Addressing the communication needs of cancer patients for Magnetic Resonance Imaging (MRI) investigations-A phenomenological study on the experiences of MRI radiographers

INTRODUCTION

A higher demand in MRI services could increase the pressure on MRI departments to increase scanning efficiency. This presents the risk of downplaying person-centred care especially for cancer patients with increased communication needs that result from anxiety associated with the nature of their disease. This study explored the experiences of MRI radiographers in addressing the communication needs of cancer patients attending for MRI examinations.

METHODS

The study adopted a descriptive phenomenological methodology. Single contact interviews were conducted on eight MRI specialist radiographers, and these were recorded and transcribed using Microsoft Teams conferencing platform. Thematic analysis of the transcribed data was done through an inductive approach, breaking down the data into meaningful codes and thereafter, into themes and sub-themes.

RESULTS

Common themes generated from the interview data included: identified communication needs, approach to communication needs, support for radiographers and factors affecting communication. Experiences of MRI radiographers indicated increased communication needs in anxious cancer patients and approaches adopted in addressing these were mainly through listening and use of empathetic gestures. Some radiographers admitted to using "blocking" strategies to avoid being drawn into emotionally exhausting conversations. Both intrinsic factors such as radiographers' personality and experience; and extrinsic factors such as time constraints, demanding workload, inadequate staffing, and skill mix were noted to influenced MRI radiographers in addressing these communication needs.

CONCLUSION

Cancer patients can present with communication needs due to anxieties related to their disease. For the radiographer to deal with these needs, adequate support is needed, and necessary steps taken to address the identified influencing factors.

IMPLICATIONS FOR PRACTICE

MRI departments should encourage enabling environment and services that address communication needs of patients with cancer.

Treatment, not delivery, of the late preterm and term fetus with supraventricular arrhythmia

OBJECTIVE

While in-utero treatment of sustained fetal supraventricular arrhythmia (SVA) is standard practice in the previable and preterm fetus, data are limited on best practice for late preterm (34 + 0 to 36 + 6 weeks), early term (37 + 0 to 38 + 6 weeks) and term (> 39 weeks) fetuses with SVA. We reviewed the delivery and postnatal outcomes of fetuses at ≥ 35 weeks of gestation undergoing treatment rather than immediate delivery.

METHODS

This was a retrospective case series of fetuses presenting at ≥ 35 weeks of gestation with sustained SVA and treated transplacentally at six institutions between 2012 and 2022. Data were collected on gestational age at presentation and delivery, SVA diagnosis (short ventriculoatrial (VA) tachycardia, long VA tachycardia or atrial flutter), type of antiarrhythmic medication used, interval between treatment and conversion to sinus rhythm and postnatal SVA recurrence.

RESULTS

Overall, 37 fetuses presented at a median gestational age of 35.7 (range, 35.0-39.7) weeks with short VA tachycardia (n = 20), long VA tachycardia (n = 7) or atrial flutter (n = 10). Four (11%) fetuses were hydropic. In-utero treatment led to restoration of sinus rhythm in 35 (95%) fetuses at a median of 2 (range, 1-17) days; this included three of the four fetuses with hydrops. Antiarrhythmic medications included flecainide (n = 11), digoxin (n = 7), sotalol (n = 11) and dual therapy (n = 8). Neonates were liveborn at 36-41 weeks via spontaneous vaginal delivery (23/37 (62%)) or Cesarean delivery (14/37 (38%)). Cesarean delivery was indicated for fetal SVA in two fetuses, atrial ectopy or sinus bradycardia in three fetuses and obstetric reasons in nine fetuses that were in sinus rhythm at the time of delivery. Twenty-one (57%) cases were treated for recurrent SVA after birth.

CONCLUSION

In-utero treatment of the near term and term (≥ 35-week) SVA fetus is highly successful even in the presence of hydrops, with the majority of cases delivered vaginally closer to term, thereby avoiding unnecessary Cesarean section. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

A feminist approach to eating disorders in China: a qualitative study

BACKGROUND

As women continue to be more at risk from eating disorders, gender has often been a focus of concern in transcultural research. Yet feminist, qualitative studies which prioritize the voices of women/girls remain rare within transcultural work suggesting the need for greater interaction between these fields. This article seeks to contribute to the exploration of the applicability of feminist paradigmslargely developed in the West-to experiences of EDs in non-western contexts.

METHODS

This article draws on semi-structured interviews with 12 women from urban China with self-reported experience of Bulimia Nervosa (BN) and binge eating disorder (BED) in order to explore the complex ways in which gender may be implicated within eating/body distress from a transcultural point of view. The data is analysed through Reflexive Thematic Analysis.

