Mind and skin: Exploring the links between inflammation, sleep disturbance and neurocognitive function in patients with atopic dermatitis

Atopic dermatitis (AD) is a chronic, pruritic and inflammatory, dry skin condition with many known comorbidities. These include airway disease, food allergies, atopic eye disease and autoimmune conditions. Furthermore, there is often significant sleep disturbance as well as increased psychological distress and mental health problems. Severe AD therefore often has a significant impact on the quality of life of both patients and their families. In this review we discuss recent findings on the putative links between AD, its association with itch, sleep disturbance and neuropsychiatric morbidity, including the role of inflammation in these conditions. Itch was thought to predominantly drive sleep disruption in AD. We now understand changes in sleep influence immune cell distribution and the associated inflammatory cytokines, which suggests a bidirectional relationship between AD and sleep. We also increasingly recognize inflammation as a key driver in psychological symptoms and disorders. The link between cutaneous, systemic and possible brain inflammation could at least in part be driven by the sleep deprivation and itch-driven neuronal proliferation seen in AD.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

British Journal of Surgery Society.

AB0916-PARE KNOWLEDGE OF DISEASE, DIAGNOSIS, ADHERENCE AND IMPACT OF RESEARCH IN PATIENTS WITH INFLAMMATORY ARTHRITIS

Background:

The diagnosis and treatment of inflammatory arthritis has been transformed largely by the development of drugs that target specific molecules of the immune system. However, these changes have increased the complexity of the mechanisms of disease, its treatment and patients understanding. Patient education is needed in this area to facilitate decision making and to facilitate strong patient-partnerships in research.

Objectives:

The aim of this study was to examine the level of understanding of inflammatory arthritis patients and the need for strong patient-partnership in research.

Methods:

An online anonymous survey addressed questions about diagnosis, routine tests, medications and how they work, medication adherence, disease flare, heredity, pregnancy, and patient involvement in research.

Results:

There were 1,873 respondents, 1416 of which had inflammatory arthritis (IA)-RA (65.8%) and PsA (34.2%). They were predominantly female (RA 86%, PsA 85 %), aged 55±13 and 50±12. Less than 35% of patients had an understanding of diagnostic tests, what was measured and the implication for disease, with 75.5% also concerned about heredity. There was a high level of understanding of how specific medications treat inflammatory arthritis (72.9%). Adherence was also very high (>87%), with the main reasons for stopping medication without the advice of their clinician, ‘feeling better’ and ‘side effects’ however a significant proportion of patients (69.9%) reported a disease-flare following cessation of medication. Patients of childbearing age (69%) were also concerned that inflammatory arthritis reduced their chances of getting pregnant, with only 8% believing arthritis medications were safe to take during pregnancy. Finally, only 9% of patients had ever been asked to participate in a research study.

Conclusion:

This study demonstrates a need for the development of stronger patient-partnerships with clinicians and researchers in relation to patient education and engagement with research, to create a platform where patients can have meaningful input and involvement in future research studies.

Acknowledgements:

We wish to thank all the patients who contributed to this study

Disclosure of Interests:

Mary Canavan: None declared, Viviana Marzaioli: None declared, Alex Donnelly: None declared, Siobhan Wade: None declared, Alexander Fraser: None declared, Tim O’Sullivan: None declared, Sinead Harney: None declared, Arthritis Ireland: None declared, Douglas Veale Speakers bureau: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Consultant of: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Grant/research support from: Janssen, Abbvie, Pfizer, UCB, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Janssen, Abbvie, Pfizer, UCB

OP0267-HPR “I NEVER THOUGHT EXERCISE COULD HELP IMPROVE MY SLEEP”: EXPERIENCES OF PEOPLE WITH RHEUMATOID ARTHRITIS ON THE IMPACT OF EXERCISE ON SLEEP

Background:

OMERACT has identified sleep quality as one of the key outcomes for people with RA [1]. Poor sleep and reduced total sleep time (TST) are common complaints among people with RA. Poor sleep can in turn lead to deterioration in function, reduce activity levels and also impact mental health. Although sleep and mental health outcomes have been identified as important, they are frequently not measured in clinical trials. Involving key stakeholders, like people with RA, is important when designing exercise interventions as it allows consideration of particular issues that may influence future intervention delivery. This study involved people with RA who participated in a pilot RCT group exercise class to improve sleep quality.

Objectives:

To explore participants experiences of an exercise intervention in improving sleep quality and TST, to capture their reality.

Methods:

A descriptive qualitative study design of face-to-face semi-structured interviews was employed. The interview schedule explored a number of areas: experience of the intervention; outcome measures used; views regarding the intervention; perceptions regarding exercise and sleep and the impact on sleep. Interviews were transcribed verbatim by a professional transcriber. Inductive thematic analysis was used as an analytical approach. Interview transcripts were read, notes made, and ideas formulated to facilitate coding. The research team searched for patterns, analysed and coded the data, and generated themes and sub-themes. Themes were reviewed by the research team to check if they worked in relation to the coded extracts and the entire data set. The COREQ checklist provided guidance.

