Addressing medical resident mistreatment: A resident-centred approach

INTRODUCTION

Mistreatment negatively impacts the wellbeing of medical learners and is related to worse patient outcomes and team functioning. Resident perspectives on improving mistreatment reporting structures and investigations have not been explored. We aimed to understand residents' views on safe reporting structures, investigations, and resolution processes.

METHOD

We conducted an exploratory sequential mixed method study beginning with a series of qualitative interviews to inform an anonymous online survey to all Dalhousie University residents (N = 645).

RESULTS

When interviewed, residents (N = 10) discussed personal experiences with mistreatment, barriers to reporting, and how these processes could better serve them. Themes from the interviews were imbedded in an anonymous online survey to explore their prevalence among a larger group. Residents (N = 120; 19%) completed the online survey and revealed that mistreatment was very common yet underreported. Barriers to reporting included confidentiality concerns, perceptions that reporting would not change anything, and fear of retaliation. Desired outcomes for perpetrators depended on the perpetrator's position and incident severity, and most prefer a remedial approach.

CONCLUSION

Resident mistreatment remains prevalent and current processes of dealing with reports may be inadequate. Residents have thoughtful insights for improving institutional policies and procedures and should be meaningfully engaged.

Search for a Dark-Matter-Induced Cosmic Axion Background with ADMX

We report the first result of a direct search for a cosmic axion background (CaB)-a relativistic background of axions that is not dark matter-performed with the axion haloscope, the Axion Dark Matter eXperiment (ADMX). Conventional haloscope analyses search for a signal with a narrow bandwidth, as predicted for dark matter, whereas the CaB will be broad. We introduce a novel analysis strategy, which searches for a CaB induced daily modulation in the power measured by the haloscope. Using this, we repurpose data collected to search for dark matter to set a limit on the axion photon coupling of a CaB originating from dark matter cascade decay via a mediator in the 800-995 MHz frequency range. We find that the present sensitivity is limited by fluctuations in the cavity readout as the instrument scans across dark matter masses. Nevertheless, we suggest that these challenges can be surmounted using superconducting qubits as single photon counters, and allow ADMX to operate as a telescope searching for axions emerging from the decay of dark matter. The daily modulation analysis technique we introduce can be deployed for various broadband rf signals, such as other forms of a CaB or even high-frequency gravitational waves.

Intestinal colonization regulates systemic anti-commensal immune sensitivity and hyperreactivity

Healthy host-microbial mutualism with our intestinal microbiota relies to a large degree on compartmentalization and careful regulation of adaptive mucosal and systemic anti-microbial immune responses. However, commensal intestinal bacteria are never exclusively or permanently restricted to the intestinal lumen and regularly reach the systemic circulation. This results in various degrees of commensal bacteremia that needs to be appropriately dealt with by the systemic immune system. While most intestinal commensal bacteria, except for pathobionts or opportunistic pathogen, have evolved to be non-pathogenic, this does not mean that they are non-immunogenic. Mucosal immune adaptation is carefully controlled and regulated to avoid an inflammatory response, but the systemic immune system usually responds differently and more vigorously to systemic bacteremia. Here we show that germ-free mice have increased systemic immune sensitivity and display anti-commensal hyperreactivity in response to the addition of a single defined T helper cell epitope to the outer membrane porin C (OmpC) of a commensal Escherichia coli strain demonstrated by increased E. coli-specific T cell-dependent IgG responses following systemic priming. This increased systemic immune sensitivity was not observed in mice colonized with a defined microbiota at birth indicating that intestinal commensal colonization also regulates systemic, and not only mucosal, anti-commensal responses. The observed increased immunogenicity of the E. coli strain with the modified OmpC protein was not due to a loss of function and associated metabolic changes as a control E. coli strain without OmpC did not display increased immunogenicity.

A novel surgical treatment of type 3 congenital elbow luxation in a dog

Congenital luxation of the ulnar and radius is a rare orthopaedic condition in the dog. This case report describes a novel surgical treatment for congenital elbow luxation in a medium-breed dog. A 6-week-old Kelpie presented for left forelimb lameness and deformity. Radiographs and computed tomography (CT) confirmed the diagnosis of unilateral ulnar and radius luxation. The surgical repair involved open reduction followed by fixation with an extraarticular pin and a transarticular external fixator. The outcome of surgery was improved leg function and weight-bearing, however, reluxation of the radial head was diagnosed 7 weeks following surgery. This technique may offer an alternative surgical option to improve clinical signs, as well as insight into improving the management of this condition.

