The Effect of Pedagogical Approach on Physical Activity of Girls During Physical Education

Purpose: Technical approaches (TAs) such as Direct Instruction are commonly utilized when teaching games in Physical Education (PE) classes, but game-based approaches (GBAs) such as Game Sense (GS) have gained greater interest over the past 30 years. However, little is known about which approach promotes more physical activity (PA). The aim of this study was to compare the PA of girls during single-gender PE classes in an invasion games unit utilizing either a GS approach or a TA. Methods: Two upper primary school PE classes were taught invasion games using a GS approach and two classes were taught using a TA. During each of the 7 lessons students wore a wearable GPS sensor (SPT2, Sport Performance Tracking, Australia) which measured total distance, distance in each speed zone, top speed and 3D load. Results: The GS group traveled a greater distance than the TA group (+203 m, p < .001). This result was explained mostly by a greater distance covered in zone 2 speeds (0.6-1.7 m/s). The 3D load was also significantly higher in the GS group, but there were no group differences in top speed. Conclusions: Findings suggested that a GS thematic invasion unit was more effective in promoting PA levels in all-girl primary PE classes than a traditional sport-based invasion unit.

Climate change and pavement burns in the United Kingdom: a case report of two patients

Pavement burns are more common in locations familiarised with high temperatures and a dry climate zone, but have not previously been reported in temperate climates. We present two cases of patients who suffered pavement burns in the United Kingdom during an unprecedentedly hot day in July 2022. The first case involved a 66-year-old male who suffered partial and full thickness burns requiring excision and skin grafting. The second case involved a 58-year-old female with partial thickness burns also requiring excision and skin grafting. Both patients had pre-existing co-morbidities and their pavement burns were precipitated by heat stroke. Pavement burns represent a mechanism of injury that necessitates increased operative management, length of hospital stay and cost per surface area burned when compared to flame or scald burns (Silver et al., 2015). As a result of global warming, we anticipate extreme heat events, and subsequently pavement burns, to increase in incidence in the United Kingdom. There is opportunity for education of the public and health professionals for prevention.

Clinical standards for drug-susceptible TB in children and adolescents

BACKGROUND: These clinical standards aim to provide guidance for diagnosis, treatment, and management of drug-susceptible TB in children and adolescents.METHODS: Fifty-two global experts in paediatric TB participated in a Delphi consensus process. After eight rounds of revisions, 51/52 (98%) participants endorsed the final document.RESULTS: Eight standards were identified: Standard 1, Age and developmental stage are critical considerations in the assessment and management of TB; Standard 2, Children and adolescents with symptoms and signs of TB disease should undergo prompt evaluation, and diagnosis and treatment initiation should not depend on microbiological confirmation; Standard 3, Treatment initiation is particularly urgent in children and adolescents with presumptive TB meningitis and disseminated (miliary) TB; Standard 4, Children and adolescents should be treated with an appropriate weight-based regimen; Standard 5, Treating TB infection (TBI) is important to prevent disease; Standard 6, Children and adolescents should receive home-based/community-based treatment support whenever possible; Standard 7, Children, adolescents, and their families should be provided age-appropriate support to optimise engagement in care and clinical outcomes; and Standard 8, Case reporting and contact tracing should be conducted for each child and adolescent.CONCLUSION: These consensus-based clinical standards, which should be adapted to local contexts, will improve the care of children and adolescents affected by TB.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

972 Communication During the Pandemic

Aim

Since the COVID-19 pandemic facemasks have become compulsory in UK hospitals impacting on the visual and vocal (93%) aspects of communication. This QIP looks at the difference a clear mask made to patients.

Method

Clearmask^TM was used in place of a surgical mask and patients were asked to rate the difference on a likert scale. 100 patients were seen at two appointments, once with a Clearmask and another with a surgical mask. Dragon voice recognition software was used as a control.

Results

95% of patients rated communication better with the clearmask, Patients felt more engaged and were more likely to engage with the clinician. The effect was amplified when English was not the first language.

Conclusions

Clear facemasks improved communication and allow patients to become more engaged in consults and are more likely to allow information to be divulged to a clinician.

Personal protective equipment training & lived experience for healthcare staff during COVID-19

Objectives

To describe the lived experience of healthcare staff during the Coronavirus Disease 2019 (COVID-19) pandemic relating to the use of personal protective equipment (PPE) and investigate risks associated with PPE use, error mitigation and acceptability of mindfulness incorporation into PPE practice.

Methods

A qualitative human factors' study at two Irish hospitals occurred in late 2020. Data was collected by semi-structured interview and included role description, pre-COVID-19 PPE experience, the impact of COVID-19 on lived experience, risks associated with PPE use, contributory factors to errors, error mitigation strategies and acceptability of incorporating mindfulness into PPE practice.

