CAnceR IN PreGnancy (CARING) - a retrospective study of cancer diagnosed during pregnancy in the United Kingdom

BACKGROUND

The incidence of cancer diagnosed during pregnancy is increasing. Data relating to investigation and management, as well as maternal and foetal outcomes is lacking in a United Kingdom (UK) population.

METHODS

In this retrospective study we report data from 119 patients diagnosed with cancer during pregnancy from 14 cancer centres in the UK across a five-year period (2016-2020).

RESULTS

Median age at diagnosis was 33 years, with breast, skin and haematological the most common primary sites. The majority of cases were new diagnoses (109 patients, 91.6%). Most patients were treated with radical intent (96 patients, 80.7%), however, gastrointestinal cancers were associated with a high rate of palliative intent treatment (63.6%). Intervention was commenced during pregnancy in 68 (57.1%) patients; 44 (37%) had surgery and 31 (26.1%) received chemotherapy. Live births occurred in 98 (81.7%) of the cases, with 54 (55.1%) of these delivered by caesarean section. Maternal mortality during the study period was 20.2%.

CONCLUSIONS

This is the first pan-tumour report of diagnosis, management and outcomes of cancer diagnosed during pregnancy in the UK. Our findings demonstrate proof of concept that data collection is feasible and highlight the need for further research in this cohort of patients.

Evaluation of Radiotherapy Dose and Survival Outcomes for Teenagers, and Young Adults with Nasopharyngeal Carcinoma in UK and Ireland

PURPOSE/OBJECTIVE(S)

Nasopharyngeal carcinoma (NPC) follows a bimodal distribution with a smaller incidence peak in teenagers and young adults (TYAs). In TYAs, an over-whelming proportion are associated with Epstein-Barr virus (EBV). We have evaluated the variation in TYA NPC practice patterns across the UK and Ireland, along with survival outcomes.

MATERIALS/METHODS

We performed a multicenter, observational cohort study, of patients aged 13-25 years, with histologically confirmed NPC, treated between the years 2002-2022. An initial expression of interest was sent to selected centers treating H&N patients in the UK and Ireland. For analysis, patients were assessed based on total prescribed dose, with a cut off for low dose (LD) (≤61.2Gy) versus a high dose (HD)(>61.2Gy).

RESULTS

Ninety-five patients, from 9 centers, were eligible for inclusion. Patient demographics are shown in table1. At a median follow up of 45 months (IQR 23-111), 3-year overall survival (OS) was 98% (95% CI 93%-100%) with LD versus 91% (95% CI 83%-99%) with HD (Hazard ratio (HR) = 3.0; 95% CI 0.3-27, p = 0.3). 3-year progression free survival (PFS) was 84% (95% CI 71%-97%) with LD versus 83% (95% CI 72%-94%) with HD (HR 1.3; 95% CI 0.4-4.0, p = 0.6), and 5-year PFS was 84% (95% CI 71%-97%) with LD versus 83% (95% CI 72%-94%) with HD (HR 1.3; 95% CI 0.4-4.0, p = 0.6). Incidence of distant metastasis (DM) was 9.9%. 2 patients (6%) with T3-T4 tumors, treated with LD, had locoregional failure (LRF) compared to 1 patient (3%) treated with HD.

CONCLUSION

We have demonstrated excellent survival outcomes for the UK & Ireland TYA NPC patients. As the majority of cases in this age group have EBV+ NPC, with survival similar between LD and HD protocols, we propose that pediatric protocols, with lower radiotherapy doses should be considered for all TYA NPC, with the aim of reducing late effects. Additional analysis to better understand the impact of heterogeneity between both groups, including choice of protocol, induction and adjuvant treatment will follow this study. Prospective evaluation, as part of an international collaboration, is required to optimize the management strategy for this rare cohort of patients.

A Multicenter Study of Clinician and Patient Reported Acute and Late Toxicity after Radical (Chemo)Radiotherapy for Non-Endemic Nasopharyngeal Cancer

PURPOSE/OBJECTIVE(S)

Curative (chemo)radiotherapy ((CT)RT) for Nasopharyngeal cancers (NPC) achieves excellent disease control but is associated with significant late toxicities despite modern treatment delivery. Contemporary late toxicity data, including patient reported outcomes (PROs), is limited in the non-endemic population; we present a large contemporary series of toxicity outcomes and late PROs following treatment of non-endemic NPC.

MATERIALS/METHODS

Adult patients completing radical (CT)RT for primary NPC between February 2016 and 2020 at 7 large UK cancer centers were identified on institutional databases. Patients were excluded if they had prior head and neck cancer or prior therapeutic head and neck surgery (except neck dissection). Patients with an active other cancer were excluded from PRO assessment. Demographic, treatment, acute toxicity and outcome data were collected retrospectively from patient records. Disease-free patients were invited to complete an M.D. Anderson Dysphagia Index (MDADI) and University of Washington (UoW) Quality of Life (QoL) PROs questionnaires.

