Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Ibuprofen exposure in Europe; ePiE as an alternative to costly environmental monitoring

The EU Water Framework Directive and Priority Substance Directive provide a framework to identify substances that potentially pose a risk to surface waters and provide a legal basis whereby member states are required to monitor and comply with environmental quality standards (EQSs) set for those substances. The cost and effort to continuously measure and analyse real world concentrations in all water bodies across Europe are high. Establishing the reliability of environmental exposure models to predict concentrations of priority substances is key, both to fill data gaps left by monitoring campaigns, and to predict the outcomes of actions that might be taken to reduce exposure. In this study, we aimed to validate the ePiE model for the pharmaceutical ibuprofen by comparing predictions made using the best possible consumption data with measured river concentrations. The results demonstrate that the ePiE model makes useful, conservative exposure predictions for ibuprofen, typically within a factor of 3 of mean measured values. This exercise was performed across a number of basins within Europe, representative of varying conditions, including consumption rates, population densities and climates. Incorporating specific information pertaining to the basin or country being assessed, such as custom WWTP removal rates, was found to improve the realism and accuracy of predictions. We found that the extrapolation of consumption data between countries should be kept to a minimum when modelling the exposure of pharmaceuticals, with the per capita consumption of ibuprofen varying by nearly a factor of 10.

Local anaesthetic transperineal (LATP) prostate biopsy using a probe-mounted transperineal access system: a multicentre prospective outcome analysis

OBJECTIVES

To assess the feasibility of local anaesthetic transperineal (LATP) technique using a single-freehand transperineal (TP) access device, and report initial prostate cancer (PCa) detection, infection rates, and tolerability.

PATIENTS AND METHODS

Observational study of a multicentre prospective cohort, including all consecutive cases. LATP was performed in three settings: (i) first biopsy in suspected PCa, (ii) confirmatory biopsies for active surveillance, and (iii) repeat biopsy in suspected PCa. All patients received pre-procedure antibiotics according to local hospital guidelines. Local anaesthesia was achieved by perineal skin infiltration and periprostatic nerve block without sedation. Ginsburg protocol principles were followed for systematic biopsies including cognitive magnetic resonance imaging-targeted biopsies when needed using the PrecisionPoint™ TP access device. Procedure-related complications and oncological outcomes were prospectively and consecutively collected. A validated questionnaire was used in a subset of centres to collect data on patient-reported outcome measures (PROMs).

RESULTS

Some 1218 patients underwent LATP biopsies at 10 centres: 55%, 24%, and 21% for each of the three settings, respectively. Any grade PCa was diagnosed in 816 patients (67%), of which 634 (52% of total) had clinically significant disease. Two cases of sepsis were documented (0.16%) and urinary retention was observed in 19 patients (1.6%). PROMs were distributed to 419 patients, with a 56% response rate (n = 234). In these men, pain during the biopsy was described as either 'not at all' or 'a little' painful by 64% of patients. Haematuria was the most common reported symptom (77%). When exploring attitude to re-biopsy, 48% said it would be 'not a problem' and in contrast 8.1% would consider it a 'major problem'. Most of the patients (81%) described the biopsy as a 'minor or moderate procedure tolerable under local anaesthesia', while 5.6% perceived it as a 'major procedure that requires general anaesthesia'.

CONCLUSION

Our data suggest that LATP biopsy using a TP access system mounted to the ultrasound probe achieves excellent PCa detection, with a very low sepsis rate, and is safe and well tolerated. We believe a randomised controlled trial comparing LATP with transrectal ultrasound-guided biopsy (TRUS) to investigate the relative trade-offs between each biopsy technique would be helpful.

Maternal steroid levels and the autistic traits of the mother and infant

BACKGROUND

Prenatal sex steroids have been associated with autism in several clinical and epidemiological studies. It is unclear how this relates to the autistic traits of the mother and how early this can be detected during pregnancy and postnatal development.

METHODS

Maternal serum was collected from pregnant women (n = 122) before or during their first ultrasound appointment [mean = 12.7 (SD = 0.7) weeks]. Concentrations of the following were measured via immunoassays: testosterone, estradiol, dehydroepiandrosterone sulphate, progesterone; and sex hormone-binding globulin which was used to compute the free fractions of estradiol (FEI) and testosterone (FTI). Standardised human choriogonadotropin (hCG) and pregnancy-associated plasma protein A (PAPP-A) values were obtained from clinical records corresponding to the same serum samples. Mothers completed the Autism Spectrum Quotient (AQ) and for their infants, the Quantitative Checklist for Autism in Toddlers (Q-CHAT) when the infants were between 18 and 20 months old.

RESULTS

FEI was positively associated with maternal autistic traits in univariate (n = 108, Pearson's r = 0.22, p = 0.019) and multiple regression models (semipartial r = 0.19, p = 0.048) controlling for maternal age and a diagnosis of PCOS. Maternal estradiol levels significantly interacted with fetal sex in predicting infant Q-CHAT scores, with a positive relationship in males but not females (n = 100, interaction term: semipartial r = 0.23, p = 0.036) after controlling for maternal AQ and other covariates. The opposite was found for standardised hCG values and Q-CHAT scores, with a positive association in females but not in males (n = 151, interaction term: r = -0.25, p = 0.005).