Measuring school level attributable risk to support school-based HPV vaccination programs

Background

In Australia in 2017, 89% of 15-year-old females and 86% of 15-year-old males had received at least one dose of the HPV vaccine. However, considerable variation in HPV vaccination initiation (dose one) across schools remains. It is important to understand the school-level characteristics most strongly associated with low initiation and their contribution to the overall between-school variation.

Methods

A population-based ecological analysis was conducted using school-level data for 2016 on all adolescent students eligible for HPV vaccination in three Australian jurisdictions. We conducted logistic regression to determine school-level factors associated with lower HPV vaccination initiation (< 75% dose 1 uptake) and estimated the population attributable risk (PAR) and the proportion of schools with the factor (school-level prevalence).

Results

The factors most strongly associated with lower initiation, and their prevalence were; small schools (OR = 9.3, 95%CI = 6.1–14.1; 33% of schools), special education schools (OR = 5.6,95%CI = 3.7–8.5; 8% of schools), higher Indigenous enrolments (OR = 2.7,95% CI:1.9–3.7; 31% of schools), lower attendance rates (OR = 2.6,95%CI = 1.7–3.7; 35% of schools), remote location (OR = 2.6,95%CI = 1.6–4.3; 6% of schools,) and lower socioeconomic area (OR = 1.8,95% CI = 1.3–2.5; 33% of schools). The highest PARs were small schools (PAR = 79%, 95%CI:76–82), higher Indigenous enrolments (PAR = 38%, 95%CI: 31–44) and lower attendance rate (PAR = 37%, 95%CI: 29–46).

Conclusion

This analysis suggests that initiatives to support schools that are smaller, with a higher proportion of Indigenous adolescents and lower attendance rates may contribute most to reducing the variation of HPV vaccination uptake observed at a school-level in these jurisdictions. Estimating population-level coverage at the school-level is useful to guide policy and prioritise resourcing to support school-based vaccination programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13088-x.

Search for Invisible Axion Dark Matter in the 3.3-4.2 μeV Mass Range

We report the results from a haloscope search for axion dark matter in the 3.3-4.2  μeV mass range. This search excludes the axion-photon coupling predicted by one of the benchmark models of "invisible" axion dark matter, the Kim-Shifman-Vainshtein-Zakharov model. This sensitivity is achieved using a large-volume cavity, a superconducting magnet, an ultra low noise Josephson parametric amplifier, and sub-Kelvin temperatures. The validity of our detection procedure is ensured by injecting and detecting blind synthetic axion signals.

Intra-articular methylprednisolone and bupivacaine for treatment of sesamoid disease in dogs

INTRODUCTION

The sesamoid disease is a cause of lameness in dogs, and there is limited literature relating to diagnosis, treatment and outcome of treatment in dogs with the sesamoid disease. Our aim was to compare the efficacy of intra-articular metacarpophalangeal/metatarsophalangeal joint injection with methylprednisolone and bupivacaine (IMPB) or conservative management with nonsteroidal anti-inflammatories and rest (CMNR) for treatment of this disease.

MATERIALS AND METHODS

We conducted a retrospective survey of dogs treated for the sesamoid disease with IMPB or CMNR. The medical records of all dogs that received IMPB or were recommended CMNR for treatment of sesamoid pain were reviewed, and a client questionnaire was delivered to owners. Response to treatment, rapidity of response, length of resolution and recurrence of clinical signs associated with the sesamoid disease were assessed.

RESULTS

A total of 78 dogs were included in the study. One week after IMPB, 52/58 (89.7%) dogs demonstrated resolution of lameness compared with 1 week of CMNR, 0/18 (P < 0.001). There was limited statistical evidence in client satisfaction between treatment groups, IMPB 36/53 (67.9%) and CMNR 16/17 (94%) (P = 0.052). Dogs presenting with the sesamoid disease had comorbidities in 51/78 (65.4%) of cases. Elbow disease was the most common comorbidity 29/78 (37.2%).

CONCLUSION

Our results support the use of IMPB for short-term (1 week) resolution of lameness associated with sesamoid disease in dogs. Dogs treated with CMNR had slower improvement; however, there was no difference in lameness or client satisfaction between treatment groups at long-term follow-up (12 months).

Differences in school factors associated with adolescent HPV vaccination initiation and completion coverage in three Australian states

BACKGROUND

Schools are the primary setting for the delivery of adolescent HPV vaccination in Australia. Although this strategy has achieved generally high vaccination coverage, gaps persist for reasons that are mostly unknown. This study sought to identify school-level correlates of low vaccination course initiation and completion in New South Wales, Tasmania, and Western Australia to inform initiatives to increase uptake.

