Impact of institutional prophylaxis guidelines on rates of pediatric venous thromboembolism following trauma-A multicenter study from the pediatric trauma society research committee

BACKGROUND

A paucity of data exists with regard to the incidence, management, and outcomes of venous thromboembolism (VTE) in injured children. We sought to determine the impact of institutional chemoprophylaxis guidelines on VTE rates in a pediatric trauma population.

METHODS

A retrospective review of injured children (≤15 years) admitted between 2009 and 2018 at 10 pediatric trauma centers was performed. Data were gathered from institutional trauma registries and dedicated chart review. The institutions were surveyed as to whether they had chemoprophylaxis guidelines in place for high-risk pediatric trauma patients, and outcomes were compared based on the presence of guidelines using χ 2 analysis ( p < 0.05).

RESULTS

There were 45,202 patients evaluated during the study period. Three institutions (28,359 patients, 63%) had established chemoprophylaxis policies during the study period ("Guidelines"); the other seven centers (16,843 patients, 37%) had no such guidelines ("Standard"). There were significantly lower rates of VTE in the Guidelines group, but these patients also had significantly fewer risk factors. Among critically injured children with similar clinical presentations, there was no difference in VTE rate. Specifically within the Guidelines group, 30 children developed VTE. The majority (17/30) were actually not indicated for chemoprophylaxis based on institutional guidelines. Still, despite protocols only one VTE patient in the guidelines group who was indicated for intervention ended up receiving chemoprophylaxis prior to diagnosis. No consistent ultrasound screening protocol was in place at any institution during the study.

CONCLUSION

The presence of an institutional policy to guide chemoprophylaxis for injured children is associated with a decreased overall frequency of VTE, but this disappears when controlling for patient factors. However, the overall efficacy is impacted by a combination of deficits in guideline compliance and structure. Further prospective data are needed to help determine the ideal role for chemoprophylaxis and protocols in pediatric trauma.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

The utility of Endoscopic Functional Luminal Imaging (EndoFLIP) in the diagnosis and management of children with achalasia

BACKGROUND

Per-oral endoscopic myotomy (POEM) has is an alternative treatment to laparoscopic Heller myotomy for children with achalasia. The EndoFLIP functional luminal imaging system is used to measure esophagogastric junction (EGJ) distensibility pre- and post-POEM. Previous adult studies have established a correlation between obstructive symptoms and Distensibility Index (DI). Here we analyze the utility of EndoFLIP in diagnosis and management of achalasia in the largest study on pediatric POEM patients and hypothesize that DI may aid diagnosis and treatment of pediatric achalasia.

METHODS

Demographics, preoperative basal and residual pressures measured on manometry, and EndoFLIP measurements pre- and post-POEM were recorded for children that underwent POEM. Pearson correlation coefficient and T-scores were used to assess for correlation between manometry measurements and pre-POEM DI. Linear regression was conducted to analyze the relationship between pre-POEM DI, Eckardt scores, and manometry pressures.

RESULTS

Of 33 patients that underwent POEM and EndoFLIP since 2014 (21 male, 12 female), the median pre-POEM Eckardt score decreased from 7 to 1 post-POEM. The median basal pressure was 50 ± 25 mmHg, pre-POEM DI was 0.9 (0.8-1.6) mm²/mmHg and the post-POEM DI was 3.8 (3.2-4.4) mm²/mmHg. There was no correlation between DI and basal pressure or residual pressure, though there was a strong negative correlation between Eckardt scores and DI.

CONCLUSION

The EndoFLIP system is a valuable tool in adult patients in diagnosing achalasia and defining the endpoint of the POEM procedure. We find that there is a role for EndoFLIP in the pediatric population in diagnosis and management of the disease.

TYPE OF STUDY & LEVEL OF EVIDENCE

Study of diagnostic test; Level IV.

ECG changes in psychiatric patients on psychotropic medications

Funding Acknowledgements

Type of funding sources: None.

Background

Suicide and euthanasia accounts for 14.3% of deaths in those with psychiatric conditions. The rest are attributed to preventable causes such as cardiovascular disease, respiratory disease, and infections. Several psychotropic medications have been associated with sudden death due to their effect on prolonging QT interval, resulting in the development of a polymorphic ventricular arrhythmia, Torsades de Pointes (TdP). TdP may be self-limiting or lead to sudden cardiac arrest and death.

Purpose

This study aims to evaluate the cardiotoxic effects of psychotropic medications.

Method

This is a descriptive retrospective study of patients submitted to the local psychiatric wards within one year. Patients with psychotropic drug prescriptions were included while patients below 18 years old, pregnant, or did not have ECG performed were excluded. The control group consisted of sex- and age- matched patients with ECG conducted for occupational health purposes. Multiple regression models were conducted to investigate the predictors of significant ECG differences.

Result

Of the 154 psychiatric inpatients admitted, exclusions were 44 patients due to exclusion criteria and 19 patients due to difficulty in physical file access. The study population (n = 91) had a mean age of 36.7 years old with 40.7% female and 59.3% male. The predominant diagnoses were schizophrenia and delusional disorders (58.2%). 86 psychiatric patients (94.5%) were prescribed antipsychotic drugs (APD).