LIMITATIONS

Sample size of this cohort was small, with potential ascertainment bias given elective recruitment. Clinical covariates were controlled in multiple regression models, but additional research is needed to confirm the statistically significant findings in larger cohorts.

CONCLUSION

Maternal steroid factors during pregnancy are associated with autistic traits in mothers and their infants.

92 Reshaping the Diagnostic Pathways for Investigation of Haematuria During and After The COVID-19 Pandemic: Diagnostic Accuracy of Strategies for Detection of Bladder Cancer from The IDENTIFY Cohort Study

Introduction

Diagnostic haematuria services have been reduced due to the COVID-19 pandemic, compromising patient care, and necessitating a more pragmatic pathway.

Method

The IDENTIFY study was an international, prospective, multicentre cohort study of over 11,000 patients referred to secondary care for investigation of haematuria. Using this data, we developed strategies using combinations of imaging and cytology as triage tests to maximise cancer detection within a pragmatic pathway.

Results

8112 patients (74·4%) received an ultrasound or a CT urogram, with or without cytology. 5737 (70·7%) patients had visible haematuria (VH) and 2375 (29·3%) had non-visible haematuria (NVH). Diagnostic test performance was used to determine optimal age cut-offs for four proposed strategies. We recommended proceeding directly to transurethral resection of bladder tumour for patients of any age with positive triage tests for cancer. Patients with negative triage tests under 35-years-old with VH, or under 50-years-old with NVH can safely be discharged without undergoing flexible cystoscopy. The remaining patients may undergo flexible cystoscopy, with a greater priority for older patients to capture high risk bladder cancer.

Conclusions

We suggest diagnostic strategies in patients with haematuria, which focus on detection of bladder cancer, whilst reducing the burden to healthcare services in a resource-limited setting.

A simplified index to quantify the irritation/corrosion potential of chemicals - Part II: Eye

Eye irritation is a key human health endpoint assessed by in vitro and in vivo methods. One of the commonly used scoring methods to quantify the eye irritation potential of chemicals is the Modified Maximum Average Score (MMAS). It is dependent on the eye irritation effects (e.g. corneal opacity) originally proposed by Draize and then partially adopted by the OECD TG 405. These scores are not always fully reported in regulatory dossiers and lead to several drawbacks, 1) the difficulty to translate MMAS into a classification within the existing EU CLP/UN GHS criteria, 2) the absence of corrosion (serious eye damage), and 3) the dependency on input parameters which are usually not required under the OECD TGs (e.g. eye surface area). This study determined if classification can be driven by a maximum of two observed effects thereby simplifying the scoring calculation. The Simplified Irritation Index (SII_EYE), based only on corneal opacity and conjunctival redness, was developed using validated studies representing multiple chemical groups. A correlation was observed between the MMAS and the SII_EYE allowing harmonisation of the classification for the existing data. This index proved to be useful in the development of in silico model.

A simplified index to quantify the irritation/corrosion potential of chemicals - Part I: Skin

Skin irritation is a key human health endpoint assessed by in vitro and in vivo methods. The OECD TG 404 guideline (in vivo) is based on erythema and oedema translated semi-quantitatively into Draize scores, providing hazard statements for substance classification following EUCLP/UNGHS criteria. Draize scores require quantitation from subjective in vivo observations, to obtain a scoring index, the Primary Irritation Index (PII). However, it is not recognised under REACH due to translating difficulties, notably the cut-off limit for classification and non-inclusion of corrosive effects. The aim of this study was to determine if classification can be driven by just one of the observed effects, erythema only, to create a Simplified Irritation Index (SII_SKIN). This simplifies the scoring calculation and reduces subjectivity. A quantitative approach with cut-off limits is thus proposed for classification. Substances can be classified as non-irritant, potentially irritant, irritant, or corrosive. The Simplifed Irritation Index (SII_SKIN) is based on validated studies, representing multiple chemical groups. A significant correlation between SII_SKIN and the harmonised classification was observed, and a proportionate relationship between the SII_SKIN and the corresponding PII. The index proved to be useful in the development of an in silico model.

The diagnostic yield of computed tomography in the management of acute flank pain and the emergency intervention rate for a proven acute ureteric stone

INTRODUCTION

The diagnostic and management pathways for patients presenting with acute flank pain are complex. Although computed tomography (CT) of the kidneys, ureters and bladder (KUB) is the gold standard investigation for urolithiasis, the multitude of differential diagnoses must also be considered in the context of long-term risk from ionising radiation. This study investigated the integrated role and diagnostic yield of non-contrast CT in cases of acute flank pain.

METHODS

A retrospective cohort study was undertaken of 1,442 consecutive patients investigated with CT KUB between March 2013 and February 2015. The primary outcome was diagnostic yield of CT with secondary outcomes being predictors of need for urological intervention.

