Targeting methanotrophs and isolation of a novel psychrophilic Methylobacter species from a terrestrial Arctic alkaline methane seep in Lagoon Pingo, Central Spitsbergen (78° N)

The microbial diversity associated with terrestrial groundwater seepage through permafrost soils is tightly coupled to the geochemistry of these fluids. Terrestrial alkaline methane seeps from Lagoon Pingo, Central Spitsbergen (78°N) in Norway, with methane-saturated and oxygen-limited groundwater discharge providing a potential habitat for methanotrophy. Here, we report on the microbial community's comparative analyses and distribution patterns at two sites close to Lagoon Pingo's methane emission source. To target methane-oxidizing bacteria from this system, we analysed the microbial community pattern of replicate samples from two sections near the main methane seepage source. DNA extraction, metabarcoding and subsequent sequencing of 16S rRNA genes revealed microbial communities where the major prokaryotic phyla were Pseudomonadota (42-47%), Gemmatimonadota (4-14%) and Actinobacteriota (7-11%). Among the Pseudomonadota, members of the genus Methylobacter were present at relative abundances between 1.6 and 4.7%. Enrichment targeting the methane oxidising bacteria was set up using methane seep sediments as inoculum and methane as the sole carbon and energy source, and this resulted in the isolation of a novel psychrophilic methane oxidizer, LS7-T4AT. The optimum growth temperature for the isolate was 13 °C and the pH optimum was 8.0. The morphology of cells was short rods, and TEM analysis revealed intracytoplasmic membranes arranged in stacks, a distinctive feature for Type I methanotrophs in the family Methylomonadaceae of the class Gammaproteobacteria. The strain belongs to the genus Methylobacter based on high 16S rRNA gene similarity to the psychrophilic species of Methylobacter psychrophilus Z-0021T (98.95%), the psychrophilic strain Methylobacter sp. strain S3L5C (99.00%), and the Arctic mesophilic species of Methylobacter tundripaludum SV96T (99.06%). The genome size of LS7-T4AT was 4,338,157 bp with a G + C content of 47.93%. The average nucleotide identities (ANIb) of strain LS7-T4AT to 10 isolated strains of genus Methylobacter were between 75.54 and 85.51%, lower than the species threshold of 95%. The strain LS7-T4AT represents a novel Arctic species, distinct from other members of the genus Methylobacter, for which the name Methylobacter svalbardensis sp. nov. is proposed. The type of strain is LS7-T4AT (DSMZ:114308, JCM:39463).

Ibrutinib as first-line therapy for mantle cell lymphoma: a multicenter, real-world UK study

ABSTRACT

During the COVID-19 pandemic, ibrutinib with or without rituximab was approved in England for initial treatment of mantle cell lymphoma (MCL) instead of immunochemotherapy. Because limited data are available in this setting, we conducted an observational cohort study evaluating safety and efficacy. Adults receiving ibrutinib with or without rituximab for untreated MCL were evaluated for treatment toxicity, response, and survival, including outcomes in high-risk MCL (TP53 mutation/deletion/p53 overexpression, blastoid/pleomorphic, or Ki67 ≥ 30%). A total of 149 patients from 43 participating centers were enrolled: 74.1% male, median age 75 years, 75.2% Eastern Cooperative Oncology Group status of 0 to 1, 36.2% high-risk, and 8.9% autologous transplant candidates. All patients received ≥1 cycle ibrutinib (median, 8 cycles), 39.0% with rituximab. Grade ≥3 toxicity occurred in 20.3%, and 33.8% required dose reductions/delays. At 15.6-month median follow-up, 41.6% discontinued ibrutinib, 8.1% due to toxicity. Of 104 response-assessed patients, overall (ORR) and complete response (CR) rates were 71.2% and 20.2%, respectively. ORR was 77.3% (low risk) vs 59.0% (high risk) (P = .05) and 78.7% (ibrutinib-rituximab) vs 64.9% (ibrutinib; P = .13). Median progression-free survival (PFS) was 26.0 months (all patients); 13.7 months (high risk) vs not reached (NR) (low risk; hazard ratio [HR], 2.19; P = .004). Median overall survival was NR (all); 14.8 months (high risk) vs NR (low risk; HR, 2.36; P = .005). Median post-ibrutinib survival was 1.4 months, longer in 41.9% patients receiving subsequent treatment (median, 8.6 vs 0.6 months; HR, 0.36; P = .002). Ibrutinib with or without rituximab was effective and well tolerated as first-line treatment of MCL, including older and transplant-ineligible patients. PFS and OS were significantly inferior in one-third of patients with high-risk disease and those unsuitable for post-ibrutinib treatment, highlighting the need for novel approaches in these groups.

Levels and distribution profiles of Per- and Polyfluoroalkyl Substances (PFAS) in a high Arctic Svalbard ice core