RESULTS

A total of 180 eligible patients were identified: 68% male, median age 54 years, 11% ≥70 years. EBV status was positive in 61% (unknown 12%). Patients had stage I (5%), II (22%), III (37%), IV (36%) disease; 95% were performance status ≤1 at baseline. Median follow-up was 31.2 months (range 0-68). A total of 54% received 70Gy in 33-35# and 43% received 65-66 Gy in 30-33#. 66% received induction and 65% received concurrent chemotherapy. 9.5% had residual disease at the first follow-up scan. Subsequent locoregional or distant recurrence occurred in 5% and 12% respectively. At last assessment, 84% patients were alive, 16% had died (of which 70% had active disease). Acute treatment toxicity included: 63% of patients required enteral support (median duration 98 days) with 9% a feeding tube at 1 year post treatment. 18% G3 dermatitis, 53% G3 mucositis. 82% requiring opioids and 40% admitted for symptom management. 90 patients completed the PROs (76% response rate) at a median of 37.8 months post treatment (Table 1). These demonstrate significant QoL detriment: 28% report significant pain, 24% require regular analgesia, and 59% report significant impact on daily activity. This was found to persist at different timepoints (not shown).

CONCLUSION

Excellent cancer survival outcomes are seen in a non-selected, non-endemic NPC population. However significant acute and late toxicity following radical treatment is identified which can profoundly negatively impact QoL in a relatively young cohort. This highlights the importance of ongoing efforts to reduce toxicity and supports the prospective evaluation of potential toxicity sparing technologies, such as proton beam radiotherapy.

Biomarkers of systemic inflammation predict survival with first-line immune checkpoint inhibitors in non-small-cell lung cancer

INTRODUCTION

Pembrolizumab is an established first-line option for patients with advanced non-small-cell lung cancer (NSCLC) expressing programmed death-ligand 1 ≥50%. Durable responses are seen in a subset of patients; however, many derive little clinical benefit. Biomarkers of the systemic inflammatory response predict survival in NSCLC. We evaluated their prognostic significance in patients receiving first-line pembrolizumab for advanced NSCLC.

METHODS

Patients treated with first-line pembrolizumab for advanced NSCLC with programmed death-ligand 1 expression ≥50% at two regional Scottish cancer centres were identified. Pretreatment inflammatory biomarkers (white cell count, neutrophil count, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, albumin, prognostic nutritional index) were recorded. The relationship between these and progression-free survival (PFS) and overall survival (OS) were examined.

RESULTS

Data were available for 219 patients. On multivariate analysis, albumin and neutrophil count were independently associated with PFS (P < 0.001, P = 0.002, respectively) and OS (both P < 0.001). A simple score combining these biomarkers was explored. The Scottish Inflammatory Prognostic Score (SIPS) assigned 1 point each for albumin <35 g/l and neutrophil count >7.5 × 10⁹/l to give a three-tier categorical score. SIPS predicted PFS [hazard ratio 2.06, 95% confidence interval (CI) 1.68-2.52 (P < 0.001)] and OS [hazard ratio 2.33, 95% CI 1.86-2.92 (P < 0.001)]. It stratified PFS from 2.5 (SIPS2), to 8.7 (SIPS1) to 17.9 months (SIPS0) (P < 0.001) and OS from 5.1 (SIPS2), to 12.4 (SIPS1) to 28.7 months (SIPS0) (P < 0.001). The relative risk of death before 6 months was 2.96 (95% CI 1.98-4.42) in patients with SIPS2 compared with those with SIPS0-1 (P < 0.001).

CONCLUSIONS

SIPS, a simple score combining albumin and neutrophil count, predicts survival in patients with NSCLC receiving first-line pembrolizumab. Unlike many proposed prognostic scores, SIPS uses only routinely collected pretreatment test results and provides a categorical score. It stratifies survival across clinically meaningful time periods that may assist clinicians and patients with treatment decisions. We advocate validation of the prognostic utility of SIPS in this and other immune checkpoint inhibitor treatment settings.

A brief intervention to reduce burnout and improve sleep quality in medical students

BACKGROUND

Perceived stress, burnout, and poor sleep quality are high among medical students. Interventions designed to target these issues are necessary to promote the health and well-being of medical students. The purpose of this study was twofold: 1) to assess the feasibility of implementing a sunrise alarm clock intervention with medical students and 2) to evaluate the impact of the intervention on perceived stress, burnout scores, and sleep quality.

METHODS

We conducted a feasibility study to evaluate the efficacy of a two-week, sunrise alarm clock intervention in combination with electronic device removal at bedtime. We assessed first- and second-year medical students' perceived stress, burnout scores, including Emotional Exhaustion, Depersonalization, and Low Sense of Personal Achievement, and sleep quality before and after the intervention. In addition, we measured smartphone addiction prior to the intervention.

RESULTS

A total of 57 students consented to participate, of which 55 completed both the pre- and post-assessments (3.5% attrition). The mean age of the participants was 24.8 ± 1.9 years, 50.9% (n = 29) identified as women, and 68.4% (n = 39) identified as white. Pre-intervention, 42.1% (n = 24) of students met criteria for smartphone addiction and 77.2% (n = 44) met criteria for poor sleep quality. In addition, 22.8% (n = 13) of participants had high emotional exhaustion, 64.9% (n = 31) high depersonalization, and 42.1% (n = 24) low sense of personal accomplishment prior to the intervention. Following the two-week intervention, participants showed improvements in emotional exhaustion (p = 0.001, Cohen's d = 0.353), depersonalization (p = 0.001, Cohen's d = 0.411) low sense of personal accomplishment (p = 0.023, Cohen's d = 0.275), perceived stress (p < .001, Cohen's d = .334), and sleep quality (p < 0.001, Cohen's d = 0.925). The number of participants who reported poor sleep quality decreased to 41.8% (n = 23), demonstrating a significant decline (p = 0.026). Participants also improved subjective sleep quality (p < 0.001, Cohen's d = 1.033), sleep duration (p = 0.001, Cohen's d = 0.431), sleep latency (p < 0.001, Cohen's d = 0.433), and sleep efficiency (p = 0.021, Cohen's d = 0.673).