RESULTS

A cause for acute flank pain was identified in 717 patients (50%), there was an incidental finding in 389 patients (27%) and normal imaging was reported in 336 patients (23%). A diagnosis was more commonly made in male than in female patients (70% vs 40%) and with increasing age (46% in patients aged <30 years, 56% in those aged 30-49 years and 63% in those aged ≥50 years). The overall rate for an ipsilateral urinary tract stone was 41%. Factors strongly associated with emergency intervention included stone size >10mm (odds ratio [OR]: 11.7, 95% confidence interval [CI]: 3.3-42.7), stones located at the pelviureteric junction (OR: 7.8, 95% CI: 2.6-22.9), C-reactive protein >50mg/l and ≤100mg/l (OR: 15.2, 95% CI: 5.1-45.3), and estimated glomerular filtration rate ≤30ml/min (OR: 5.8, 95% CI: 1.5-21.8).

CONCLUSIONS

This contemporary study identifies age and sex as independent variables affecting the diagnostic yield of CT KUB in cases of acute flank pain, and highlights factors associated with a need for emergency intervention in proven ureteric stones.

Design and Implementation of a Computer Decision Support System for the Diagnosis and Management of Dementia Syndromes in Primary Care

Background: Diagnosis and management of dementia is a complex process and primary care physicians are under-equipped to deal with uncertainties in the provision of optimal care for the patient.

Objective: To develop a computer decision support system (CDSS) which could assist physicians with diagnosis and management and improve patient care. Methods: A design group including general practitioners derived logic pathways for diagnosis and management of dementia and validated them with a multi-professional expert group. Logic pathways were used to construct a comprehensive CDSS rendered as a series of expert consultations. The CDSS was inserted into commercially available GP systems and bench and field-tested.

Results: The complexity of dementia diagnosis and management can be captured in logic pathways which can be expressed as decision trees within existing electronic patient records. The resulting CDSS appears useable in routine practice.

Conclusion: The impact of this CDSS will be evaluated in a randomised controlled trial of educational interventions in primary care.

ExomeChip-Wide Analysis of 95 626 Individuals Identifies 10 Novel Loci Associated With QT and JT Intervals

BACKGROUND

QT interval, measured through a standard ECG, captures the time it takes for the cardiac ventricles to depolarize and repolarize. JT interval is the component of the QT interval that reflects ventricular repolarization alone. Prolonged QT interval has been linked to higher risk of sudden cardiac arrest.

METHODS AND RESULTS

We performed an ExomeChip-wide analysis for both QT and JT intervals, including 209 449 variants, both common and rare, in 17 341 genes from the Illumina Infinium HumanExome BeadChip. We identified 10 loci that modulate QT and JT interval duration that have not been previously reported in the literature using single-variant statistical models in a meta-analysis of 95 626 individuals from 23 cohorts (comprised 83 884 European ancestry individuals, 9610 blacks, 1382 Hispanics, and 750 Asians). This brings the total number of ventricular repolarization associated loci to 45. In addition, our approach of using coding variants has highlighted the role of 17 specific genes for involvement in ventricular repolarization, 7 of which are in novel loci.

CONCLUSIONS

Our analyses show a role for myocyte internal structure and interconnections in modulating QT interval duration, adding to previous known roles of potassium, sodium, and calcium ion regulation, as well as autonomic control. We anticipate that these discoveries will open new paths to the goal of making novel remedies for the prevention of lethal ventricular arrhythmias and sudden cardiac arrest.

A Review of the Environmental Degradation, Ecotoxicity, and Bioaccumulation Potential of the Low Molecular Weight Polyether Polyol Substances

"Polyalkylene glycol" is the name given to a broad class of synthetic organic chemicals which are produced by polymerization of one or more alkylene oxide (epoxide) monomers, such as ethylene oxide (EO) and propylene oxide (PO), with various initiator substances which possess amine or alcohol groups. A generalization of this polymerization reaction is illustrated in Fig. 1.

Assessing uptake of national HIV screening and testing guidance-Part 1: Awareness, use and usefulness

BACKGROUND

In 2013, the Public Health Agency of Canada released the HIV Screening and Testing Guide (the Guide) to support routine HIV screening and testing practices of health care providers in Canada and promote early detection of new HIV cases. Little was known regarding health care providers' awareness and use of the Guide.

OBJECTIVE

To determine Canadian health care providers' awareness, use and perceived usefulness of the Guide.

METHODS

An open, anonymous online survey, including questions on awareness, use and usefulness, was developed with stakeholders, validated and pre-tested. It was then disseminated to a convenience sample of health care providers across Canada between June and August 2016.

RESULTS

A total of 1,075 participants representing all Canadian provinces and territories responded to the survey, with the majority being nurses (54%) and physicians (12%). About two-thirds of respondents (65%) were aware of the Guide; of those, approximately half used it. Thirty-five percent of participants were not aware of the Guide, including none of the 173 health care providers in primary care (family/general practice). Among participants who were aware of and used the Guide, over 80% reported incorporating recommendations from the Guide into their practice and 77% reported frequently or always being able to find information they were looking for.

CONCLUSIONS

The HIV Screening and Testing Guide appears to be very useful for those who are aware of it and use it; however, awareness of the Guide appears to be low in primary care. Although these results need to be interpreted in light of the convenience sample, it suggests broader dissemination efforts may be needed to reach all of the potential users of the Guide.