Per- and polyfluoroalkyl substances (PFAS) are a group of persistent organic contaminants of which some are toxic and bioaccumulative. Several PFAS can be formed from the atmospheric degradation of precursors such as fluorotelomer alcohols (FTOHs) as well as hydrochlorofluorocarbons (HFCs) and other ozone-depleting chlorofluorocarbon (CFC) replacement compounds. Svalbard ice cores have been shown to provide a valuable record of long-range atmospheric transport of contaminants to the Arctic. This study uses a 12.3 m ice core from the remote Lomonosovfonna ice cap on Svalbard to understand the atmospheric deposition of PFAS in the Arctic. A total of 45 PFAS were targeted, of which 26 were detected, using supercritical fluid chromatography (SFC) tandem mass spectrometry (MS/MS) and ultra-performance liquid chromatography (UPLC) MS/MS. C₂ to C₁₁ perfluoroalkyl carboxylic acids (PFCAs) were detected continuously in the ice core and their fluxes ranged from 2.5 to 8200 ng m^-2 yr^-1 (9.51-16,500 pg L^-1). Trifluoroacetic acid (TFA) represented 71 % of the total mass of C₂ - C₁₁ PFCAs in the ice core and had increasing temporal trends in deposition. The distribution profile of PFCAs suggested that FTOHs were likely the atmospheric precursor to C₈ - C₁₁ PFCAs, whereas C₂ - C₆ PFCAs had alternative sources, such as HFCs and other CFC replacement compounds. Perfluorooctanesulfonic acid (PFOS) was also widely detected in 82 % of ice core subsections, and its isomer profile (81 % linear) indicated an electrochemical fluorination manufacturing source. Comparisons of PFAS concentrations with a marine aerosol proxy showed that marine aerosols were insignificant for the deposition of PFAS on Lomonosovfonna. Comparisons with a melt proxy showed that TFA and PFOS were mobile during meltwater percolation. This indicates that seasonal snowmelt and runoff from post-industrial accumulation on glaciers could be a significant seasonal source of PFAS to ecosystems in Arctic fjords.

Managing relapsed refractory lymphoma with palliative oral chemotherapy: A multicentre retrospective study

PEP-C (prednisolone, etoposide, procarbazine and cyclophosphamide) is an orally administered daily chemotherapy regimen used with palliative intent in relapsed refractory lymphoma. To our knowledge, no data on PEP-C have been reported since the original group described the regimen. Here we present a multicentre retrospective cohort reporting our use of PEP-C in 92 patients over an 8-year period. We find that even heavily pretreated lymphoma can respond to PEP-C, particularly low-grade lymphoma (including mantle cell) and lymphoma that was sensitive to the previous line of systemic therapy (chemosensitive). These characteristics may help in the selection of patients likely to derive benefit. The median overall survival of patients with chemosensitive lymphoma treated with PEP-C is 217 days. Within the limitations of a retrospective cohort, we find that PEP-C is well tolerated: the most common toxicity leading to discontinuation is marrow suppression. We suggest that PEP-C should be considered for patients with relapsed refractory lymphoma in two settings: first, where there is no licensed alternative; and second, where the licensed alternative is an intravenous drug and the patient would prefer to choose an oral chemotherapy option.

COVID-19 survey burden for health care workers: literature review and audit

Objectives

Concerns have been raised about the quantity and quality of research conducted during the COVID-19 pandemic, particularly related to the mental health and wellbeing of health care workers (HCWs). For understanding the volume, source, methodological rigour and degree of overlap in COVID-19, studies were conducted among HCWs in the United Kingdom (UK).

Study design

Mixed methods approach, literature review and audit.

Methods

First, a literature review of published research studies and second, an audit of studies HCWs have been invited to complete. For the literature review, we searched Medline, PsycINFO and Nexis, webpages of three medical organisations (Royal Society of Medicine, Royal College of Nursing and British Medical Association), and the YouGov website. For the audit, a non-random purposive sample of six HCWs from different London NHS Trusts reviewed email, WhatsApp and SMS messages they received for study invitations.

Results

The literature review identified 27 studies; the audit identified 70 study invitations. Studies identified by the literature review were largely of poor methodological rigour: only eight studies (30%) provided response rate, one study (4%) reported having ethical approval, and one study (4%) reported funding details. There was substantial overlap in the topics measured. In the audit, volunteers received a median of 12 invitations. The largest number of study invitations were for national surveys (n = 23), followed by local surveys (n = 16) and research surveys (n = 8).

Conclusion

HCWs have been asked to complete numerous surveys that frequently have methodological shortcomings and overlapping aims. Many studies do not follow scientific good-practice and generate questionable, non-generalisable results.

Diffuse large B cell lymphoma (DLBCL) in patients older than 65 years: analysis of 3 year Real World data of practice patterns and outcomes in England

BACKGROUND

We wished to examine treatment and outcome patterns in older diffuse large B-cell lymphoma (DLBCL) patients, with a focus on the effect of route-to-diagnosis to outcome.

METHODS

Data were extracted from Public Health England's National Cancer Registration and Analysis Service between 2013 and 2015 included route-to-diagnosis, disease characteristics and survival for 9186 patients ≥65 years. Systemic Anti-Cancer Therapy data identified front-line regimens, cycles and doses.

RESULTS

Route-to-diagnosis were emergency (34%), NHS urgent cancer pathway (rapid haemato-oncologist review <2 weeks), (29%) and standard GP referral (25%). The most common regimen was R-CHOP (n = 4392). 313 patients received R-miniCHOP (7% of R-CHOP). For all patients, 3-year overall survival (OS) for 65-79 years was 57% and for ≥80 years was 32%. Three-year OS for R-CHOP-treated patients diagnosed via emergency presentation was 54% (adjusted hazard ratio (HR) 1.63, p < 0.01) and 75% (adjusted HR 0.81, p < 0.01) on the NHS urgent cancer pathway (reference HR:1.00: GP referrals). 3-year OS was 54% for both R-miniCHOP and R-CHOP in ≥80 years.

CONCLUSIONS

Our comprehensive population analysis is the first to show that the NHS urgent cancer pathway is associated with a superior survival after adjusting for multiple confounders. Equivalent survival for R-CHOP and R-mini-CHOP was demonstrated in those ≥80 years.

