Randomized controlled pilot trial with ion-exchange water softeners to prevent eczema (SOFTER trial)

BACKGROUND

Observational studies suggest an increased risk of eczema in children living in hard versus soft water areas, and there is, therefore, an interest in knowing whether softening water may prevent eczema. We evaluated the feasibility of a parallel-group assessor-blinded pilot randomized controlled trial to test whether installing a domestic ion-exchange water softener before birth in hard water areas reduces the risk of eczema in infants with a family history of atopy.

METHODS

Pregnant women living in hard water areas (>250 mg/L calcium carbonate) in and around London UK, were randomized 1:1 antenatally to either have an ion-exchange water softener installed in their home or not (ie to continue to receive usual domestic hard water). Infants were assessed at birth and followed up for 6 months. The main end-points were around feasibility, the primary end-point being the proportion of eligible families screened who were willing and able to be randomized. Clinical end-points were evaluated including frequency of parent-reported doctor-diagnosed eczema and visible eczema on skin examination. Descriptive analyses were conducted, and no statistical testing was performed as this was a pilot study.

RESULTS

One hundred and forty-nine families screened were eligible antenatally and 28% (41/149) could not have a water softener installed due to technical reasons or lack of landlord approval. Eighty of 149 (54%) were randomized, the primary end-point. Two participants withdrew immediately after randomization, leaving 39 participants in each arm (78 total). Attrition was 15% (12/78) by 6 months postpartum. All respondents (n = 69) to the study acceptability questionnaire reported that the study was acceptable. Fifty-six of 708 (7.9%) water samples in the water softener arm were above the hard water threshold of 20 mg/L CaCO₃ . At 6 months of age 27/67 infants (40%) developed visible eczema, 12/36 (33%) vs. 15/31 (48%) in the water softener and control groups, respectively, difference -15% (95% CI -38, 8.3%), with most assessments (≥96%) remaining blinded. Similarly, a lower proportion of infants in the water softener arm had parent-reported, doctor-diagnosed eczema by 6 months compared to the control arm, 6/17 (35%) versus 9/19 (47%), difference -12% (95% CI -44, 20%).

CONCLUSION

A randomized controlled trial of water softeners for the prevention of atopic eczema in high-risk infants is feasible and acceptable.

P5740ACE2 activity level is associated with embolic stroke of undetermined source

Background

ACE2 activity levels correlate with adverse left atrial remodelling in patients with atrial fibrillation (AF). Several biochemical and structural markers have been associated with embolic stroke of undetermined source (ESUS). The relationship between ACE2 activity and ESUS is unknown.

Purpose

Randomised controlled trials failed to demonstrate a clear benefit of oral anticoagulation in an unselected ESUS population. As selective use of oral anticoagulation guided by biomarker risk-profiling may benefit these patients, we evaluated the association between ACE2 activity and ESUS.

Methods

This prospective case control study compared patients with ESUS against a control group matched for vascular risk factors. ESUS was diagnosed following cerebral vascular imaging and 24 hours of cardiac monitoring to exclude AF. Blood samples were collected for measurement of ACE2 activity, D-Dimer and high sensitivity troponin T (hsTnT).

Results

A total of 51 patients in the ESUS group were compared with 47 patients in the Control group. ACE2 activity and D-Dimer levels were significantly higher in the ESUS group. There was a significant but weak positive correlation between ACE2 activity and hsTnT (r=0.20, p<0.05). Left atrial volume index (LAVI) on echocardiography was significantly higher in the ESUS group. On regression modelling adjusting for LAVI, only ACE2 activity remained significant for ESUS, with a 20% rise in odds for every 4 unit increase in ACE2 activity (OR 1.20; 95% CI: 1.01 - 1.36, p=0.04).