A significantly higher proportion of psychiatric patients has a history of smoking (p &lt; 0.001), alcohol consumption (p = 0.001), and illicit drug use (p &lt; 0.001). They also exhibited significantly more co-morbid illnesses including hypertension (p = 0.022), hyperlipidaemia (p = 0.013), diabetes (p = 0.026) and thyroid disease (p = 0.023) than the control population.

Psychiatric patients had a significantly higher mean heart rate (79.9 vs 69.6 ms; p &lt; 0.001) and QTc interval (452.2 vs 418.6ms; p &lt; 0.001). Mean QTc interval was significantly longer for psychiatric patients in both male (454.2 vs 414.5ms; p &lt; 0.001) and female (449.3 vs 425.6 ms; p = 0.029) gender. Psychotropic drug use is a significant predictor for both prolonged heart rate (p &lt; 0.001) and prolonged QTc interval (p &lt; 0.001). Electrolyte imbalance is a significant predictor of prolonged QTc interval only (p = 0.036). One year follow of both groups detected only 1 psychiatric patient with palpitation.

Conclusion

Psychiatric patients on psychotropic medications have a longer baseline heart rate and QTc interval, which was not associated with MACE at 1 year. None of the underlying comorbidities and lifestyle choices were significant predictors of this. Electrolyte abnormalities and psychotropic drug use significantly predicted QTc prolongation. However, these findings were largely driven by APD use. A follow-up study of a longer period is recommended to investigate whether patients with prolonged QTc interval are of higher risk of MACE occurrence.

Quality of internet information to aid patient decision making in locally advanced and recurrent rectal cancer

BACKGROUND

To review whether online decision aids are available for patients contemplating pelvic exenteration (PE) for locally advanced and recurrent rectal cancer (LARC and LRRC).

METHODS

A grey literature review was carried out using the Google Search™ engine undertaken using a predefined search strategy (PROSPERO database CRD42019122933). Written health information was assessed using the DISCERN criteria and International Patient Decision Aids Standards (IPDAS) with readability content assessed using the Flesch-Kincaid reading ease test and Flesch-Kincaid grade level score.

RESULTS

Google search yielded 27, 782, 200 results for the predefined search criteria. 131 sources were screened resulting in the analysis of 6 sources. No sources were identified as a decision aid according to the IPDAS criteria. All sources provided an acceptable quality of written health information, scoring a global score of 3 for the DISCERN written assessment. The median Flesch-Kincaid reading ease was 50.85 (32.5-80.8) equating to a reading age of 15-18 years and the median Flesch-Kincaid grade level score was 7.65 (range 3-9.7), which equates to a reading age of 13-14.

CONCLUSIONS

This study has found that there is a paucity of online information for patients contemplating PE. Sources that are available are aimed at a high health literate patient. Given the considerable morbidity associated with PE surgery there is a need for high quality relevant information in this area. A PDA should be developed to improve decision making and ultimately improve patient experience.

Venous thromboembolic risk stratification in pediatric trauma: A Pediatric Trauma Society Research Committee multicenter analysis

BACKGROUND

Venous thromboembolism (VTE) in injured children is rare, but its consequences are significant. Several risk stratification algorithms for VTE in pediatric trauma exist with little consensus, and all are hindered in development by relying on registry data with known inaccuracies. We performed a multicenter review to evaluate trauma registry fidelity and confirm the effectiveness of one established algorithm across diverse centers.

METHODS

Local trauma registries at 10 institutions were queried for all patients younger than 18 years admitted between 2009 and 2018. Additional chart review was performed on all "VTE" cases and random non-VTE controls to assess registry errors. Corrected data were then applied to our prediction algorithm using 10 real-time variables (Glasgow Coma Scale, age, sex, intensive care unit admission, transfusion, central line placement, lower extremity/pelvic fracture, major surgery) to calculate VTE risk scores. Contingency table classifiers and the area under a receiver operator characteristic curve were calculated.

RESULTS

Registries identified 52,524 pediatric trauma patients with 99 episodes of VTE; however, chart review found that 13 cases were misclassified for a corrected total of 86 cases (0.16%). After correction, the algorithm still displayed strong performance in discriminating VTE-fated encounters (sensitivity, 69%; area under the receiver operating characteristic curve, 0.96). Furthermore, despite wide institutional variability in VTE rates (0.04-1.7%), the algorithm maintained a specificity of >91% and a negative predictive value of >99.7% across centers. Chart review also revealed that 54% (n = 45) of VTEs were directly associated with a central line, usually femoral (n = 34, p < 0.001 compared with upper extremity), and that prophylaxis rates were underreported in the registries by about 50%; still, only 19% of the VTE cases had been on prophylaxis before diagnosis.

CONCLUSION

The VTE prediction algorithm performed well when applied retrospectively across 10 diverse pediatric centers using corrected registry data. These findings can advance initiatives for VTE screening/prophylaxis guidance following pediatric trauma and warrant prospective study.

LEVEL OF EVIDENCE

Clinical decision rule evaluated in a single population, level III.