Advanced Hodgkin lymphoma in the East of England: a 10-year comparative analysis of outcomes for real-world patients treated with ABVD or escalated-BEACOPP, aged less than 60 years, compared with 5-year extended follow-up from the RATHL trial

Treatment with ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) or escalated(e)-BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisolone) remains the international standard of care for advanced-stage classical Hodgkin lymphoma (HL). We performed a retrospective, multicentre analysis of 221 non-trial ("real-world") patients, aged 16-59 years, diagnosed with advanced-stage HL in the Anglia Cancer Network between 2004 and 2014, treated with ABVD or eBEACOPP, and compared outcomes with 1088 patients in the Response-Adjusted Therapy for Advanced Hodgkin Lymphoma (RATHL) trial, aged 18-59 years, with median follow-up of 87.0 and 69.5 months, respectively. Real-world ABVD patients (n=177) had highly similar 5-year progression-free survival (PFS) and overall survival (OS) compared with RATHL (PFS 79.2% vs 81.4%; OS 92.9% vs 95.2%), despite interim positron-emission tomography-computed tomography (PET/CT)-guided dose-escalation being predominantly restricted to trial patients. Real-world eBEACOPP patients (n=44) had superior PFS (95.5%) compared with real-world ABVD (HR 0.20, p=0.027) and RATHL (HR 0.21, p=0.015), and superior OS for higher-risk (international prognostic score ≥3 [IPS 3+]) patients compared with real-world IPS 3+ ABVD (100% vs 84.5%, p=0.045), but not IPS 3+ RATHL patients. Our data support a PFS, but not OS, advantage for patients with advanced-stage HL treated with eBEACOPP compared with ABVD and suggest higher-risk patients may benefit disproportionately from more intensive therapy. However, increased access to effective salvage therapies might minimise any OS benefit from reduced relapse rates after frontline therapy.

Parental perceptions of COVID-19-like illness in their children

Objectives

The objective of the study is to explore parents' perceptions of COVID-19–like symptoms in their child and attitudes towards isolating from others in the household when unwell.

Study design

The study used qualitative, semistructured interviews.

Methods

The study involved thirty semistructured telephone interviews with parents of children between 4 and 18 years. Thirty semistructured telephone interviews with parents of children between 4 and 18 years.

Results

We found four themes relating to symptom attribution (‘normalising symptoms’, ‘err on the side of caution’, ‘experience of temperature’, ‘symptoms not normal for us’). In general, parents were more likely to attribute symptoms to COVID-19 if a temperature was present or the symptoms were perceived as ‘unusual’ for their family. Four themes relating to self-isolation (‘difficult to prevent contact with children’, ‘isolation would be no different to lockdown life’, ‘ability to get food and supplies’, ‘limited space’). Parents believed they would find isolation within the household difficult or impossible if they had dependent children, had limited space or could not shop for groceries.

Conclusions

The findings highlight complexities in symptom perception, attribution and household isolation. We suggest that they can be overcome by (a) providing better guidance on what symptoms require action, (b) providing guidance as to how to prevent infection within the household and (c) by supporting families with grocery shopping through a potential second or third wave.

Functional Associations and Resilience in Microbial Communities

Microbial communities have inherently high levels of metabolic flexibility and functional redundancy, yet the structure of microbial communities can change rapidly with environmental perturbation. To understand whether such changes observed at the taxonomic level translate into differences at the functional level, we analyzed the structure of taxonomic and functional gene distribution across Arctic and Antarctic locations. Taxonomic diversity (in terms of alpha diversity and species richness) differed significantly with location. However, we found that functional genes distributed evenly across bacterial networks and that this functional distribution was also even across different geographic locations. For example, on average 15% of the functional genes were related to carbon cycling across all bacterial networks, slightly over 21% of the genes were stress-related and only 0.5% of the genes were linked to carbon degradation functions. In such a distribution, each bacterial network includes all of the functional groups distributed following the same proportions. However, the total number of functional genes that is included in each bacterial network differs, with some clusters including many more genes than others. We found that the proportion of times a specific gene must occur to be linked to a specific cluster is 8%, meaning the relationship between the total number of genes in the cluster and the number of genes per function follows a linear pattern: smaller clusters require a gene to appear less frequently to get fixed within the cluster, while larger clusters require higher gene frequencies. We suggest that this mechanism of functional association between equally rare or equally abundant genes could have implications for ecological resilience, as non-dominant genes also associate in fully functioning ecological networks, potentially suggesting that there are always pre-existing functional networks available to exploit new ecological niches (where they can become dominant) as they emerge; for example, in the case of rapid or sudden environmental change. Furthermore, this pattern did not correlate with taxonomic distribution, suggesting that bacteria associate based on functionality and this is independent of its taxonomic position. Our analyses based on ecological networks also showed no clear evidence of recent environmental impact on polar marine microbial communities at the functional level, unless all communities analyzed have changed exactly in the same direction and intensity, which is unlikely given we are comparing areas changing at different rates.

Microbial metabolism directly affects trace gases in (sub) polar snowpacks

Concentrations of trace gases trapped in ice are considered to develop uniquely from direct snow/atmosphere interactions at the time of contact. This assumption relies upon limited or no biological, chemical or physical transformations occurring during transition from snow to firn to ice; a process that can take decades to complete. Here, we present the first evidence of environmental alteration due to in situ microbial metabolism of trace gases (methyl halides and dimethyl sulfide) in polar snow. We collected evidence for ongoing microbial metabolism from an Arctic and an Antarctic location during different years. Methyl iodide production in the snowpack decreased significantly after exposure to enhanced UV radiation. Our results also show large variations in the production and consumption of other methyl halides, including methyl bromide and methyl chloride, used in climate interpretations. These results suggest that this long-neglected microbial activity could constitute a potential source of error in climate history interpretations, by introducing a so far unappreciated source of bias in the quantification of atmospheric-derived trace gases trapped within the polar ice caps.

