Change in emotional distress, anxiety, depression and PTSD from pre- to post-flood exposure in women residing in low-income settings in South Africa

Floods are increasing in frequency and may increase the risk for experiencing emotional distress, anxiety, depression and PTSD. The aim of this study was to determine the extent of damage, loss, injury and death resulting from floods that occurred in and around the city of Durban, South Africa, in April 2022, and associated changes in mental health pre- to post-floods in a low-income setting. Seventy-three women between the ages of 18 and 45, residing in flood affected, low-income settings, were interviewed prior to the floods occurring. Mental health measures were repeated with 69 of the 73 women during the post-flood interview along with a questionnaire measuring flood-related exposures. Loss of infrastructure (lacked access to drinking water, electricity, fresh food, could not travel to work, had to stay in a shelter and could not get hold of friends or family) was a predictor of post-flood change in levels of emotional distress and anxiety. Higher levels of prior trauma exposure were associated with higher post-flood levels of emotional distress. Higher pre-flood food insecurity was also associated with higher post-flood anxiety. Women affected by poverty, food insecurity and a history of trauma are vulnerable to the additive adverse mental health effects of floods. Proactive approaches to diminishing the impact of floods on the livelihood of women is needed and post-flood relieve efforts may be more affective if they are enhanced by providing mental health support.

COVID-19-associated mortality in individuals with serious mental disorders in Sweden during the first two years of the pandemic- a population-based register study

BACKGROUND

Reports at the beginning of the COVID-19 pandemic suggested differences in COVID-19-associated mortality between individuals with serious mental disorders (SMD) and the population at large.

AIM

To compare the pattern of COVID-19-associated mortality in individuals with and without SMD in Sweden over the two main pandemic years.

METHODS

We compared the pattern of COVID-19-associated mortality in individuals with and without SMD in Sweden during 2020 and 2021. For SMD, we included psychotic disorder, bipolar disorder, and severe depression. The analysis was based on summary data from the Swedish Board of Health and Welfare covering the entire adult Swedish population.

RESULTS

The overall relative risk (RR) for experiencing a COVID-19-associated death was 1.66 (CI 1.50-1.83; p < 0.001) for individuals with SMD versus individuals without SMD. The corresponding RRs were 3.25 (CI 2.84-3.71; p < 0.001) for individuals with psychotic disorder, 1.06 (CI 0.88-1.26; p = 0.54) for individuals with bipolar disorder, and 1.03 (CI 0.80-1.32; p = 0.80) for individuals with severe depression. Compared to their respective counterparts in the non-SMD group, in the psychotic disorder and severe depression group, the RR were higher in women than in men. In the bipolar disorder group, the RR was higher in men than in women. The RR of COVID-19-associated death was generally higher in younger individuals with SMD. Individuals with psychosis between 18 and 59 years had the highest RR of COVID-19-associated death with 7.25 (CI 4.54-11.59; p<0.001).

CONCLUSIONS

Individuals with SMD, and particularly those with psychotic disorders, had a higher risk of COVID-19-associated death than the general population. As this is a pattern also seen with other infections, people with SMD may be similarly vulnerable in future pandemics.

Failure to rescue following postoperative pneumonia in pediatrics: Is there a racial disparity?

INTRODUCTION

Racial disparities in measures of health and healthcare processes are well described. Limited work exists on disparities in failure to rescue - hospital mortality following a major adverse event. Postoperative pneumonia is a serious, potentially preventable adverse event that often leads to death, i.e., failure to rescue. This study examined the association of racial grouping with failure to rescue following postoperative pneumonia.

METHODS

We utilized the National Surgical Quality Improvement Program-Pediatrics Participant Use Data File to assemble a cohort of children <18 years who underwent inpatient surgery from 2012 to 2022. We included Black and White patients who developed pneumonia following an index surgery. The primary outcome was failure to rescue, defined as mortality following postoperative pneumonia. We used logistic regression models to estimate the odds ratio and 95% confidence intervals of failure to rescue, comparing Black and White children.

RESULTS

The study cohort included 3139 children <18 years who developed pneumonia following inpatient surgery. Of those, 2333 (74.3%) were White and 806 (25.7%) were Black. Failure to rescue occurred in 117 of the children (3.7%); 82 were White (3.5%) and 35 were Black (4.3%). After adjusting for gender, age, American Society of Anesthesiologists Physical Status classification, emergent/urgent vs. elective case status, year of operation, and pre-existing comorbidities, the odds of failure to rescue for Black children with postoperative pneumonia did not differ from White children (adjusted-Odds Ratio: 1.00; 95% Confidence Interval 0.62-1.61; p-value = .992).

CONCLUSION

We found no significant difference in the odds of failure to rescue following postoperative pneumonia between Black or White children. To improve postoperative care for all children and to narrow the racial gap in postoperative mortality, future studies should continue to investigate the association of race with failure to rescue following other postoperative complications.