RESULTS

The data analysis suggested two broad themes: (1) Chinese versus Western codes for judging female appearance: from surveillance to liberation (2) Discipline, appetite and control: the gendered/cultural meanings of binging and purging. In terms of the first theme, many participants had spent time in the West which was understood as a less regulated context in terms of gendered body surveillance and eating. Complicating existing assumptions about the 'Westernisation' thesis, different communication codes and peer interactions across Chinese and Western contexts played a central role in how participants experienced their bodies. In the second theme, binging and purging emerged as a way to manage a number of contradictions surrounding Chinese femininity, including respecting familial food cultures, contradictory discourses on female 'appetite', and the need to display a female body which signified cultural imperatives of self-restraint and discipline.

CONCLUSIONS

The data emphasises the importance of examining the culturally specific meanings of eating problems and their gendered contexts, whilst there is clearly much that echoes Western feminist work on Western samples. Although limited, the study crucially points to the importance of examining how ED subcategories other than AN can be explored from a transcultural and feminist point of view.

A case study of the development of a videofluoroscopy service: Integration and collaboration between the speech & language therapy and radiographer teams

BACKGROUND

Videofluoroscopy (VFSS) is a dynamic fluoroscopic examination of swallowing function to assess oropharyngeal dysphagia. In the United Kingdom (UK), this test is typically performed by a team of Speech and Language Therapists (SLTs), radiologists and radiographers. While VFSS is undertaken across the UK, recent literature reflects wide variation in the procedure itself.

OBJECTIVES

The role of the advanced practitioner gastrointestinal (GI) radiographer within a VFSS service will be illustrated by the narrative description of a VFSS service in a large NHS teaching hospital in England. The paper compares the existing VFSS service against recent literature outlining national practice, with particular focus upon the growing role of the advanced practitioner GI radiographer. Existing pressures upon the National Health Service (NHS) are examined as contributing factors. Lastly, further plans to improve the clinic are delineated.

KEY FINDINGS

Recent literature shows a wide national variation in the running of VFSS services. Pertinently, the evidence suggests that radiologists are becoming progressively less involved in these clinics, with a move towards more practitioner-led services. The changes to the described VFSS service are in line with national trends, and the described clinic is an effective example of a practitioner-led service which fully utilises the role of the advanced practitioner GI radiographer.

CONCLUSION

This paper demonstrates that a practitioner-led service can benefit both patients and staff. Further improvement work is ongoing, with a particular need to involve service users and collect more meaningful outcome measures.

IMPLICATIONS FOR PRACTICE

The growing move towards practitioner-led clinics is likely to continue. However, the wide variation in practice nationally and lack of consistent, recognised training that meets the needs of both SLT and radiographers, needs to be addressed.

Stratification of alopecia areata reveals involvement of CD4 T cell populations and altered faecal microbiota

Alopecia areata (AA) is an immune-mediated disease that causes non-scarring hair loss. Autoreactive CD8 T cells are key pathogenic effectors in the skin, and AA has been associated both with atopy and with perturbations in intestinal homeostasis. This study aimed to investigate mechanisms driving AA by characterizing the circulating immunophenotype and faecal microbiome, and by stratifying AA to understand how identified signatures associated with heterogeneous clinical features of the condition. Flow cytometric analyses identified alterations in circulating B cells and CD4 T cells, while 16S sequencing identified changes in alpha and beta diversity in the faecal microbiome in AA. The proportions of transitional and naïve B cells were found to be elevated in AA, particularly in AA samples from individuals with >50% hair loss and those with comorbid atopy, which is commonly associated with extensive hair loss. Although significant changes in circulating CD8 T cells were not observed, we found significant changes in CD4+ populations. In individuals with <50% hair loss higher frequencies of CCR6+CD4 ("Th17") and CCR6+CXCR3+CD4 ("Th1/17") T cells were found. While microbial species richness was not altered, AA was associated with reduced evenness and Shannon diversity of the intestinal microbiota, again particularly in those with <50% hair loss. We have identified novel immunological and microbial signatures in individuals with alopecia areata. Surprisingly, these are associated with lower levels of hair loss, and may therefore provide a rationale for improved targeting of molecular therapeutics.

Periodontal disease as a primary cause of surgical site infection in fractures of the mandible: is smoking a confounding variable?