Results

Of 45 participants, 23 of whom were nursing staff (51%), 34 (76%) had previously worn PPE and 25 (56%) used a buddy system. COVID-19 lived experience impacted most on social life/home-work interface (n=36, 80%). Nineteen staff (42%) described mental health impacts. The most cited risk concerned 'knowledge of procedures' (n=18, 40%). Contributory factors to PPE errors included time (n=15, 43%) and staffing pressures (n=10, 29%). Mitigation interventions included training/education (n=12, 40%). The majority (n=35, 78%) supported mindfulness integration into PPE practice.

Conclusions

PPE training should address healthcare staff lived experiences and consider incorporation of mindfulness and key organisational factors contributing to safety.

Sterilization of gowns: making the most of a scarce commodity during the COVID-19 pandemic

Baylor Clinic in Mbabane, Eswatini, convened a crisis meeting to tackle critical shortages of long-sleeved disposable gowns that resulted from COVID-19 pandemic constraints on available personal protective equipment (PPE). A strategy deemed safe, affordable and sustainable was adopted to autoclave and re-use gowns based on a risk-stratified approach. Key objectives were to ensure essential infection control and prevention (ICP) for medical doctors, nurses, and laboratory teams. Administrative, environmental and personal protective measures for ICP were enhanced through regular staff training. This strategy for gown re-use has been invaluable in motivating responsible stewardship and maximization of available gowns during the COVID-19 pandemic.

Management of minor burns during the COVID-19 pandemic: A patient-centred approach

INTRODUCTION

The UK government introduced lockdown measures on 23 March 2020 due to the first wave of the COVID-19 pandemic. A restructuring of clinical services was necessary to accommodate mandatory changes while also maintaining the best possible standards for patient care. The present study explored the initial management, follow-up and patient-reported outcomes of burn injuries <15% total body surface area (TBSA) during the height of the COVID-19 lockdown at a tertiary burns centre.

METHODS

A retrospective review of all adult patients with burns <15% TBSA during the national lockdown (23 March 2020 to 10 May 2020) was undertaken at The Queen Elizabeth Hospital Birmingham (QEHB), UK. All referrals from non-QEHB telemedicine (external) or QEHB emergency (internal) departments were reviewed for management, length of hospital stay and pattern of follow-up (ward attender, self-care, community or outreach nurses). A telephone survey based on a structured questionnaire was conducted to establish patients' satisfaction.

RESULTS

A total of 84 burn patients were included in the study. The mean age was 39 years (age range = 19-91 years) and the male:female ratio was 4:1. Patients were managed non-operatively (n = 69, 82%) or operatively (n = 15, 18%). Patients attended the ward attender acute burns clinic only once (n = 36, 61%). The telephone survey captured 70% (n = 59) of the study population and 57 patients (97% of respondents) were pleased with the ongoing care and burn healing.

CONCLUSION

The integration of patient led self-care, reduction in admissions, minimal clinics attendance and a telemedicine follow-up is an effective model for small burns management during the COVID-19 pandemic. A high degree of patient satisfaction was achieved with continuous and approachable communication channels with the burn multidisciplinary team. We continue to implement this effective model of burns management throughout the COVID-19 pandemic and the subsequent period.

LAY SUMMARY

The lockdown measures due to the first wave of COVID-19 pandemic affected the way we manage all medical emergencies including burns. The initial management, follow-up and patient satisfaction for small burn injuries during lockdown has not been reported previously. The aim of this study is to examine the outcome in terms of small burn management, hospital stay, number of clinic reviews, healing and patient satisfaction during the lockdown period in a burn centre in the UK. This would look at the need for operations and whether patients stayed longer if they required an intervention. We reviewed adult patients with small burns during the national lockdown (23 March 2020 to 10 May 2020) at The Queen Elizabeth Hospital Birmingham (QEHB). All referrals from telemedicine, referral system (external) or QEHB (internal) were reviewed for management, length of hospital stay and pattern of follow-up. Patients were reviewed in the acute burns clinic and given advice for burn management and dressing for self-care. Follow-up was mostly via email (telemedicine) A telephone survey based on a structured questionnaire was conducted to find out patients' satisfaction. Four times more men than women had small burns during the lockdown period. The average age was 39 years. The majority were managed conservatively with dressings (82%) and a small proportion required an operation (18%). Most patients attended the acute burns clinic only once (61%) for initial assessment and management. The telephone survey captured 70% of patient and 97% of respondents were pleased with the care and burn healing. The integration of patient-led self-care, reduction in admissions, minimal clinics attendance and a telemedicine follow-up is an effective model for burns management during the COVID-19 pandemic. A high degree of patient satisfaction was achieved with continuous and approachable communication channels with burn multidisciplinary team. We continue to implement this effective model of burns management throughout the COVID-19 pandemic and the subsequent period.

