project 4

BACKGROUND

Both subjective and objective information is necessary to assess quality of life (QOL).

AIMS

To explore the role of subjective and objective QOL dimensions and their cross-sectional and longitudinal predictors.

METHOD

The relationship between QOL, as measured by the Lancashire Quality of Life Profile (LQL), and demographic variables, diagnosis, psychopathology, disability, functioning, affect balance, self-esteem, service use and service satisfaction was investigated at two points in time, using factor analysis and multiple regression techniques.

RESULTS

One subjective and two objective LQL factors with strong face validity were identified. Cross-sectional predictors of the subjective factor were primarily subjective measures; longitudinally, few predictors of this factor were identified. The cross-sectional and longitudinal predictors of the objective factors were primarily demographic and observer-rated measures.

CONCLUSIONS

Subjective and objective data are distinct types of information. Objective measures may be more suitable in detecting treatment effects. Subjective information is necessary to complete the QOL picture and to enhance the interpretation of objective data.

Stroke rehabilitation: benefits of educational initiatives

The supportive education of stroke survivors and their carers has been identified as a key area of interest to rehabilitation nurses. The Audit Commission recommends the widespread use of stroke units within the NHS (Audit Commission, 2000). The aim of this review is to determine the authority of available evidence and to discuss how such evidence might influence practice. The literature tended to assume that education had a positive effect on the outcome of rehabilitation. Various education interventions were attempted, including information-giving through the use of written material as well as more supportive and facilitative approaches. Factors that may affect the ability to learn or absorb information were identified and attempts have been made to evaluate the effect of educational interventions.

Validation of cardiologists' decisions to initiate reperfusion therapy for acute myocardial infarction with electrocardiograms viewed on liquid crystal displays of cellular telephones

BACKGROUND

The transmission of 12-lead electrocardiograms from remote locations to hand-held computers of cardiologists is now possible with the development of wireless technology and computer software. This investigation determined whether the cardiologist's decisions regarding reperfusion therapy for patients with symptoms suggestive of an acute myocardial infarction are the same when given electrocardiograms displayed on a cellular telephone as on a standard paper recording.

METHODS

Cardiologists were given 20 electrocardiograms of patients with acute chest pain suggestive of acute myocardial infarction to test the diagnostic reliability of the Nokia 9000i cellular telephone liquid crystal display (LCD) screen. The cardiologists made their decision to initiate or not initiate reperfusion therapy for the patients after viewing their electrocardiograms displayed on both 5-mm and 1-mm formatted grids and twice on traditional printout electrocardiograms. The control level of intraobserver agreement between the responses from the 2 sets of paper display electrocardiograms was compared with the experimental level of intraobserver agreement between the 1-mm LCD electrocardiograms and both sets of paper display electrocardiograms to determine whether the viewing medium affected the cardiologist's decisions. The 1-mm and 5-mm LCD screen electrocardiograms were compared to determine if the grid size affected the cardiologist's decisions.

RESULTS

Ninety-three percent of the 2 sets of paper-guided decisions were in agreement. When comparing the 1-mm LCD-guided decisions with both sets of paper-guided decisions, 94% and 89% of the decisions, respectively, were in agreement. The differences between the control and experimental degrees of intraobserver agreement of 1% and 4% were not statistically significant (P1 =.81, P2 =.29). Ninety-one percent of the 1-mm LCD-guided decisions were in agreement with the 5-mm LCD-guided decisions.

CONCLUSIONS

Cardiologists' decisions did not vary significantly when viewing either traditional paper electrocardiograms or LCD screen electrocardiograms. Even though there was not a significant difference in the cardiologists' decisions when they viewed electrocardiograms displayed on both the 1-mm and 5-mm grid, it is recommended that the 1-mm grid be used for clinical implementation of the LCD screen.

Inhibition of farnesyltransferase with A-176120, a novel and potent farnesyl pyrophosphate analogue

Farnesylation of Ras is required for its transforming activity in human cancer and the reaction is catalysed by the enzyme farnesyltransferase. Recently, we discovered a novel chemical series of potent farnesyl pyrophosphate (FPP) analogues which selectively inhibited farnesyltransferase. Our most potent compound to date in this series, A-176120, selectively inhibited farnesyltransferase activity (IC(50) 1.2+/-0.3 nM) over the closely related enzymes geranylgeranyltransferase I (GGTaseI) (IC(50) 423+/-1.8 nM), geranylgeranyltransferase II (GGTaseII) (IC(50) 3000 nM) and squalene synthase (SSase) (IC(50)>10000 nM). A-176120 inhibited ras processing in H-ras-transformed NIH3T3 cells and HCT116 K-ras-mutated cells (ED(50) 1.6 and 0.5 microM, respectively). The anti-angiogenic potential of A-176120 was demonstrated by a decrease in Ras processing, cell proliferation and capillary structure formation of human umbilical vein endothelial cells (HUVEC), and a decrease in the secretion of vascular endothelial growth factor (VEGF) from HCT116 cells. In vivo, A-176120 reduced H-ras NIH3T3 tumour growth and extended the lifespan of nude mice inoculated with H- or K-ras-transformed NIH3T3 cells. A-176120 also had an additive effect in combination with cyclophosphamide in nude mice inoculated with K-ras NIH3T3 transformed cells. Overall, our results demonstrate that A-176120 is a potent FPP mimetic with both antitumour and anti-angiogenic properties.

The effectiveness of nursing in stroke units

BACKGROUND

Richard Warner examines how nurses might contribute to the effectiveness of organised stroke care by linking the theoretical basis of nursing with outcomes that could be more meaningful to the stroke survivor.

CONCLUSION

Although research shows that specialised stroke units are effective in limiting morbidity and mortality, and in promoting functional ability, the various care roles of the multidisciplinary team are not clear.