Results:

Twelve females participated with a mean age of 58 (SD 7.4); mean RA diagnosis of 9.9 (SD 7.4) years; moderate to severe disability (HAQ-DI: 1.5 (SD 0.60). Four main themes were generated: 1) Positive impact of exercise on sleep -“I really didn’t think any type of exercise would help me sleep better if I’m honest.”;2) Positive experiences of exercise intervention to improve sleep-“I learnt so much regarding walking that I didn’t even think about.”;3) Clear mental health benefits –“If you don’t sleep well then it will have a knock-on effect to your mental health”; 4) Achieving empowerment and ownership when exercising -“I feel empowered now and confident that I’m not doing harm to myself”.The findings demonstrated that participants were clearly surprised that exercise could improve sleep.

Conclusion:

In a variety of inflammatory conditions exercise is recommended as an effective intervention for the treatment of sleeping disorders. Although there is a growing consensus that exercise will benefit sleep, research is severely lacking in those with RA. This study demonstrates that participants were clearly surprised that exercise could improve their sleep. Due to the multifactorial nature of RA, engaging in exercise may not only improve sleep quality but also mitigate some of its symptoms.

References:

[1]Kirwan JR, Boonen A, Harrison MJ, Hewlett SE, et al (2011) OMERACT 10 Patient Perspective Virtual Campus: Valuing health; measuring outcomes in rheumatoid arthritis fatigue, RA sleep, arthroplasty, and systemic sclerosis; and clinical significance of changes in health. The Journal of Rheumatology;38:1728–34.

Disclosure of Interests:

None declared

Variables associated with survival in patients with invasive bladder cancer with and without surgery

We recorded the survival of 141 patients assessed for radical cystectomy, which included cardiopulmonary exercise testing. The median Kaplan-Meier survival estimates were: 1540 days for the whole cohort; 2200 days after cystectomy scheduled (n = 108); and 843 days without surgery. The mortality hazard remained double that expected for a matched general population, but survival was better in patients scheduled for surgery than those who were not: the mortality hazard ratio (95%CI) after cystectomy was 0.43 (0.26-0.73) the mortality hazard without surgery, p = 0.001. The mortality hazard ratios for the three-variable Bayesian Model Averaging survival model for all 141 patients were: referral for surgery (0.5); haemoglobin concentration (0.98); and efficiency of carbon dioxide output (1.05). Efficiency of carbon dioxide output was the single variable in the postoperative model (n = 108), mortality hazard 1.08 (per unit increase). The ratio of observed to expected peak oxygen consumption associated best with mortality in 33 patients not referred for surgery, hazard ratio 0.001. Our results can inform consultations with patients with invasive bladder cancer and suggest that interventions to increase fitness and haemoglobin may improve survival in patients who do and who do not undergo radical cystectomy.

Validation and psychometric evaluation of a brief screening questionnaire for psychological distress in patients with psoriasis

BACKGROUND

Patients with psoriasis are at risk of a co-morbid diagnosis of depression and/or anxiety. It is therefore essential for dermatologists to have valid and effective instruments that can screen and monitor depression and anxiety symptoms in psoriasis patients.

OBJECTIVE

The aim of this study was to validate the Mental Health Inventory (MHI-5) as a brief measure that can be used to evaluate psychological distress related to anxiety and depression in psoriasis patients.

METHODS

The sample included 76 adult dermatological outpatients diagnosed with psoriasis. Participants completed the MHI-5, the Hospital Anxiety and Depression Scale (HADS) and six subscales of the Self-Compassion Scale (SCS). Confirmatory factor analysis (CFA) was applied to examine the factor structure of MHI-5. Convergent validity was examined by applying correlations among all measures. Discriminant validity was examined by applying hierarchical regression models. Reliability was examined by calculating Cronbach's alpha coefficient.

RESULTS

Confirmatory factor analysis showed that the proposed one-factor model has a good fit to the data. The MHI-5 demonstrated satisfactory convergent validity by yielding significant moderate to strong correlations with the HADS and with the positive and negative subscales of the SCS. Discriminant validity was also evident with being at risk of anxiety predicting MHI-5 scores above and beyond the effect of gender and age. Hierarchical regressions were not performed because a very small number of participants (n = 3) were classified at risk of depression. The MHI-5 showed high internal consistency (α = 0.84).

CONCLUSION

This investigation provided evidence that MHI-5 is a reliable and valid instrument that can be used to effectively capture psychological distress in psoriasis patients.

WP1-12 Reducing infection rates in an intrathecal baclofen service; closing the audit cycle

Objectives

Intrathecal baclofen (ITB) is a recognised treatment strategy for the management of spasticity. We have 30 years of experience, and 160 patients currently receiving treatment.

Design

An audit (Jan 13 – Jul 15) demonstrated complication rates of 4.4% (infection) and 4.92% (catheter). After this we recommended 1 vancomycin wash of the pump pocket, 2 occlusive dressing of pressure sores, 3 timely MRSA pre-screening, and this was introduced June-August 2016. We present a re-audit of the service.

Subjects

All patients admitted for ITB pump surgery between June 2016 and June 2018.

Methods

The database of patients was used, from which the patient notes were reviewed with information relating to each surgical procedure recorded.