The Chemical Complexity of e-Cigarette Aerosols Compared With the Smoke From a Tobacco Burning Cigarette

Background: As e-cigarette popularity has increased, there is growing evidence to suggest that while they are highly likely to be considerably less harmful than cigarettes, their use is not free of risk to the user. There is therefore an ongoing need to characterise the chemical composition of e-cigarette aerosols, as a starting point in characterising risks associated with their use. This study examined the chemical complexity of aerosols generated by an e-cigarette containing one unflavored and three flavored e-liquids. A combination of targeted and untargeted chemical analysis approaches was used to examine the number of compounds comprising the aerosol. Contributions of e-liquid flavors to aerosol complexity were investigated, and the sources of other aerosol constituents sought. Emissions of 98 aerosol toxicants were quantified and compared to those in smoke from a reference tobacco cigarette generated under two different smoking regimes. Results: Combined untargeted and targeted aerosol analyses identified between 94 and 139 compounds in the flavored aerosols, compared with an estimated 72-79 in the unflavored aerosol. This is significantly less complex (by 1-2 orders of magnitude) than the reported composition of cigarette smoke. Combining both types of analysis identified 5-12 compounds over and above those found by untargeted analysis alone. Gravimetrically, 89-99% of the e-cigarette aerosol composition was composed of glycerol, propylene glycol, water and nicotine, and around 3% comprised other, more minor, constituents. Comparable data for the Ky3R4F reference tobacco cigarette pointed to 58-76% of cigarette smoke "tar" being composed of minor constituents. Levels of the targeted toxicants in the e-cigarette aerosols were significantly lower than those in cigarette smoke, with 68.5->99% reductions under ISO 3308 puffing conditions and 88.4->99% reductions under ISO 20778 (intense) conditions; reductions against the WHO TobReg 9 priority list were around 99%. Conclusion: These analyses showed that the e-cigarette aerosols contain fewer compounds and at significantly lower concentrations than cigarette smoke. The chemical diversity of an e-cigarette aerosol is strongly impacted by the choice of e-liquid ingredients.

Protect Our Kids: a novel program bringing hemorrhage control to schools

Background

Following the shooting at Sandy Hook Elementary School, the Hartford Consensus produced the Stop the Bleed program to train bystanders in hemorrhage control. In our region, the police bureau delivers critical incident training to public schools, offering instruction in responding to violent or dangerous situations. Until now, widespread training in hemorrhage control has been lacking. Our group developed, implemented and evaluated a novel program integrating hemorrhage control into critical incident training for school staff in order to blunt the impact of mass casualty events on children.

Methods

The staff of 25 elementary and middle schools attended a 90-minute course incorporating Stop the Bleed into the critical incident training curriculum, delivered on-site by police officers, nurses and doctors over a three-day period. The joint program was named Protect Our Kids. At the conclusion of the course, hemorrhage control kits and educational materials were provided and a four-question survey to assess the quality of training using a ten-point Likert scale was completed by participants and trainers.

Results

One thousand eighteen educators underwent training. A majority were teachers (78.2%), followed by para-educators (5.8%), counselors (4.4%) and principals (2%). Widely covered by local and state media, the Protect Our Kids program was rated as excellent and effective by a majority of trainees and all trainers rated the program as excellent.

Conclusions

Through collaboration between trauma centers, police and school systems, a large-scale training program for hemorrhage control and critical incident response can be effectively delivered to schools.

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

BACKGROUND

Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality.

METHODS

We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis.

FINDINGS

We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36-39) and median bodyweight at presentation was 2·8 kg (2·3-3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88-4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59-2·79], p<0·0001), sepsis at presentation (1·20 [1·04-1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4-5 vs ASA 1-2, 1·82 [1·40-2·35], p<0·0001; ASA 3 vs ASA 1-2, 1·58, [1·30-1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02-1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41-2·71], p=0·0001; parenteral nutrition 1·35, [1·05-1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47-0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50-0·86], p=0·0024) or percutaneous central line (0·69 [0·48-1·00], p=0·049) were associated with lower mortality.

INTERPRETATION

Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030.

FUNDING

Wellcome Trust.

Immune Thrombocytopenic Purpura Splenectomy in the Context of New Medical Therapies

BACKGROUND

As medical therapy improves, splenectomy has been relegated to third- or fourth-line therapy for immune thrombocytopenic purpura (ITP) in many hematologic practices. However, these medications have well-known associated morbidity and changes in treatment algorithms may affect the timing and degree of response to splenectomy as well as complications in heavily treated ITP patients.

MATERIALS AND METHODS

This is a retrospective study of consecutive patients who underwent ITP splenectomy from January 1994 to June 2017. Nonresponders after splenectomy and those with recurrent disease were compared to complete responders.

RESULTS

The cohort included 84 patients. Median number of medications received before splenectomy was 3 (1-6). 14.3% of patients had a medication-related complication, including heart failure, adrenal insufficiency, diabetes mellitus, infection, and osteoporosis. After splenectomy, 83.5% had a complete response, 7.5% partial response, and 9% no response. Complete response was associated with response to steroids before surgery (P < 0.01). Among responders, 19% had recurrent disease, which was associated with lower platelet count at diagnosis (P < 0.01). Forty-four patients (52.0%) had nonelective splenectomies for persistent bleeding or dangerously low platelets despite maximal medical therapy. Ten patients had Clavien-Dindo grade II or higher surgical complications (11.9%). Seven of these complications were related to recurrent or refractory ITP.