CONCLUSIONS

These findings suggest that the two-week sunrise alarm clock protocol with electronic device removal was effective in improving sleep quality and reducing burnout scores, and perceived stress. However, additional research comparing this intervention to a proper control group is needed to draw meaningful conclusions about the effectiveness of this intervention.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Medical Students' Knowledge, Attitudes, and Behaviors With Regard to Skin Cancer and Sun-Protective Behaviors

Background

Skin cancer is the most prevalent cancer in the United States. Training medical students about the importance of sun-protective behaviors is critical to reducing skin cancer rates. However, minimal research has explored osteopathic medical students' knowledge and behaviors with regard to the sun's effect on skin health.

Objective

To assess first-year osteopathic medical students' knowledge about skin cancer and UV radiation, attitudes toward tanning, and sun-protective behaviors to establish baseline values.

Methods

Using a descriptive, cross-sectional study design, the authors evaluated students' knowledge, attitudes, and behaviors through a quiz.

Results

A total of 121 first-year osteopathic medical students completed the quiz. The mean (SD) score was 74.6% (11.5%). Two-thirds of participants (n=82) correctly identified basal cell carcinoma as the most common skin cancer, and the majority identified the ABCDs (asymmetry, border irregularity, color, and diameter) of melanoma detection (96 [79.3%], 106 [87.6%], 108 [89.3%], and 94 [77.7%], respectively). Most participants were aware that cloud cover and swimming underwater do not provide UV ray protection (121 [100%] and 109 [90.1%], respectively), a fact that is often misconceived. Forty participants (33.1%) usually or always used some form of sun protection when outdoors. Forty-seven participants (38.8%) believed that a tan makes one look healthy, and 43 participants (35.6%) sunbathed with the intention of tanning.

Conclusion

Physicians are uniquely positioned to counsel patients regarding sun-protective behaviors. Thus, a medical school curriculum that includes education about the sun's effect on health is needed for the prevention and early recognition of skin cancer in future patients.

Technical note: Genetic principal component models for multitrait single-step genomic evaluation

A reparameterization of the multivariate linear mixed model in genetic evaluation to principal components is described. This yields an equivalent model with a sparser coefficient matrix in the mixed model equations and, thus, reduced computational requirements to solve them. It is especially advantageous for analyses incorporating genomic relationship information with many nonzero elements in the inverse of the relationship matrix. Moreover, the framework lends itself directly to dimension reduction and, thus, further computational savings by omitting genetic principal components with negligible eigenvalues. The potential impact on computational demands is illustrated for an application to single-step genomic evaluation of Australian sheep.

Glucocorticoid corticosteroids for Duchenne muscular dystrophy

BACKGROUND

Duchenne muscular dystrophy (DMD) is the most common muscular dystrophy of childhood. This incurable disease is characterised by muscle wasting and loss of walking ability leading to complete wheelchair dependence by 13 years of age. Prolongation of walking is one of the major aims of treatment.

OBJECTIVES

The aim of this review was to assess whether glucocorticoid corticosteroids stabilize or improve muscle strength and walking in boys with DMD.

SEARCH STRATEGY

This is an update of the Cochrane systematic review first published in 2004 (Manzur 2004). We searched the Cochrane Neuromuscular Disease Group Trials Register (August 2006) using the term 'Duchenne muscular dystrophy'. We also searched MEDLINE (January 1966 to July 2007), EMBASE (January 1980 to August 2006), CINAHL and LILACS (January 1982 to August 2006). We wrote to authors of published studies and other experts in this disease to help identify other trials, checked the references in the identified trials and hand searched the abstracts of relevant journals.

SELECTION CRITERIA

Types of studies: randomised or quasi-randomised trials.

TYPES OF PARTICIPANTS

all patients with a definite diagnosis of Duchenne muscular dystrophy. Types of interventions: glucocorticoids such as prednisone, prednisolone, deflazacort or others, with a minimum treatment period of three months.

PRIMARY OUTCOME MEASURE

prolongation of walking (independent walking without long leg calipers).

SECONDARY OUTCOME MEASURES

strength outcome measures, manual muscle strength testing using Medical Research Council strength scores, functional outcome measures and adverse events.

DATA COLLECTION AND ANALYSIS

We identified six randomised controlled trials that met the inclusion criteria for our review, and one of these (Beenakker 2005) is a new addition to this update, as it was published subsequent to our first review (Manzur 2004). Two review authors independently selected the trials for the review and assessed methodological quality. Data extraction and inputting were double-checked.

PRIMARY OUTCOME MEASURE

data from one small study used prolongation of walking as an outcome measure and did not show significant benefit.

SECONDARY OUTCOME MEASURES

The meta-analysis of the results from four randomised controlled trials with altogether 249 participants showed that glucocorticoid corticosteroids improved muscle strength and function over six months. Improvements were seen in time taken to rise from the floor (Gowers' time), nine metres walking time, four-stair climbing time, ability to lift weights, leg function grade and forced vital capacity. One randomised controlled trial with altogether 28 participants showed that glucocorticoid corticosteroids stabilize muscle strength and function for up to two years. The most effective prednisolone regime appears to be 0.75 mg/kg/day, given in a daily dose regime. Not enough data were available to compare efficacy of prednisone with deflazacort. Adverse effects: Excessive weight gain, behavioural abnormalities, cushingoid appearance and excessive hair growth were all more common with glucocorticoid corticosteroids than placebo. Long-term adverse effects of glucocorticoid therapy could not be evaluated because of the short-term duration of the randomised studies.Non-randomised studies: A number of non-randomised studies with important efficacy and adverse effects data are tabulated and discussed.