Conceptualizing the health and well-being impacts of social enterprise: a UK-based study

Social enterprises-businesses that work for social benefit rather than for the maximization of financial returns to shareholders or owners-could potentially prove to be an innovative and sustainable way of tackling 'upstream' social determinants of health. However, empirical work focusing upon how, and to what extent, social enterprise-led activity may impact upon health and well-being is still relatively scarce. This study examines how social enterprises portray their impact, and how such impacts may be considered in health and well-being terms. Through analysing evaluative reports of the work of social enterprises in Scotland (n = 17) utilizing a 'process coding' method, we investigate both the self-reported impacts of the work of social enterprises and the mechanisms by which these are said to be derived. Revisiting previous conceptualizations in the extant literature, this work allows us to present an 'empirically-informed' conceptual model of the health and well-being impacts of social enterprise-led activity, and thus presents a significant advance on previous hypothetical, theoretically-based conceptualizations. It is considered that these findings further improve our overall knowledge of ways in which social enterprise and other parts of the third sector could be considered as potentially valuable 'non-obvious' public health actors.

Non-F HBV/HDV-3 coinfection is associated with severe liver disease in Western Brazilian Amazon

The clinical outcome of hepatitis B virus (HBV) infection may be related to host and viral genetic factors, as well as to the type of infection (monoinfection and coinfection). To analyze the distribution/combination of HBV/hepatitis D virus (HDV) genotypes and the associated clinical characteristics, 409 serum samples from patients with chronic HBV (94 of them coinfected by HDV) followed at the Viral Hepatitis Referral Center of Rio Branco, Brazil were enrolled. HBV DNA and HDV RNA were amplified, respectively, by polymerase chain reaction (PCR) and nested PCR using specific primers in the PreC/C region and the S gene, and by reverse-transcription PCR and seminested PCR using specific primers in the delta antigen region and sequenced. The proportion of women (56.1%) was significantly higher than males in this cohort ( P < 0.01). Women were significantly younger (39.8 years; 8-77 years) than males (44.7 years; 12-79 years; P < 0.01). Sixty-eight (18%) patients were infected with HBV-F genotype and 264 (69.8%) with HBV/non-F genotypes. Coinfection by HDV was detected in 23.9% (94 of 409) of this population and was more frequent in male (54.2%, 51 of 94) than in female patients (44.7%, 42 of 94; P = 0.015). HDV-3 was the most prevalent (88.9%) genotype. Almost 70% of HDV-3 coinfected patients were infected with HBV/non-F genotypes. Severe liver disease was diagnosed in 41 patients, 60.9% (25 of 41) of them coinfected with HDV. HBV/HDV coinfection was associated with male sex, age above 30 years, severe liver disease, and increased alanine aminotransferase levels. HBV/HDV-3 coinfection is associated with severe liver disease, in Rio Branco, Brazil.

Gun-shot injuries in UK military casualties - Features associated with wound severity

INTRODUCTION

Surgical treatment of high-energy gun-shot wounds (GSWs) to the extremities is challenging. Recent surgical doctrine states that wound tracts from high-energy GSWs should be laid open, however the experience from previous conflicts suggests that some of these injuries can be managed more conservatively. The aim of this study is to firstly characterise the GSW injuries sustained by UK forces, and secondly test the hypothesis that the likely severity of GSWs can be predicted by features of the wound.

METHODS

The UK Military trauma registry was searched for cases injured by GSW in the five years between 01 January 2009 and 31 December 2013: only UK personnel were included. Clinical notes and radiographs were then reviewed. Features associated with energy transfer in extremity wounds in survivors were further examined with number of wound debridements used as a surrogate marker of wound severity.

RESULTS

There were 450 cases who met the inclusion criteria. 96 (21%) were fatally injured, with 354 (79%) surviving their injuries. Casualties in the fatality group had a median New Injury Severity Score (NISS) of 75 (IQR 75-75), while the median NISS of the survivors was 12 (IQR 4-48) with 10 survivors having a NISS of 75. In survivors the limbs were most commonly injured (56%). 'Through and through' wounds, where the bullet passes intact through the body, were strongly associated with less requirement for debridement (p<0.0001). When a bullet fragmented there was a significant association with a requirement for a greater number of wound debridements (p=0.0002), as there was if a bullet fractured a bone (p=0.0006).