Fractures of the mandible are common in contemporary oral and maxillofacial practice. Wound infection is the most common complication after open reduction and internal fixation, and the management of these is complex and costly in terms of morbidity to the patient, and in fiscal terms. Whilst numerous epidemiological studies implicate smoking, alcohol, drug use, and adverse behaviour, as well as fracture complexity and diabetes, as important risk factors, the role of periodontal disease is only occasionally mentioned and not formally investigated. The aim of this study therefore was to assess the presence of periodontal disease and its severity according to the 2018 EFP/AAP periodontitis case classification in patients with fractured mandibles who presented to a single level 1 trauma centre, and to look for a possible association with surgical site infection. A total of 305 patients were assessed retrospectively following open reduction and internal fixation via transoral incisions with load-sharing osteosynthesis. The postoperative infection rate was 22.95%. Multivariate and multiple logistic regression revealed that there was a strong association between periodontal staging and postoperative surgical site infection. Crucially, the study predicts that patients with severe periodontal disease (periodontal stage III and IV) are over seven times more likely to develop a wound infection than disease-negative individuals. This has implications for risk adjustment, prognostication, treatment planning, and postoperative care. Surprisingly in this study, cigarette smoking, an established risk factor in the pathogenesis of periodontal disease, did not achieve statistical significance, potentially conflicting with the established literature.

An open invitation to productive conversations about feminism and the spectrum of eating disorders (part 1): basic principles of feminist approaches

Despite the long history of feminist research in the field and the clear relevance of questions of gender to this sphere, many continue to question the relevance of feminism for understanding and treating eating disorders in 2022. In this set of two papers, we explore some of the tensions, omissions and misconceptions which surround feminist approaches to eating disorders. At the core of these two papers is our assertion that such approaches can make significant contributions in the eating disorders field along six key lines: enriching the science of eating disorders, unpacking diagnostics, contextualizing treatment and prevention, attending to lived experiences, diversifying methodologies, and situating recoveries. In this first paper, we outline what feminist approaches are and dig into some key tensions that arise when feminist approaches come to the table. These include critiques of sociocultural approaches to understanding eating disorders, the relationship between feminist approaches and biological and genetic attributions for eating disorders, and the role of men. We then offer a key contribution that feminist approaches have made to eating disorders scholarship: an invitation to unpack diagnostic approaches and situate eating disorders within the landscape of food, weight, and shape concerns in the twenty-first century.

An open invitation to productive conversations about feminism and the spectrum of eating disorders (part 2): Potential contributions to the science of diagnosis, treatment, and prevention

The role of feminism in eating disorders research, treatment, and advocacy continues to be debated, with little agreement in sight about the role-or lack thereof-of feminist eating disorders work. In these debates, the opportunity to open fruitful conversations about eating disorders that generate new possibilities for researching, treating, and preventing them is missed. This article is the second in a series of two papers that invite such a discussion. In this article, we focus on five key contributions that feminist eating disorder work has made and can make moving forward. These are contextualizing treatment, attending to lived experiences, expanding the meanings of "sociocultural influences," diversifying methodologies, and situating recoveries. We do not propose to offer a "final word" on feminisms and eating disorders, but instead to start conversations about how we understand, research, and treat eating disorders.

The epidemiology of alopecia areata: a population-based cohort study in UK primary care

BACKGROUND

There is a lack of population-based information on the disease burden and management of alopecia areata (AA).

OBJECTIVES

To describe the epidemiology of AA, focusing on incidence, demographics and patterns of healthcare utilization.

METHODS

Population-based cohort study of 4·16 million adults and children, using UK electronic primary care records from the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network database, 2009-2018. The incidence and point prevalence of AA were estimated. Variation in AA incidence by age, sex, deprivation, geographical distribution and ethnicity was examined. Patterns of healthcare utilization were evaluated in people with incident AA.

RESULTS

The AA incidence rate was 0·26 per 1000 person-years. AA point prevalence in 2018 was 0·58% in adults. AA onset peaked at age 25-29 years for both sexes, although the peak was broader in females. People of nonwhite ethnicity were more likely to present with AA, especially those of Asian ethnicity [incidence rate ratio (IRR) 3·32 (95% confidence interval 3·11-3·55)]. Higher AA incidence was associated with social deprivation [IRR most vs. least deprived quintile 1·47 (1·37-1·59)] and urban living [IRR 1·23 (1·14-1·32)]. People of higher social deprivation were less likely to be referred for specialist dermatology review.