Results

There were 92 surgical procedures and 78 patients (M 30, F 48). 12 patients had complications, requiring 18 surgical procedures. Out of 18 surgical procedures, 10 were catheter- and 7 pump-related). Our infection rate was lower at 1% of all surgeries (compared with 4.4%), or 0.6% of all ITB pump patients per year (compared with 3.4%), and our catheter complication rate was 6.25% of all patients per year. Our annual incidence rate of all complications was 5.6% in both groups.

Conclusions

The infection risk is lower and complication rate remains stable. We will discuss factors which may influence the risk of complication, and consider recommendations for the future.

Effect of exercise modality on markers of insulin sensitivity and blood glucose control in pregnancies complicated with gestational diabetes mellitus: a systematic review

BACKGROUND/AIM

Exercise can be used as a strategy to attenuate hyperglycaemia experienced during gestational diabetes mellitus (GDM). To maximize its use for clinical management, the most effective modality should be identified. The purpose of this review is to elucidate the most effective modality of exercise on insulin sensitivity and blood glucose control in pregnant women with or at risk of GDM.

METHODS

A search was undertaken in MEDLINE, PubMed, Scopus, CINAHL, the Cochrane Library, Embase and the Maternity & Infant Healthcare Database. Studies that met inclusion criteria were randomized controlled trials and case-controlled studies, which compared exercise interventions with standard care during pregnancy in women with or at risk of GDM.

RESULTS

Two interventions using resistance training, eight using aerobic exercise and two using a combination of both modalities were included. The interventions showed consistently that requirements of insulin therapy, dosage, and latency to administration were improved in the exercise groups. Less consistent results were observed for capillary blood glucose measurements; however, both modalities and combination of modalities were effective at improving blood glucose control in already diagnosed patients and pregnant women with obesity. Discrepancies in the timing of intervention, GDM diagnostic criteria, and the different measures used to assess glucose metabolism make it difficult to draw clear recommendations.

CONCLUSION

Exercising three times per week for 40-60 min at 65-75% age-predicted heart rate maximum using cycling, walking or circuit training as a modality improved glycaemic control in GDM patients and reduced incidence of GDM in pregnant women with obesity. Further studies looking specifically at the effects of different modalities of exercise on glucose metabolism with combined strategies to enhance insulin sensitivity should be explored to maximize benefits for GDM pregnancies. Consistency in design and delivery of exercise-only interventions is required to make recommendations on a suitable exercise prescription in this population. In practice, adherence to consensus in diagnostic cut-offs for GDM diagnosis is fundamental for standardizing future research.

A land use regression model for explaining spatial variation in air pollution levels using a wind sector based approach

Estimating pollutant concentrations at a local and regional scale is essential in environmental and health policy decision making. Here we present a novel land use regression (LUR) modelling methodology that exploits the high temporal resolution of fixed-site monitoring (FSM) to produce a national-scale air quality model for the key pollutant NO₂. The methodology partitions concentration time series from a national FSM network into wind-dependent sectors or "wedges". A LUR model is derived using predictor variables calculated within the directional wind sectors, and compared against the long-term average concentrations within each sector. Validation results, based on 15 FSM training sites, show that the model captured 78% of the spatial variability in NO₂ across the Republic of Ireland. This compares favourably to traditional LUR models based on purpose-designed monitoring campaigns despite using approximately half the number of monitoring points. Results also demonstrate the value of incorporating the relative position of emission source and receptor into the empirical LUR model structure. We applied the model at a high-resolution across the Republic of Ireland to enable applications such as the study of environmental exposure and human health, assessing representativeness of air quality monitoring networks and informing environmental management and policy makers. While the study focuses on Ireland, the methodology also has potential applicability for other criteria pollutants where appropriate FSM and meteorological networks exist.

A re-audit of the technical quality of undergraduate root canal treatment after the introduction of new technology and teaching practices

AIM

To revaluate through re-audit the technical quality of undergraduate nonsurgical root canal treatment (RCTx) in a dental teaching hospital as a result of recommended changes to teaching practices.

METHODOLOGY

The technical quality of undergraduate RCTx was evaluated radiographically after educational changes and the mandatory introduction of new technologies (nickel-titanium files, apex locators, greater taper gutta-percha points) in 182 root canals. Evaluation was based on four criteria: presence of voids, root canal filling termination (0-2 mm of radiographic apex), all roots filled and the prepared canal contained the original anatomy. Chi-squared analysis was used to determine statistically significant improvements in quality between the respective audits (P < 0.05).

RESULTS

Twenty-three of the 40 canals in single-rooted teeth (57.5%) and 68 of the 129 (52.7%) canals in multirooted teeth analysed had an acceptable root filling. This compared with 48% of canals in single-rooted teeth and 38% of canals in multirooted teeth in the original audit. Specifically, the frequency of root canal voids and unsatisfactory apical root filling termination were reduced in multirooted teeth by 23% and 14% and in single-rooted teeth by 11% and 12%, respectively, compared with the original audit. When multirooted teeth were taken as one unit, 45.2% were considered to be acceptable, significantly better than the 18.8% multirooted teeth in the original audit (P = 0.042). Deviations from the canal anatomy on radiographic examination were rare findings in both audits.

CONCLUSIONS

Changes to endodontic teaching practices significantly improved the technical standards of undergraduate root filling in multirooted teeth. The regular auditing of undergraduate teaching practice is necessary to inform current teaching, instigate change and improve standards.