CONCLUSIONS

More complex wounds, as indicated by the requirement for repeated debridements, are associated with injuries where the bullet does not pass straight through the body, or where a bone is fractured. Gunshot wounds should be assessed according to the likely energy transferred, extremity wounds without features of high energy transfer do not require extensive exploration.

HBV/HDV co-infection in the Western Brazilian Amazonia: an intriguing mutation among HDV genotype 3 carriers

HDV infection still remains a serious public health problem in Amazonia. There are few data regarding the biomolecular aspects of HBV/HDV co-infection in this region. We studied 92 patients HBsAg(+) /anti-HDV IgG(+) followed at the Hepatitis Referral Centers of Porto Velho (RO), Rio Branco and Cruzeiro do Sul (AC), Brazil, from March 2006 to March 2007 for whom the HDV and/or the HBV genotype could be determined. The HDV genotype could be determined in 90 patients, while the HBV genotypes could be positively determined in 74. HBV subgenotype F2 is the most prevalent (40.2%), followed by the subgenotypes A1 (15.2%) and D3 (8.7%), while 16.4% were other subgenotypes or genotypes, 4.3% were discordant and 15.2% were unamplifiable. Surprisingly, HDV genotype 3 (HDV-3) was found in all of the HBV/HDV-infected patients that could be genotyped for HDV, confirming that HDV-3 can associate with non-F HBV genotypes. However, a HDV-3 mutant was found in 29.3% of patients and was more frequently associated with non-F HBV genotypes (P < 0.001) than were nonmutant strains, suggesting that the mutation may facilitate association of HDV-3 with non-F HBV genotypes.

Acute bilateral leg amputation following combat injury in UK servicemen

BACKGROUND

This study aims to characterise the injuries and surgical management of British servicemen sustaining bilateral lower limb amputations.

METHODS

The UK Military Trauma Registry was searched for all cases of primary bilateral lower limb amputation sustained between March 2004 and March 2010. Amputations were excluded if they occurred more than 7 days after injury or if they were at the ankle or more distal.

RESULTS

There were 1694 UK military patients injured or killed during this six-year study period. Forty-three of these (2.8%) were casualties with bilateral lower limb amputations. All casualties were men with a mean age of 25.1 years (SD 4.3): all were injured in Afghanistan by Improvised Explosive Devices (IEDs). Six casualties were in vehicles when they were injured with the remaining 37 (80%) patrolling on foot. The mean New Injury Severity Score (NISS) was 48.2 (SD 13.2): four patients had a maximum score of 75. The mean TRISS probability of survival was 60% (SD 39.4), with 18 having a survival probability of less than 50% i.e. unexpected survivors. The most common amputation pattern was bilateral trans-femoral (TF) amputations, which was seen in 25 patients (58%). Nine patients also lost an upper limb (triple amputation): no patients survived loss of all four limbs. In retained upper limbs extensive injuries to the hands and forearms were common, including loss of digits. Six patients (14%) sustained an open pelvic fracture. Perineal/genital injury was a feature in 19 (44%) patients, ranging from unilateral orchidectomy to loss of genitalia and permanent requirement for colostomy and urostomy. The mean requirement for blood products was 66 units (SD 41.7). The maximum transfusion was 12 units of platelets, 94 packed red cells, 8 cryoprecipitate, 76 units of fresh frozen plasma and 3 units of fresh whole blood, a total of 193 units of blood products.

CONCLUSIONS

Our findings detail the severe nature of these injuries together with the massive surgical and resuscitative efforts required to firstly keep patients alive and secondly reconstruct and prepare them for rehabilitation.

Photonic coherent state transfer with Hamiltonian dynamics

We report the observation of near-perfect light wave transfer by emulating quantum state transfer on a lattice with Hamiltonian dynamics, i.e., time-dependent intersite couplings. The structure transferring a single waveguide excitation over 11 sites with a fidelity of 0.93 works for classical light as well as single photons. As our implementation of perfect quantum state transfer uses a photonic setting, we introduce polarization as a new degree of freedom to the transport protocol. We demonstrate rotation operations of up to 40° on polarization during state transfer.

Improved rolling circle amplification (RCA) of hepatitis B virus (HBV) relaxed-circular serum DNA (RC-DNA)

For functional analysis of HBV isolates, epidemiological studies and correct identification of recombinant genomes, the amplification of complete genomes is necessary. A method for completely in vitro amplification of full-length HBV genomes starting from serum RC-DNA is described. This uses in vitro completion/ligation of plus-strand HBV RC-DNA and amplification using Rolling-Circle Amplification, eventually followed by a genomic PCR. The method can amplify complete HBV genomes from sera with viral loads ranging from >1.0E+8 IU/ml down to 1.0E+3 IU/ml. The method can be applied to archived sera that have undergone long-term storage or to archived DNA serum extracts. The genomes can easily be cloned. HBV genotypes A-G can all be amplified with no apparent problems. A recombinant subgenotype A3/genotype E genome was identified and fully sequenced.