Adapting SimpleTreat for simulating behaviour of chemical substances during industrial sewage treatment

The multimedia model SimpleTreat, evaluates the distribution and elimination of chemicals by municipal sewage treatment plants (STP). It is applied in the framework of REACH (Registration, Evaluation, Authorization and Restriction of Chemicals). This article describes an adaptation of this model for application to industrial sewage treatment plants (I-STP). The intended use of this re-parametrized model is focused on risk assessment during manufacture and subsequent uses of chemicals, also in the framework of REACH. The results of an inquiry on the operational characteristics of industrial sewage treatment installations were used to re-parameterize the model. It appeared that one property of industrial sewage, i.e. Biological Oxygen Demand (BOD) in combination with one parameter of the activated sludge process, the hydraulic retention time (HRT) is satisfactory to define treatment of industrial wastewater by means of the activated sludge process. The adapted model was compared to the original municipal version, SimpleTreat 4.0, by means of a sensitivity analysis. The consistency of the model output was assessed by computing the emission to water from an I-STP of a set of fictitious chemicals. This set of chemicals exhibit a range of physico-chemical and biodegradability properties occurring in industrial wastewater. Predicted removal rates of a chemical from raw sewage are higher in industrial than in municipal STPs. The latter have typically shorter hydraulic retention times with diminished opportunity for elimination of the chemical due to volatilization and biodegradation.

Corrosion and microstructural analysis data for AISI 316L and AISI 347H stainless steels after exposure to a supercritical water environment

This article presents corrosion data and microstructural analysis data of austenitic stainless steels AISI 316L and AISI 347H exposed to supercritical water (25 MPa, 550 °C) with 2000 ppb of dissolved oxygen. The corrosion tests lasted a total of 1200 h but were interrupted at 600 h to allow measurements to be made. The microstructural data have been collected in the grain interior and at grain boundaries of the bulk of the materials and at the superficial oxide layer developed during the corrosion exposure.

Neurovascular Interactions in the Neurologically Compromised Neonatal Brain

Neurological brain injuries such as hypoxic ischaemic encephalopathy (HIE) and associated conditions such as seizures have been associated with poor developmental outcome in neonates. Our limited knowledge of the neurological and cerebrovascular processes underlying seizures limits their diagnosis and timely treatment. Diffuse optical tomography (DOT) provides haemodynamic information in the form of changes in concentration of de/oxygenated haemoglobin, which can improve our understanding of seizures and the relationship between neural and vascular processes. Using simultaneous EEG-DOT, we observed distinct haemodynamic changes which are temporally correlated with electrographic seizures. Here, we present DOT-EEG data from two neonates clinically diagnosed as HIE. Our results highlight the wealth of mutually-informative data that can be obtained using DOT-EEG techniques to understand neurovascular coupling in HIE neonates.

An overview of recent evidence on barriers and facilitators to HIV testing

BACKGROUND

To address the issue of undiagnosed HIV infections, the Public Health Agency of Canada released the Human Immunodeficiency Virus-HIV Screening and Testing Guide in 2012, which identified several barriers and facilitators for HIV testing.

OBJECTIVE

The objective of this overview is to summarize the most recent evidence regarding barriers and facilitators to HIV testing, to expand upon the research conducted for the HIV Screening and Testing Guide.

METHODS

A review of the literature published between 2010 and 2014 was conducted using Scopus, PubMed (MEDLINE), and the Cochrane Library; websites of groups such as the Centers for Disease Control and Prevention, European Centre for Disease Prevention and Control, Australian Department of Health, and New Zealand Ministry of Health were searched for recent reports. Studies were categorized based on the barrier or facilitator identified, and the results were summarized.

RESULTS

In addition to the known barriers of lack of perceived risk, lack of comfort or knowledge, provider time constraints, and fear of the diagnosis, stigma and discrimination, new studies have identified additional barriers including: fear regarding disclosure or lack of confidentiality, lack of access, lack of compensation of providers, and lack of human resources to carry out testing. In addition to the known facilitators of increased awareness and normalization of HIV screening and testing, opt-out testing was identified as a facilitator in recent studies.

CONCLUSION

Since 2010, research has advanced our knowledge of barriers and facilitators and can be applied to help decrease the number of undiagnosed HIV infections.

Heart rate passivity of cerebral tissue oxygenation is associated with predictors of poor outcome in preterm infants

AIM

Near-infrared spectroscopy (NIRS) and transcranial Doppler (TCD) allow non-invasive assessment of cerebral haemodynamics. We assessed cerebrovascular reactivity in preterm infants by investigating the relationship between NIRS- and TCD-derived indices and correlating them with severity of clinical illness.

METHODS

We recorded the NIRS-derived cerebral tissue oxygenation index (TOI) and TCD-derived flow velocity (Fv), along with other physiological variables. Moving correlation coefficients between measurements of cerebral perfusion (TOI, Fv) and heart rate were calculated. We presumed that positivity of these correlation coefficients - tissue oxygenation heart rate reactivity index (TOHRx) and flow velocity heart rate reactivity index (FvHRx) - would indicate a direct relationship between cerebral perfusion and cardiac output representing impaired cerebrovascular autoregulation.