CONCLUSIONS

By providing the first large-scale estimates of the incidence and point prevalence of AA, our study helps to understand the burden of AA on the population. Understanding the variation in AA onset between different population groups may give insight into the pathogenesis of AA and its management.

Frontal Fibrosing Alopecia survey of severity assessment methods in routine clinical practice and validation of the IFFACG measurement guidance

BACKGROUND

Lack of validated and responsive outcome measures in the management of Frontal Fibrosing Alopecia (FFA) significantly limits our ability to assess disease progression and treatment response over time.

OBJECTIVES

The aim of this study was to understand how FFA extent and progression is currently assessed in UK specialist centres, validate components of the International FFA Cooperative Group (IFFACG) statement on FFA assessment, and identify pragmatic advice to improve FFA management in clinic.

METHODS

Consultant Dermatologists with a specialist interest in hair loss (n=17) were invited to take part. Preferred FFA assessment methods were explored using questionnaires and clinical scenarios. Participants were asked to identify and mark the current hairline in 10 frontal and 10 temporal hairline images, with assessment repeated 3 months later (to assess intra-individual variability) and 12 months later (to test whether inter-individual accuracy could be improved with simple instruction).

RESULTS

All 17 clinicians (100%) completed the questionnaire at each time interval. We identified a wide variation in assessment techniques between our experts. Measurements were perceived as the most accurate method of assessing frontal recession whereas photography was preferred for temporal recession. Inter-rater reliability between clinicians measuring the frontal hairline scenarios indicated a moderate strength of agreement (ICC 0.613; 95% CI: 0.398 to 0.848), yet intra-rater reliability was found to be poor with wide limits of agreement (-8.71mm to 9.92mm) on follow-up. Importantly, when clear guidance was provided on how the hairline should be identified (questionnaire 3), inter-rater reliability improved significantly, with an ICC 0.702 suggesting moderate agreement (95% CI: 0.508 to 0.890; p<0.001). A similar pattern was seen with temporal hairline measurements, which again improved in accuracy with instruction.

CONCLUSION

We show that accuracy of measurements in FFA can be improved with simple instruction and validate components of the IFFACG measurement recommendations.

Quantitative analysis of tegmen bone mineral density in obese and non-obese patients

BACKGROUND

Certain factors have been linked to lateral skull base demineralisation or erosion, which may predispose to spontaneous cerebrospinal fluid leak. There are relatively few quantitative reports of skull base changes in patient populations.

METHOD

A novel refined measurement algorithm for quantification of tegmen bone mineral density was developed, and bone mineral density between obese and non-obese patient groups was compared. Computed tomography scans were analysed by three blinded reviewers, and tegmen bone mineral densities were compared.

RESULTS

There were 23 patients in the obese group and 27 matched controls in the non-obese group. Inter-rater reliability was 'strong' to 'near complete' (κ = 0.75-0.86). No differences in tegmen bone mineral density were found between the groups (p = 0.64). The number of active blood pressure medications correlated positively with lateral skull base bone mineral density.

CONCLUSION

A novel, refined, quantitative measurement algorithm for the assessment of tegmen bone mineral density was developed and validated. Obesity was not found to significantly affect tegmen bone mineral density.

Regulating “untrustworthy patients”: Constructions of “trust” and “distrust” in accounts of inpatient treatment for anorexia

Trust has been seen as a lynchpin of therapeutic relationships. Yet due to perceptions that anorexia is one of the most difficult illnesses to treat and that patients are “treatment resistant”, achieving trust between patient and treatment provider may be challenging. This article draws on qualitative data from 14 semi-structured interviews with women who have experience of inpatient treatment for anorexia in order to analyse how trust and distrust figured in treatment contexts. In so doing, the article draws upon feminist approaches which are critical of conceptions of the “devious” “anorexic” and of the clinical discourses within which these constructions are produced. Our analysis suggests a lack of trust shown toward patients in inpatient contexts – particularly a disqualification of “voice” – which has a number of consequences for participants’ subjectivities, including the erosion of self-esteem; demotivation; dropping out/termination of treatment; and triggering experiences of trauma. As such, our analysis raises serious questions about what participants described as routine treatment practices in inpatient treatment for anorexia, and about the serious consequences of constructing “anorexics” as manipulative and untrustworthy.