Meningococcal encephalitis associated with cerebellar tonsillar herniation and acute cervicomedullary injury

A 13-year-old girl presented with a progressive ascending paralysis, bulbar dysfunction and finally respiratory arrest. Magnetic resonance (MR) showed acute cervicomedullary injury and hindbrain herniation. An emergency foramen magnum decompression and external ventricular drainage insertion were performed, and meningococcal infection was diagnosed. The patient recovered completely. Meningococcal encephalitis may have an atypical presentation, and a surgery can optimise the outcome.

Does direct admission from an emergency department with on-site neurosurgical services facilitate time critical surgical intervention following a traumatic brain injury in children?

OBJECTIVES

To compare the proportion of trauma craniotomies performed within 4 hours of presentation to emergency departments (ED) with and without on-site neurosurgery.

DESIGN

A retrospective cohort analysis of data collected prospectively between January 2005 and April 2010 from patients with traumatic brain injury who were admitted to the paediatric intensive care unit (PICU) following traumatic brain injury.

METHODS

Times for admission to ED, PICU and theatre were obtained through analysis of prospectively collected data management systems. Emergency department admission to neurosurgical theatre lag time was calculated using Microsoft Excel. Statistical analysis was performed using R (version 2.11.0). Subjects. Fifty-seven cases were identified. Twenty patients were admitted directly from ED to an on-site neurosurgical unit. The remaining 37 were transferred from regional EDs.

RESULTS

Thirty-one craniotomies were performed. Thirteen in-patients admitted directly to hospital with neurosurgery on site. Eighteen in patients admitted at the local hospital and then transferred to the neurosurgical unit. Thirteen of Thirty-one (42%) craniotomies were performed within 4 hours. In the on-site group 10 of 13 (77%) craniotomies were performed within 4 hours compared to 3 of 18 (17%) in those transferred from regional ED (p = 0.001232) (Fisher exact test). Eleven patients were transferred directly from ED to neurosurgical theatre for emergency craniotomies. Within this subgroup, seven patients came from the cohort of admissions to a hospital with on-site neurosurgery. The remaining four patients were transferred from regional ED. There were eight extradural haematomas, one subdural haematoma and two intraparenchymal haemorrhages. The mean time from ED presentation to theatre was 1.68 hours and 5.46 hours for the on-site and regional transfer groups, respectively. There were no mortalities.

CONCLUSIONS

Forty-two per cent of trauma craniotomies are performed within 4 hours. However, presentation to an ED with on-site neurosurgical services significantly facilitates time critical surgery in children following a traumatic brain injury.

HBVdb: a knowledge database for Hepatitis B Virus

We have developed a specialized database, HBVdb (http://hbvdb.ibcp.fr), allowing the researchers to investigate the genetic variability of Hepatitis B Virus (HBV) and viral resistance to treatment. HBV is a major health problem worldwide with more than 350 million individuals being chronically infected. HBV is an enveloped DNA virus that replicates by reverse transcription of an RNA intermediate. HBV genome is optimized, being circular and encoding four overlapping reading frames. Indeed, each nucleotide of the genome takes part in the coding of at least one protein. However, HBV shows some genome variability leading to at least eight different genotypes and recombinant forms. The main drugs used to treat infected patients are nucleos(t)ides analogs (reverse transcriptase inhibitors). Unfortunately, HBV mutants resistant to these drugs may be selected and be responsible for treatment failure. HBVdb contains a collection of computer-annotated sequences based on manually annotated reference genomes. The database can be accessed through a web interface that allows static and dynamic queries and offers integrated generic sequence analysis tools and specialized analysis tools (e.g. annotation, genotyping, drug resistance profiling).

Identification of novel recombinants of hepatitis B virus genotypes F and G in human immunodeficiency virus-positive patients from Argentina and Brazil

Hepatitis B virus (HBV) genotype G (HBV/G) infection is almost always detected along with a co-infecting HBV strain that can supply HBeAg, typically HBV/A2. In this study we describe, in two human immunodeficiency virus (HIV)-positive patients from Argentina and Brazil, the first report of HBV/G infection in Argentina and co-circulation of HBV/G, HBV/F and G/F recombinants in the American continent. HBV isolates carrying the 36 bp insertion of HBV/G were the most prevalent in both patients, with >99 % of colonies hybridizing to a probe specific for this insertion. Phylogenetic analyses of full-length genomes and precore/core fragments revealed that F4 and F1b were the co-infecting subgenotypes in the Brazilian and Argentinian patients, respectively. Bootscanning analysis provided evidence of recombination in several clones from both patients, with recombination breakpoints located mainly at the precore/core region. These data should encourage further investigations on the clinical implications of HBV/G recombinants in HBV/HIV co-infected patients.