A field-test battery for elite, young soccer players

The validity and reliability of a battery of field-based performance tests was examined. The opinions of coaches, fitness professionals and players (n=170, 172 and 101 respectively) on the importance of performance testing were established using a questionnaire. On 2 occasions, separated by 7 days, 80 elite, young soccer players (mean±SD [and range]: age 13.2±2.6 [8.9-19.1] years; stature 1.59±0.18 m [1.32-1.91]; body mass 50.6±17.1 [26.5-88.7] kg) completed a battery of field-based tests comprised of heart rate response to a submaximal Multi-stage fitness test, 3 types of vertical jump, sprints over 10 and 20 m, and an agility test. Physical performance testing was considered important by coaches (97%), fitness professionals (94%) and players (83%). The systematic bias ratio and the random error components of the 95% ratio limits of agreement for the first and second tests, for the U9-U11 vs. U12-U14 vs. U15-U18 age groups, were [Systematic bias (*/÷ ratio limits)]: Heart rate (Level 5): 0.983 (*/÷ 1.044) vs. 0.969 (*/÷ 1.056) vs. 0.983 (*/÷ 1.055); Rocket jump: 0998 (*/÷ 1.112) vs. 0.999 (*/÷ 1.106) vs. 0.996 (*/÷ 1.093); 10 m sprint: 0.997 (*/÷ 1.038) vs. 0.994 (*/÷ 1.033) vs. 0.994 (*/÷ 1.038); Agility test: 1.010 (*/÷1.050) vs. 1.014 (*/÷1.050) vs. 1.002 (*/÷1.053). All tests, except heart rate recovery from the Multi-stage fitness test, were able to distinguish between different ability and age groups of players (p<0.05). Thus, the field-test battery demonstrated logical and construct validity, and was shown to be a reliable and objective tool for assessing elite, young soccer players.

Pre-morbid human T-lymphotropic virus type I proviral load, rather than percentage of abnormal lymphocytes, is associated with an increased risk of aggressive adult T-cell leukemia/lymphoma

Out of 153 newly referred human T-lymphotropic virus type I infected patients, 42 (27%) had 5% or more abnormal lymphocytes, consistent with the diagnosis of smoldering adult T-cell leukemia/lymphoma. The abnormal lymphocyte percentage was higher in patients with human T-lymphotropic virus type I associated inflammatory disease compared with asymptomatic carriers (P=0.006). Over 4.5 years median follow up, 4 patients, all with 10 or more human T-lymphotropic virus type I DNA copies/100 peripheral blood mononuclear cells at presentation, but only one with 5% or more abnormal lymphocytes at presentation, developed adult T-cell leukemia/lymphoma. Thus, high pre-morbid human T-lymphotropic virus type I proviral load, rather than fulfilment of the classification criteria for smoldering adult T-cell leukemia/lymphoma, was associated with an increased risk of developing aggressive adult T-cell leukemia/lymphoma.

Mean Corpuscular Volume as a Marker for Adherence to Zidovudine-Containing Therapy in HIV-Infected Adults

OBJECTIVES

To assess whether mean corpuscular volume (MCV) is useful in detecting non-adherence to AZTcontaining therapy.

DESIGN

Observational study within randomised controlled trial.

METHODS

We combined data from two treatment arms in SPARTAC, an RCT of short-course cART in primary HIV infection, classifying participants as responders (HIV-RNA decrease ≥1 log(10) or reaching <400copies/ml) or nonresponders following cART initiation. We assessed the sensitivity and specificity of using different percentage increases in MCV for accurately differentiating between responders and non-responders. We further examined changes in MCV levels up to 24 weeks after protocol-indicated cART cessation.

RESULTS

Of 119 participants included in this analysis, 73 (61%) were women, 71 of whom were randomised in Africa. Ninety-eight (88%) and 84 (85%) were classified as responders at 4 and 12 weeks respectively following cART initiation. MCV increased by a mean 3% and 1% at week 4, and 14% and <1% at 12 weeks for responders and non-responders. A 2% MCV increase at 4 weeks had 62% sensitivity and specificity for identifying virological response. At 12 weeks, an 8% increase had 89% sensitivity and specificity. In responders, MCV remained lower for individuals in African compared to non-African sites throughout and rose from 85 vs 90 fL at cART start to 96 vs 103 fL at 12 weeks post-initiation then fell to 88 vs 93 fL and 86 vs 89 fL at 12 and 48 weeks post-cessation.

CONCLUSION

In low-income countries, where HIV RNA may be unavailable, 12-weekly MCV measurements may be useful in monitoring adherence to AZT-containing regimens.

Use of Zidovudine and Interferon Alfa With Chemotherapy Improves Survival in Both Acute and Lymphoma Subtypes of Adult T-Cell Leukemia/Lymphoma

Purpose

Adult T-cell leukemia/lymphoma (ATLL) is a mature (post-thymic) T-cell lymphoma associated with human T-lymphotropic virus type 1 infection. Survival in aggressive subtypes remains poor, and treatment resistance is frequent. Use of zidovudine (ZDV) and interferon alfa (IFN-α) has been associated with improved response rates in small studies and prolonged overall survival in leukemic ATLL subtypes in a recent meta-analysis.

Patients and Methods

We report the clinicopathologic characteristics, treatment, and outcome of 73 patients with aggressive ATLL (acute ATLL, 29; lymphoma ATLL, 44) diagnosed and treated in England between 1999 and 2009. The impact of ZDV/IFN-α on treatment response and survival was assessed.