Impact of COVID-19 lockdown and link to women and children's experiences of violence in the home in South Africa

Background

Evidence on the impact of COVID-19 and lockdown remains at an early stage. There is limited research about the impact of hard lockdown restrictions on families, specifically how these restrictions impact on women and children’s experiences of domestic violence, including intimate partner violence (IPV) and child abuse in South Africa. We conducted research among men and women in Gauteng province, South Africa to understand their experiences of the COVID-19 national lockdown and its impact and link to women and children’s experiences of domestic violence.

Methods

We conducted a qualitative study, using social media to recruit men and women who were 18 years and older, living with a spouse and/or children in Gauteng province, South Africa during the lockdown. To collect the data, we conducted telephone interviews, and analyzed data using the thematic approach.

Results

The lockdown had unprecedented negative economic impacts on families, and exacerbated some of the risk factors for violence against women and children in the home in South Africa. Some women reported experiences of emotional violence. Experiences of physical violence were mostly amongst children. The risk factors for women and children’s experiences of violence in the home differed by socio-economic class. Job losses and reduction in earnings resulted to food insecurity which was a key driver of violence in most low socio-economic status (SES) families. Confinement in the home with spouses was an unfamiliar and difficult experience, associated with conflict and perpetration of violence by men in high SES families. Participants across socio-economic groups reported high levels of stress with limited psychosocial support available during the lockdown.

Conclusions

Our finding showing a link between low-socio-economic status and increased risk for domestic violence during the lockdown in South Africa suggests the need for socio-economic interventions to mitigate these risks. Structural and social relief measures need to be strengthened to reduce the loss of jobs and income and to address food insecurity during pandemics. Psychosocial support should be provided to men and women to mitigate the mental health impacts of the pandemics and lockdown.

OUP accepted manuscript

Background

Mucosa-associated invariant T (MAIT) cells are innate-like T cells with specialized antimicrobial functions. Circulating MAIT cells are depleted in chronic human immunodeficiency virus (HIV) infection, but studies examining this effect in peripheral tissues, such as the female genital tract, are lacking.

Methods

Flow cytometry was used to investigate circulating MAIT cells in a cohort of HIV-seropositive (HIV⁺) and HIV-seronegative (HIV⁻) female sex workers (FSWs), and HIV⁻ lower-risk women (LRW). In situ staining and quantitative polymerase chain reaction were performed to explore the phenotype of MAIT cells residing in paired cervicovaginal tissue. The cervicovaginal microbiome was assessed by means of 16S ribosomal RNA gene sequencing.

Results

MAIT cells in the HIV⁺ FSW group were low in frequency in the circulation but preserved in the ectocervix. MAIT cell T-cell receptor gene segment usage differed between the HIV⁺ and HIV⁻ FSW groups. The TRAV1-2–TRAJ20 transcript was the most highly expressed MAIT TRAJ gene detected in the ectocervix in the HIV⁺ FSW group. MAIT TRAVJ usage was not associated with specific genera in the vaginal microbiome.

Conclusions

MAIT cells residing in the ectocervix are numerically preserved irrespective of HIV infection status and displayed dominant expression of TRAV1-2–TRAJ20. These findings have implications for understanding the role of cervical MAIT cells in health and disease.

Assessment of dispersion of airborne particles of oral/nasal fluid by high flow nasal cannula therapy

Background

Nasal High Flow (NHF) therapy delivers flows of heated humidified gases up to 60 LPM (litres per minute) via a nasal cannula. Particles of oral/nasal fluid released by patients undergoing NHF therapy may pose a cross-infection risk, which is a potential concern for treating COVID-19 patients.

Methods

Liquid particles within the exhaled breath of healthy participants were measured with two protocols: (1) high speed camera imaging and counting exhaled particles under high magnification (6 participants) and (2) measuring the deposition of a chemical marker (riboflavin-5-monophosphate) at a distance of 100 and 500 mm on filter papers through which air was drawn (10 participants). The filter papers were assayed with HPLC. Breathing conditions tested included quiet (resting) breathing and vigorous breathing (which here means nasal snorting, voluntary coughing and voluntary sneezing). Unsupported (natural) breathing and NHF at 30 and 60 LPM were compared.

Results

Conclusion

During quiet breathing, 60 LPM NHF therapy may cause oral/nasal fluid to be released as particles, at levels of tens of μL per cubic metre of air. Vigorous breathing (snort, cough or sneeze) releases 200 to 1000 times more oral/nasal fluid than quiet breathing (p < 0.001 with both imaging and chemical marker methods). During vigorous breathing, 60 LPM NHF therapy caused no statistically significant difference in the quantity of oral/nasal fluid released compared to unsupported breathing. NHF use does not increase the risk of dispersing infectious aerosols above the risk of unsupported vigorous breathing. Standard infection prevention and control measures should apply when dealing with a patient who has an acute respiratory infection, independent of which, if any, respiratory support is being used.