Probable corticosteroid-induced reactivation of latent hepatitis B virus infection in an HIV-positive patient involving immune escape

We describe a patient infected with human immunodeficiency virus who possessed a serological profile suggesting a previous cleared acute hepatitis B virus (HBV) infection, including high levels of antibodies against HBV surface antigen (anti-HBs). Following the administration of inhaled glucocorticosteroids combined with protease inhibitor-based antiretroviral treatment, the patient developed an unexpected severe acute hepatitis despite persistence of anti-HBs. A genotype A2 strain emerged with 2 major mutations in the S gene, sK122R and sD144E. Molecular and biological analyses strongly suggested reactivation of a latent HBV infection. The importance and the molecular basis of these 2 epitopes in immune-escape mechanisms and host-virus interactions are discussed.

Randomized controlled trials in the era of molecular oncology: methodology, biomarkers, and end points

BACKGROUND

We previously reported metrics of systemic therapy randomized controlled trials (RCTs) in breast cancer, colorectal cancer (CRC), and non-small-cell lung cancer (NSCLC) published 1975-2004. To evaluate trends in the era of targeted therapies (TT), we have repeated a similar analysis of RCTs published 2005-2009.

METHODS

A search for phase III RCTs of systemic agents published in five major journals 2005-2009 was carried out. Trials were classified as TT if they involved any non-hormonal targeted agent. We extracted data regarding biomarker use. Integral biomarkers were defined as tests used to determine eligibility, stratification, or allocation. Descriptive statistics were used to analyze trends over time.

RESULTS

One hundred and thirty-seven eligible RCTs were evaluated. Compared with 1995-2004, the number (17-27 RCTs/year) and size (median sample size 446-722, P < 0.001) of RCTs increased. The proportion of RCTs evaluating TT increased from 4% (7/167) to 29% (40/137) (P < 0.001). There was an increase in the proportion of trials with financial support from industry [57% (95/167) to 78% (107/137), P = 0.001]. Biomarkers were included in 58% (80/137) of RCTs; integral biomarkers were included in 36% (49/137) of trials. Among the 49 RCTs using integral biomarkers, 40 (82%) used HER2 and/or ER/PR status in studies of breast cancer.

CONCLUSIONS

RCTs published in 2005-2009 are larger, more likely to evaluate TT, and be supported by industry. Biomarkers may be increasingly used, but the most common use relates to traditional use of ER/PR and evolving use of HER2 in breast cancer RCTs.

Local realism of macroscopic correlations

We identify conditions under which correlations resulting from quantum measurements performed on macroscopic systems (systems composed of a number of particles of the order of the Avogadro number) can be described by local realism. We argue that the emergence of local realism at the macroscopic level is caused by an interplay between the monogamous nature of quantum correlations and the fact that macroscopic measurements do not reveal properties of individual particles.

Hepatitis B virus infection from an evolutionary point of view: how viral, host, and environmental factors shape genotypes and subgenotypes

Hepatitis B virus (HBV) has an overwhelming distribution in the world and causes important human health problems. It has infected one-third of the global population and more than 350 million people are chronic carriers. Several aspects of HBV infection confer adaptive advantages that lead to a highly efficient dissemination of the virus through different routes of transmission. HBV genotypes and subgenotypes have been associated with differences in clinical and virological characteristics, indicating that they may play a role in the virus-host relationship. In particular, a clear association between genotype A and chronic outcomes in both children and adults depending on the subgenotype involved, and between genotype C and a higher risk of complications from HBV infection, has been demonstrated. Interestingly, subgenotype A2 and genotype C are respectively likely to predominate in high-risk groups for sexual transmission and in areas where perinatal transmission is the major mode of HBV dissemination. An evolutionary approach to HBV infection, based on the principles of natural selection, may offer explanations for how modes of transmission may favor some genotypes and subgenotypes over others and, ultimately, influence HBV virulence.