AUTHORS' CONCLUSIONS

There is evidence from randomised controlled studies that glucocorticoid corticosteroid therapy in Duchenne muscular dystrophy improves muscle strength and function in the short-term (six months to two years). The most effective prednisolone regime appears to be 0.75 mg/kg/day, given daily. In the short term, adverse effects were significantly more common but not clinically severe. Long-term benefits and hazards of glucocorticoid treatment cannot be evaluated from the currently published randomised studies. Non-randomised studies support the conclusions of functional benefits but also identify clinically significant adverse effects of long-term treatment. These benefits and adverse effects have implications for future research studies and clinical practice.

Glucocorticoid corticosteroids for Duchenne muscular dystrophy

BACKGROUND

Duchenne muscular dystrophy is the most common muscular dystrophy of childhood. This incurable disease is characterised by muscle wasting and loss of walking ability leading to complete wheelchair dependence by 13 years of age. Prolongation of walking is one of the major aims of treatment.

OBJECTIVES

The aim of this review was to assess whether glucocorticoid corticosteroids stabilize or improve muscle strength and walking in boys with DMD.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group specialised register (October 2003) using the term 'Duchenne muscular dystrophy'. We also searched MEDLINE (January 1966 to October 2003), EMBASE (January 1980 to October 2003), CINAHL and LILACS (January 1982 to October 2003). We wrote to authors of published studies and other experts in this disease to help identify other trials, checked the references in the identified trials and handsearched the abstracts of relevant journals.

SELECTION CRITERIA

Types of studies: randomised or quasi-randomised trials.

TYPES OF PARTICIPANTS

all patients with a definite diagnosis of Duchenne muscular dystrophy. Types of interventions: glucocorticoids such as prednisone, prednisolone, deflazacort or others, with a minimum treatment period of three months.

PRIMARY OUTCOME MEASURE

prolongation of walking (independent walking without long leg calipers).

SECONDARY OUTCOME MEASURES

strength outcome measures, manual muscle strength testing using Medical Research Council strength scores, functional outcome measures and adverse events.

DATA COLLECTION AND ANALYSIS

We identified five randomised controlled trials that met the inclusion criteria for our review. Two reviewers independently selected the trials for the review and assessed methodological quality. Data extraction and inputting were double-checked.

PRIMARY OUTCOME MEASURE

data from one small study used prolongation of walking as an outcome measure and did not show significant benefit.

SECONDARY OUTCOME MEASURES

The meta-analysis of the results from three randomised controlled trials showed that glucocorticoid corticosteroids improved muscle strength and function over six months. Improvements were seen in time taken to rise from the floor (Gowers' time), nine metres walking time, four-stair climbing time, ability to lift weights, leg function grade and forced vital capacity. One randomised controlled trial showed that glucocorticoid corticosteroids stabilize muscle strength and function for up to two years. The most effective prednisolone regime appears to be 0.75 mg/kg/day. Not enough data were available to compare efficacy of prednisone with deflazacort.Adverse effects: Excessive weight gain, behavioural abnormalities, cushingoid appearance and excessive hair growth were all more common with glucocorticoid corticosteroids than placebo. Long-term adverse effects of glucocorticoid therapy could not be evaluated because of the short-term duration of the randomised studies.Non-randomised studies: a number of non-randomised studies with important efficacy and adverse effects data are tabulated and discussed.

REVIEWERS' CONCLUSIONS

There is evidence from randomised controlled studies that glucocorticoid corticosteroid therapy in Duchenne muscular dystrophy improves muscle strength and function in the short-term (six months to two years). The most effective prednisolone regime appears to be 0.75 mg/kg/day. In the short term, adverse effects were significantly more common but not clinically severe. Long-term benefits and hazards of glucocorticoid treatment cannot be evaluated from the currently published randomised studies. Non-randomised studies support the conclusions of functional benefits but also indicate clinically significant adverse effects of long-term treatment. These benefits and adverse effects have implications for future research studies and clinical practice.

The value of synovial fluid assays in the diagnosis of joint disease: a literature survey

OBJECTIVE

To carry out a critical appraisal of the literature in an attempt to assess the current value of synovial fluid (SF) analysis in the diagnosis of joint disease.

METHODS

A literature search was undertaken using the Medline, Biomed, Bids, Pubmed, and Embase electronic databases using the keywords: synovial fluid (SF) analysis, SF crystals, joint sepsis, acute arthritis, and SF cell counts, cytology, biomarkers, and microbiology.

RESULTS

Publications fell into three main categories. Firstly, reports assessing the value of the three traditional assays (microbiology, white blood cell counts, and microscopy for pathogenic crystals). For these quality control evidence was found to be sparse, and tests for sensitivity, specificity, and reliability showed worrying variations. These poor standards in SF analysis may be due to lack of inclusion of some tests within routine pathology services. Secondly, claims for the usefulness of "new" assays (cytology and biochemical markers). For cytology, the supporting evidence was mainly anecdotal and there were no reports on specificity, sensitivity, and reliability. Interpretation difficulties are a major hindrance to the clinical use of biochemical assays, which remain primarily research tools. Finally, work on the diagnostic value of SF analysis in general. The appraisal confirmed that SF analysis remains of major diagnostic value in acute arthritis, where septic arthritis or crystal arthropathy is suspected, and in intercritical gout.