RESULTS

We studied 31 preterm infants at a median age of 2 days, born at a median gestational age of 26 + 1 weeks. TOHRx was significantly correlated with gestational age (R = -0.57, p = 0.007), birth weight (R = -0.58, p = 0.006) and the Clinical Risk Index for Babies II (R = 0.55, p = 0.0014). TOHRx and FvHRx were significantly correlated (R = 0.39, p = 0.028).

CONCLUSION

Heart rate has a key influence on cerebral haemodynamics in preterm infants, and TOHRx may be of diagnostic value in identifying impaired cerebrovascular reactivity leading to adverse clinical outcome.

A comparison of kangaroo mother care and conventional incubator care for thermal regulation of infants < 2000 g in Nigeria using continuous ambulatory temperature monitoring

Although skin-to-skin contact (or kangaroo mother care, KMC) for preterm infants is a practical alternative to incubator care, no studies have compared these methods using continuous ambulatory temperature monitoring. To compare thermal regulation in low birthweight infants (< 2000 g) managed by KMC alternating with conventional care (CC) and to determine the acceptability to mothers of KMC, an experimental study with a crossover design with observational and qualitative data collected on temperature patterns and mothers attitudes to skin-to-skin care was conducted in the neonatal wards of three hospitals in Lagos, Nigeria. Thirteen eligible infants were nursed by their mothers or surrogates in 38 4-hour sessions of KMC and the results compared with 38 sessions of incubator care. The risk of hypothermia was reduced by > 90% when nursed by KMC rather than conventional care, relative risk (RR) 0.09 (0.03-0.25). More cases of hyperthermia (> 37.5 degrees C) occurred with KMC, and coreperiphery temperature differences were widened, but the risk of hyperthermia > 37.9 degrees C (RR 1.3, 0.9-1.7) was not significant. Micro-ambient temperatures were higher during KMC, although the average room temperatures during both procedures did not differ significantly. Mothers felt that KMC was safe, and preferred the method to CC because it did not separate them from their infants, although some had problems adjusting to this method of care. Where equipment for thermal regulation is lacking or unreliable, KMC is a preferable method for managing stable low birthweight infants.

37. ADXS11-001, mitomycin, 5-FU and radiation for anal cancera A phase I/II study

Background Human papillomavirus (HPV) DNA is present in the majority of squamous cell cancers of the anus. ADXS11–001 immunotherapy is a live attenuated Listeria monocytogenes (Lm) bioengineered to secrete an HPV-16-E7 fusion protein targeting HPV-transformed cells. The Lm vector infects antigen-presenting cells, stimulating both MHC class 1 and 2 pathways resulting in specific T-cell immunity to tumours. The Brown University Oncology Research Group has initiated a phase I/II study evaluating two treatment schedules of ADXS11–001 with standard chemoradiation for anal cancer. Methods: Patients with newly diagnosed anal cancer with a primary tumour >4 cm or lymph node involvement, without distant metastases, are eligible. All patients receive two courses of mitomycin, 5-FU with concurrent radiation (54 Gy in 30 fractions by IMRT). Patients receive four treatments of ADXS11–001, 1 × 109 colony-forming units intravenously once approximately every 28 days. In treatment schedule 1, the first dose is given before chemoradiation and the second to fourth doses are given every 28 days after completion of radiation. In treatment schedule 2, the second dose of ADXS11–001 is administered during chemoradiation. Results: Three patients have been treated with ADXS11–001 and chemoradiation on treatment schedule 1. One patient developed grade 3 chills and one patient experienced grade 2 flu-like symptoms post-infusion, both resolved with symptomatic treatment. Conclusions: ADXS11–001 is a highly novel form of immunotherapy designed to generate an immune response against HPV transformed cells. Accrual is continuing to evaluate safety and efficacy for patients with anal cancer.

Outreach training: the special interest group's report

Following three sessions at ADEE Annual Meetings, the special interest group on outreach training presents a brief report of its proceedings. Outreach, here, is clinical teaching away from the home dental school. After covering the diversity and benefits of programmes, the report considers different models and the relationship between contexts and outcomes. It concludes that: outreach provides access to additional resources; programmes prepare students for the demands of the profession; a programme's design should harmonise with both its context and its objectives; and, the educational benefits warrant the additional organisation involved.

Analysis of Clinical Record Data for Anticoagulation Management within an EHR System

OBJECTIVES

This paper reports an evaluation of the properties of a generic electronic health record information model that were actually required and used when importing an existing clinical application into a generic EHR repository.

METHOD

A generic EHR repository and system were developed as part of the EU Projects Synapses and SynEx. A Web application to support the management of anticoagulation therapy was developed to interface to the EHR system, and deployed within a north London hospital with five years of cumulative clinical data from the previous existing anticoagulation management application. This offered the opportunity to critique those parts of the generic EHR that were actually needed to represent the legacy data.

RESULTS

The anticoagulation records from 3,226 patients were imported and represented using over 900,000 Record Components (i.e. each patient's record contained on average 289 nodes), of which around two thirds were Element Items (i.e. value-containing leaf nodes), the remainder being container nodes (i.e. headings and sub-headings). Each node is capable of incorporating a rich set of context properties, but in reality it was found that many properties were not used at all, and some infrequently (e.g. only around 0.5% of Record Components had ever been revised).