Participant characteristics Control (n=47) ESUS (n=51) P value Age (years) 65.65±6.78 67.20±6.89 0.26 Female gender 22 (45.8) 19 (38.0) 0.43 Hypertension 22 (45.8) 24 (48.0) 0.83 Diabetes mellitus 9 (18.8) 12 (24.0) 0.53 CHA2DS2VASc score 2 (1–3) 2 (1–3) 0.50 LA size & Biomarkers   LA volume index (ml/m2) 36.5 (32.6–42.5) 39.1 (36.2–46.0) 0.04   ACE2 (pmol/ml/min) 7.24 (2.66–14.64) 10.16 (4.54–18.80) 0.04   D-Dimer (mg/L) 0.35 (0.3–0.5) 0.40 (0.30–0.60) 0.02   hsTroponin T (ng/L) 7.0 (5–10) 9.00 (6.0–13.5) 0.05 Values are expressed as mean ± standard deviation, median (IQR), or n (%).

Median ACE2 activity

Conclusion(s)

ACE2 activity is associated with ESUS independent of left atrial volume and correlate with elevated Troponin. Further studies are warranted to investigate the utility of ACE2 activity in identifying ESUS patients that may benefit from oral anticoagulation.

Acknowledgement/Funding

This study received project funding from the Eastern Health Foundation

Assessment of Advanced Life Support competence when combining different test methods—Reliability and validity

Robust assessment of Advanced Life Support (ALS) competence is paramount to the credibility of ALS-provider certification and for estimating the learning outcome and retention of ALS competence following the courses. The European Resuscitation Council (ERC) provides two sets of MCQs and four Cardiac Arrest Simulation Test (CASTest) scenarios for the assessments according to guidelines 2005.

AIMS

To analyse the reliability and validity of the individual sub-tests provided by ERC and to find a combination of MCQ and CASTest that provides a reliable and valid single effect measure of ALS competence.

METHODS

Two groups of participants were included in this randomised, controlled experimental study: a group of newly graduated doctors, who had not taken the ALS course (N=17) and a group of students, who had passed the ALS course 9 months before the study (N=16). Reliability in terms of inter-rater agreement and generalisability across skills scenarios were estimated. Validity was studied in terms of equality of test difficulty and ability to discriminate performance between the groups.

RESULTS

Inter-rater agreement on checklist scores were generally high, Intraclass Correlation Coefficients between 0.766 and 0.977. Inter-rater agreements on pass/fail decisions were not perfect. The one MCQ test was significantly more difficult than the other. There were no significant differences between CASTests. Generalisability theory was use to identify a composite of MCQ and CASTest scenarios that possessed high reliability, equality of test sets, and ability to discriminate between the two groups of supposedly different ALS competence.

CONCLUSIONS

ERC sub-tests of ALS competence possess sufficient reliability and validity. A combined ALS score with equal weighting of one MCQ and one CASTest can be used as a single measurement of ALS competence.

The relation between mortality from malignant melanoma and early detection in the Cancer Research Campaign Mole Watcher Study

Between 1987 and 1989 the Cancer Research Campaign funded a health education programme for the early detection of cutaneous malignant melanoma in the general population in 6 health districts of England and 1 health board in Scotland (population of 3 million). The intervention was evaluated by studying its effects on annual and cumulative mortality rates for melanoma. Population-based data on mortality from melanoma were collected in the intervention areas, the health regions covering those areas, and 5 other health regions of England from 1981 to 1996. Deaths from melanoma in cases diagnosed after the start of the intervention were used to study cumulative mortality rates. The annual mortality rates for melanoma, 1981 to 1996, showed no significant difference in their trends between the intervention areas, and other areas of England and Wales. After adjustment for pre-intervention rates, there was also no significant reduction in cumulative mortality from melanoma in the intervention areas compared with the non-intervention areas: rate ratio 1.2 (95% Cl 0.9-1.7) in men, 0.9 (95% Cl 0.7-1.3) in females. The lack of a significant reduction in melanoma mortality associated with the intervention raises questions about this approach to early detection and emphasises the need for new strategies.