Clinical trial registration

ACTRN12614000924651

Postoperative Analgesia in Neonates and Infants Using Epidural Chloroprocaine and Clonidine

INTRODUCTION

In neonates and infants, epidural analgesia has gained popularity as a means of providing postoperative analgesia, limiting opioid-related adverse effects and improving the postoperative course. In addition to a local anesthetic agent, adjunctive agents may be added to further augment analgesia. Clonidine is an α2-adrenergic agonist that is frequently added to single-shot caudal analgesia, but there are limited data regarding its use in a continuous epidural infusion, especially in patients ≤12 months of age.

METHODS

We retrospectively reviewed the hospital records of neonates and infants who received postoperative epidural infusions with 2-chloroprocaine, and clonidine was identified over a 4-year period.

RESULTS

The study cohort included 52 neonates and infants ranging in age from 0 to 12 months and in weight from 2.1 to 10.1 kilograms. The catheters were dosed with either 1.5% 2-chloroprocaine (n=47) or 3% 2-chloroprocaine (n=5) with clonidine (median concentration 0.2 µg/mL) infused at a median rate of 0.72 mL/kg/hour. Pain scores were uniformly ≤3 at all evaluation points during the first 72 postoperative hours with a limited need for supplemental systemic opioids. No serious adverse effects were noted.

CONCLUSION

With the recognized limitations of a retrospective study, these preliminary data demonstrate the safety of adding clonidine to an epidural infusion of 2-chloroprocaine in neonates and infants less than 12 months of age. Future studies are needed to determine its analgesic efficacy compared to 2-chloroprocaine alone and the optimal clonidine concentration for postoperative epidural infusions.

Human Immunodeficiency Virus-Infected Women Have High Numbers of CD103-CD8+ T Cells Residing Close to the Basal Membrane of the Ectocervical Epithelium

Background

Genital mucosa is the main portal of entry for various incoming pathogens, including human immunodeficiency virus (HIV), hence it is an important site for host immune defenses. Tissue-resident memory T (TRM) cells defend tissue barriers against infections and are characterized by expression of CD103 and CD69. In this study, we describe the composition of CD8+ TRM cells in the ectocervix of healthy and HIV-infected women.

Methods

Study samples were collected from healthy Swedish and Kenyan HIV-infected and uninfected women. Customized computerized image-based in situ analysis was developed to assess the ectocervical biopsies. Genital mucosa and blood samples were assessed by flow cytometry.

Results

Although the ectocervical epithelium of healthy women was populated with bona fide CD8+ TRM cells (CD103+CD69+), women infected with HIV displayed a high frequency of CD103-CD8+ cells residing close to their epithelial basal membrane. Accumulation of CD103-CD8+ cells was associated with chemokine expression in the ectocervix and HIV viral load. CD103+CD8+ and CD103-CD8+ T cells expressed cytotoxic effector molecules in the ectocervical epithelium of healthy and HIV-infected women. In addition, women infected with HIV had decreased frequencies of circulating CD103+CD8+ T cells.

Conclusions

Our data provide insight into the distribution of CD8+ TRM cells in human genital mucosa, a critically important location for immune defense against pathogens, including HIV.

Tissue-resident MAIT cell populations in human oral mucosa exhibit an activated profile and produce IL-17

Mucosa‐associated invariant T (MAIT) cells are unconventional T lymphocytes defined by their innate‐like characteristics and broad antimicrobial responsiveness. Whether MAIT cells are part of the tissue‐resident defense in the oral mucosal barrier is unknown. Here, we found MAIT cells present in the buccal mucosa, with a tendency to cluster near the basement membrane, and located in both epithelium and the underlying connective tissue. Overall MAIT cell levels were similar in the mucosa compared to peripheral blood, in contrast to conventional T cells that showed an altered representation of CD4⁺ and CD8⁺ subsets. The major mucosal MAIT cell subset displayed a tissue‐resident and activated profile with high expression of CD69, CD103, HLA‐DR, and PD‐1, as well as a skewed subset distribution with higher representation of CD4^–/CD8^– double‐negative cells and CD8αα⁺ cells. Interestingly, tissue‐resident MAIT cells had a specialized polyfunctional response profile with higher IL‐17 levels, as assessed by polyclonal stimulus and compared to tissue nonresident and circulating populations. Furthermore, resident buccal MAIT cells were low in perforin. Together, these data indicate that MAIT cells form a part of the oral mucosal T cell compartment, where they exhibit a tissue‐resident‐activated profile biased toward IL‐17 production.

Correction: Seminal plasma induces inflammation and enhances HIV-1 replication in human cervical tissue explants

[This corrects the article DOI: 10.1371/journal.ppat.1006402.].