CONCLUSIONS

Many ITP patients have complications related to medication use, and 52.0% required nonelective splenectomy despite maximal medical therapy. Earlier splenectomy may avoid medication-related complications and may reduce the complications from splenectomy. Splenectomy remains an effective and safe treatment for ITP.

Prospective evaluation of the cardiac safety of HER2-targeted therapies in patients with HER2-positive breast cancer and compromised heart function: the SAFE-HEaRt study

Purpose

HER2-targeted therapies have substantially improved the outcome of patients with breast cancer, however, they can be associated with cardiac toxicity. Guidelines recommend holding HER2-targeted therapies until resolution of cardiac dysfunction. SAFE-HEaRt is the first trial that prospectively tests whether these therapies can be safely administered without interruptions in patients with cardiac dysfunction.

Methods

Patients with stage I–IV HER2-positive breast cancer candidates for trastuzumab, pertuzumab or ado-trastuzumab emtansine (TDM-1), with left ventricular ejection fraction (LVEF) 40–49% and no symptoms of heart failure (HF) were enrolled. All patients underwent cardiology visits, serial echocardiograms and received beta blockers and ACE inhibitors unless contraindicated. The primary endpoint was completion of the planned HER2-targeted therapies without developing either a cardiac event (CE) defined as HF, myocardial infarction, arrhythmia or cardiac death or significant asymptomatic worsening of LVEF. The study was considered successful if planned oncology therapy completion rate was at least 30%.

Results

Of 31 enrolled patients, 30 were evaluable. Fifteen patients were treated with trastuzumab, 14 with trastuzumab and pertuzumab, and 2 with TDM-1. Mean LVEF was 45% at baseline and 46% at the end of treatment. Twenty-seven patients (90%) completed the planned HER2-targeted therapies. Two patients experienced a CE and 1 had an asymptomatic worsening of LVEF to ≤ 35%.

Conclusion

This study provides safety data of HER2-targeted therapies in patients with breast cancer and reduced LVEF while receiving cardioprotective medications and close cardiac monitoring. Our results demonstrate the importance of collaboration between cardiology and oncology providers to allow for delivery of optimal oncologic care to this unique population.

Electronic supplementary material

The online version of this article (10.1007/s10549-019-05191-2) contains supplementary material, which is available to authorized users.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Venous thromboembolism in adult elective spinal surgery

Aims

To evaluate the incidence of primary venous thromboembolism (VTE), epidural haematoma, surgical site infection (SSI), and 90-day mortality after elective spinal surgery, and the effect of two protocols for prophylaxis.

Patients and Methods

A total of 2181 adults underwent 2366 elective spinal procedures between January 2007 and January 2012. All patients wore anti-embolic stockings, mobilised early and were kept adequately hydrated. In addition, 29% (689) of these were given low molecular weight heparin (LMWH) while in hospital. SSI surveillance was undertaken using the Centers for Disease Control and Prevention criteria.

Results

In patients who only received mechanical prophylaxis, the incidence of VTE was 0.59% and that of SSI 2.1%. In patients who were additionally given LMWH, the incidence of VTE was 0% and that of SSI 0.7%. The unadjusted p-value was 0.04 for VTE and 0.01 for SSI. There were no cases of epidural haematoma or 90-day mortality in either group. When adjusted for case-mix, LMWH remained a significant factor (p = 0.006) for VTE, but not for SSI.

Conclusion

A peri-operative protocol involving mechanical anti-embolism stockings, adequate hydration, and early post-operative mobilisation is effective in significantly reducing the incidence of VTE. The addition of LMWH is safe in patients at higher risk of developing VTE. Cite this article: Bone Joint J 2017;99-B:1204–9.

The Elimination of Radiative Heat Transfer in Fine Celled PU Rigid Foams

Considerable research in the early 1980s led to the identification of radiative heat transfer as a major contributor to the overall thermal conductivity of PU rigid foam.

Fundamental heat transfer analysis showed that for foam model matrices in which the primary variable was cell-size, an approximately linear relationship was obtained between the radiative heat transfer thermal conductivity contribution λ rad and cell-size. λ rad, was shown to theoretically decrease to below 1 mW/mK when foam cell-sizes were reduced to about 50 μ. This decrease to below 1 mW/mK is considered in this presentation as an effective elimination of the radiative heat transfer mechanism.

With the establishment of a phase-out timetable for R-11, considerable global research activity was focused on the development of fine celled technology capable of exploiting these predictions. In recent years technology for the production of closed cell foams with cell-sizes in the range 100-300 μ have been developed. More recently open celled foams have now been developed for vacuum panel applications with cell-sizes down to the 50 μ level. This series of foams provided a unique opportunity to determine directly the real level of radiative heat transfer that occurs and to therefore determine for the first time the real effectiveness of polyurethane foam matrices to attenuate radiative heat transfer.

The theoretical framework for the investigation adopts what is known as a 3 flux approximation, which allows both absorption and scattering contributions to be taken into account. Spectral I-R directional-hemispherical transmission and reflection measurements were performed using an integrating sphere accessory on a BIORAD FTS-40 spectrometer equipped with a CsI beam splitter. The wavelength region of investigation covered 98% of the black body spectrum.