SAT0351 CHEMOKINE PATHWAYS ARE ENRICHED IN PSORIATIC ARTHRITIS (PSA) SKIN LESIONS WITH INCREASED EXPRESSION OF ATYPICAL CHEMOKINE RECEPTOR 2 (ACKR2)

Background:

Skin in people with psoriasis has been comprehensively studied; uninvolved skin has abnormal gene expression. Less is known specifically about skin in PsA, the assumption being that it is identical to psoriasis. Chemokines and ACKR2 are among the upregulated genes in uninvolved psoriasis compared to healthy skin[1]. ACKR2 is a scavenging receptor of inflammatory CC chemokines and has been proposed as a regulator of cutaneous inflammation in psoriasis. It has not been studied in PsA.

Objectives:

To compare the transcriptome of PsA lesional, PsA uninvolved and healthy control skin and evaluate ACKR2 expression in PsA.

Methods:

Biopsies were taken from healthy control (HC) skin and paired lesional and uninvolved skin from patients with PsA. Libraries for bulk RNA sequencing were prepared from polyA selected RNA and sequenced on NovaSeq 6000. Sequencing data were analysed using Searchlight2. ACKR2 mRNA expression was validated by qPCR. RNAscope was used to localise ACKR2 expressing cells and sections were co-stained with podaplanin or stained in serial sections with CD45. Chemokine protein expression in skin was evaluated using Luminex technology.

Results:

Nine HC and 9 paired skin samples from patients with PsA were sequenced. The PsA skin lesions (PsA L) formed a distinct population in the transcriptomic principal component analysis (PCA) plot while HC and PsA uninvolved skin (PsA U) were overlapping. Only 15 genes were differentially expressed between HC and PsA U and none coded for chemokines. There were however significantly upregulated chemokines and receptors in PsA L. Unexpectely, ACKR2 was the 2ndmost upregulated chemokine receptor in PsA L with unchanged expression in PsA U compared with HC (PsA L vs HC log2fold 3.38, p.adj=9.51E-41; PsA L vs PsA U log2fold 3.58, p.adj=3.24E-45; PsA U vs HC log2fold -0.2, p.adj=0.732).

The upregulation of ACKR2 in PsA L and unchanged expression in PsA U was confirmed by qPCR. RNAscope demonstrated strong expression of ACKR2 in the suprabasal layer of the epidermis in PsA L. In HC and PsA U, only occasional ACKR2 positive cells were seen in the epidermis. ACKR2 was expressed in lymphatic vessel walls but was not observed in CD45+ leukocytes.

Provisional skin chemokine protein expression data showed poor correlation between mRNA levels and protein expression for the ACKR2 ligands CCL2, CCL3, CCL7, CCL8, CCL11, CCL13 and CCL22 in HC and PsA U, with negative correlation between ACKR2 mRNA expression and CCL2, CCL8 and CCL11 protein expression. In PsA L, chemokine mRNA correlated with protein expression, but protein expression of chemokine ligands did not correlate with ACKR2 expression.

Conclusion:

This data set shows expected upregulation of chemokines and their receptors in PsA L but relatively unchanged gene expression in PsA U, which contrasts to previous studies in psoriasis. Notably, this study demonstrates a strong upregulation of ACKR2 in keratinocytes in PsA L, with unchanged expression in PsA U. The RNA expression and preliminary protein data suggest that ACKR2 has little effect on the levels of its ligands in PsA skin lesions. However, this study may have missed local effects of ACKR2 in the epidermis.

References:

[1]Singh, M.D., et al.,Elevated expression of the chemokine-scavenging receptor D6 is associated with impaired lesion development in psoriasis.Am J Pathol, 2012.181(4): p. 1158-64.

Acknowledgments:

Funded by the Chief Scientist Office and a private donation to the University of Glasgow. Dr Sabarinadh Chilaka helped to prepare libraries for RNA sequencing.

Disclosure of Interests:

Hanna Johnsson: None declared, John Cole: None declared, Gillian Wilson: None declared, Marieke Pingen: None declared, Fiona McMonagle: None declared, Susan Holmes: None declared, Iain McInnes Grant/research support from: Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Janssen, and UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Gilead, Janssen, Novartis, Pfizer, and UCB, Stefan Siebert Grant/research support from: BMS, Boehringer Ingelheim, Celgene, GlaxoSmithKline, Janssen, Novartis, Pfizer, UCB, Consultant of: AbbVie, Boehringer Ingelheim, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Celgene, Janssen, Novartis, Gerard Graham: None declared

Craniomaxillofacial trauma management in austere and war zone environments - A role for composite tissue allotransplantation?