MAIT cells in the human oral mucosa are activated and perforinlow

Mucosa-associated invariant T (MAIT) cells are a class of non-classical T lymphocytes defined by their invariant Vα7.2-containing MR1-restricted T cell receptor, as well as high expression of CD161. At present, the characteristics of MAIT cells in the oral mucosa are poorly defined. In this study, we have analyzed buccal biopsies and matched blood samples from a cohort of healthy volunteers. MAIT cells were present in the buccal mucosa, with a tendency to cluster around the basal layer, a region also found to contain a higher frequency of MR1-expressing antigen-presenting cells. The frequency of MAIT cells was similar in the buccal mucosa compared to matched peripheral blood, in contrast to other major T cell subsets. However, the buccal mucosal MAIT cells displayed a tissue resident activated profile, with high CD69, HLA-DR and PD-1 expression, as well as a skewed subset distribution with higher representation of CD4/CD8 double-negative cells and of CD8αα+ cells within the CD8+ subset. The Jα chain usage in the MAIT cell TCR was more variable in oral mucosal MAIT cells than in peripheral blood MAIT cells. Functionally, the oral mucosal MAIT cells had lower perforin levels, indicative of a lower cytolytic potential. Interestingly, aspects of the oral MAIT cell population were associated with life-style factors such as consumption of bacterially fermented milk products and alcohol intake. Together, these data show that MAIT cells form a part of the oral mucosal T cell compartment, where they exhibit a tissue-resident activated profile. Thus, MAIT cells are positioned in the oral cavity and equipped to handle resident microbiota as well as invading pathogens.

Seminal plasma induces inflammation and enhances HIV-1 replication in human cervical tissue explants

The most immediate and evident effect of mucosal exposure to semen in vivo is a local release of proinflammatory mediators accompanied by an influx of leukocytes into the female genital mucosa (FGM). The implication of such response in HIV-1 transmission has never been addressed due to limitations of currently available experimental models. Using human tissue explants from the uterine cervix, we developed a system of mucosal exposure to seminal plasma (SP) that supports HIV-1 replication. Treatment of ectocervical explants with SP resulted in the upregulation of inflammatory and growth factors, including IL-6, TNF, CCL5, CCL20, CXCL1, and CXCL8, and IL1A, CSF2, IL7, PTGS2, as evaluated by measuring protein levels in explant conditioned medium (ECM) and gene expression in tissue. SP treatment was also associated with increased recruitment of monocytes and neutrophils, as observed upon incubation of peripheral blood leukocytes with ECM in a transwell system. To evaluate the impact of the SP-mediated response on local susceptibility to HIV-1, we infected ectocervical explants with the CCR5-tropic variant HIV-1BaL either in the presence of SP, or after explant pre-incubation with SP. In both experimental settings SP enhanced virus replication as evaluated by HIV-1 p24gag released in explant culture medium over time, as well as by HIV-1 DNA quantification in explants infected in the presence of SP. These results suggest that a sustained inflammatory response elicited by SP soon after coitus may promote HIV-1 transmission to the FGM. Nevertheless, ectocervical tissue explants did not support the replication of transmitted/founder HIV-1 molecular clones, regardless of SP treatment. Our system offers experimental and analytical advantages over traditional models of HIV-1 transmission for the study of SP immunoregulatory effect on the FGM, and may provide a useful platform to ultimately identify new determinants of HIV-1 infection at this site.

Insensitivity to pain induced by a potent selective closed-state Nav1.7 inhibitor

Pain places a devastating burden on patients and society and current pain therapeutics exhibit limitations in efficacy, unwanted side effects and the potential for drug abuse and diversion. Although genetic evidence has clearly demonstrated that the voltage-gated sodium channel, Nav1.7, is critical to pain sensation in mammals, pharmacological inhibitors of Nav1.7 have not yet fully recapitulated the dramatic analgesia observed in Nav1.7-null subjects. Using the tarantula venom-peptide ProTX-II as a scaffold, we engineered a library of over 1500 venom-derived peptides and identified JNJ63955918 as a potent, highly selective, closed-state Nav1.7 blocking peptide. Here we show that JNJ63955918 induces a pharmacological insensitivity to pain that closely recapitulates key features of the Nav1.7-null phenotype seen in mice and humans. Our findings demonstrate that a high degree of selectivity, coupled with a closed-state dependent mechanism of action is required for strong efficacy and indicate that peptides such as JNJ63955918 and other suitably optimized Nav1.7 inhibitors may represent viable non-opioid alternatives for the pharmacological treatment of severe pain.