CONCLUSIONS

Given the importance of SF tests, rationalisation of their use, together with improved quality control, should be immediate priorities. Further investigation is recommended into the contribution of SF inspection and white cell counts to diagnosis, as well as of the specificity and sensitivity of SF microbiological assays, crystal identification, and cytology.

The molecular epidemiology of tuberculosis in inner London

The study used DNA fingerprint typing (spoligotyping and Heminested-lnverse-PCR) of Mycobacterium tuberculosis from all culture-confirmed inner London patients over a 12-month period to describe transmission. The methodology was evaluated by comparison with standard IS6110 typing and by examining its ability to identify known household clusters of cases. Isolates sharing indistinguishable typing patterns using both techniques were defined as clustered. Clusters were investigated to identify epidemiological links. The methodology showed good discriminatory power and identified known household clusters of cases. Of 694 culture-confirmed cases, 563 (81%) were typed. Eleven (2%) were due to laboratory cross-contamination and were excluded. Of the remaining 552 isolates 148 (27%) were clustered. Multivariate analysis indicated that clustering was more common in those with pulmonary smear positive disease (P < 0.02); those born in the United Kingdom (P < 0.0003) and in patients living in south London (P = 0.02). There was also a trend towards clustering being more common in those not known to have HIV infection (P = 0.051). The results suggest that in inner London, recent local transmission makes an important contribution to notification rates.

Bladder rupture after blunt trauma: guidelines for diagnostic imaging

PURPOSE

The purpose of this study was to establish guidelines for diagnostic imaging for bladder rupture in the blunt trauma victim with multiple injuries, in whom the delay caused by unnecessary testing can hamper the trauma surgeon and threaten outcome.

METHODS

We undertook chart review (1995-1999) of patients with blunt trauma and bladder rupture at our four institutions and performed focused literature review of retrospective series.

RESULTS

Of our 53 patients identified, all had gross hematuria and 85% had pelvic fracture. Literature review revealed similar rates.

CONCLUSION

The classic combination of pelvic fracture and gross hematuria constitutes an absolute indication for immediate cystography in blunt trauma victims. Existing data do not support lower urinary tract imaging in all patients with either pelvic fracture or hematuria alone. Clinical indicators of bladder rupture may be used to identify atypical patients at higher risk. Patients with isolated hematuria and no physical signs of lower urinary tract injury may be spared the morbidity, time, and expense of immediate cystographic evaluation.

The utilization of synovial fluid analysis in the UK

OBJECTIVE

To ascertain what use is being made of synovial fluid analysis in the UK, who is carrying out polarized light microscopy (PLM), and what confidence clinicians have in the results. Subjects and methods. A postal survey was developed, piloted, adjusted and then posted to 535 people, 90% of whom were senior rheumatologists and 10% orthopaedic surgeons, whose names had been obtained from professional lists.

RESULTS

Three hundred and eleven replies (59%) were obtained after 1 month. Analysis of the replies showed that only microbiological tests and PLM are used regularly, that these are used mainly for the diagnosis of acute arthritis, and that the majority of respondents would like data from these assays to be available within 24 h. The majority of the respondents (95%) had access to PLM and 80% said that clinicians should be able to use it. However, PLM is currently being undertaken by a variety of people: non-specialist technicians (34% of respondents), specialist technicians (35%) and clinicians (31%). Respondents were confident in microbiological assays but not in cell counts or PLM, unless they were undertaking it themselves.

CONCLUSIONS

There is an urgent need for guidelines, standardization and education about the use of synovial fluid assays in the UK.

Randomized controlled trial of intravenous immunoglobulin versus oral prednisolone in chronic inflammatory demyelinating polyradiculoneuropathy

This multicenter, randomized, double-blind, crossover trial compared a six week course of oral prednisolone tapering from 60 mg to 10 mg daily with intravenous immunoglobulin (IVIg) 2.0 g/kg given over one to two days for treating chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Twenty-four of the thirty-two randomized patients completed both treatment periods. Both treatments produced significant improvements in the primary outcome measure, change in an 11-point disability scale two weeks after randomization. There was slightly, but not significantly, more improvement after IVIg than with prednisolone, the mean difference between the groups in change in disability grade being 0.16 (95% CI = -0.35 to 0.66). There were also slightly, but not significantly, greater improvements favoring IVIg in the secondary outcome measures: time to walk 10 meters after two weeks and improvement in disability grade after six weeks. Results may have been biased against IVIg by the eight patients who did not complete the second arm of the trial. A serious adverse event (psychosis) attributable to treatment occurred in one patient while on prednisolone and in none with IVIg.

Making vaccines more acceptable--methods to prevent and minimize pain and other common adverse events associated with vaccines