Competing with giants. Survival strategies for local companies in emerging markets

The arrival of a multinational corporation often looks like a death sentence to local companies in an emerging market. After all, how can they compete in the face of the vast financial and technological resources, the seasoned management, and the powerful brands of, say, a Compaq or a Johnson & Johnson? But local companies often have more options than they might think, say the authors. Those options vary, depending on the strength of globalization pressures in an industry and the nature of a company's competitive assets. In the worst case, when globalization pressures are strong and a company has no competitive assets that it can transfer to other countries, it needs to retreat to a locally oriented link within the value chain. But if globalization pressures are weak, the company may be able to defend its market share by leveraging the advantages it enjoys in its home market. Many companies in emerging markets have assets that can work well in other countries. Those that operate in industries where the pressures to globalize are weak may be able to extend their success to a limited number of other markets that are similar to their home base. And those operating in global markets may be able to contend head-on with multinational rivals. By better understanding the relationship between their company's assets and the industry they operate in, executives from emerging markets can gain a clearer picture of the options they really have when multinationals come to stay.

Bond strength and clinical efficiency for two light guide sizes in orthodontic bracket bonding

The purpose of this study was to establish a possible increase in efficiency in bracket bonding with light-cured adhesive by using a larger size on the light transmitting unit. Two light guides were compared, a standard-sized 11-mm light guide and a 19-mm elliptical extra broad light guide, the latter designed to allow simultaneously curing of two adjacent brackets. Fifty extracted human premolars mounted in five phantom maxillary arches were bonded according to a standard procedure with Mini Uni-Twin stainless steel brackets. The two light guides were randomly chosen for each half of the maxillary arch. After bonding, all teeth were tested for tensile bond strength to failure. In the clinical study 30 patients were bonded according to a split mouth technique with the two light guides alternatively used randomly for each side of the jaw. Time for bonding and the occurrence of bracket failures were recorded. The results showed no statistically significant differences between the standard and elliptical light guides regarding tensile bond strength, or bracket failure frequency. However, with the larger light guide size a significantly shorter total bonding time for each patient was required. It is therefore concluded that the elliptical light guide in combination with a light transmitting unit of sufficient quality gave a similar bonding result as the standard light guide, offering the clinician a reduction in chair side time during the bonding procedure.

High response rates with short infusional 2-chlorodeoxyadenosine in de novo and relapsed low-grade lymphoma. Australian and New Zealand Lymphoma Study Group

Thirty-five patients (eight de novo, 27 relapsed disease) with low-grade non-Hodgkin's lymphoma (diffuse small lymphocytic, follicular small cleaved cell, follicular mixed cell, and lymphoplasmacytoid) were treated with 2-chlorodeoxyadenosine (2CdA) at a daily dose of 0.14 mg/kg for 5d (2 h infusion) for an average of three cycles. Minor treatment delays, generally due to haematological toxicities, occurred in nine of 105 cycles. Major toxicities were lymphopenia, neutropenia and thrombocytopenia. Opportunistic infections occurred in seven patients. Overall response rate was 69% (five complete, 19 partial) reaching 88% for de novo patients (two complete, five partial). Elevated beta 2-microglobulin level was negatively predictive of response (P = 0.0014). Eight of 24 responders relapsed, with a median follow-up of 13 months. 2CdA administered as an intermittent infusion shows considerable single-agent activity in low-grade lymphomas achieving high response rates of prolonged duration. Consideration of schedules where 2CdA is alternatively administered with combination chemotherapy appears warranted.

Using qualitative research in community nurse casework

This paper explores how methods and skills frequently employed in qualitative research can be used by community nurses to promote an interpretation of the setting that is valid and client-focused. It discusses the construction and use of casenotes, the development of theoretical sensitivity, employing native-language terms, and looks at the importance of a critical awareness of additional documentary evidence.

Problems with registration of cutaneous malignant melanoma in England

The aim of the study was to assess the completeness and accuracy of cancer registration for cutaneous malignant melanoma. The study was conducted in seven health districts in England and one health board in Scotland from 1987 to 1989 with a total resident population of 3.6 million. Records from pigmented lesion clinics and pathology laboratories collected during the Cancer Research Campaign's health education programme to promote the early detection of melanoma were matched with cancer registrations from a total of five regional cancer registries. In England 74% out of a total of 642 cases of invasive malignant melanomas (ICD 172) and 44% out of a total of 155 in situ melanomas (ICD 232) had been registered compared with 96% and 100% respectively in Scotland. A significantly higher proportion of late-stage cases was found among registered than among non-registered cases in England (P < 0.001). In all registries the majority of superficial spreading in situ melanomas were miscoded as invasive cases. The annual incidence of invasive malignant melanoma in the English study areas was found to be seven per 100,000 in men and 11 per 100,000 in women, similar to that reported in Scotland. The registries are best at recording thick or late-stage melanomas. As the skin cancer target for Health of the Nation depends on monitoring trends in the incidence of malignant melanoma, future improved ascertainment of cases and changes in the type of cases being registered must be taken into account.