Facial composite tissue allotransplantation (CTA) is a powerful reconstructive option in cases of extensive severe facial injury and tissue loss. Despite the risk of allograft rejection and the post-operative need for lifelong immunosuppression, facial CTA can be used to restore the normal structural appearance and function of the face. Areas of socioeconomic deprivation and armed conflict zones have a high preponderance of patients with facial burns and other severe injuries. However, these regions often also suffer from lack of resources, expert surgical care and limited facilities. The purpose of this manuscript is to provide a comprehensive review of key principles relevant to facial CTA and their potential applicability in such austere environments. We present a concise literature review of the surgical and immunological basis of facial CTA aimed at the plastic surgery readership, as well as issues surrounding organ transplantations in low- and middle- income countries. We then consider the particular challenges posed by austere settings and countries of active armed conflict and discuss how these may impact the suitability of facial CTA for treating severe facial injuries in these circumstances. Facial CTA is recognised as giving huge benefits for patients with severe facial defects with potentially superior results compared with conventional autograft techniques. Its performance in austere settings is limited by scarce resources and increased pre-, intra- and post- operative risks. However, a case can be made for its use even in these more challenging situations when general organ transplantation compliance and expertise input have been addressed.

Alopecia areata is characterized by dysregulation in systemic type 17 and type 2 cytokines, which may contribute to disease-associated psychological morbidity

BACKGROUND

Alopecia areata (AA) is a common autoimmune disease, causing patchy hair loss that can progress to involve the entire scalp (totalis) or body (universalis). CD8⁺ NKG2D⁺ T cells dominate hair follicle pathogenesis, but the specific mechanisms driving hair loss are not fully understood.

OBJECTIVES

To provide a detailed insight into the systemic cytokine signature associated with AA, and to assess the association between cytokines and depression.

METHODS

We conducted multiplex analysis of plasma cytokines from patients with AA, patients with psoriatic arthritis (PsA) and healthy controls. We used the Hospital Anxiety and Depression Scale (HADS) to assess the occurrence of depression and anxiety in our cohort.

RESULTS

Our analysis identified a systemic inflammatory signature associated with AA, characterized by elevated levels of interleukin (IL)-17A, IL-17F, IL-21 and IL-23 indicative of a type 17 immune response. Circulating levels of the type 2 cytokines IL-33, IL-31 and IL-17E (IL-25) were also significantly increased in AA. In comparison with PsA, AA was associated with higher levels of IL-17F, IL-17E and IL-23. We hypothesized that circulating inflammatory cytokines may contribute to wider comorbidities associated with AA. Our assessment of psychiatric comorbidity in AA using HADS scores showed that 18% and 51% of people with AA experienced symptoms of depression and anxiety, respectively. Using linear regression modelling, we identified that levels of IL-22 and IL-17E are positively and significantly associated with depression.

CONCLUSIONS

Our data highlight changes in both type 17 and type 2 cytokines among people with AA, suggesting that complex systemic cytokine profiles may contribute both to the pathogenesis of AA and to the associated depression. What's already known about this topic? NKG2D⁺ CD8⁺ T cells cause hair loss in alopecia areata (AA) but the immunological mechanisms underlying the disease are not fully understood. AA is associated with changes in levels of interleukin (IL)-6, tumour necrosis factor-α, IL-1β and type 17 cytokines. Psychiatric comorbidity is common among people with AA. What does this study add? People with AA have increased plasma levels of the type 2 cytokines IL-33, IL-31 and IL-17E (IL-25), in addition to the type 17 cytokines IL-17A, IL-21, IL-23 and IL-17F. Levels of IL-17E and IL-22 positively predict depression score. What is the translational message? AA is associated with increased levels of multiple inflammatory cytokines, implicating both type 17- and type 2 immune pathways. Our data indicate that therapeutic strategies for treating AA may need to address the underlying type 17- and type 2 immune dysregulation, rather than focusing narrowly on the CD8⁺ T-cell response. An immunological mechanism might contribute directly to the depression observed in people with AA.

Urogenital symptoms in mitochondrial disease: overlooked and undertreated

Background and purpose

Bowel symptoms are well documented in mitochondrial disease. However, data concerning other pelvic organs is limited. A large case–control study has therefore been undertaken to determine the presence of lower urinary tract symptoms (LUTS) and sexual dysfunction in adults with genetically confirmed mitochondrial disease.

Methods

Adults with genetically confirmed mitochondrial disease and control subjects were recruited from a specialist mitochondrial clinic. The presence and severity of LUTS and their impact on quality of life, in addition to sexual dysfunction and bowel symptoms, were captured using four validated questionnaires. Subgroup analysis was undertaken in patients harbouring the m.3243A>G MT‐TL1 mitochondrial DNA mutation. A subset of patients underwent urodynamic studies to further characterize their LUTS.