The 'Morph'ology of cytotechnology education

'Morph' means to change gradually and completely from one thing into another usually in a way that is surprising or seems magical. How can cytotechnology education be morphed into an expanded curriculum to teach new skills for advanced practice? The challenges cytotechnology programmes are facing today are many. The biggest of these challenges is the decreasing volume of Pap tests. Pap tests have been our 'bread and butter' throughout history; however, advances in health care and technology are inevitable, thus requiring changes in our educational practices. While these challenges seem insurmountable, we have the ability to expand the field of cytotechnology by taking advantage of existing opportunities. One example of these opportunities is performing rapid on site evaluation (ROSE) for specimen adequacy and perhaps taking it one step further by giving a preliminary diagnosis as a billable procedure. Now is the time to take gradual steps towards change in the current practice of cytotechnology. Let's join together and make the journey surprising and magical.

Profile of Frequent Attenders to a Dublin Inner City Emergency Department

A retrospective review of the demographics, co-morbidities and substance misuse of the 20 most frequent presenters to the Mater Misericordiae University Hospital emergency department during 2014 was carried out in an attempt to better understand the epidemiology of their presentations. Eighty-five percent were male and 15% female (p<0.001). The average age was 40.6 years with a median 38.5 years. All were unemployed and 7 (35%) had no fixed abode. Thirteen patients (65%) lived an average of 4.5 kilometres from the ED. In this study the presence of a mental illness, homelessness, alcohol or drug misuse were associated with significantly higher attendance rates (p=0.001, p<0.001, p<0.05, p<0.001 respectively). Early identification of these patients and targeting them for effective case-based community-led treatment strategies could improve their quality of life, decrease their cost of care and ultimately lead to more effective utilisation of our already overburdened emergency departments.

The phenology of Rubus fruticosus in Ireland: herbarium specimens provide evidence for the response of phenophases to temperature, with implications for climate warming

To date, phenological research has provided evidence that climate warming is impacting both animals and plants, evidenced by the altered timing of phenophases. Much of the evidence supporting these findings has been provided by analysis of historic records and present-day fieldwork; herbaria have been identified recently as an alternative source of phenological data. Here, we used Rubus specimens to evaluate herbaria as potential sources of phenological data for use in climate change research and to develop the methodology for using herbaria specimens in phenological studies. Data relevant to phenology (collection date) were recorded from the information cards of over 600 herbarium specimens at Ireland's National Herbarium in Dublin. Each specimen was assigned a score (0-5) corresponding to its phenophase. Temperature data for the study period (1852 - 2007) were obtained from the University of East Anglia's Climate Research Unit (CRU); relationships between temperature and the dates of first flower, full flower, first fruit and full fruit were assessed using weighted linear regression. Of the five species of Rubus examined in this study, specimens of only one (R. fruticosus) were sufficiently abundant to yield statistically significant relationships with temperature. The results revealed a trend towards earlier dates of first flower, full flower and first fruit phenophases with increasing temperature. Through its multi-phenophase approach, this research serves to extend the most recent work-which validated the use of herbaria through use of a single phenophase-to confirm herbarium-based research as a robust methodology for use in future phenological studies.

WITHDRAWN: Commercial hospital discharge packs for breastfeeding women

BACKGROUND

Exclusive breastfeeding until around six months of age, followed by the introduction of solids with continued breastfeeding, is considered to be the optimal nutritional start for newborn infants.

OBJECTIVES

To determine whether the exclusivity and duration of breastfeeding is affected by giving mothers commercial discharge packs in hospital which contain artificial formula or promotional material for artificial formula. These packs are those which are commonly given to mothers on leaving hospital after giving birth (thus discharge packs).

SEARCH STRATEGY

Comprehensive electronic search of the register of clinical trials maintained and updated by the Cochrane Pregnancy and Childbirth Group and CINAHL and MEDLINE.

SELECTION CRITERIA

All randomised controlled trials with or without blinding to examine the effects of commercial discharge packs on breastfeeding.

PARTICIPANTS

Consenting postpartum women who initiate breastfeeding while in hospital or immediately upon discharge.

INTERVENTIONS

Commercial discharge packs which contain free samples of infant formula or promotional material versus non commercial discharge packs (specifically those from which free samples of infant formula have been removed or have been replaced with e.g. breast pads) or no pack.

MAIN OUTCOME MEASURES

The proportion of women breastfeeding at six weeks and 3 months (13 weeks) postpartum.Other outcomes: Rates of breastfeeding at other fixed time points between 0 and 6 months postpartum.

DATA COLLECTION AND ANALYSIS

Data were extracted by one reviewer and checked by a second reviewer.

MAIN RESULTS

Nine randomised controlled trials involving a total of 3730 women were analysed. The studies only included women from North America. The meta-analysis showed that when comparing commercial discharge packs with any of the controls (no intervention, non-commercial pack and combinations of these), exclusive breastfeeding was reduced at all time points in the presence of commercial hospital discharge packs. There was no evidence to support the conjecture that use of hospital discharge packs causes the early termination of non-exclusive breastfeeding. Where the introduction of solid food was measured, giving a commercial pack (with or without formula) reduced the time before solid food was introduced.