From the experimental reflection and transmission spectra and the three flux approximation method, the spectral extinction coefficient was determined and then Rosseland averaged. From this Rosseland averaged extinction coefficient, the foam radiative thermal conductivity λ rad at a mean temperature of 283°C was calculated. Using a mean intercept length analysis of an SEM characterization of the foam both parallel and perpendicular to the symmetry axis, it was possible to determine the Z-average cell-size.

Analysis of the results displayed a strong linear relationship of λ rad, with the Z-average foam cell size.

It is shown that for the very fine open celled foams designed for vacuum panel applications, λ rad values below 1 mW/mK could be obtained. This remarkable level of radiative attenuation for PU foam, in combination with the expected thermal conductivity contribution from solid conduction, is shown to strongly support their suitability as potential vacuum insulation matrices.

First Measurement of Electron Neutrino Appearance in NOvA

We report results from the first search for ν_{μ}→ν_{e} transitions by the NOvA experiment. In an exposure equivalent to 2.74×10^{20} protons on target in the upgraded NuMI beam at Fermilab, we observe 6 events in the Far Detector, compared to a background expectation of 0.99±0.11(syst) events based on the Near Detector measurement. A secondary analysis observes 11 events with a background of 1.07±0.14(syst). The 3.3σ excess of events observed in the primary analysis disfavors 0.1π<δ_{CP}<0.5π in the inverted mass hierarchy at the 90% C.L.

Power, policy and the Prunus africana bark trade, 1972-2015

ETHNOPHARMACOLOGICAL RELEVANCE

After almost 50 years of international trade in wild harvested medicinal bark from Africa and Madagascar, the example of Prunus africana holds several lessons for both policy and practice in the fields of forestry, conservation and rural development. Due to recent CITES restrictions on P. africana exports from Burundi, Kenya and Madagascar, coupled with the lifting of the 2007 European Union (EU) ban in 2011, Cameroon's share of the global P. africana bark trade has risen from an average of 38% between 1995 and 2004, to 72.6% (658.6 metric tons) in 2012. Cameroon is therefore at the center of this international policy arena.

METHODS AND MATERIALS

This paper draws upon several approaches, combining knowledge in working with P. africana over a 30-year period with a thorough literature review and updated trade data with "ground-truthing" in the field in 2013 and 2014. This enabled the construction of a good perspective on trade volumes (1991-2012), bark prices (and value-chain data) and the gaps between research reports and practice. Two approaches provided excellent lenses for a deeper understanding of policy failure and the "knowing-doing gap" in the P. africana case. A similar approach to Médard's (1992) analyses of power, politics and African development was taken and secondly, studies of commodity chains that assess the power relations that coalesce around different commodities (Ribot, 1998; Ribot and Peluso, 2003).

RESULTS

Despite the need to conserve genetically and chemically diverse P. africana, wild populations are vulnerable, even in several "protected areas" in Burundi, Cameroon, the Democratic Republic of Congo and in the forest reserves of Madagascar. Secondly, hopes of decentralized governance of this forest product are misplaced due to elite capture, market monopolies and subsidized management regimes. At the current European price, for P. africana bark (US$6 per kg) for example, the 2012 bark quota (658.675t) from Cameroon alone was worth over US$3.9 million, with the majority of this accruing to a single company. In contrast to lucrative bark exports, the livelihood benefits and financial returns to local harvesters from wild harvest are extremely low. For example, in 2012, the 48 active harvesters working within Mount Cameroon National Park (MCNP) received less than 1US$ per day from bark harvests, due to a net bark price of 0.33 US$ per kg (or 43% of the farm gate price for wild harvested bark). In addition, the costs of inventory, monitoring and managing sustainable wild harvests are far greater than the benefits to harvesters.

CONCLUSION

Without the current substantial international donor subsidies, sustainable harvest cannot be sustained. What is required to supply the current and future market is to develop separate, traceable P. africana bark supply chains based on cultivated stocks. On-farm production would benefit thousands of small-scale farmers cultivating P. africana, including local women, for whom wild harvesting is too onerous. This change requires CITES and EU support and would catalyze P. africana cultivation in across several montane African countries and Madagascar, increasing farm-gate prices to harvesters compared to economic returns from wild harvest.

Glycaemic control is harder to achieve than blood pressure or lipid control in Irish adults with type 1 diabetes

We sought to determine the attainment of targets for glycaemic control and vascular risk reduction in an Irish cohort of T1DM adults. Of 797 patients (53% male, mean age 40.3 ± 14.8 years, HbA1c 8.5 ± 1.6% (69.6 ± 17.8 mmol mol(-1))), 15%, 68% and 62% achieved targets for HbA1c, blood pressure and LDL cholesterol, respectively.

Young adult type 1 diabetes care in the West of Ireland: an audit of hospital practice

BACKGROUND

It is well recognised that management of young adults with type 1 diabetes (T1DM) poses difficult challenges for physicians and health care organisations as a whole. In Ireland and in particular the west of Ireland there has been little audit or research on young adults with T1DM and the services available to them.

DESIGN

In 2011 a retrospective review of this patient population in our territory referral centre was carried out.