The growing abundance of highly immunogenic vaccines has arrived with a burden of pain, distress, and common adverse reactions that in turn may interfere with parental compliance and aggravate anti-vaccine sentiment. In a study of 150 children in each of 2 age-groups, we found that approximately 20% of the subjects suffered serious distress or worse. During the procedural phase, approximately 90% of the 15-to-18 month old children and 45% of the 4-to-6 year old children showed serious distress or worse. To address non-adherence with pediatric vaccine schedules, we must consider all of the possible issues that might prevent a parent from taking a child to a health care provider for vaccination. In that same study we identified useful predictors for both preparatory and procedural distress - predictors that might be used in identifying children who might benefit from preventive interventions. Vaccine providers might consider a variety of interventions. Attitude, empathy, instruction, and practice have all been shown to have a salutatory effect upon pain and anxiety with medical procedures in general and specifically with vaccinations. Distraction has also been found to be an effective method for distress and pain prevention in children. More formal methods of clinical hypnosis which combine a deep state of relaxation with focused imagery and suggestion have also been found to be effective in helping children and adolescents prepare for, cope with, and tolerate the pain and anxiety associated with medical procedures. So-called 'sugar nipples' delivering small amounts of sucrose orally at the time of a painful procedure in an infant has been not been shown to decrease vaccination pain and studies on refrigerant topical anesthetics are mixed. Studies have found a eutectic mixture of 2.5% lidocaine and 2.5% prilocaine (EMLA) effective in providing adequate local anesthesia in children, but it suffers from problems in practical application. Studies with various injection techniques have not identified ready solutions, and although jet injection appears to provoke less anxiety and cause less immediate pain, studies also indicate a somewhat greater incidence of delayed local reactogenicity including soreness and edema. Other measures to prevent or rapidly treat other common adverse events have been shown effective and should be considered as well.

Identification of new X-chromosomal genes required for Drosophila oogenesis and novel roles for fs(1)Yb, brainiac and dunce

We performed a screen for female sterile mutations on the X chromosome of Drosophila melanogaster and identified new loci required for developmental events in oogenesis as well as new alleles of previously described genes. We present mapping and phenotypic characterization data for many of these genes and discuss their significance in understanding fundamental developmental and cell biological processes. Our screen has identified genes that are involved in cell cycle control, intracellular transport, cell migration, maintenance of cell membranes, epithelial monolayer integrity and cell survival or apoptosis. We also describe new roles for the genes dunce (dnc), brainiac (brn) and fs(1)Yb, and we identify new alleles of Sex lethal (Sxl), ovarian tumor (otu), sans filles (snf), fs(1)K10, singed (sn), and defective chorion-1 (dec-1).

A survey of the microbiological quality of private water supplies in England

Results from statutory testing of private water supplies in nine Public Health Laboratories in England were compiled, and the effects of supply class, source, treatment and location on water quality were examined. A total of 6551 samples from 2911 supplies was examined, over a 2-year period, of which 1342 (21%) samples, and 949 (33%) supplies on at least one occasion, failed current regulations for Escherichia coli. Total coliforms, including E. coli, were detected in 1751 (27%) samples from 1215 (42%) supplies. The percentage of samples positive for E. coli was highest in summer and autumn, and lowest in winter. Samples taken from larger supplies and from boreholes were less frequently contaminated than those from other sources. Chlorination, filtration or UV light treatment improved the bacteriological quality of supplies, but still resulted in a low level of compliance with the regulations. The public health implications of the study are discussed.

Drosophila Lissencephaly-1 functions with Bic-D and dynein in oocyte determination and nuclear positioning

Here we show that the Drosophila homologue of Lissencephaly-1, DLis-1, acts together with Bicaudal-D (Bic-D), Egalitarian (Egl), dynein and microtubules to determine oocyte identity. DLis-1 is further required for nurse-cell-to-oocyte transport during oocyte growth, and for the positioning of the nucleus in the oocyte. Immunostaining of DLis-1 protein reveals a cortical localization that is independent of microtubules. DLis-1 may function in this position as a cortical anchor for the other nuclear-localization factors. DLis-1 and Bic-D are further required for nuclear localization in the developing nervous system, indicating that homologues of Bic-D, dynein and Egl-like proteins may also be involved in vertebrate neural migration and that their absence may cause a Miller-Dieker-like lissencephaly.

Olanzapine in dementia with Lewy bodies: a clinical study

OBJECTIVES

Dementia with Lewy bodies (DLB) is now a well-recognized form of dementia in which psychosis and behavioural disturbance are common. Treatment with conventional neuroleptics is often very poorly tolerated. Olanzapine, a newly introduced atypical neuroleptic which binds to multiple receptor types with relatively low affinity for D2 receptors, may be a useful treatment option in DLB.

MAIN OUTCOME MEASURES

The Behavioural Pathology in Alzheimer's Disease Rating Scale, The Neuropsychiatric Inventory, Unified Parkinson's Disease Rating Scale and The Webster Disability Scale.

DESIGN

We present the results of eight DLB patients with associated psychotic and behavioural difficulties. All patients were given olanzapine 2.5-7.5 mg. Their psychotic phenomena and behavioural and extrapyramidal symptoms were monitored at 2-weekly intervals.

RESULTS

Three out of the eight patients could not tolerate olanzapine even at the lowest available dose. Two patients had clear improvement in psychotic and behavioural symptoms. Three patients were able to tolerate olanzapine but gained only minimal benefit.

CONCLUSIONS

Olanzapine at the doses used conferred little advantage over conventional neuroleptics and should only be given with great caution to patients with DLB. The utility of smaller doses deserves further evaluation.