MAIT cells reside in the female genital mucosa and are biased towards IL-17 and IL-22 production in response to bacterial stimulation

The female genital tract (FGT) mucosa is a critically important site for immune defense against microbes. Mucosal-associated invariant T (MAIT) cells are an innate-like T-cell population that recognizes microbial riboflavin metabolite antigens in an MR1-dependent manner. The role of MAIT cells in the FGT mucosa is unknown. Here, we found that MAIT cells and MR1+ antigen-presenting cells were present in the upper and lower FGT, with distinct tissue localization of MAIT cells in endometrium vs. cervix. The MAIT cells from the FGT and blood displayed a distinct phenotype with expression of interleukin (IL)-18Rα, CD127, α4β7, PD-1, as well as the transcription factors promyelocytic leukemia zinc finger (PLZF), RORγt, Helios, Eomes, and T-bet. Their expression levels of PLZF and Eomes were lower in the FGT compared with blood. When stimulated with Escherichia coli, MAIT cells from the FGT displayed a bias towards IL-17 and IL-22 expression, whereas blood MAIT cells produced primarily IFN-γ, TNF, and Granzyme B. Furthermore, both FGT- and blood-derived MAIT cells were polyfunctional and contributed to the T-cell-mediated response to E. coli. Thus, MAIT cells in the genital mucosa have a distinct IL-17/IL-22 profile and may have an important role in the immunological homeostasis and control of microbes at this site.

Innate Invariant NKT Cell Recognition of HIV-1-Infected Dendritic Cells Is an Early Detection Mechanism Targeted by Viral Immune Evasion

Invariant NKT (iNKT) cells are innate-like T cells that respond rapidly with a broad range of effector functions upon recognition of glycolipid Ags presented by CD1d. HIV-1 carries Nef- and Vpu-dependent mechanisms to interfere with CD1d surface expression, indirectly suggesting a role for iNKT cells in control of HIV-1 infection. In this study, we investigated whether iNKT cells can participate in the innate cell-mediated immune response to HIV-1. Infection of dendritic cells (DCs) with Nef- and Vpu-deficient HIV-1 induced upregulation of CD1d in a TLR7-dependent manner. Infection of DCs caused modulation of enzymes in the sphingolipid pathway and enhanced expression of the endogenous glucosylceramide Ag. Importantly, iNKT cells responded specifically to rare DCs productively infected with Nef- and Vpu-defective HIV-1. Transmitted founder viral isolates differed in their CD1d downregulation capacity, suggesting that diverse strains may be differentially successful in inhibiting this pathway. Furthermore, both iNKT cells and DCs expressing CD1d and HIV receptors resided in the female genital mucosa, a site where HIV-1 transmission occurs. Taken together, these findings suggest that innate iNKT cell sensing of HIV-1 infection in DCs is an early immune detection mechanism, which is independent of priming and adaptive recognition of viral Ag, and is actively targeted by Nef- and Vpu-dependent viral immune evasion mechanisms.

Presence of CD8+ T cells in the ectocervical mucosa correlates with genital viral shedding in HIV-infected women despite a low prevalence of HIV RNA-expressing cells in the tissue

The female genital tract is a portal of entry for sexual HIV transmission and a possible viral reservoir. In this study, the ectocervical CD8+ T cell distribution was explored in situ and was related to expression of CD3 and HLA-DR and presence of HIV RNA. For this purpose, ectocervical tissue samples and genital secretions were collected from HIV-seropositive (HIV+) Kenyan female sex workers (FSWs) (n = 20), HIV-seronegative (HIV-) FSWs (n = 17), and HIV(-) lower-risk women (n = 21). Cell markers were assessed by in situ staining and by quantitative PCR. HIV RNA expression in tissue was analyzed by in situ hybridization, and viral shedding was assessed by quantitative PCR. The HIV+ FSW group had a higher amount of total cells and CD8+, CD3+, and HLA-DR+ cells compared with the HIV(-)FSW group and HIV- lower-risk women. The majority of CD8+ cells were CD3+ T cells, and the numbers of CD8+ cells correlated significantly with plasma and cervical viral load. HIV RNA expression in situ was found in 4 of the 20 HIV+FSW women but did not correlate with cervical or plasma viral load. Thus, the HIV+ women displayed high numbers of CD8+, CD3+, and HLA-DR+ cells, as well as a limited number of HIV RNA+ cells, in their ectocervical mucosa; hence, this localization cannot be neglected as a potential viral reservoir. The elevated levels of CD8+ T cells may play a role in the immunopathogenesis of HIV in the female genital tract.

Comparison of interferon {gamma} release assays and conventional screening tests before tumour necrosis factor {alpha} blockade in patients with inflammatory arthritis

OBJECTIVE

To compare the performance of two interferon gamma release assays (IGRAs) and conventional screening tests in patients with inflammatory arthritis undergoing screening for latent tuberculosis infection (LTBI) before treatment with anti-tumour necrosis factor alpha (anti-TNFalpha) compounds.

METHODS

Successive patients were subjected to conventional LTBI screening, including a tuberculin skin test (TST). The T-SPOT.TB test was performed on all patients and the QuantiFERON-TB Gold test was performed on a large subset. The results of the IGRAs were compared with the results of conventional screening tests.

RESULTS

A total 150 patients were evaluated. The majority (57.9%) had rheumatoid arthritis. Previous vaccination with Bacille Calmette-Guerin was confirmed in 82% of patients. No patient had received prior anti-TB treatment. A total of 57 patients (38.0%) had at least one positive conventional risk factor. In contrast, an unequivocally positive T-SPOT.TB test was seen in only 14/143 (9.8%). There was 98.2% agreement between the two IGRAs. Statistically significant associations were found between each of the IGRAs and both TST and risk history, but not chest x-ray (CXR). A positive IGRA result was significantly associated with increased age. TB was not reactivated in any patient during the follow-up period.