RESULTS

The average glycaemic control in this population was poor at 81mmols/mol and diabetes related complications were present in 32%. Engagement by this population with services was poor with an average of 3 missed clinic appointments over a 24 month period.

CONCLUSION

These results have prompted a re think of how health care professionals can deliver a service that better suits the needs of this challenging patient group.

A reporter assay for the next generation of biomaterials: porous-wall hollow glass microspheres

OBJECTIVES/HYPOTHESIS

The primary objective was to design a reporter assay to measure molecular release kinetics from a new porous-wall hollow glass microsphere biomaterial with great potential in regenerative medicine and drug delivery. Second, future avenues for research will be discussed specifically in regard to potential clinical uses in laryngology.

STUDY DESIGN

Basic science data report.

METHODS

We developed an assay using fluorescent nanocrystals or quantum dots (Qdot 605) as a reporter. A Nuance FX multispectral imaging system was used to detect fluorescence in aqueous phase. Spectral output of known concentrations of aqueous Qdot 605 was measured by the Nuance system to create a standard curve.

RESULTS

These data were plotted and fit to a curve. Qdot 605 emission demonstrates excellent correlation with concentration in a log-log relationship [R(2) = 0.99649, median error = 9.9%], indicating that the Qdot 605 assay is reliable and should be explored regarding its ability to evaluate the drug-eluting properties of this material.

CONCLUSIONS

We have derived a method to measure Qdot concentration using fluorescent microscopy, which will facilitate future research on this exciting new biomaterial. This material has great potential for use in head and neck surgery. Specific avenues within laryngology to be investigated include laryngeal and tracheal reconstruction, vocal fold healing, and nerve regeneration. Furthermore, we believe this is the first documented use of the Nuance system to determine aqueous molecular concentrations.

LEVEL OF EVIDENCE

NA.

Invasive Streptococcus pneumoniae trigger platelet activation via Toll-like receptor 2

BACKGROUND

Sepsis is the most common manifestation of invasive pneumococcal disease and is characterized by a severe systemic inflammatory state that leads to circulatory compromise or end organ malperfusion or dysfunction. Patients suffering from sepsis often display low platelet counts characterized by thrombocytopenia as a result of platelet activation.

OBJECTIVE

To investigate the mechanism through which platelets become activated in sepsis upon binding to Streptococcus pneumoniae.

PATIENTS AND METHODS

We determined S. pneumoniae inducible platelet reactivity using light transmission aggregometry. Dense granule secretion was measured by luminometry using a luciferin/luciferase assay.

RESULTS

Streptococcus pneumoniae induced platelet aggregation in a strain-dependent manner. Induction of aggregation was not attributable to capsule serotype, as unencapsulated strains also induced platelet aggregation. Platelet aggregation was not associated with pneumolysin toxin, as a pneumolysin-deficient mutant of S. pneumoniae induced aggregation equally as well as the parent strain. Platelet aggregation also occurred in the absence of plasma proteins or antibody, and was GPIIbIIIa dependent but aspirin independent. Toll-like receptor 2 (TLR2) is present on platelets and acts as a receptor for gram-positive bacterial lipoteichoic acid and peptidoglycan. Inhibition of TLR2 but not TLR4 (also present on platelets) completely abolished platelet aggregation. S. pneumoniae-induced platelet aggregation resulted in activation of the PI3kinase/RAP1 pathway, leading to integrin GPIIbIIIa activation and dense granule release.

CONCLUSIONS

Our results demonstrate a novel interaction between S. pneumoniae and TLR2, which results in platelet activation that is likely to contribute to the thrombotic complications of sepsis.

Non-adherence to interferon-beta therapy in Swedish patients with multiple sclerosis

OBJECTIVES

To explore the occurrence and reasons for stopping, switching or continuing first prescribed interferon-beta therapy in patients with multiple sclerosis in Sweden, with respect to demographic, clinical and/or therapy-related factors.

MATERIALS AND METHODS

A retrospective study reviewing the medical charts of 259 patients with multiple sclerosis, comparing patients continuing therapy for at least 3 years with those switching or stopping therapy.

RESULTS

Sixty 9% stopped (15%), or switched (54%), interferon-beta therapy within 3 years. Stoppers had longer disease duration before starting therapy (P = 0.002), less frequently relapsing-remitting multiple sclerosis (P = 0.046), and more often Expanded Disability Status Scale scores 6-9.5 (P = 0.045) compared to Switchers. The most common reasons for switching/stopping therapy were perceived lack of effect and side-effects.

CONCLUSIONS

Adherence to initial immune-modulating therapy is low; identification of patients at higher risk of stopping therapy and provision of adequate support are essential.

WITHDRAWN: Physiotherapist-led programmes and interventions for rehabilitation of anterior cruciate ligament, medial collateral ligament and meniscal injuries of the knee in adults

BACKGROUND

Soft-tissue injuries of the knee, mainly involving the anterior cruciate ligament (ACL), the medial collateral ligament (MCL) and menisci, are common and their rehabilitation after non-surgical or surgical treatment often involves intensive and prolonged physiotherapy.