CONCLUSIONS

The process of developing generic EHR information models, arising from research and embodied within new-generation interoperability standards and specifications, has been strongly driven by requirements. These requirements have been gathered primarily by collecting use cases and examples from clinical communities, and been added to successive generations of these models. A priority setting approach has not to date been pursued - all requirements have been received and almost invariably met. This work has shown how little of the resulting model is actually needed to represent useful and usable clinical data. A wider range of such evaluations, looking at different kinds of existing clinical system, is needed to balance the theoretical requirements gathering processes, in order to result in EHR information models of an ideal level of complexity.

Recommendations to increase the validity and comparability of peripheral measurements by near infrared spectroscopy in neonates. 'Round table', section of haematology, oxygen transport and microcirculation, 48th annual meeting of ESPR, Prague 2007

Several studies of peripheral measurements with near infrared spectroscopy (NIRS) and venous or arterial occlusion have been performed in neonates. Results have been variable. Reasons include differences in patient populations, technical aspects of the devices used or the way measurements were made. It is therefore important that there should be common elements for measurement protocols. This statement proposes a standardised approach to allow comparison between different study populations and devices.

Detection of orthopaedic implants by airport metal detectors

OBJECTIVES

To report the effect of patient's body mass index (BMI), implant type, size, location, number, and material on detection by certified Transportation Security Administration (TSA) and Federal Aviation Administration (FAA) airport metal detectors set to today's standard sensitivity.

DESIGN

Retrospective clinical study.

SETTING

Level 1 university trauma center.

PATIENTS

Ninety-six regularly scheduled trauma clinic patients with a wide variety of orthopaedic implants were enrolled in the study from August 2004 through December 2004.

INTERVENTION

Patients walked through an airport arch metal detector and were also wanded with a handheld metal detector.

MAIN OUTCOME MEASUREMENTS

Detection of implants by arch detector or wand was recorded. We also gathered information regarding BMI, location of implants, type, metal composition, and size.

RESULTS

All unilateral prostheses (8/8) and bilateral prostheses (1/1) were detected. Subjects with 4 or fewer screws and no other implants were never detected by the arch metal detector (0/7). For the remaining 78 subjects, the 2 best predictors of detection by the arch were having plates of length >10 holes and having titanium nails (P < 0.001 for each predictor, Wald's test for effects in a logistic model).

CONCLUSIONS

Prostheses, plates of length >10 holes, and titanium nails were the best predictors of detection by the arch. These 3 factors accounted for 42 of the 43 detections by the arch. Body mass index was not shown to affect detectability of orthopaedic implants.

Three dimensional optical imaging of blood volume and oxygenation in the neonatal brain

Optical methods provide a means of monitoring cerebral oxygenation in newborn infants at risk of brain injury. A 32-channel optical imaging system has been developed with the aim of reconstructing three-dimensional images of regional blood volume and oxygenation. Full image data sets were acquired from 14 out of 24 infants studied; successful images have been reconstructed in 8 of these infants. Regional variations in cerebral blood volume and tissue oxygen saturation are present in healthy preterm infants. In an infant with a large unilateral intraventricular haemorrhage, a corresponding region of low oxygen saturation was detected. These results suggest that optical tomography may provide an appropriate technique for investigating regional cerebral haemodynamics and oxygenation at the cotside.

Three-dimensional whole-head optical tomography of passive motor evoked responses in the neonate

Optical tomography has been used to reconstruct three-dimensional images of the entire neonatal head during motor evoked responses. Data were successfully acquired during passive movement of each arm on four out of six infants examined, from which eight sets of bilateral images of hemodynamic parameters were reconstructed. Six out of the eight images showed the largest change in total hemoglobin in the region of the contralateral motor cortex. The mean distance between the peak response in the image and the estimated position of the contralateral motor cortex was 10.8 mm. These results suggest that optical tomography may provide an appropriate technique for non-invasive cot-side imaging of brain function.

The effects of body fat on pulmonary function and gas exchange in cynomolgus monkeys

Obesity adversely affects lung function in humans often reducing arterial blood oxygenation. To determine if obesity adversely affects lung function in cynomolgus monkeys, which is a species that is often used for pulmonary research, pulmonary mechanics, ventilation, functional residual capacity (FRC), and arterial blood gases were measured using spontaneous respiration and on mechanical ventilation with room air or 100% O(2). Body fat percentage was measured by dual energy X-ray absorption. Blood leptin levels were measured by radioimmune assay. Obese monkeys breathed faster with lower tidal volume, but pulmonary resistance and dynamic lung compliance did not change with body fat. FRC and blood leptin were, respectively, negatively and positively correlated with percent body fat. FRC correlated moderately with ventilatory parameters and strongly with arterial oxygen tension, alveolar-arterial oxygen difference and venous admixture. Therefore, obesity in cynomolgus monkeys had marked, deleterious effects on FRC, ventilation and arterial oxygenation. Obesity may be an important confounding variable in lung function studies in primates.