INTERPRETATION

This study suggests that IGRAs may be useful when screening for LTBI before anti-TNFalpha therapy in patients with immune-mediated inflammatory diseases. The observations reported here also highlight the inadequate performance of CXR as a marker of LTBI.

Improving the efficacy of sacral nerve stimulation for faecal incontinence by alteration of stimulation parameters

Background

Sacral nerve stimulation (SNS) is an effective treatment for faecal incontinence, but only standard stimulation parameters have been used. This study assessed the clinical impact of altering the parameters.

Methods

Twelve patients with partially improved faecal incontinence following SNS underwent acute testing to select optimal stimulation parameters; rectal compliance was used as a surrogate marker. Parameters tested were: stimulation off; frequency 14 (standard), 31 or 6·9 Hz; and pulse duration 210 (standard), 450 or 90 µs. Patients completed a 2-week bowel diary, St Mark's continence score (SMCS) and Rockwood faecal incontinence quality-of-life (FIQL) score before testing using standard settings, and after testing using optimized settings.

Results

Optimal settings, determined by greatest increase in rectal compliance, were shorter pulse width in five patients and higher frequency in seven. Optimized stimulation resulted in a decrease in mean episodes of incontinence from 2·3 to 1·2 per week (P = 0·031), soiling from 3·3 to 1·7 days per week (P = 0·016), faecal urgency from 31 to 18 per cent of all evacuations (P = 0·055) and SMCS from 12·3 to 8·7 (P = 0·008); the FIQL coping/behaviour score improved (P = 0·008).

Conclusion

With a shorter pulse width and higher frequency, clinical efficacy in patients undergoing SNS for faecal incontinence can be improved.

A dose-ranging study of the pharmacokinetics and pharmacodynamics of the selective apoptotic antineoplastic drug (SAAND), OSI-461, in patients with advanced cancer, in the fasted and fed state

PURPOSE

To evaluate the safety, pharmacokinetics and determine the recommended dose of the selective apoptotic antineoplastic drug, OSI-461 administered on a twice-daily regimen to patients with advanced solid malignancies.

METHODS

In this phase I trial, 33 patients were treated with OSI-461 doses ranging from 400 to 1,200 mg given twice daily in 4-week cycles. Pharmacokinetic studies were performed to characterize the plasma disposition of OSI-461 and the effect of food intake on OSI-461 absorption. Secondary biomarker studies were performed to assess the biologic activity of OSI-461 including the measurement of pGSK-3beta, a PKG substrate, and pharmacogenetic studies to identify polymorphisms of CYP3A that influence drug metabolism and of ABCG2, involved in drug resistance.

RESULTS

Thirty-three patients were treated with 86 courses of OSI-461. The dose-limiting toxicities were grade 3 abdominal pain, found in one patient at the 1,000 mg BID fed dose level and all patients at the 1,200 mg BID fed dose level. There was also one episode each of grade 3 fatigue and grade 3 constipation at the 1,000 and 1,200 mg BID fed dose levels, respectively. Other common toxicities included mild to moderate fatigue, nausea, anorexia and mild elevation in bilirubin. Pharmacokinetic studies of OSI-461 revealed approximately a twofold increase in AUC(0-24) when OSI-461 was administered with food. An increase in pGSK-3beta post-dose was seen in the majority of patients and was greater at higher dose levels. No patients exhibited CYP3A4 polymorphisms, while 100% of patients were found to have the CYP3A5*3/CYP3A5*3 polymorphism. Two known polymorphisms of the ABCG2 gene, G34 --> A34 and C421 --> A421, occurred at frequencies of 11.76 and 29%, respectively.

CONCLUSIONS

Toxicity and pharmacodynamic data show that the recommended oral dose of OSI-461 is 800 mg twice daily administered with food. The drug appears to be well-tolerated, and overall bioavailability appears to be markedly increased when the drug is administered with food. These results support further disease-directed evaluations of OSI-461 at a dose of 800 mg BID in combination with other chemotherapeutic agents.

Robust, routine haematology reference ranges for healthy adults

Accurate, reliable laboratory reference ranges are essential for effective clinical evaluation and monitoring. We present robust reference ranges established for haematology, coagulation and haematinic parameters using the Sysmex XE 2100, CA 1500 and Beckman-Coulter Access analysers. Blood samples were taken from 250 healthy laboratory personnel and routine haematology, coagulation and haematinic parameter analysis performed. Our data represent findings from an extensive study to establish reference ranges in healthy adults.