Results

The overall response rate ranged from 49% with chemotherapy alone to 81% with combined first-line therapy (chemotherapy with concurrent/sequential ZDV/IFN-α). Median overall survival (OS) was 9 months: 7.5 months for acute ATLL and 10 months for lymphoma ATLL. Use of ZDV/IFN-α at any time prolonged survival in acute (P < .001) and lymphoma ATLL (P < .001) and was the sole factor associated with reduction in risk of death in aggressive ATLL (hazard ratio, 0.23; 95% CI, 0.09 to 0.60; P = .002). Combined first-line therapy prolonged median OS in acute (P = .0081) and lymphoma ATLL (P = .001) compared with chemotherapy alone.

Conclusion

These data support the use of low-dose ZDV/IFN-α with chemotherapy in first-line treatment of acute and lymphoma ATLL.

A parainfluenza-3 outbreak in a SCT unit: sepsis with multi-organ failure and multiple co-pathogens are associated with increased mortality

The estimated frequency of parainfluenza virus 3 (PIV-3) infections following haematopoietic SCT (HSCT) is 2–7%, whereas reported mortality ranges from 18 to 33%. We report a retrospective outcome analysis following an outbreak of PIV-3 infection in our transplant unit. A total of 16 HSCT patients developed PIV-3 infection. All patients had upper respiratory tract infection, whereas lower respiratory tract infection occurred in 8 patients. Overall, 13 patients were treated with aerosolised Ribavirin (2 g t.d.s. for 5 days) and i.v. Ig (0.5 g/kg) as per standard protocol. One patient refused treatment, whereas two patients with full immune reconstitution were not treated. Overall mortality was 62.5%. Sepsis with multi-organ failure and the presence of pulmonary co-pathogens were both significantly associated with PIV-3-related mortality. Our series confirms that high mortality is associated with PIV-3 infection in HSCT recipients. In patients who develop PIV-3 infection, despite strict enforcement of infection control policies, the best strategy might be careful risk assessment, with effective broad-spectrum anti-microbials in those who are at risk of secondary infection.

Measuring patient satisfaction for the Quality and Outcomes Framework

The general medical services (GMS) contract Quality and Outcomes Framework (QOF) awards up to 70 points for measuring patient satisfaction with either the Improving Practices Questionnaire (IPQ) or the General Practice Assessment Questionnaire (GPAQ). The usefulness of data collected depends crucially on the validity and reliability of the measurement instrument. The literature was reviewed to assess the validity and reliability of these questionnaires. The literature was searched for peer-review publications that assessed the reliability and validity of the IPQ and GPAQ, using online literature databases and hand-searching of references up to June 2006. One paper claimed to assess the validity and reliability of the IPQ. No paper reported the reliability and validity of the GPAQ, but three papers assessed an earlier version (the GPAS). No published evidence could be found that the IPQ, GPAQ, or GPAS have been validated against external criteria. The GPAS was found to have acceptable reliability and test-retest reliability. Neither of the instruments mandated by the GMS contract has been formally assessed for reliability: their reproducibility remains unknown. The validation of the two questionnaires approved by the QOF to assess patient satisfaction with general practice appears to be suboptimal. It is recommended that future patient experience surveys are piloted for validity and reliability before being implemented widely.

The Football Association medical research programme: an audit of injuries in academy youth football

OBJECTIVES

To undertake a prospective epidemiological study of the injuries sustained in English youth academy football over two competitive seasons.

METHODS

Player injuries were annotated by medical staff at 38 English football club youth academies. A specific injury audit questionnaire was used together with a weekly return form that documented each club's current injury status.

RESULTS

A total of 3805 injuries were reported over two complete seasons (June to May) with an average injury rate of 0.40 per player per season. The mean (SD) number of days absent for each injury was 21.9 (33.63), with an average of 2.31 (3.66) games missed per injury. The total amount of time absent through injury equated to about 6% of the player's development time. Players in the higher age groups (17-19 years) were more likely to receive an injury than those in the younger age groups (9-16 years). Injury incidence varied throughout the season, with training injuries peaking in January (p<0.05) and competition injuries peaking in October (p<0.05). Competition injuries accounted for 50.4% of the total, with 36% of these occurring in the last third of each half. Strains (31%) and sprains (20%) were the main injury types, predominantly affecting the lower limb, with a similar proportion of injuries affecting the thigh (19%), ankle (19%), and knee (18%). Growth related conditions, including Sever's disease and Osgood-Schlatter's disease, accounted for 5% of total injuries, peaking in the under 13 age group for Osgood-Schlatter's disease and the under 11 age group for Sever's disease. The rate of re-injury of exactly the same anatomical structure was 3%.

CONCLUSIONS

Footballers are at high risk of injury and there is a need to investigate ways of reducing this risk. Injury incidence at academy level is approximately half that of the professional game. Academy players probably have much less exposure to injury than their full time counterparts. Areas that warrant further attention include the link between musculoskeletal development and the onset of youth related conditions such as Sever's disease and Osgood-Schlatter's disease, the significant number of non-contact injuries that occur in academy football, and the increased rates of injury during preseason training and after the mid season break. This study has highlighted the nature and severity of injuries that occur at academy level, and the third part of the audit process now needs to be undertaken: the implementation of strategies to reduce the number of injuries encountered at this level.

The Football Association Medical Research Programme: an audit of injuries in professional football--analysis of hamstring injuries

OBJECTIVE

To conduct a detailed analysis of hamstring injuries sustained in English professional football over two competitive seasons.

METHODS

Club medical staff at 91 professional football clubs annotated player injuries over two seasons. A specific injury audit questionnaire was used together with a weekly form that documented each clubs' current injury status.