METHODS

Initiation was defined as the number of first doses given in a school in 2016 divided by vaccine-eligible student enrolments. Completion was the number of third doses given in a school in 2015-2016 divided by the number of first doses. Low initiation and completion were defined as coverage ≤ 25thpercentile of all reporting schools. We investigated correlations between covariates using Spearman's rank correlation coefficients. Due to multicollinearity, we used univariable logistic regression to investigate associations between school characteristics and low coverage.

RESULTS

Median initiation was 84.7% (IQR: 75.0%-90.4%) across 1,286 schools and median completion was 93.8% (IQR: 86.0%-97.3%) across 1,295 schools. There were strong correlations between a number of school characteristics, particularly higher Indigenous student enrolments and lower attendance, increasing remoteness, higher postcode socioeconomic disadvantage, and smaller school size. Characteristics most strongly associated with low initiation in univariate analyses were small school size, location in Tasmania, and schools catering for special educational needs. Low completion was most strongly associated with schools in Tasmania and Western Australia, remote location, small size, high proportion of Indigenous student enrolments, and low attendance rates.

CONCLUSION

This study provides indicative evidence that characteristics of schools and school populations are associated with the likelihood of low initiation and completion of the HPV vaccination course. The findings will guide further research and help target initiatives to improve vaccination uptake in schools with profiles associated with lower coverage.

A summary of the updated report on the incidence and epidemiological trends of keratinocyte cancers in the United Kingdom 2013-2018

Skin cancer is the commonest cancer in the UK. Skin cancer referrals via the two-week wait (urgent suspected cancer) pathway outnumber any other suspected malignancy.^{1, 2} The commonest skin cancers are keratinocyte cancers (KCs) which represents Basal Cell Carcinomas (BCC) and Cutaneous Squamous Cell Carcinomas (cSCC). Accurate KC incidence reporting is crucial for healthcare planning.

Novel radical pelvectomy technique to treat chondrosarcoma in a large-breed dog

Surgical management of chondrosarcoma with hemipelvectomy is well described, but there have been no reports on extensive excision involving bilateral pubis and unilateral ischium. This report describes a novel pelvectomy technique for the treatment of chondrosarcoma in a large-breed dog. A 12-year-old Labrador Retriever presented for tenesmus due to a large, intra-pelvic mass which was confirmed on computed tomography (CT). Surgery involved removal of the entire left ischium and both pubic bones with preservation of both hind limbs. Histopathology confirmed the diagnosis of a high-grade chondrosarcoma with tumour-free margins of less than 3 mm. The dog recovered well following surgery and regained ambulation within 9 days. Four months postoperatively, the dog had no ongoing pain or tenesmus and only a mild gait abnormality in the left hind limb. Pelvectomy involving the entire pubis and unilateral ischium was well tolerated in a large-breed dog. This technique may offer a novel surgical option to treat neoplasia previously considered too extensive for complete excision.

Maternal low-dose aspartame and stevia consumption with an obesogenic diet alters metabolism, gut microbiota and mesolimbic reward system in rat dams and their offspring

OBJECTIVE

We examined the impact of maternal low-dose aspartame and stevia consumption on adiposity, glucose tolerance, gut microbiota and mesolimbic pathway in obese dams and their offspring.

DESIGN

Following obesity induction, female Sprague-Dawley rats were allocated during pregnancy and lactation to: (1) high fat/sucrose diet (HFS) +water (obese-WTR); (2) HFS +aspartame (obese-APM; 5-7 mg/kg/day); (3) HFS +stevia (obese-STV; 2-3 mg/kg/day). Offspring were weaned onto control diet and water and followed until 18 weeks. Gut microbiota and metabolic outcomes were measured in dams and offspring. Cecal matter from offspring at weaning was used for faecal microbiota transplant (FMT) into germ-free (GF) mice.

RESULTS

Maternal APM and STV intake with a HFS diet increased body fat in offspring at weaning and body weight long-term with APM. Maternal APM/HFS consumption impaired glucose tolerance in male offspring at age 8 weeks and both APM and STV altered faecal microbiota in dams and offspring. Maternal obesity/HFS diet affected offspring adiposity and glucose tolerance more so than maternal LCS consumption at age 12 and 18 weeks. APM and STV altered expression of genes in the mesolimbic reward system that may promote consumption of a palatable diet. GF mice receiving an FMT from obese-APM and obese-STV offspring had greater weight gain and body fat and impaired glucose tolerance compared with obese-WTR.