Association between treatment effects on disease progression (DP) endpoints and overall survival (OS) in patients with metastatic renal cell carcinoma (mRCC)

5105

Background: Access to safe and effective novel therapies may be expedited if DP endpoints (progression-free survival [PFS], time to progression [TTP], or event-free survival) are established as valid surrogates for OS in pivotal studies in mRCC. While the association between DP endpoints and OS has been established in other cancers, it has not been rigorously examined in patients with mRCC. We assessed the association between treatment effects on DP endpoints and treatment effects on OS in controlled trials of patients with mRCC. Methods: A systematic literature search was conducted (Medline, conference abstracts, references of retrieved studies/ reviews) to identify studies meeting the following criteria: controlled trials in mRCC of IL-2, IFN-α, sunitinib, sorafenib, pazopanib, bevacizumab, temsirolimus, or everolimus; English language; publication date≥1997; median time to DP and OS reported for 2 or more treatment groups. For each treatment group comparison, we calculated the differences in median time to DP and median OS and analyzed the association between the differences in median time to DP and differences in median OS using weighted ordinary least-squares (OLS) regression. Results: A total of 21 studies representing 6182 patients, 52 treatment groups, and 35 comparisons were identified. The median difference between treatment groups in time to DP averaged 1.3 months; the median difference between treatment groups in OS averaged 2.8 months. The correlation between differences in median time to DP and differences in median OS was 0.69 (p < 0.0001). In weighted OLS regression, a 1 month difference in DP was associated with a 1.4 month difference in OS (p < 0.0001, adjusted R-sq = 0.46). Conclusions: In patients receiving treatment for mRCC, treatment effects on DP endpoints are predictive of treatment effects on OS.

[Table: see text]

Forward trauma surgery in Afghanistan: lessons learnt on the modern asymmetric battlefield

The deployment of 16 Air Assault Brigade to Helmand Province, Afghanistan in April-October 2006 was supported by a two -surgeon Field Surgical Team (FST) embedded within a 25 bed medical facility. We report the summative operative experience of the FST in order to analyse workload, case-mix and outline future training requirements. Within this period, 138 patients underwent 255 theatre episodes and 322 surgical procedures. 106 of the 138 patients requiring surgery were battle-injured. Surgical procedures undertaken involved wound excision (95), major amputation (9), laparotomy (9), application of external-fixation/skeletal traction (6), thoracotomy (4), plaster application (6), dural repair (2), and one tracheostomy with 13 other procedures. Procedures undertaken at subsequent surgery included delayed primary closure (65), split skin graft (7), wound excision (5), tendon repair (3) and 32 others. Complications included two patients with delayed reactionary haemorrhage/ post-surgical bleeding requiring re-operation. There was one in-hospital death. Thirty-two patients underwent surgery to treat disease or non-battle injury (DNBI), including 9 patients with major burns who required 26 procedures for burn excision and primary skin grafting. Many of the operations required the deployed team to operate outside of their normal NHS comfort zone. The experiences and lessons learnt and re-learnt by this surgical team should be part of our institutional memory.

Virological and histological re-evaluation of Labrea hepatitis

BACKGROUND

a peculiar form of fulminant hepatitis known as Labrea hepatitis, probably related to hepatitis B and D, has been reported in Brazilian Amazon as early as the 1930s.

METHODS

we reviewed the postmortem liver biopsies of 9 patients with Labrea Hepatitis. Immunostaining for HBV and HDV antigens were performed.

RESULTS

we found several important characteristics in the liver tissues: 1) moderate hepatocellular necro-inflammation, 2) hepatocellular ballooning, 3) ballooned hepatocytes with fat droplets surrounding the nucleus (morula-like cells or spongiocytes), 4) mild to moderate necrosis and/or mild portoseptal fibrosis. Hepatitis B surface antigen (HBsAg) was identified in 7 of the 9 cases and was concentrated in the Morula-like cells. Hepatitis B core antigen (HBcAg) was present in 5 cases, mostly in the hepatocyte's nucleous. The hepatitis D virus antigen (HDV Ag) was present in 5 cases, mostly in the cytoplasm and concentrated in the Morula-like cells.

CONCLUSION

labrea hepatitis is a fatal disease mostly affecting isolated communities in the Amazon. Evidence implicates HBV and HDV in the etiology of this disease, but this hypothesis needs to be confirmed with genotyping and sequencing research on HBV DNA and HDV RNA extracted from the liver and sera of these patients.