OBJECTIVES

To examine the evidence for effectiveness of various physiotherapist-led (or 'directed') rehabilitation programmes, and of various interventions used within these programmes, for rehabilitation of acute or chronic ACL, MCL or meniscal injuries of the knee in adults.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group's specialised register (to June 2001), MEDLINE (from 1966 to August 1999), EMBASE (from 1980 to February 1997), CINAHL (1982 to April 1999), CURRENT CONTENTS (up to March 1999) and reference lists of relevant articles, and consulted colleagues. Date of the most recent search: June 2001.

SELECTION CRITERIA

Randomised or quasi-randomised clinical trials evaluating physiotherapist-led rehabilitation programmes, or components of rehabilitation programmes, for the treatment or post-surgical rehabilitation of ACL, MCL or knee meniscal injuries. Excluded were trials investigating electrical stimulation, or various interventions such as cryotherapy, immobilisation braces and continuous passive motion when used in initial or early treatment. Laboratory based trials reporting intermediate outcomes were also excluded.

DATA COLLECTION AND ANALYSIS

All trials, judged as fitting the selection criteria by two reviewers, were independently assessed by two reviewers for methodological quality by use of an 11 item checklist. Data were independently extracted by two reviewers. Any disagreement was resolved by discussion. Although quantitative data from most trials are presented, using relative risks or mean differences together with 95 per cent confidence intervals, trial heterogeneity and lack of outcome data prevented meaningful pooling of results from comparable trials.

MAIN RESULTS

Thirty-one trials, involving 1545 mainly young and male patients, met the inclusion criteria of the review. Methodological quality was highly variable: allocation concealment and / or assessor blinding were rare, and assessment of outcome was often incomplete and short-term. ACL injury and /or deficiency was the main focus of 18 trials, MCL injury of two trials, meniscal injury of nine trials and a mixture of soft-tissue injuries in the other two trials. The trial comparisons fell into five main categories: rehabilitation programme versus control (6 trials); one rehabilitation programme versus another (6 trials); different timing of rehabilitation (4 trials); one component of a programme versus another (6 trials); supplementary interventions to a programme versus none (9 trials). No trial provided sufficient evidence to establish the relative effectiveness of the intervention(s) under investigation.

AUTHORS' CONCLUSIONS

The available evidence for physiotherapist-led rehabilitation of ACL, MCL and meniscal injuries is wide ranging in terms of scope but insufficient to establish the relative effectiveness of the various approaches and methods in current use. There is a need for further research involving good quality, large scale randomised trials with sufficiently long follow-up to fully assess knee function and recovery.

Effect of phthiocerol dimycocerosate deficiency on the transcriptional response of human macrophages to Mycobacterium tuberculosis

The control of mycobacterial infections is dependent on the finely tuned synergism between the innate and adaptive immune responses. The macrophage is the major host cell for Mycobacterium tuberculosis and the degree of virulence of mycobacteria may influence the initial macrophage response to infection. The cell wall molecule, phthiocerol dimycocerosate (DIM), is an important virulence factor that influences the early growth of M. tuberculosis in the lungs. To explore the basis for this effect we have compared the early gene response of human THP-1 macrophages to infection with virulent M. tuberculosis and the DIM-deficient DeltafadD26 M. tuberculosis strain using microarrays. Detailed analysis revealed a common core of macrophage genes, which were rapidly induced following infection with both strains, and deficiency of DIM had no significant effect on this initial macrophage transcriptional responses. In addition to chemokines and pro-inflammatory cytokines, the early response genes included components of the Toll-like receptor signalling, antigen presentation and apoptotic pathways, interferon response genes, cell surface receptors and their ligands, including TNF-related apoptosis inducing ligand (TRAIL) and CD40, and other novel genes. Therefore, although fadD26 deficiency is responsible for the early attenuation of the growth of M. tuberculosis in vivo, this effect is not associated with differences in the initial macrophage transcriptional response.

Developing a foundation apprenticeship in care

This article explores the development of a foundation apprenticeship in care at Sheffield Teaching Hospitals NHS Foundation Trust. The benefits for recruitment and development of the workforce are discussed.

Risk of herpes simplex virus type 2 acquisition increases over early adulthood: evidence from a cohort study

DESIGN/ SETTING: A cohort study of 1037 people born in Dunedin, New Zealand, in 1972 or 1973.

PARTICIPANTS

At assessment at age 32 years, 884 participants (432 women and 452 men; 87.1% of the surviving cohort) provided both sera and information on sexual behaviour.

MAIN OUTCOME MEASURES

The proportion of participants with antibodies to HSV-2 infection at ages 26 and 32 years was measured, and the incidence rates from first coitus to age 26 years and from age 26 to 32 years calculated, adjusting for the number of sexual partners and same-sex contact in these age periods.

RESULTS

At age 32 years, 14.6% of men and 22.5% of women had antibodies to HSV-2. The incidence rates for men and women from first coitus to age 26 years were, respectively, 6.5 and 14.3 per 1000 person-years. The incidence rates for men and women from age 26-32 years, respectively, were 14.3 and 15.8 per 1000 person-years. When adjusted for sexual behaviour, the incidence rate ratio, comparing the older with the younger age periods, was 2.9 (95% confidence interval (CI) 1.7 to 4.9) for men and 2.0 (1.2 to 3.4) for women. The adjusted incidence rate ratio when comparing women to men from first coitus to age 26 years was 2.5 (1.6 to 4.0), and from age 26-32 years was 1.3 (0.78 to 2.2). A test for interaction indicated that men and women had different patterns of incidence over time (p = 0.039).