Results

Data from 58 patients and 19 controls (gender and age matched) were collected. Adults with mitochondrial disease had significantly more overactive bladder (81.5% vs. 56.3%, P = 0.039) and low stream (34.5% vs. 5.3%, P = 0.013) urinary symptoms than controls. Urodynamic studies in 10 patients confirmed that bladder storage symptoms predominate. Despite high rates of LUTS, none of the patient group was receiving treatment. Female patients and those harbouring the m.3243A>G MT‐TL1 mutation experienced significantly more sexual dysfunction than controls (53.1% vs. 11.1%, P = 0.026, and 66.7% vs. 26.3%, P = 0.011, respectively).

Conclusions

Lower urinary tract symptoms are common but undertreated in adult mitochondrial disease, and female patients and those harbouring the m.3243A>G MT‐TL1 mutation experience sexual dysfunction. Given their impact on quality of life, screening for and treating LUTS and sexual dysfunction in adults with mitochondrial disease are strongly recommended.

Use of bioengineered human commensal gut bacteria-derived microvesicles for mucosal plague vaccine delivery and immunization

Plague caused by the Gram‐negative bacterium, Yersinia pestis, is still endemic in parts of the world today. Protection against pneumonic plague is essential to prevent the development and spread of epidemics. Despite this, there are currently no licensed plague vaccines in the western world. Here we describe the means of delivering biologically active plague vaccine antigens directly to mucosal sites of plague infection using highly stable microvesicles (outer membrane vesicles; OMVs) that are naturally produced by the abundant and harmless human commensal gut bacterium Bacteroides thetaiotaomicron (Bt). Bt was engineered to express major plague protective antigens in its OMVs, specifically Fraction 1 (F1) in the outer membrane and LcrV (V antigen) in the lumen, for targeted delivery to the gastrointestinal (GI) and respiratory tracts in a non‐human primate (NHP) host. Our key findings were that Bt OMVs stably expresses F1 and V plague antigens, particularly the V antigen, in the correct, immunogenic form. When delivered intranasally V‐OMVs elicited substantive and specific immune and antibody responses, both in the serum [immunoglobulin (Ig)G] and in the upper and lower respiratory tract (IgA); this included the generation of serum antibodies able to kill plague bacteria. Our results also showed that Bt OMV‐based vaccines had many desirable characteristics, including: biosafety and an absence of any adverse effects, pathology or gross alteration of resident microbial communities (microbiotas); high stability and thermo‐tolerance; needle‐free delivery; intrinsic adjuvanticity; the ability to stimulate both humoral and cell‐mediated immune responses; and targeting of primary sites of plague infection.

Responses to warnings about the impact of eating disorders on fertility: a qualitative study

Eating disorders (EDs) have often been discussed as a risk to reproductive health. But existing research is quantitative in nature, paying no attention to issues of patient experience. In discussing data from 24 semi-structured interviews, this article draws on sociological approaches to medical 'risk' and feminist approaches to EDs to explore how women with experience of an ED responded to fertility warnings within treatment contexts. In doing so, it is suggested that responses to fertility warnings offer unique insight into the potentially damaging limitations of biomedical approaches to eating problems and their focus on EDs as individual 'pathologies' (rather than culturally embedded expressions of gendered embodiment). At best warnings are seen as making problematic assumptions about the aspirations of female patients, which may curtail feelings of agency and choice. At worst, they may push women further into destructive bodily and eating practices, and silence the distress that may be articulated by an ED.

Perceived stress and well-being among dental hygiene and dental therapy students

Aims To explore dental hygiene and dental therapy students' (DHDTS') perception of stress and well-being during their undergraduate education and establish base-line data for further studies of this group of dental professionals.Subjects and methods A questionnaire was distributed to Years 1, 2 and 3 DHDTS and final year outreach dental students (DS) (as a comparison group), at the University of Portsmouth Dental Academy (UPDA), during summer 2015. Data were collected on students' perception of levels of stress and well-being. Statistical analyses were undertaken using SPSS software. Mann-Whitney U tests with Bonferroni corrections were used and the level for a statistically significant difference was set at p <0.002.Results A response rate of 81% (DHDTS) and 85% (DS) was achieved. Clinical factors and academic work were perceived as stressful for both DHDTS and DS, with no significant difference between the groups. The majority of respondents reported levels of depression, anxiety, and stress to be within the normal range. All students reported high levels of positive well-being, with DHDTS scoring significantly higher than DS in the dimensions of personal growth, purpose in life, self-acceptance and positive relations with others (p <0.002).Conclusions DHDTS and DS identified sources of stress within their undergraduate education, but also perceived themselves as positively-functioning individuals.