Patient attitudes regarding payment for participation in a phase I cancer clinical trial

6573

Background: Research industry practice reimburses healthy phase 1 study subjects and yet cancer patients who participate in a phase 1 study are rarely reimbursed. The ethical problems of disproportionate risk/benefit ratio and coercive informed consent are cited as reasons for not paying cancer study subjects. The purpose of this study is to determine if payment to participate in a phase 1 clinical trial affects a cancer subject's willingness to participate (WTP) in a clinical trial and to determine if any payment would reduce the therapeutic misconception. Methods: Eligible adults had consented to participate in a phase 1 clinical trial of an investigational drug at UCCC but had not yet initiated treatment. Subjects were identified by UCCC staff, consented to participate in this study, and then administered a questionnaire by phone. Primary analyses were descriptive in nature. Results: Thirty subjects were enrolled. The median age was 57 years (range 30–76); 53% were female; 97% were Caucasian; 77% had at least some college education; 47% had an annual household income of < $50,000. When asked an open-ended question, 53% of subjects stated that the main purpose of the phase 1 trial in which they consented to participate was efficacy. The majority of subjects (80%) did not think they should be paid to participate in a phase 1 cancer trial. Most subjects (73%) expected to benefit from phase I study participation and greater than 80% of subjects stated that payment would not change their perception or hope of benefit. There was a minor trend towards increased WTP with increased reimbursement or payment. Thirty-seven percent of subjects acknowledged that payment might affect what side effects they report. Conclusions: While payment appeared to have little or no affect on a cancer subject's expectation of benefit from a phase 1 trial, WTP increased slightly with increasing payment. Given these results, it seems that payment would not reduce the therapeutic misconception related to participation in phase 1 cancer trials. This study should be expanded to confirm these findings.

No significant financial relationships to disclose.

Pharmacological modulation of gut mucosal and large vessel blood flow

BACKGROUND

Constipation, diminished gut blood flow, ischaemic colitis and drug therapy may be associated.

AIM

To study the effect of constipating medication on, and the regulation of, gut blood flow.

METHODS

24 healthy females (mean age 30) received, in a double-blind, three-way crossover study: (i) placebo, (ii) ipratropium 40 microg by inhalation (positive control known to reduce rectal mucosal blood flow) and (iii) oral loperamide 4 mg. Mucosal blood flow was measured at the splenic flexure and rectum using laser Doppler flowmetry. Blood flow in the superior and inferior mesenteric arteries was measured by trans-abdominal Doppler ultrasound.

RESULTS

Ipratropium decreased rectal mucosal blood flow by 16% (P=0.009) and splenic flexure mucosal blood flow by 8% (P=0.075). Loperamide caused no change in rectal (P=0.40) or splenic flexure mucosal blood flow (P=0.73). Neither treatment changed superior or inferior mesenteric artery blood flow. Splenic flexure mucosal blood flow showed a positive correlation with rectal mucosal blood flow (r=0.69; P<0.0001).

CONCLUSIONS

Vasoactive agents may reduce gut mucosal blood flow in the absence of reduced large vessel flow. Constipating drugs do not necessarily reduce gut blood flow. Rectal mucosal blood flow correlates with splenic flexure mucosal flow, and potentially may be used as a more convenient surrogate for studying splenic flexure blood flow.

Output factor measurements for a kilovoltage x-ray therapy unit

Output factors at the surface for treatment cones and lead cut-outs have been measured for a Pantak Therapax SXT 150 superficial therapy unit with x-ray beam qualities from 1 to 13 mm A1 HVL. A variety of phantom materials and two ionisation chambers were tested for their suitability in output factor and percentage depth dose measurement. Solid water proved a useful water-equivalent phantom material with discrepancies between measurements in water and solid water less than 2.3% for percentage depth dose and less than 0.6% for output factors. Larger measurement discrepancies were found for Plastic Water and Perspex. A PTW Markus chamber was found to compare well with a NE 2532/3 low energy chamber in percentage depth dose measurement, but discrepancies arose between the chambers in output factor measurements, up to 5% for small field sizes. Measurements indicated that the Markus chamber had an energy dependent response in the kilovoltage range, which could account for the discrepancy in output factor measurement.

Development and evaluation of an information booklet/decision-making guide for patients with colorectal cancer considering therapy in addition to surgery

The aim of this project was to develop and evaluate a decision-making guide for patients with colorectal cancer contemplating adjuvant therapy. Initially, a focus group was held, and then a draft booklet was developed, which was reviewed by patients and professionals. A subsequent revised booklet and a questionnaire were mailed to 24 patients and 32 professionals for evaluation. Further changes resulted in the final 100-page decision-making guide, which had a Flesch-Kincaid reading level of 8.0 and DISCERN rating 5. Seventeen patients (71%) and 22 professionals (69%) completed the questionnaire. All patients agreed/strongly agreed the guide was 'informative' and 'written in a way you like' and 94% considered it 'helpful for making decisions'. Professionals found it 'informative' (95%), 'written in a pleasing style' (95%), 'easy to understand' (91%) and felt it would 'help patients make decisions' (76%), 'be appropriate to give to patients' (91%) and would 'improve patient knowledge and preparedness' (100%). Further work aims to assess the impact of the guide upon patient outcomes.