AUTHORS' CONCLUSIONS

The giving of commercial hospital discharge packs (with or without formula) appears to reduce the number of women exclusively breastfeeding at all times but has no significant effect upon the earlier termination of non-exclusive breastfeeding.

Phage display mutagenesis of the chimeric dual cytokine receptor agonist myelopoietin

Myelopoietins comprise a class of chimeric cytokine receptor agonists consisting of an hIL-3 (human interleukin-3) receptor agonist and an hG-CSF (human granulocyte colony-stimulating factor) receptor agonist linked head-to-tail at their respective carboxy and amino termini. The combination of an early acting cytokine (hIL-3) with a late acting one (hG-CSF) allows efficient hematopoeitic reconstruction following myeloablative insult, and drives differentiation of non-myelocytic lineages (ie thrombocytic lineages) that are inaccessible using hG-CSF alone, in both preclinical models and clinical settings. A myelopoietin species was displayed and mutagenized on filamentous bacteriophage: both component agonists of myelopoietin were presented in biologically functional conformations as each recognized its corresponding receptor. Five amino acid positions in a short region of the hG-CSF receptor agonist module of myelopoietin that had been identified as important for proliferative activity were mutagenized. Display was used because it allows very 'deep' mutagenesis at selected residues: >10(5) substitution variants were affinity-screened using the hG-CSF receptor and 130 new, active variants of myelopoietin were identified and characterized. None of the selected variants were significantly more active than the parental myelopoietin species in a hG-CSF-dependent cell proliferation assay, though many were as active. Many of these relatively high-activity variants contained parental amino acids at several positions, suggesting the parental sequence may already be optimal at these positions for the assays used, and potentially accounting for the failure to identify enhanced bioactivity variants. Analysis of substitutions of high-activity variants complements and extends previous alanine scanning, and other genetic and biochemical data for hG-CSF variants.

Improving the health of Oklahomans: status and goals of adult immunization

This article will discuss the prevalence and impact of the infectious diseases affecting adult Oklahomans for which vaccines are available. Evidence for vaccine utilization and the present status and future aspirations for population-wide immunization rates in Oklahoma will also be reviewed. The information and data herein are taken mainly from recommendations established by the US Preventive Services Task Force (USPSTF); the Centers for Disease Control (CDC) publication Epidemiology and Prevention of Vaccine-Preventable Disease; the findings of the Advisory Committee on Immunization Practices (ACIP) as published in the CDC's Morbidity and Mortality Weekly Report; the Oklahoma State Department of Health (OSDH) State of the State's Health Report; and the Behavioral Risk Factor Surveillance System (BRFSS), a telephone survey conducted by the CDC.

Prokaryotic diversity in Zostera noltii-colonized marine sediments

The diversity of microorganisms present in a sediment colonized by the phanerogam Zostera noltii has been analyzed. Microbial DNA was extracted and used for constructing two 16S rDNA clone libraries for Bacteria and Archaea. Bacterial diversity was very high in these samples, since 57 different sequences were found among the 60 clones analyzed. Eight major lineages of the Domain Bacteria were represented in the library. The most frequently retrieved bacterial group (36% of the clones) was delta-Proteobacteria related to sulfate-reducing bacteria. The second most abundant group (27%) was gamma-Proteobacteria, including five clones closely related to S-oxidizing endosymbionts. The archaeal clone library included members of Crenarchaeota and Euryarchaeota, with nine different sequences among the 15 analyzed clones, indicating less diversity when compared to the Bacteria organisms. None of these sequences was closely related to cultured Archaea organisms.

Commercial hospital discharge packs for breastfeeding women

BACKGROUND

Exclusive breastfeeding until around six months of age, followed by the introduction of solids with continued breastfeeding, is considered to be the optimal nutritional start for newborn infants.

OBJECTIVES

To determine whether the exclusivity and duration of breastfeeding is affected by giving mothers commercial discharge packs in hospital which contain artificial formula or promotional material for artificial formula. These packs are those which are commonly given to mothers on leaving hospital after giving birth (thus discharge packs).

SEARCH STRATEGY

Comprehensive electronic search of the register of clinical trials maintained and updated by the Cochrane Pregnancy and Childbirth Group and CINAHL and MEDLINE.

SELECTION CRITERIA

All randomised controlled trials with or without blinding to examine the effects of commercial discharge packs on breastfeeding.

PARTICIPANTS

Consenting postpartum women who initiate breastfeeding while in hospital or immediately upon discharge.

INTERVENTIONS

Commercial discharge packs which contain free samples of infant formula or promotional material versus non commercial discharge packs (specifically those from which free samples of infant formula have been removed or have been replaced with e.g. breast pads) or no pack.

MAIN OUTCOME MEASURES

The proportion of women breastfeeding at six weeks and 3 months (13 weeks) postpartum. Other outcomes: Rates of breastfeeding at other fixed time points between 0 and 6 months postpartum.

DATA COLLECTION AND ANALYSIS

Data were extracted by one reviewer and checked by a second reviewer.

MAIN RESULTS

Nine randomised controlled trials involving a total of 3730 women were analysed. The studies only included women from North America. The meta-analysis showed that when comparing commercial discharge packs with any of the controls (no intervention, non-commercial pack and combinations of these), exclusive breastfeeding was reduced at all time points in the presence of commercial hospital discharge packs. There was no evidence to support the conjecture that use of hospital discharge packs causes the early termination of non-exclusive breastfeeding. Where the introduction of solid food was measured, giving a commercial pack (with or without formula) reduced the time before solid food was introduced.