Cancer Research Campaign health education programme to promote the early detection of cutaneous malignant melanoma. I. Work-load and referral patterns

From 1987 to 1989 a campaign to promote the early detection of cutaneous malignant melanoma was conducted in the areas of seven health authorities in England and Scotland (total population 3.6 million). Data were collected on 17,155 patients attending pigmented lesion clinics (PLCs) in each study area during the campaign. After a dramatic rise in PLC referral rates in the first month of the campaign the average monthly referral rate among the target population in the study period settled to an average of 13 per 10(5), a twofold increase compared with the pre-campaign period. Over 85% of patients at all PLCs were seen within 4 weeks of referral from their general practitioners. The melanoma to non-melanoma detection ratio was (1:33). The organization of future early detection initiatives needs careful review and planning, in order to improve their effectiveness in all sections of the population, and to enable health services to cope with the increased work-load.

Cancer Research Campaign health education programme to promote the early detection of cutaneous malignant melanoma. II. Characteristics and incidence of melanoma

The effect on the detection and characteristics of melanoma, resulting from the Cancer Research Campaign's health education programme to promote the early detection of melanoma in the general population, was studied from 1987 to 1989. The seven study areas in England and Scotland yield a target population of 3.6 million. Data were collected from local clinic-based registers, pathology laboratories, and the cancer registries. The average annual incidence rates of melanoma were seven and 12 per 10(5) in males and females, respectively, age-standardized to England and Wales, 1988. These rates are similar to the national figures for Scotland, where there is a national melanoma register, but higher than those reported by the English and Welsh cancer registries. The incidence was significantly higher in females than males (P < 0.001), and increased with age. Fifty-three per cent and 65% of cases in males and females, respectively, were thin (Breslow thickness < or = 1.5 mm), similar to the national figures from Scotland. No significant decrease in the incidence of late-stage tumours was found in either sex as a result of the campaign. Because of difficulties with ascertainment of cases in England, the main evaluation will focus on future trends in mortality rates for melanoma.

All-trans retinoic acid in the treatment of acute promyelocytic leukaemia

All-trans-retinoic acid (ATRA) is known to induce differentiation of promyelocytes in vitro and also to induce remission of acute promyelocytic leukaemia in vivo. We treated 11 patients with poor prognosis acute promyelocytic leukaemia (APL) with ATRA and obtained seven complete and one partial remission. Remissions took one to three months to achieve and were associated with adverse effects including dry skin and bone pain. In eight patients the white cell count rose above 20 x 10(9)/L within the first ten days of retinoic acid treatment and this was associated with the development of pulmonary leukostasis in three patients which was fatal in one. Another two patients died of intracranial haemorrhage also within the first ten days. ATRA is a promising new agent in the induction therapy of this particular category of acute leukaemia.

Umbilical cord sclerosis as an indicator of congenital syphilis

In two cases of congenital syphilis examination of the umbilical cord showed a distinctive picture of perivascular sclerosis and inflammation. Large numbers of spirochaetes were shown in the sclerotic zone in both cases. No organisms were demonstrable in the placental disc and there were no morphological changes suggestive of syphilis. It is concluded that the finding of sclerosing funisitis, together with the clinical circumstances, should raise the possibility of congenital syphilis.

The anaemic inpatient. A survey of current hospital practice

The haemoglobin levels of all patients in a large teaching hospital (except those receiving cytotoxic chemotherapy or radiotherapy) were examined over a three-week period. One hundred and eleven patients with haemoglobin levels below 100 g/L were found, and the approach to this problem by the clinicians was scrutinized. In most patients, there was a good and obvious explanation for the anaemia; in just under 50%, however, the causes were often mixed or less obvious. Frequently the anaemia was not investigated when, perhaps, it should have been and, when treated, it was often treated inappropriately. Excessive, inappropriate and indiscriminate use of oral iron therapy was a prominent finding.