RESULTS

Completed injury records for the two competitive seasons were obtained from 87% and 76% of the participating clubs respectively. Hamstring strains accounted for 12% of the total injuries over the two seasons with nearly half (53%) involving the biceps femoris. An average of five hamstring strains per club per season was observed. A total of 13 116 days and 2029 matches were missed because of hamstring strains, giving an average of 90 days and 15 matches missed per club per season. In 57% of cases, the injury occurred during running. Hamstring strains were most often observed during matches (62%) with an increase at the end of each half (p<0.01). Groups of players sustaining higher than expected rates of hamstring injury were Premiership (p<0.01) and outfield players (p<0.01), players of black ethnic origin (p<0.05), and players in the older age groups (p<0.01). Only 5% of hamstring strains underwent some form of diagnostic investigation. The reinjury rate for hamstring injury was 12%.

CONCLUSION

Hamstring strains are common in football. In trying to reduce the number of initial and recurrent hamstring strains in football, prevention of initial injury is paramount. If injury does occur, the importance of differential diagnosis followed by the management of all causes of posterior thigh pain is emphasised. Clinical reasoning with treatment based on best available evidence is recommended.

BTS randomised feasibility study of active symptom control with or without chemotherapy in malignant pleural mesothelioma: ISRCTN 54469112

BACKGROUND

The incidence of mesothelioma is rising rapidly in the UK. There is no generally accepted standard treatment. The BTS recommends active symptom control (ASC). It is not known whether chemotherapy in addition prolongs survival or provides worthwhile palliation with acceptable toxicity. Palliation as recorded by patients has been fully reported for only two regimens: mitomycin, vinblastine, and cisplatin (MVP), and vinorelbine (N). The BTS and collaborators planned to conduct a phase III randomised trial comparing ASC only, ASC+MVP, and ASC+N in 840 patients with survival as the primary outcome measure. The aim of the present study was to assess the acceptability of the trial design to patients and the suitability of two standard quality of life (QL) questionnaires for mesothelioma.

METHODS

Collaborating centres registered all new patients with mesothelioma. Those eligible and giving informed consent completed EORTC QLQ-C30+LC13 and FACT-L QL questionnaires and were randomised between all three or any two of (1) ASC only, (2) ASC+4 cycles of MVP, and (3) ASC+12 weekly doses of N.

RESULTS

During 1 year, 242 patients were registered of whom 109 (45%) were randomised (55% of the 197 eligible patients). Fifty two patients from 20 centres were randomised to an option including ASC only. This translates into a rate of 312 per year from 60 centres interested in collaborating in the phase III trial. The EORTC QL questionnaire was superior to FACT-L in terms of completeness of data and patient preference. Clinically relevant palliation was achieved with ASC.

CONCLUSION

The planned phase III trial is feasible.

The Football Association Medical Research Programme: an audit of injuries in professional football: an analysis of ankle sprains

AIM

To conduct a detailed analysis of ankle sprains sustained in English professional football over two competitive seasons.

METHODS

Club medical staff at 91 professional football clubs annotated player injuries. A specific injury audit questionnaire was used together with a weekly form that documented each club's current injury status.

RESULTS

Completed injury records for the two competitive seasons were obtained from 87% and 76% of the participating clubs. Ankle ligament sprains accounted for 11% of the total injuries over the two seasons, with over three quarters (77%) of sprains involving the lateral ligament complex. A total of 12 138 days and 2033 matches were missed because of ankle sprains. More sprains were caused by contact mechanisms than non-contact mechanisms (59% v 39%) except in goalkeepers who sustained more non-contact sprains (21% v 79%, p<0.01). Ankle sprains were most often observed during tackles (54%). More ankle sprains were sustained in matches than in training (66% v 33%), with nearly half (48%) observed during the last third of each half of matches. A total of 44% of sprains occurred during the first three months of the season. A high number of players (32%) who sustained ankle sprains were wearing some form of external support. The recurrence rate for ankle sprains was 9% (see methodology for definition of reinjury).

CONCLUSION

Ankle ligament sprains are common in football usually involving the lateral ligament complex. The high rate of occurrence and recurrence indicates that prevention is of paramount importance.

The Football Association Medical Research Programme: an audit of injuries in professional football-analysis of preseason injuries

OBJECTIVES

To conduct a detailed analysis of preseason football injuries sustained in English professional football over two competitive seasons.

METHODS

Club medical staff at 91 professional football clubs annotated player injuries. A specific injury audit questionnaire was used together with a weekly form that documented each club's current injury status.

RESULTS

17% (1025) of the total number of injuries over the two seasons were sustained during the preseason, the mean number of days absent per injury was 22.3 days. Younger age groups (17-25 yrs) were more likely to sustain a preseason injury than more experienced players (26-35+) (p<0.01). There were relatively more "slight" and "minor" injuries (as defined in the methodology), overuse, and tendon related injuries sustained during preseason compared to the in season (p<0.01). The thigh (23%), knee (17%), and ankle (17%) were the most common locations for injuries during the preseason, there was a relatively greater number of lower leg injuries (15%) during the preseason (p<0.05). Achilles tendonitis was most prevalent in the preseason, with 33% of all Achilles related injuries sustained during this period (p<0.01). Muscle strains were the most common injury during preseason (37%). Rectus femoris muscle strains were observed twice as frequently during the preseason relative to the in season (p<0.01). Ligament sprains were the second most common injury during preseason (19%). Non-contact mechanisms were the cause of significantly more injuries during the preseason (p<0.01), with relatively more preseason injuries sustained while running or shooting (p<0.01). For 70% of the injuries reported during the preseason, the ground condition was described as dry.