REVIEWER'S CONCLUSIONS

The giving of commercial hospital discharge packs (with or without formula) appears to reduce the number of women exclusively breastfeeding at all times but has no significant effect upon the earlier termination of non-exclusive breastfeeding.

Characterization of the human glutamate receptor subunit 3 gene (GRIA3), a candidate for bipolar disorder and nonspecific X-linked mental retardation

The X-chromosome breakpoint in a female patient with a balanced translocation t(X;12)(q24;q15), bipolar affective disorder and mental retardation was mapped within the glutamate receptor 3 (GRIA3) gene by fluorescence in situ hybridization. The GRIA3 cDNA of 5894 bp was cloned, and the gene structure and pattern of expression were determined. The most abundant GRIA3 transcript is composed of 17 exons. An additional 5 exons (2a, 2b, 5a, 5b, and 5c) from the 5' end of the GRIA3 open reading frame were identified by EST analysis (ESTs AI379066 and AA947914). Two new polymorphic microsatellite repeats, (TC)(n=12-26) and (AC)(n=15-19), were identified within GRIA3 5' and 3'UTRs. No mutations were detected in families segregating disorders mapping across GRIA3, one with X-linked bipolar affective disorder (BP) and one with a nonspecific X-linked mental retardation (MRX27). To assess the possibility of the involvement of the GRIA3 gene in familial cases of complex BP, a large set of 373 individuals from 40 pedigrees segregating BP were genotyped using closely linked (DXS1001) and intragenic (DXS1212 and GRIA3 3' UTR (AC)(n))) GRIA3 STR markers. No evidence of linkage was found by parametric Lod score analysis (the highest Lod score was 0. 3 at DXS1212, using the dominant transmission model) or by affected sib-pair analysis.

Skin signs of systemic disease

BACKGROUND

Dermatological problems are a common presentation in general practice and skin disorders may be a manifestation of underlying systemic disease.

OBJECTIVE

To describe cutaneous manifestations of some commonly occurring systemic diseases.

DISCUSSION

This article alerts the general practitioner to those skin conditions that may warrant further assessment for underlying disease and those that may complicate known disorders such as diabetes.

Indirect evidence of human skeletal muscle damage and collagen breakdown after eccentric muscle actions

Indirect markers of muscle damage and collagen breakdown were recorded for up to 9 days after a bout of concentric, followed by a bout of eccentric, muscle actions. Nine untrained participants performed two bouts of 50 maximum effort repetitions on an isokinetic dynamometer (angular velocity 1.05 rad x s(-1), range of motion 1.75 rad). An initial concentric bout of muscle actions was followed by an eccentric bout 21 days later, using the same knee extensors. Concentric actions induced no changes in maximum voluntary isometric contraction force (MVC), nor induced any changes in the serum enzyme activities of creatine kinase, a lactate dehydrogenase isoenzyme (LDH-1), or alkaline phosphatase. Similarly, concentric actions induced no change in markers of collagen breakdown, namely plasma hydroxyproline and serum type 1 collagen concentration. In contrast, eccentric actions induced a 23.5+/-19.0% (mean+/-s) decrease in MVC immediately post-exercise (P < 0.05), and increased the serum enzyme activities of creatine kinase and LDH-1 to 486+/-792 and 90+/-11 IU.l(-1) respectively on day 3 post-exercise, and to 189+/-159 and 96+/-13 IU x l(-1) respectively on day 7 post-exercise (all P< 0.05). Eccentric actions induced no significant changes in plasma hydroxyproline, but increased collagen concentration on days 1 and 9 post-exercise (48.6% and 44.3% increases above pre-exercise on days 1 and 9 respectively; both P < 0.05). We conclude that eccentric but not concentric actions may result in temporary muscle damage, and that collagen breakdown may also be affected by eccentric actions. With caution, indices of collagen breakdown may be used to identify exercise-induced damage to connective tissue.

Fibroblast growth factor homologous factor 2 (FHF2): gene structure, expression and mapping to the Börjeson-Forssman-Lehmann syndrome region in Xq26 delineated by a duplication breakpoint in a BFLS-like patient

Börjeson-Forssman-Lehmann syndrome (BFLS) is a syndromal X-linked mental retardation, which maps by linkage to the q26 region of the human X chromosome. We have identified a male patient with BFLS-like features and a duplication, 46,Y,dup(X)(q26q28), inherited from his phenotypically normal mother. Fluorescence in situ hybridisation using yeast artificial chromosome clones from Xq26 localised the duplication breakpoint to an approximately 400-kb interval in the Xq26.3 region between DXS155 and DXS294/DXS730. Database searches and analysis of available genomic DNA sequence from the region revealed the presence of the fibroblast growth factor homologous factor gene, FHF2, within the duplication breakpoint interval. The gene structure of FHF2 was determined and two new exons were identified, including a new 5' end exon, 1B. FHF2 is a large gene extending over approximately 200 kb in Xq26.3 and is composed of at least seven exons. It shows tissue-specific alternative splicing and alternative transcription starts. Northern blot hybridisation showed highest expression in brain and skeletal muscle. The FHF2 gene localisation and tissue-specific expression pattern suggest it to be a candidate gene for familial cases of the BFLS syndrome and other syndromal and non-specific forms of X-linked mental retardation mapping to the region.