Renin-aldosterone system can respond to furosemide in patients with hyperkalemic hyporeninism

Thirty-four patients (65.3+/-3.3 years of age, mean+/-SEM) with hyperkalemia (serum potassium >5.0 mEq/L) had measurement of their renin-aldosterone system. Nineteen patients (56%) had plasma renin activity (PRA) >1.5 ng/mL/h, which was not low, while 15 (44%) had PRA <1.5. Twelve of the 15 hyporeninemic hyperkalemic patients were studied to determine whether their renin-aldosterone system responded to 2 weeks of furosemide, 20 mg daily. Four were nonresponders: PRA averaged 0.3+/-0.1 ng/mL/h, and it did not increase with furosemide or respond to captopril before or after furosemide. Eight patients were responders: PRA averaged 0.6+/-0.2 ng/mL/h and increased with furosemide to 5.5+/-3.4 ng/mL/h. Captopril failed to increase PRA before furosemide, but PRA increased to 15.3+/-8.4 ng/mL/h after furosemide. Plasma aldosterone was low in both nonresponders and responders (3.5+/-1.2 ng/dL vs 5.8+/-2.5 ng/dL) and did not increase significantly with furosemide (4.3+/-1.7 ng/dL vs 8.7+/-2.5 ng/dL). Serum potassium did not fall and therefore did not limit the rise in aldosterone. Renin responders had greater body weight, were predominantly female (6/8 vs 2/4) and were more likely to have diabetes mellitus (7/8 vs 0/4). Plasma atrial natriuretic peptide (ANP) fell with furosemide in 8 of 8 responders and in 1 of the 2 nonresponders in whom it was measured. Neither group had suppressed plasma prorenin levels, indicating no suppression of renin gene expression. These results indicate that many hyperkalemic patients do not have suppressed PRA. Further, a majority of patients with suppressed PRA have high levels of ANP and can respond to diuretic therapy with a rise in PRA and a fall in ANP, suggesting physiologic suppression of the renin system by volume expansion. A minority of hyperkalemic patients with suppressed PRA had PRA that did not increase under these study conditions.

vasa is required for GURKEN accumulation in the oocyte, and is involved in oocyte differentiation and germline cyst development

The Drosophila gene vasa is required for pole plasm assembly and function, and also for completion of oogenesis. To investigate the role of vasa in oocyte development, we generated a new null mutation of vasa, which deletes the entire coding region. Analysis of vasa-null ovaries revealed that the gene is involved in the growth of germline cysts. In vasa-null ovaries, germaria are atrophied, and contain far fewer developing cysts than do wild-type germaria; a phenotype similar to, but less severe than, that of a null nanos allele. The null mutant also revealed roles for vasa in oocyte differentiation, anterior-posterior egg chamber patterning, and dorsal-ventral follicle patterning, in addition to its better-characterized functions in posterior embryonic patterning and pole cell specification. The anterior-posterior and dorsal-ventral patterning phenotypes resemble those observed in gurken mutants. vasa-null oocytes fail to efficiently accumulate many localized RNAs, such as Bicaudal-D, orb, oskar, and nanos, but still accumulate gurken RNA. However, GRK accumulation in the oocyte is severely reduced in the absence of vasa function, suggesting a function for VASA in activating gurken translation in wild-type ovaries.

Role of Bicaudal-D in patterning the Drosophila egg chamber in mid-oogenesis

The Bicaudal-D (Bic-D) gene is required early in Drosophila oogenesis for the differentiation of an oocyte from one of a cluster of 16 interconnected germarial cells. To analyze the role of Bic-D later in oogenesis, we have constructed Drosophila lines in which Bic-D expression is under the control of the hsp70 promoter. In these flies, Bic-D activity can be induced early in oogenesis, allowing an oocyte to be made. Then, by shifting females to non-inducing conditions, Bic-D levels are depleted for the remainder of oogenesis. Using this system, we find that Bic-D is indeed required in the later stages of oogenesis. In ovaries from mutant females, oocyte growth is reduced, apparently due to defects in nurse-cell-to-oocyte transport. Smaller oocyte size results in the misalignment of follicle cells and the underlying germ line, leading to ventralization of dorsal follicle cells and to defects in centripetal cell migration. In addition, we show that Bic-D is required for the localization of specific mRNAs at both the anterior and posterior of the oocyte.

Evidence for a causal relationship between the structure, size, and load of calcium pyrophosphate dihydrate crystals, and attacks of pseudogout

OBJECTIVE

To investigate any relationship between the nature, size, and numbers of synovial fluid (SF) calcium pyrophosphate dihydrate (CPPD) crystals, and attacks of pseudogout.

METHODS

Knee SF was aspirated from nine selected patients, first during an attack of pseudogout (acute sample) and again later when the attack had subsided (interval sample). CPPD crystals were extracted, weighed, examined by high resolution transmission electron microscopy (HRTEM), and characterised by size and crystal habit (monoclinic or triclinic). Structural analysis was carried out by x ray powder diffraction (XRD) and the proportions of monoclinic to triclinic CPPD were estimated from densitometric measurements of selected key reflections.

RESULTS

The mean crystal size, by HRTEM, indicated that the crystals in the acute sample were larger than those in the interval sample. The ratio of monoclinic to triclinic CPPD, whether estimated from their morphological appearance by HRTEM, or from XRD, was greater in the acute than in the interval sample in all nine patients. The total amount of extracted mineral varied, but in every patient the concentration of CPPD per ml of fluid, and the total mineral per joint, were greater in the acute sample than in the interval sample.

CONCLUSION

In this highly selected group of patients, the large numbers of CPPD crystals associated with attacks of pseudogout included a greater proportion of monoclinic crystals, and larger crystals, than those present when inflammation had subsided. A special, phlogistic population of crystals may exist, originating in different joint tissues, or cleared in a different manner, than the more common populations of smaller crystals with a greater proportion of triclinic CPPD, seen in chronic disease.