CONCLUSIONS

Players are at a greater risk of slight and minor injuries, overuse injuries, lower leg injuries (especially the Achilles tendon) and rectus femoris strains during the preseason period. Prevention of preseason injury is important to ensure availability of players for the commencement of the season and to decrease the risk of injury later in the season, we recommend the implementation of a risk management policy for this purpose. Areas requiring further investigation include methods of prevention for the common preseason injuries that have been identified, a detailed analysis of preseason and closed season training programmes, and a smaller study involving exposure data.

The association football medical research programme: an audit of injuries in professional football

OBJECTIVES

To undertake a prospective epidemiological study of the injuries sustained in English professional football over two competitive seasons.

METHODS

Player injuries were annotated by club medical staff at 91 professional football clubs. A specific injury audit questionnaire was used together with a weekly form that documented each club's current injury status.

RESULTS

A total of 6,030 injuries were reported over the two seasons with an average of 1.3 injuries per player per season. The mean (SD) number of days absent for each injury was 24.2 (40.2), with 78% of the injuries leading to a minimum of one competitive match being missed. The injury incidence varied throughout the season, with training injuries peaking during July (p<0.05) and match injuries peaking during August (p<0.05). Competition injuries represented 63% of those reported, significantly (p<0.01) more of these injuries occurring towards the end of both halves. Strains (37%) and sprains (19%) were the major injury types, the lower extremity being the site of 87% of the injuries reported. Most injury mechanisms were classified as being non-contact (58%). Re-injuries accounted for 7% of all injuries, 66% of these being classified as either a strain or a sprain. The severity of re-injuries was greater than the initial injury (p<0.01).

CONCLUSIONS

Professional football players are exposed to a high risk of injury and there is a need to investigate ways of reducing this risk. Areas that warrant attention include the training programmes implemented by clubs during various stages of the season, the factors contributing to the pattern of injuries during matches with respect to time, and the rehabilitation protocols employed by clubs.

Speech and language functioning in paediatric HIV disease

The Human Immunodeficiency Virus (HIV) can potentially cause impairment to linguistic functioning. This study was the first to compare selected aspects of speech motor control, expressive language and receptive language functioning in individual HIV infected children. Results suggested clinically stable HIV infected children can develop linguistic impairment. Such impairment is in danger of going unnoticed without assessment. Thorough and regular assessment of the linguistic functioning of long-term survivors of paediatric HIV disease is essential if optimal speech and language therapy management strategies are to be devised.

Let's talk: a working party for special schools

The Special Schools Working Party was formed in summer 1996 to improve communication channels and foster understanding between speech and language therapist, school and home. It consists of representatives from all three groups in the six schools involved. The Working Party has produced a document which describes everyone's role and agreed procedures for liaison and training. Its greatest benefit lies in the opportunities for discussion and exchange of ideas. In the future the Working Party is planning to audit customer satisfaction of the service and continue to develop ideas for improving its accessibility.

A case for long-term treatment with anticonvulsants

Seizures occurring in the neonatal period are one of the most significant discriminating factors in predicting childhood neurologic mortality and morbidity (epilepsy, cerebral palsy and mental retardation). Data derived from retrospective and prospective studies indicate that different variables, such as cause and severity of seizure activity, birth weight, neurologic examination and electroencephalogram, help predict which of these children will be severely affected. Most physicians treat such children with an anticonvulsant (phenobarbital) for the first year of life on the supposition that this therapy will minimize mortality and long-term morbidity. There are no controlled studies to indicate whether anticonvulsant therapy affects the outcome in children with neonatal seizures. It may now be possible to select those who are at significantly higher risk for neurologic morbidity, and these infants may benefit from anticonvulsant prophylaxis with phenobarbital.

CT demonstration of hyperdense cerebral vasculature due to bromide therapy

An increase in the effective atomic number of blood is among the factors allowing or influencing the visualization of the major cerebral vessels on noncontrast CT. Bromine (atomic number, 50) attenuates 70 keV X-rays significantly and was responsible for a striking enhancement of the major cerebral vessels on the noncontrast CT in a child being treated for epilepsy. Although oral bromides are only occasionally used in the treatment of epilepsy, their use causes an increase in blood density and thus bromides need to be considered along with other etiologies (reviewed) that allow visualization of the major cerebral vessels on noncontrast CT.

Effect of transfusion therapy on arteriographic abnormalities and on recurrence of stroke in sickle cell disease

Stroke is a relatively frequent and severe complication of sickle cell disease. We performed cerebral arteriograms in 30 patients with sickle cell disease to evaluate the cause of acute neurologic deficits and to assess the effects of transfusion therapy given for a year or more after the acute episode. Twenty-three patients with motor and speech deficits had multiple abnormalities of major cerebral arteries. The internal carotid and anterior and middle cerebral arteries showed stenosis and/or occlusion at their common junction. Irregular luminal surfaces suggested that endothelial damage and intimal hyperplasia were the basis of stroke. Prolonged transfusion therapy nearly stopped progression of stenosis and markedly decreased the irregularity of the luminal surfaces; in 4 untransfused patients, the degree of stenosis doubled and the luminal abnormalities persisted. Prior to transfusion, 90% of patients had recurrence of stroke. With transfusion therapy, only 10% of patients had recurrence despite persistent arterial abnormalities. Clinical recurrences per patient-month decreased 75-fold. The patients tolerated prolonged transfusion therapy well, despite progressive iron accumulation. Seven patients with smooth abnormalities of a single artery, nonocclusive changes, or with normal arteriograms did not receive transfusions. Only one of this group had recurrence of symptoms.