Pharmacokinetics of oral indoramin

A randomized crossover study was carried out in 7 healthy subjects to investigate the pharmacokinetics of indoramin from two oral formulations (film-coated and uncoated 50 mg tablets) and to determine the effect of a standard mean on the plasma concentration time curve of the film-coated form. The results indicated that peak plasma concentrations occurred in 1 to 4 hours after treatment with a single dose of 2 tablets, with an overall elimination half-life of 5 hours. No significant differences could be shown between treatments in any of the pharmacokinetic variables determined. However, administration of film-coated indoramin after a standard meal narrowed the range of peak concentrations but the time at which peak concentrations of the drug occurred did not appear to be related to whether or not indoramin was given after the meal.

Pharmacokinetics of meptazinol in man following repeated intramuscular administration

A study was performed in 6 healthy volunteers to determine whether 50 mg intramuscular doses of meptazinol repeated four hourly for 24 h would lead to accumulation of the drug. The first dose of meptazinol was rapidly absorbed with a subsequent mean (+/- SD) elimination half-life of 1.6 +/- 0.33 h. This value was unaffected by the administration of intermediate doses. There was no significant accumulation of the drug; 95% of the steady-state plasma concentration was achieved after a mean (+/- SD) of 1.9 +/- 0.39 and 99% after a mean (+/- SD) of 2.9 +/- 0.63 doses. These findings are consistent with the theoretical prediction for a rapidly absorbed drug with a plasma elimination half-life of 1.6 h. No clinically relevant changes were seen in pulse blood pressure, haematological or biochemical screens. Reported side effects were of a subjective and minor nature.

Respiratory failure due to leukostasis in leukaemia

A case is presented in which leukostasis, which followed splenectomy for chronic granulocytic leukaemia in metamorphosis, was associated with respiratory failure. The pathophysiology and predisposing factors are discussed.

The Australasian Reference Thromboplastin: II. Are corrected prothrombin ratios valid?

A comparative study was made of 2 thromboplastins, the Australasian Reference Thromboplastin, and Simplastin, in a large group of patients on long-term Warfarin therapy. 373 individual samples were obtained. Calibration constants were obtained for those patients with prothrombin ratios within the therapeutic range, and for those well outside the therapeutic range, and found to be different. Study of the relationship between the 2 thromboplastins indicates that comparability is linear only within a specified limited range of prothrombin ratios. At the two extreme ends the relationship is curved, suggesting a logarithmic relationship. Attention is drawn to the need of caution in interpretation of corrected ratios calculated on a linear relationship especially when the ratio is above 4.0 as this may have clinical implications.

The Australasian Reference Thromboplastin: I. A study in bleeding patients

The prothrombin time, activated partial thromboplastin time, thrombin time, and skin bleeding time, with assays of factors II, VII, IX, and X, platelet count, and liver function tests were performed on a group of patients receiving long term warfarin therapy. There were 17 bleeding patients and 13 non-bleeding patients. A study was made, using the Australasian Reference Thromboplastin and 2 other thromboplastic reagents in common use. The Australasian Reference Thromboplastin was shown to be more sensitive to the coumarin induced coagulation defect than rabbit brain thromboplastin, and hence of more value in preventing haemorrhagic complications. The level of factor II assayed by the one stage method was a useful independent indicator of the intensity of oral anticoagulation, and correlated well with the development of bleeding.

Some correlates of trust

Trust has been variously defined by behavioral scientists and not very thoroughly investigated. In this study trust was defined as an expectancy held by an individual that the behavior of another person or a group would be altruistic and personally beneficial. An attempt was made, using this conceptual definition, to identify some personality and behavioral correlates of trust. Seven interpersonal relations groups with approximately 10 male and female undergraduates per group were studied with use of the Janis and Field self-esteem inventory, Schutz's FIRO-B scale, and the Rotter internal-external scale. It was discovered that a trusted person is one who is highly influential, has an internal locus of control, a low need to control others, high self-esteem, and is open to being influenced by others.