Loop diathermy excision compared with cervical laser vaporisation for the treatment of intraepithelial neoplasia: a randomised controlled trial

OBJECTIVE

To determine whether loop diathermy excision of the transformation zone and laser vaporisation are equally effective in the treatment of cervical intraepithelial neoplasia.

DESIGN

Randomised controlled trial.

POPULATION

Women referred for evaluation of cytological abnormality who were considered suitable for outpatient local destructive treatment.

SETTING

Seven colposcopy units in the North West Region.

METHODS

Loop diathermy excision of the transformation zone and laser vaporisation.

MAIN OUTCOME MEASURE

Smear reported as moderate dyskariosis or worse following treatment.

RESULTS

Of 289 women randomised, 285 had one or more smears following treatment. Women were more likely to have a smear reported as moderate dyskariosis or worse following laser vaporisation [hazard ratio 3.01 (95% CI 1.27 to 7.12)]. The cumulative risk of a smear reported as moderate dyskariosis or worse was 6.0% at six months and 12.1% at three years in those allocated laser vaporisation, and 2.0% at six months, and 3.3% at three years in those allocated loop diathermy excision of the transformation zone.

CONCLUSIONS

Loop diathermy excision is a more effective treatment of cervical intraepithelial neoplasia than laser vaporisation.

Cardiovascular risk: the safety of local anesthesia, vasoconstrictors, and sedation in heart disease

As part of a large pragmatic study, the authors investigated heart rate, blood pressure, dysrhythmic and ischemic responses to lidocaine 2% with a combination vasoconstrictor (noradrenaline 1:50,000 and vasopressin 0.25 IU/mL), and midazolam sedation in a medically compromised population. There were anesthesia-induced physiological changes to both hemodynamics and the electrocardiogram. The use of midazolam significantly ameliorated the sympathoadrenal response to stress, and the greatest hemodynamic and electrocardiographic changes were observed during surgery.

Are differences in stage at presentation a credible explanation for reported differences in the survival of patients with colorectal cancer in Europe?

Popular reporting of a comparison of cancer survival rates across 17 European countries, based on data collected by national and regional cancer registries, has left an impression of inadequate treatment of patients in the UK. A subsequent study has suggested that the poor survival rates reported for the UK can, in large part, be explained by more advanced stage at presentation. We believe this conclusion to be unsound and use this study as an example to illustrate the methodological difficulties which may arise during such international comparisons. As the NHS cancer plan aspires to achieve for the UK parity with the best cancer care in Europe, careful thought needs to be given to identifying countries with which the UK can usefully compare itself and the most appropriate indicators for this comparison.

Simian virus 40 detection in human mesothelioma: reliability and significance of the available molecular evidence

Simian virus 40 was discovered as a contaminant of early poliovirus vaccines that were inadvertently administered to millions of people in Europe and the United States between 1955 and 1963. Although SV40 was proven to be oncogenic in rodents and capable of transforming human and animal cells in vitro, its role in human cancer could not be proven epidemiologically. The matter was forgotten until 1993 when SV40 was accidentally found to cause mesotheliomas in hamsters injected intra-cardially. Subsequently, DNA sequences associated with its powerful oncogenic principal, the large T antigen, were found with high frequency in human pleural mesothelioma using the polymerase chain reaction (PCR). Since then many laboratories have confirmed the human findings. However, a few laboratories have failed to reproduce these data and the authors of the studies have claimed that the detection of SV40 DNA may simply represent PCR contamination artefacts. The controversy raised by this viewpoint is reviewed in this article together with a critical appraisal of the reliability of the molecular techniques used to detect SV40 DNA, in order to evaluate the potential aetiopathogenic role of SV40 in human mesothelioma.

Association of SV40 with human tumours

SV40 was discovered as a contaminant of poliovirus vaccines that were inadvertently administered to millions of people in Europe and the United States between 1955 and 1963. Shortly afterwards, SV40 was proven to be oncogenic in rodents and capable of transforming human and animal cells in vitro. The possibility that SV40 might cause tumours in humans thus became a subject of scientific and public interest and scrutiny. However, largely due to a lack of significant epidemiological evidence, interest in assessing SV40's potential carcinogenic role in humans diminished. Recently, many laboratories have reported the presence of SV40-like DNA in a high proportion of human mesotheliomas, ependymomas and osteosarcoma (the three main types of tumours caused by virus in hamsters), renewing the question whether SV40 might be a human tumour virus. Molecular data from these studies are reviewed to re-evaluate the potential role of SV40 as a human carcinogen.

Randomized controlled trial to assess the effectiveness of a videotape about radiotherapy

In a randomized controlled trial, the additional provision of information on videotape was no more effective than written information alone in reducing pre-treatment worry about radiotherapy. Images of surviving cancer patients, however, may provide further reassurance to patients once therapy is completed.