CONCLUSION

In the general population, the risk of acquiring HSV-2 infection seems to increase with age at least to the early 30s, and differences in risk of acquisition for women compared with men become less with age. Health promotion and treatment to control HSV-2 infection should be aimed at all ages, not just at the young.

Fc gamma R expression on NK cells influences disease severity in rheumatoid arthritis

Rheumatoid arthritis (RA) is associated with autoantibodies, the best known of which is rheumatoid factor (RF). RF/IgG complexes interact with FcgammaR on the surface of neutrophils, NK cells and monocyte/macrophages. We have analyzed the expression pattern and allelic polymorphisms of three FcgammaR genes (FcgammaRIIA, FcgammaRIIC and FcgammaRIIIA) in a large sample of RA patients and normal donors. We have found that the level of FcgammaR (CD16 and CD32) expression on NK cells is lower in RA patients than in normal individuals. Genotypic analysis demonstrated that the CD32 isoform expressed by the majority of RA patients was not the activating FcgammaRIIc1 isoform, commonly seen in normal individuals, but rather the inhibitory FcgammaRIIb isoform. The combination of the FcgammaRIIIA-176F allele with a lack of CD32 expression in NK cells appeared to be characteristic of RA subjects with aggressive disease. Since FcgammaRII and FcgammaRIIIA are predominantly expressed by NK cells, these data further suggest that FcgammaR-mediated activation of NK cells could be a disease-determining factor in RA patients.

Introduction: Is viral shedding a surrogate marker for transmission of genital herpes?

Genital herpes, caused by either herpes simplex virus type 1 or 2 (HSV-1 and HSV-2), is a significant public health problem worldwide. It increases the risk of infection with HIV, upregulates HIV after infection and can be associated with serious morbidity and mortality. It is now known that clinical and subclinical viral reactivation with resultant shedding from anogenital mucosa occurs frequently, resulting in transmission during sexual contact. Sexual transmission of HSV infection is common, even between monogamous individuals. Antiviral therapy reduces the frequency and degree of viral shedding and lowers the transmission rate in discordant monogamous couples, although transmission can still occur in people prescribed antiviral therapy. These encouraging data raise important questions for the management of genital HSV infection, particularly with regard to the prevention of transmission. Although the quantity of virus present is clearly important in transmission of some viruses, it is not clear whether this is the case for HSV transmission. Ideally, a surrogate marker needs to be able to identify individuals with detectable amounts of virus, and differentiate them from individuals with detectable amounts of virus that are transmissible. The aim of this supplement is to explore the issues surrounding the validation of surrogate markers of transmission of HSV, using examples from other human viral diseases, and to review the available evidence. In the future, exploration of these issues may shed light on management and prevention strategies. In particular, the results may clarify what evidence is required to warrant prescribing a drug for reducing HSV transmission, and for which patient populations this strategy is appropriate.

HSV shedding

Viral shedding of HSV occurs frequently in infected individuals. HSV is shed asymptomatically from multiple anatomical sites and shedding, like exposure, is a significant risk for transmission. However, the relationship between shedding frequency, viral titer and transmission is unknown. HSV-2 shedding is affected by the site and time since acquisition of infection. The advent of sensitive PCR techniques has shown that the magnitude and frequency of viral shedding is higher than shown previously with viral culture techniques. It has also clearly demonstrated that suppressive (daily) antiviral therapy reduces clinical and subclinical reactivation rates, and has been successfully used in the prevention of recurrent oral and genital HSV infections. A recent study has demonstrated that daily antiviral therapy with valaciclovir can significantly reduce transmission of HSV-2 between discordant heterosexual couples in monogamous relationships.

HSV-2 transmission

A number of important risk factors for the acquisition of HSV-2 have been established including female gender, black or Hispanic ethnic origin, HIV infection, age, and increased number of sexual partners. Transmission is influenced by a number of biological factors such as sexual behavior, use of condoms, duration of relationships, and knowledge of a partner's serologic status. Vertical transmission (transmission of HSV from mother to neonate) is potentially life-threatening; neonatal HSV infection is associated with significant morbidity and mortality. The valaciclovir transmission study provides evidence that an antiviral agent can interrupt the transmission of a viral sexually transmitted disease between serologically discordant sexual partners. This review explores the importance of the cofactors that affect transmission, and makes recommendations on considerations for the prophylactic use of antiviral agents for the prevention of transmission in other patient populations.

Lessons from HIV and hepatitis viruses

Surrogate markers are an important component in the process of investigating management and prevention strategies, and for increasing understanding of viral diseases. The importance of surrogate markers and applied statistical models is particularly true for HIV. For HIV infection, the development of such methods provides new approaches for evaluation of HIV therapies and vaccines, and for the study of HIV transmission and its pathogenesis. The complex natural history of hepatitis B infection demonstrates that viral load is not the only predictor of transmission of this virus; for hepatitis C infection, viral load per se is not a prognostic factor for disease progression, but cumulative viral load may affect the outcome, and therapy is aimed at eliminating active viral replication.