Changes in cartilage metabolism in arthritis are reflected by altered serum and synovial fluid levels of the cartilage proteoglycan aggrecan. Implications for pathogenesis

The metabolism of the cartilage proteoglycan aggrecan was studied in patients with osteoarthritis (OA, n = 83), rheumatoid arthritis (RA, n = 127), and in controls (n = 117) using monoclonal antibody-based radioimmunoassays for glycosaminoglycans in the serum and synovial fluid (SF) to detect epitope 846 on chondroitin sulfate (probably only on recently synthesized molecules) and a keratan sulfate (KS) epitope AN9PI, present on intact and degraded molecules. Epitope 846 levels were always elevated in SF over serum (mean 38-fold in OA and 8.6-fold in RA) being highest in OA patients with the longest disease duration and greatest loss of cartilage, and lowest in RA joints with high leucocyte counts. Serum levels were more often elevated in RA (56%) than in OA (19%) and probably reflect increased aggrecan synthesis in diseased joints. KS levels were higher in SF than in serum in 69% of patients (up to 2.3-fold); levels were inversely (OA) and directly (RA) related to SF leucocyte counts. Serum KS was reduced in both diseases and in RA was inversely related to both systemic and joint inflammation markers. SF 846 levels were inversely related to SF KS in both diseases. These epitopes may provide a measure of the balance between cartilage synthesis and degradation in these diseases.

Submicroscopic crystals in osteoarthritic synovial fluids

OBJECTIVES

To investigate the hypothesis that synovial fluid (SF) from patients with osteoarthritis (OA) may contain calcium phosphate crystals that are either too small, or too few in number to be identified by conventional light microscopy techniques.

METHODS

Twelve SF from 11 patients with established knee OA, five SF from patients with rheumatoid arthritis (RA), and two control samples of SF from patients with pseudogout were subjected to an enzyme/hypochlorite extraction procedure. The patients with OA and RA had no radiographic evidence of chondrocalcinosis, or SF crystals on polarised light microscopy. Extracted material was examined and analysed by analytical electron microscopy (AEM) and x ray powder diffraction (XRD).

RESULTS

Mineral was found in 11 of 12 OA samples, ranging from 2-120 micrograms/ml SF. Analytical electron microscopy revealed calcium pyrophosphate dihydrate (CPPD) crystals in five (confirmed by XRD in three) and basic calcium phosphates (BCP) in eight (five on XRD). Two samples with confirmed CPPD contained some rods with a mean length below 100 nm. The majority of BCP clusters were also less than 100 nm in diameter. BCP was detected in 1/5 RA samples. Control samples contained CPPD crystals of the expected size range of 0.42-17.9 microns.

CONCLUSIONS

The data indicate that many OA SF may contain CPPD or BCP crystals which are too small or too few in number to be identified by conventional techniques. Crystal deposition is not an 'on-off' phenomenon in OA.

Purchasing services for end stage renal failure: the potential and limitations of existing information sources

Renal replacement therapy services already consume considerable health service resources and, as patient stock levels rise and unmet need continues to be identified, the pressure to spend more on renal services will increase. Purchasers of services must decide how to respond to these pressures, and a clear assessment of need and the effectiveness and efficiency of services are key issues when contracts are being developed for such services. This paper reports an examination of the quality and potential of information currently available from routine data sources to support the contracting process. The results expose gaps in current knowledge and identify areas for future research. Locally, purchasers should consider surveying their population to identify the incidence of renal disease, including the reasons for any unmet need. Nationally, research is required to investigate the following: the relationship between ethnicity and the development of renal disease; the criteria for allocating patients to the alternative treatment modalities; and the treatments in terms of their costs and cost-effectiveness.

The effect of age on the inflammatory response to arthritis-associated crystals

The effect of age on the inflammatory response to urate and hydroxyapatite crystals was examined using both in vivo (intradermal skin testing) and in vitro (neutrophil death following incubation with urate crystals) methods. No significant difference in crystal-induced inflammation was found between young (< 25 years) and elderly (> 75 years) subjects and there was no correlation between the in vivo and in vitro tests. There was good correlation (0.63, p < 0.001) between the intradermal responses to urate and hydroxyapatite, suggesting that subjects, regardless of their age, are consistent in their response to these two types of arthritis-associated crystal. Advanced age does not lead to a major alteration in the inflammatory response to arthritis-associated crystals.

Nail-patella syndrome associated with mixed crystal deposition arthropathy

This report describes a case of nail-patella syndrome in a woman with a strong family history who presented with effusions in her shoulder and knees. Microscopic examination of the shoulder fluid suggested the presence of calcium pyrophosphate dihydrate (CPPD) crystals, and examination of the knee fluid suggested both hydroxyapatite (HAP) and CPPD crystals. To our knowledge, the coexistence of these two conditions has not been reported in the past. Moreover, it brings up a new element regarding the inflammatory origin of the nail-patella syndrome.

Survival of calcium pyrophosphate crystals in stored synovial fluids

Eleven synovial fluids containing calcium pyrophosphate dihydrate (CPPD) were examined repeatedly over an eight week period to assess whether storage conditions and duration influenced the number of crystals present. Aliquots of each fluid were stored at room temperature, 4 degrees C, and -70 degrees C. At -70 degrees C there was no change in crystal count after eight weeks' storage. At room temperature and 4 degrees C crystal counts declined slowly over the eight week period, though CPPD crystals were still readily apparent after eight weeks in 10/11 (4 degrees C) and 8/11 (room temperature) fluids. No change in crystal morphology was detected and, apart from one fluid kept at room temperature in which fungal hyphae were noted at six weeks, no new crystals were seen. Calcium pyrophosphate dihydrate crystals in synovial fluid can be maintained for prolonged periods by freezing.