Decision support software for dementia diagnosis and management in primary care: relevance and potential

Dementia, which affects a large and growing number of older people, presents particular challenges to primary care. There is an acknowledged need to develop interventions that address practitioners' needs for information and guidance regarding the diagnosis and management of dementia. This paper examines the potential usefulness and constraints of a Computer Decision Support System (CDSS) to assist practitioners in diagnosing and managing dementia. Questionnaire information was obtained from 97 primary care practitioners regarding their current practice and views on dementia care, priority given to training and familiarity with computer use. Implications of these findings for the relevance and value of CDSS are discussed. The paper is part of a larger ongoing study, the aim of which is the evaluation of three educational interventions for primary care practitioners.

Design and implementation of a computer decision support system for the diagnosis and management of dementia syndromes in primary care

BACKGROUND

Diagnosis and management of dementia is a complex process and primary care physicians are under-equipped to deal with uncertainties in the provision of optimal care for the patient.

OBJECTIVE

To develop a computer decision support system (CDSS) which could assist physicians with diagnosis and management and improve patient care.

METHODS

A design group including general practitioners derived logic pathways for diagnosis and management of dementia and validated them with a multiprofessional expert group. Logic pathways were used to construct a comprehensive CDSS rendered as a series of expert consultations. The CDSS was inserted into commercially available GP systems and bench and field-tested.

RESULTS

The complexity of dementia diagnosis and management can be captured in logic pathways which can be expressed as decision trees within existing electronic patient records. The resulting CDSS appears useable in routine practice.

CONCLUSION

The impact of this CDSS will be evaluated in a randomised controlled trial of educational interventions in primary care.

Information architecture for a federated health record server

This paper describes the information models that have been used to implement a federated health record server and to deploy it in a live clinical setting. The authors, working at the Centre for Health Informatics and Multiprofessional Education (University College London), have built up over a decade of experience within Europe on the requirements and information models that are needed to underpin comprehensive multi-professional electronic health records. This work has involved collaboration with a wide range of health care and informatics organisations and partners in the healthcare computing industry across Europe though the EU Health Telematics projects GEHR, Synapses, EHCR-SupA, SynEx and Medicate. The resulting architecture models have fed into recent European standardisation work in this area, such as CEN TC/251 ENV 13606. UCL has implemented a federated health record server based on these models which is now running in the Department of Cardiovascular Medicine at the Whittington Hospital in North London. The information models described in this paper reflect a refinement based on this implementation experience.

Human reserve pluripotent mesenchymal stem cells are present in the connective tissues of skeletal muscle and dermis derived from fetal, adult, and geriatric donors

This study details the profile of 13 cell surface cluster differentiation markers on human reserve stem cells derived from connective tissues. Stem cells were isolated from the connective tissues of dermis and skeletal muscle derived from fetal, mature, and geriatric humans. An insulin/dexamethasone phenotypic bioassay was used to determine the identity of the stem cells from each population. All populations contained lineage-committed myogenic, adipogenic, chondrogenic, and osteogenic progenitor stem cells as well as lineage-uncommitted pluripotent stem cells capable of forming muscle, adipocytes, cartilage, bone, fibroblasts, and endothelial cells. Flow cytometric analysis of adult stem cell populations revealed positive staining for CD34 and CD90 and negative staining for CD3, CD4, CD8, CD11c, CD33, CD36, CD38, CD45, CD117, Glycophorin-A, and HLA DR-II.

Clonogenic analysis reveals reserve stem cells in postnatal mammals: I. Pluripotent mesenchymal stem cells

Clonal populations of lineage-uncommitted pluripotent mesenchymal stem cells have been identified in prenatal avians and rodents. These cells reside in the connective tissue matrices of many organs and tissues. They demonstrate extended capabilities for self-renewal and the ability to differentiate into multiple separate tissues within the mesodermal germ line. This study was designed to determine whether such cells are present in the connective tissues of postnatal mammals. This report describes a cell clone derived by isolation from postnatal rat connective tissues, cryopreservation, extended propagation, and serial dilution clonogenic analysis. In the undifferentiated state, this clone demonstrates a high nuclear-to-cytoplasmic ratio and extended capacity for self-renewal. Subsequent morphological, histochemical, and immunochemical analysis after the induction of differentiation revealed phenotypic markers characteristic of multiple cell types of mesodermal origin, such as skeletal muscle, smooth muscle, fat cells, cartilage, and bone. These results indicate that this clone consists of pluripotent mesenchymal stem cells. This report demonstrates that clonal populations of reserve stem cells are present in mammals after birth. Potential roles for such cells in the maintenance, repair, and regeneration of mesodermal tissues are discussed.

Bacterial growth state distinguished by single-cell protein profiling: does chlorination kill coliforms in municipal effluent?