Changes in indices of antioxidant status, lipid peroxidation and inflammation in human skeletal muscle after eccentric muscle actions

This study investigated the effects of chronic muscle inflammation on indices of antioxidant status and muscle injury after eccentric exercise. Eight subjects each performed 70 maximal voluntary eccentric muscle actions on an isokinetic dynamometer, using the knee extensors of a single leg. Venous blood samples were collected into serum and EDTA tubes 5 and 3 days before exercise, immediately before exercise, and then again on days 3, 4, 5, 6, 7, 10 and 12 after the bout. Needle biopsies were taken from the vastus lateralis of six subjects, a week before exercise (baseline), and again on days 4 and 7 post-exercise. The concentrations of malondialdehyde in plasma and muscle were used as markers of lipid peroxidation. Creatine kinase activity, beta-glucuronidase activity and total antioxidant capacity were determined in serum. In muscle, aqueous and bound total antioxidant capacity, the aqueous sulphydryl concentration, and beta-glucuronidase and glucose-6-phosphate dehydrogenase activity were determined. No changes were detected in serum total antioxidant capacity, serum creatine kinase and beta-glucuronidase after the baseline biopsy. After exercise serum creatine kinase and beta-glucuronidase were elevated although other serum measures were unchanged. In muscle, aqueous and bound total antioxidant capacity, sulphydryls, glucose-6-phosphate dehydrogenase and beta-glucuronidase were all elevated. Despite evidence of inflammation in this study, muscle antioxidant status was not compromised, and malondialdehyde was unaltered in muscle and plasma. Therefore, this study provides no evidence that chronic muscle inflammation compromises antioxidant status or increases lipid peroxidation.

Carbamazepine-10,11-epoxide in therapeutic drug monitoring

Carbamazepine (CBZ) is widely used in the treatment of epilepsy, frequently in combination with other anticonvulsants. Its metabolite, carbamazepine-10,11-epoxide, is pharmacologically active and is increased with concurrent use of valproate and other anticonvulsants. This pharmacokinetic interaction may be particularly important because CBZ, its epoxide, phenytoin, and lamotrigine all act on fast voltage-dependent sodium channels. Over a 2-month period, routine serum requests for CBZ (n=47) (excluding known cases of overdose) were also analyzed for CBZ epoxide, phenytoin, and lamotrigine using a simultaneous high performance liquid chromatographic (HPLC) method. Valproate was measured using fluorescence polarization immunoassay (FPIA). With concurrent phenytoin and lamotrigine administration, there was a relative increase in CBZ epoxide and a significant decrease in the ratio of CBZ to epoxide (from more than 5 to 3). If valproate was also present, the concentration of parent and metabolite increased significantly, causing potential toxicity. Two patients in this latter group had significant clinical toxicity, with parent CBZ concentrations in the reference range; a third patient suffered from poor control of seizures. This study illustrates the importance of awareness of the contribution of active metabolites in therapeutic drug monitoring and raises questions about the role of the routine monitoring of such metabolites.

Absorption enhancers as tools to determine the route of nasal absorption of peptides

The nasal absorption of a series of peptides was studied in order to examine the relationship between extent of absorption and lipophilicity and absorption enhancers were used to probe the mechanism of peptide absorption. An in situ rat nasal perfusion technique was employed to assess the nasal absorption of a series of peptides, D-FGGGGG (D-FG5), D-FD-FGGGG (D-F2G4) and D-FD-FD-FGGG (D-F3G3), [D-ala2, D-leu5]enkephalin (YD-AGFD-L) and thyrotrophin releasing hormone (TRH). The enhancers sodium tauro-24,25 dihydrofusidate (STDHF), ethylene diamine tetraacetic acid (EDTA and dimethyl-beta-cyclodextrin (DMbetaCD) were utilized to improve and elucidate the mechanisms of peptide absorption. There was no significant relationship between extent of peptide absorption and lipophilicity as determined by C log P values. STDHF was a potent absorption enhancer but demonstrated overt toxicity. Conversely, EDTA did not demonstrate extensive toxicity but was found to be a poor absorption enhancer. DMbetaCD displayed some toxicity and was also found to inhibit the absorption of D-FG5,D-F2G4 and D-F3G3. This reduction is likely to be a result of the peptide/DMbetaCD complex formation. The peptides studied appear to be predominantly absorbed by a passive paracellular mechanism.