Feminist approaches to Anorexia Nervosa: a qualitative study of a treatment group

BACKGROUND

Eating disorders (EDs) are now often approached as biopsychosocial problems. But it has been suggested by scholars interested in sociocultural factors that all is not equal within this biospsychosocial framework, with the 'social' aspects of the equation relegated to secondary factors within ED treatment contexts. Although sociocultural influences are well-established as risk factors for EDs, the exploration of whether or how such perspectives are useful in treatment has been little explored. In responding to this context, this article seeks to discuss and evaluate a 10 week closed group intervention based on feminist approaches to EDs at a residential eating disorder clinic in the East of England.

METHODS

The data was collected via one-to-one qualitative interviews and then analysed using thematic discourse analysis.

RESULTS

The participants suggested that the groups were helpful in enabling them to situate their problem within a broader cultural and group context, that they could operate as a form of 'protection' from ideologies regarding femininity, and that a focus on the societal contexts for EDs could potentially reduce feelings of self-blame. At the same time, the research pointed to the complexities of participants considering societal rather than individualised explanations for their problems, whilst it also confronted the implications of ambivalent responses toward feminism.

CONCLUSIONS

Highly visible sociocultural factors in EDs - such as gender - may often be overlooked in ED clinical contexts. Although based on limited data, this research raises questions about the marginalisation of sociocultural factors in treatment, and the benefits and challenges including the latter may involve.

The role of sociocultural perspectives in eating disorder treatment: A study of health professionals

Eating disorders are now often approached as biopsychosocial problems, because they are widely recognised as multifactorial in origin. However, it has been suggested that there is a substantial and unwarranted imbalance within this biopsychosocial framework, with the 'social' aspects of the equation relegated to secondary or facilitating factors within treatment contexts. Drawing on data from 12 qualitative interviews with health professionals in a UK region, this article examines the extent to which sociocultural perspectives on eating disorders are valued and explored in eating disorder treatment, with a particular focus on the relationship between eating disorders and gender. As girls/women are widely acknowledged to be disproportionately affected by eating problems, the article draws on feminist perspectives on eating disorders to explore whether the relationships between cultural constructions of femininity and experiences of body/eating distress are actively addressed within treatment. The study reveals high levels of inconsistency in this regard, as while some participants see such issues as central to treatment, others have 'never really considered' them before. In addition, the study examines the potential limitations of how such sociocultural issues are conceptualised and addressed, as well as why they might be marginalised in the current climate of evidence-based eating disorder treatment. The article then considers the implications of the findings for thinking about feminist perspectives on eating disorders - and the significance of gender in treatment - at the level of both research and practice.

Case finding for chronic obstructive pulmonary disease in people attending long-term condition clinics in primary care

Despite increased interest and awareness of chronic obstructive pulmonary disease (COPD), nearly half of the people with COPD remain undiagnosed. Inviting people at risk for screening is unlikely to be effective as many will not attend. Co-morbidities are common in people with COPD but COPD is also a comorbidity of other long-term conditions and people with these conditions are under regular review in primary care clinics. This study aimed to develop a pilot programme to case find people with COPD among patients attending other long-term clinics in primary care. Twenty-three general practices were recruited to participate in South West England. All current or ex-smokers aged ≥35 attending a long-term condition clinic who were not known to have COPD were asked to complete a questionnaire designed to help identify people with COPD and to perform microspirometry. Practices were asked to collect data on up to 100 patients. One thousand three hundred and thirty-three patients were assessed. Four hundred and ten people (31%) were current smokers. Six hundred and thirteen (46%) had high questionnaire scores and 287 (22%) of these also had a forced expiratory volume in 1 second (FEV1) below the lower limit of normal (LLN). The mean FEV1 in these patients was 59.0% of predicted (range 22-79.0%). Two hundred and twenty-four had an FEV1 between 50% and 80% of predicted, 50 had an FEV1 between 30% and 50% of predicted. One hundred and sixteen (40%) of the people with an FEV1 below the LLN were still smoking and 55 accepted referral to cessation services. A total of 56% of the other smokers assessed but not thought to have COPD also accepted referral. Assessing symptoms and performing microspirometry in people attending long-term condition clinics in primary care is feasible and has a high yield of identifying people likely to have previously undiagnosed COPD.