Municipal effluent is the largest reservoir of human enteric bacteria. Its public health significance, however, depends upon the physiological status of the wastewater bacterial community. A novel immunofluorescence assay was developed and used to examine the bacterial growth state during wastewater disinfection. Quantitative levels of three highly conserved cytosolic proteins (DnaK, Dps, and Fis) were determined by using enterobacterium-specific antibody fluorochrome-coupled probes. Enterobacterial Fis homologs were abundant in growing cells and nearly undetectable in stationary-phase cells. In contrast, enterobacterial Dps homologs were abundant in stationary-phase cells but virtually undetectable in growing cells. The range of variation in the abundance of both proteins was at least 100-fold as determined by Western blotting and immunofluorescence analysis. Enterobacterial DnaK homologs were nearly invariant with growth state, enabling their use as permeabilization controls. The cellular growth states of individual enterobacteria in wastewater samples were determined by measurement of Fis, Dps, and DnaK abundance (protein profiling). Intermediate levels of Fis and Dps were evident and occurred in response to physiological transitions. The results indicate that chlorination failed to kill coliforms but rather elicited nutrient starvation and a reversible nonculturable state. These studies suggest that the current standard procedures for wastewater analysis which rely on detection of culturable cells likely underestimate fecal coliform content.

Results of a genome-wide genetic screen for panic disorder

Panic disorder is characterized by spontaneous and recurrent panic attacks, often accompanied by agoraphobia. The results of family, twin, and segregation studies suggest a genetic role in the etiology of the illness. We have genotyped up to 23 families that have a high density of panic disorder with 540 microsatellite DNA markers in a first-pass genomic screen. The thirteen best families (ELOD > 6.0 under the dominant genetic model) have been genotyped with an ordered set of markers encompassing all the autosomes, at an average marker density of 11 cM. Over 110,000 genotypes have been generated on the whole set of families, and the data have been analyzed under both a dominant and a recessive model, and with the program SIBPAIR. No lod scores exceed 2.0 for either parametric model. Two markers give lod scores over 1.0 under the dominant model (chromosomes 1p and 20p), and four do under the recessive model (7p, 17p, 20q, and X/Y). One of these (20p) may be particularly promising. Analysis with SIBPAIR yielded P values equivalent to a lod score of 1.0 or greater (i.e., P < .016, one-sided, uncorrected for multiple tests) for 11 marker loci (2, 7p, 8p, 8q, 9p, 11q, 12q, 16p, 20p and 20q).

Roles of DnaK and RpoS in starvation-induced thermotolerance of Escherichia coli

DnaK is essential for starvation-induced resistance to heat, oxidation, and reductive division in Escherichia coli. Studies reported here indicate that DnaK is also required for starvation-induced osmotolerance, catalase activity, and the production of the RpoS-controlled Dps (PexB) protein. Because these dnaK mutant phenotypes closely resemble those of rpoS (sigma38) mutants, the relationship between DnaK and RpoS was evaluated directly during growth and starvation at 30 degrees C in strains with genetically altered DnaK content. A starvation-specific effect of DnaK on RpoS abundance was observed. During carbon starvation, DnaK deficiency reduced RpoS levels threefold, while DnaK excess increased RpoS levels nearly twofold. Complementation of the dnaK mutation restored starvation-induced RpoS levels to normal. RpoS deficiency had no effect on the cellular concentration of DnaK, revealing an epistatic relationship between DnaK and RpoS. Protein half-life studies conducted at the onset of starvation indicate that DnaK deficiency significantly destabilized RpoS. RpoH (sigma32) suppressors of the dnaK mutant with restored levels of RpoS and dnaK rpoS double mutants were used to show that DnaK plays both an independent and an RpoS-dependent role in starvation-induced thermotolerance. The results suggest that DnaK coordinates sigma factor levels in glucose-starved E. coli.

A prototype computer decision support system for the management of asthma

Asthma is a chronic disease estimated to affect 6-7% of the total UK population. In addition, a number of studies have shown that asthma has become commoner since the 1970s, especially in children. The diagnosis of asthma can be difficult and its management requires the involvement of patients in a long-term treatment plan, something which general practitioners may be unable to achieve easily in the average 10-min consultation. As a consequence, asthma is underdiagnosed and undertreated. Deaths from the disease are often avoidable with timely and sufficient use of the available medication. In order to support this, the British Thoracic Society (BTS) has published guidelines for asthma management based upon a stepwise approach, in which a patient is categorized as being on one of five steps according to the severity of his or her asthma. The guidelines give "rules of thumb" for deciding when the patient should move up or down the steps. The most recent version of the guidelines also included special rules for children. Within a recent European Community project on Advanced Informatics in Medicine (AIM), we developed a prototype decision support system for asthma management targeted at the primary care setting and based on the British Thoracic Society guidelines. This paper reports this development, and describes the further work needed on the prototype. Plans for evaluation of the knowledge bases and for future full application production are also described.

Bone feature analysis using image processing techniques

In order to establish the correlation between bone structure and age, and information about age-related bone changes, it is necessary to study microstructural features of human bone. Traditionally, in bone biology and forensic science, the analysis if bone cross-sections has been carried out manually. Such a process is known to be slow, inefficient and prone to human error. Consequently, the results obtained so far have been unreliable. In this paper we present a new approach to quantitative analysis of cross-sections of human bones using digital image processing techniques. We demonstrate that such a system is able to extract various bone features consistently and is capable of providing more reliable data and statistics for bones. Consequently, we will be able to correlate features of bone microstructure with age and possibly also with age related bone diseases such as osteoporosis. The development of knowledge-based computer vision-systems for automated bone image analysis can now be considered feasible.