Initiation of hepatitis B virus genome replication and production of infectious virus following delivery in HepG2 cells by novel recombinant baculovirus vector

One of the major problems in gaining further insight into hepatitis B virus (HBV)/host-cell interactions is to improve the existing cellular models for the study of HBV replication. The first objective of this study was to improve the system based on transduction of HepG2 cells with a recombinant baculovirus to study HBV replication. A new HBV recombinant baculovirus, Bac-HBV-1.1, in which the synthesis of pre-genomic RNA is driven by a strong mammalian promoter, was generated. Transduction with this new recombinant baculovirus led to higher levels of HBV replication in HepG2 cells compared with levels obtained with previously described baculovirus vectors. The initiation of a complete HBV DNA replication cycle in Bac-HBV-1.1-transduced HepG2 cells was shown by the presence of HBV replicative intermediates, including covalently closed circular DNA (cccDNA). Only low levels of cccDNA were detected in the nucleus of infected cells. Data showed that cccDNA resulted from the recycling of newly synthesized nucleocapsids and was bound to acetylated histones in a chromatin-like structure. HBV particles released into the supernatant of transduced HepG2 cells were infectious in differentiated HepaRG cells. Several Bac-HBV-1.1 baculoviruses containing HBV strains carrying mutations conferring resistance to lamivudine and/or adefovir were constructed. Phenotypic analysis of these mutants confirmed the results obtained with the transfection procedures. In conclusion, an improved cell-culture system was established for the transduction of replication-competent HBV genomes. This will be useful for future studies of the fitness of HBV mutants.

Intestinal carriage of verocytotoxigenic Escherichia coli O157, Salmonella, thermophilic Campylobacter and Yersinia enterocolitica, in cattle, sheep and pigs at slaughter in Great Britain during 2003

An abattoir survey was undertaken to determine the prevalence of foodborne zoonotic organisms colonizing cattle, sheep and pigs at slaughter in Great Britain. The study ran for 12 months from January 2003, involved 93 abattoirs and collected 7703 intestinal samples. The design was similar to two previous abattoir surveys undertaken in 1999-2000 allowing comparisons. Samples were examined for VTEC O157, Salmonella, thermophilic Campylobacter and Yersinia enterocolitica. The prevalence of VTEC O157 faecal carriage was 4.7% in cattle, 0.7% in sheep and 0.3% in pigs. A significant decrease in sheep was detected from the previous survey (1.7%). Salmonella carriage was 1.4% in cattle, a significant increase from the previous survey of 0.2%. In sheep, faecal carriage was 1.1% a significant increase from the previous survey (0.1%). In pigs, carriage was 23.4%, consistent with the previous study. Thermophilic Campylobacter spp. were isolated from 54.6% of cattle, 43.8% of sheep and 69.3% of pigs. Y. enterocolitica was isolated from 4.5% of cattle, 8.0% of sheep and 10.2% of pigs.

Pattern, management and outcome of cervical spine injuries associated with head injuries in paediatric patients

INTRODUCTION

This study examines the management and outcome of cervical spine injuries in children with head injuries, to assess the need for surgical treatment.

MATERIAL AND METHODS

We performed a retrospective analysis (1995-2005) of 445 children admitted intubated and ventilated to the intensive care unit with head injuries.

OUTCOME MEASURES

Frankel grade for spinal injuries and Glasgow Outcome Scale (GOS) for head injuries.

RESULTS

Cervical spine injuries were detected in 11 patients (incidence 2.5%, mean age: 6.3 years, range: 21 months-15 years). The injuries were: C1/2 distraction: 2; C1/2 subluxation: 2; odontoid peg fracture with C1/2 dislocation and cord transection: 1; disruption of posterior longitudinal ligament at C2: 1; odontoid peg fracture with C2/3 distraction: 1; C2/3 subluxation: 1; C3 lamina fracture: 1; C3/4 facet fracture: 1; C6/7 fracture dislocation with cord transection: 1. One patient was managed operatively, ten patients nonoperatively, two with halo vests and eight with hard collars. There were three deaths (mortality 27%) associated with severe head injuries. At 6 months follow-up, two patients remained quadriplegic (Frankel Grade A), one of them ventilator dependent, one had residual motor function but of no practical use (Frankel Grade C), five had good spinal outcome (Frankel Grade E). Seven patients had good head injury outcomes (GOS 5), one remained disabled (GOS 3).

CONCLUSION

Most children with cervical injury can be managed nonoperatively with good outcomes. Surgical management may be necessary in severe unstable injuries.

Hepatitis B virus genetic variability and evolution

Hepatitis B virus has been evolving gradually over a long period of time, resulting in a large amount of genetic diversity, despite the constraints imposed by the complex genetic organization of the viral genome. This diversity is partly due to virus/host interactions and partly due to parallel evolution in geographically distinct areas. Recombination also appears to be an important element in HBV evolution. Also, human intervention in the form of mass vaccination and antiviral treatment will reduce the burden of HBV-related liver disease but may also be accelerating evolution of the virus.