Speed of onset of action of Tilarin

Two studies have been carried out specifically to examine the speed of onset of action of intranasal nedocromil sodium 1% (Tilarin) for the relief of symptoms due to ragweed allergic rhinitis. One, a multicentre placebo-controlled comparative study using a QID regimen, 1 spray per nostril, was designed to assess the speed of onset of action of nedocromil sodium during the first week of treatment in patients with rhinitis symptoms, and to evaluate the efficacy and safety of nedocromil sodium during 6 weeks of treatment (1). A 1-week baseline, the start of which was timed to coincide with the start of the ragweed season, was followed by 6 weeks double-blind trial treatment; only patients (n = 166) who were symptomatic at the end of baseline were included in the double-blind phase. Non-parametric analyses of all variables including a summary score (stuffy nose, runny nose, itchy nose and sneezing) showed that the onset of action of nedocromil sodium occurred on the first day of treatment. Further, patients using nedocromil sodium had less symptoms during the 10 days of peak pollen, at which time physician assessment showed reduced mucosal oedema and nasal discharge, and both patient and clinician opinions favoured nedocromil sodium. No significant adverse events were reported during this 6-week study. In the second study (2), 104 patients were randomly allocated to receive either nedocromil sodium or placebo, QID. They then spent 10 hours per day for 2 consecutive days in Iowa City Park during the peak of the ragweed season. Only patients showing significant symptoms of seasonal allergic rhinitis (SAR) during 3 hourly baseline assessments were included. Over the 2-day period, symptom scores for stuffy nose, runny nose, itchy nose and sneezing, and global symptom summary scores, were recorded at 19 hourly time points. At home in the evening, patients recorded symptom scores for the post-exposure period. In comparison with placebo, nedocromil sodium significantly improved rhinitis symptoms within 2 hours, and this reduction in SAR symptoms was maintained throughout the 2-day exposure period. Post exposure symptom summary scores were also significantly lower in patients treated with nedocromil sodium than in those patients treated with placebo. Overall, very few adverse events were reported, none of them serious. In conclusion, nedocromil sodium 1% nasal spray acts rapidly, within 2 hours on the first day of treatment, to reduce ongoing symptoms of SAR. Relief of rhinitis symptoms is maintained throughout the peak pollen period with nedocromil sodium QID, which appears to be a safe and well tolerated treatment for ragweed SAR.

Cytologic diagnosis of cat scratch disease (CSD) by fine-needle aspiration

Cat scratch disease (CSD) is usually a benign, self-limited lymphadenitis, characterized by suppurative granulomas. It can, however, produce a wide spectrum of clinical symptoms and cytologic changes and be the source of diagnostic dilemmas. Identification of pleomorphic bacilli (PB) with silver impregnation stains aids in the diagnosis, but this has not been well documented in cytologic preparations or in cases without the classic morphologic changes. We reviewed 13 aspirations from eight patients (aged 13-36 yr) occurring over a 15 mo time period, all clinically or cytologically suspicious for CSD. Sites included: axilla (6), parotid (3), epitrochlear (1), neck (1), submental (1), and intraclavicular (1) nodes. Neoplasia was initially suspected clinically in 38% of the cases. All but two patients had cat exposure on subsequent interview. The cytologic differential included bacterial abscess and lymphoproliferative disorders in 31%. Neither granulomas nor suppurative inflammation were seen in all cases. Changes included: granulomas (77%), PMNs (62%), dispersed epithelioid histiocytes (46%), and suppurative granulomas (38%). A modified silver stain (Modified Steiner, Sigma Diagnostics, St. Louis, MO) was performed on all specimens. Silver positive organisms were seen in 69% of cases and were not limited to those preparations with suppurative granulomas. Fine-needle aspiration biopsy (FNAB) is an effective method for diagnosing CSD despite its heterogeneous appearance; and, when combined with clinical information and silver staining, may obviate the need for excision.

FRAXE and mental retardation

Mental impairment and instability of the CCG repeat at FRAXE is described in six kindreds. Cosegregation of FRAXA and FRAXE was found within one of these kindreds. Cytogenetic expression of FRAXE was shown to skip a generation when associated with a reduction in size of the CCG expansion when transmitted through a male; however, in general, transmission occurred through females and a copy number increased from one generation to the next. In these respects the behaviour of FRAXE paralleled that of FRAXA. A relationship between FRAXE and non-specific mental impairment is strongly suggested by the occurrence in these families of more mentally impaired male and female carriers, after removal of index cases, than could reasonably be expected by chance.

Localisation of the gene for X-linked reticulate pigmentary disorder with systemic manifestations (PDR), previously known as X-linked cutaneous amyloidosis

X-linked reticulate pigmentary disorder (PDR), previously reported as X-linked cutaneous amyloidosis (MIM#301220), is characterized by brown pigmentation of the skin which follows the lines of Blaschko in females but appears as reticulate sheets in males. Males may suffer severe gastrointestinal disorders in infancy with failure to thrive and early death. Nowadays symptomatic treatment allows survival and other manifestations may appear such as corneal dystrophy with severe photophobia or chronic respiratory disease. Amyloid deposition in the skin may be no more than an age-dependent secondary manifestation. The PDR gene was localised by linkage analysis to Xp21-p22. The background genetic map is Xpter-DXS996-22.5-DXS207-3.3-DXS999-3.3-DXS36 5-14.2-DXS989-4.1-3'DMD-3.5- DXS997-1.0-STR44-9.3-DYSI-2.3-DXS1068-11.0-DX S228 with distances between markers given in cM. Recombinants detected with DXS999 distally and DXS228 proximally, define the limits to the localisation. Linkage was found with several markers within this interval. Peak lod scores of 3.21 at theta = 0.0 were obtained between PDR and DXS989 and between PDR and 5'DYSI within the dystrophin locus.