The metabolic response to hyperglycaemic clamping in insulin-dependent diabetes

The metabolic and hormonal effects of stable hyperglycaemia (10-12 mmol/l) have been examined in five insulin-dependent diabetics and compared with the results of 8 h (1200 to 2000 h) normoglycaemic (5-6 mmol/l) clamping. Glucose levels were maintained using a glucose controlled insulin infusion system. Mean blood lactate, pyruvate, total ketone bodies, glycerol and plasma non-esterified fatty acids were similar during the period of stable glycaemia at the two glucose levels. In contrast mean blood alanine was markedly elevated during hyperglycaemic clamping (0.384 +/- 0.008 vs 0.298 +/- 0.021 mmol/l) and 3-hydroxybutyrate was slightly decreased (0.068 +/- 0.007 vs 0.084 +/- 0.008 mmol/l). Plasma glucagon levels were raised during hyperglycaemic clamping and growth hormone slightly decreased. There was a close positive correlation between mean blood alanine and mean blood glucose (r = 0.79, p less than 0.01), and a negative correlation of alanine with the amount of insulin infused (r = -0.72, p less than 0.01). It is suggested that the raised alanine results from increased peripheral glucose utilisation. In general a short period of stable hyperglycaemia is not associated with a worsening of metabolic abnormalities in insulin-dependent diabetic subjects.

A possible mechanism for the anti-ketogenic action of alanine in the rat

1. The anti-ketogenic effect of alanine has been studied in normal starved and diabetic rats by infusing l-alanine for 90min in the presence of somatostatin (10mug/kg body wt. per h) to suppress endogenous insulin and glucagon secretion. 2. Infusion of alanine at 3mmol/kg body wt. per h caused a 70+/-11% decrease in [3-hydroxybutyrate] and a 58+/-9% decrease in [acetoacetate] in 48h-starved rats. [Glucose] and [lactate] increased, but [non-esterified fatty acid], [glycerol] and [3-hydroxybutyrate]/[acetoacetate] were unchanged. 3. Infusion of alanine at 1mmol/kg body wt. per h caused similar decreases in [ketone body] (3-hydroxybutyrate plus acetoacetate) in 24h-starved normal and diabetic rats, but no change in other blood metabolites. 4. Alanine [3mmol/kg body wt. per h] caused a 72+/-9% decrease in the rate of production of ketone bodies and a 57+/-8% decrease in disappearance rate as assessed by [3-(14)C]acetoacetate infusion. Metabolic clearance was unchanged, indicating that the primary effect of alanine was inhibition of hepatic ketogenesis. 5. Aspartate infusion at 6mmol/kg body wt. per h had similar effects on blood ketone-body concentrations in 48h-starved rats. 6. Alanine (3mmol/kg body wt. per h) caused marked increases in hepatic glutamate, aspartate, malate, lactate and citrate, phosphoenolpyruvate, 2-phosphoglycerate and glucose concentrations and highly significant decreases in [3-hydroxybutyrate] and [acetoacetate]. Calculated [oxaloacetate] was increased 75%. 7. Similar changes in hepatic [malate], [aspartate] and [ketone bodies] were found after infusion of 6mmol of aspartate/kg body wt. per h. 8. It is suggested that the anti-ketogenic effect of alanine is secondary to an increase in hepatic oxaloacetate and hence citrate formation with decreased availability of acetyl-CoA for ketogenesis. The reciprocal negative-feedback cycle of alanine and ketone bodies forms an important non-hormonal regulatory system.

Freeze-fracture studies of erythrocyte plasma membrane in human neuromuscular diseases

Freeze-fracture studies were conducted in erythrocyte plasma membrane from 8 patients with Duchenne muscular dystrophy (DMD), 8 age-matched controls, 3 adult controls, 10 patients with myotonic muscular dystrophy, and 26 other neuromuscular disease controls. There was marked depletion of intramembranous particles in Duchenne dystrophy, whereas intramembranous particle density counts in other neuromuscular diseases were within normal limits. Therefore, the internal molecular architecture of the erythrocyte membrane is abnormal in Duchenne dystrophy, supporting the concept that a membrane defect involving multiple tissues is present in this disorder.

Alteration in erythrocyte membrane structure in Duchenne muscular dystrophy

Freeze-fracture studies of erythrocytes from patients with Duchenne muscular dystrophy revealed depletion of particles on both fracture faces of the plasma membrane. This study indicates that the structure of the erythrocyte plasma membrane is abnormal in Duchenne dystrophy and supports the concept that a generalized membrane abnormality is present in this disease.

Erythrocyte cation-activated adenosine triphosphatases in Duchenne muscular dystrophy

The cation-stimulated adenosine triphosphatase (ATPase) activities of erythrocyte ghosts and erythrocyte ghost plasma membrane fragments of patients with Duchenne muscular dystrophy (DMD) were compared with activities in age-matched normal male controls. DMD Mg++-stimulated ATPase activity was within the normal range. The specific activity of DMD erythrocyte ghost Na+,K+-stimulated, Mg++-dependent ATPase was also normal, and was inhibited by 10(-4) M ouabain to an extent comparable with controls. Ca++-stimulated, Mg++-dependent ATPase activity of DMD erythrocyte ghost plasma membrane fragments, assayed at 0.5 mM free Ca++, was 21% above that in age-matched male controls (n = 22, 2-tailed paired t-test, P less than 0.01). Kinetic studies indicated that the DMD erythrocyte Ca++-stimulated, Mg++-dependent ATPase has greater affinity for MgATP than the enzyme in control erythrocytes.