CONCLUSION

Maternal low-calorie sweetener consumption alongside HFS may disrupt weight regulation, glucose control and gut microbiota in dams and their offspring most notably in early life despite no direct low-calorie sweetener consumption by offspring.

A36 THE ROLE OF MICROBIAL INDOLE METABOLITES IN CONTROLLING INFLAMMATORY RESPONSES AND HEALING IN RESPONSE TO DSS-INDUCED COLITIS

Background

Failure to resolve inflammation is often associate with the complications of Crohn’s Disease (CD). The pregnane X receptor (PXR), a xenobiotic receptor, is recognized for its role in suppressing inflammation and has recently been shown to influence fibrogenesis in the liver. In the intestine, PXR-signaling can be influenced by the microbial tryptophan metabolite indole-3- propionic acid (IPA), which can modulate intestinal inflammation, in turn influencing fibrogenesis, resolution and healing. This suggests that the gut microbiota could modulate mucosal homeostasis and resolution of inflammation via microbial metabolites

Aims

To understand and characterize the interplay between microbial complexity and the regulation of host inflammatory and healing responses, specifically focusing on the PXR and its microbial metabolite ligand IPA.

Methods

Intestinal inflammation was induced using DSS (1%, 1.5%, 2% and 3.5%) for 5 days followed by healing for 25 days in C57Bl/6 stably derived moderately diverse mouse microbiota 2 (sDMDMm2) colonized gnotobiotic and C57Bl/6 specific pathogen free (SPF) mice. Inflammation, architectural changes and fibrosis were assessed using Haemotoxylin and Eosin and Masson-Trichrome histological stains. Weight was recorded daily for the first 10 days and every other day after for 25 days, for a total of 30 days. Fecal lipocalin was quantified in samples collected throughout the study to assess inflammation. Innate immune cell influx was measured by flow cytometry, and the microbiota assessed via 16S rRNA sequencing.

Results

The gnotobiotic sDMDMm2 mice were exquisitely sensitive to DSS-induced colitis, exhibiting significantly increased mortality and morbidity at 2% and 3.5% w/v DSS compared to the SPF group. To elicit the same degree of disease to assess recovery, sDMDMm2 mice were exposed to 1.5% DSS and SPF mice to 3.5% DSS. Following 25 days recovery, sDMDMm2 colonized mice showed increased levels of fecal lipocalin 2, as compared to the SPF mice. DSS-treated sDMDMm2 mice supplemented with IPA during their recovery presented lower levels of fecal lipocalin, similar to colitic SPF mice. IPA supplemented sDMDMm2 mice also exhibited greater overall survival, with no significant differences in neutrophil count compared to mice given H20 during recovery.

Conclusions

A model system with a less complex microbiota (sDMDMm2) has a higher susceptibility to acute inflammation and a diminished capacity to resolve said inflammation. Addition of the microbial metabolite IPA normalized the recovery of the sDMDMm2 colonized mice, to a response indistinguishable from SPF mice, while also increasing survival. These data highlight the importance of microbial complexity in the regulation of intestinal mucosal homeostasis.

Funding Agencies

CAG, CCC, CIHR

22 Design and Implementation of A Nutrition Clinical Pathway for Patients with Fractured Neck of Femur

Background

Patients with a fractured neck of femur (FNOF) are commonly malnourished pre-admission, have reduced oral intake in hospital and a hypermetabolic state up to three months postoperatively (E Paillaud 2000). Malnutrition is associated with functional deterioration, higher morbidity and mortality.

Evidence suggests nutritional supplementation post-surgery can reduce postoperative complications. As a result, nutritional assessment is included in the National Hip Fracture Database best practice tariff (Avenell, Cochrane Database of Systematic Reviews 2016).

Introduction

Our aim was to design and implement a clinical pathway for patients with FNOF to identify malnutrition and provide appropriate nutritional support.

Intervention

A retrospective audit of 25 patients was completed to understand baseline rates of assessment, prescription of supplements and referral to dietetics. Using these data meetings were arranged to develop a clinical pathway. Key stakeholders included dietetics, orthopaedic surgeons, geriatricians, physiotherapists and nurses. The pathway was evaluated and optimised with two Plan-Do-Study-Act (PDSA) cycles looking at 25 patients each time.

Results

Baseline: 79% received a nutritional assessment, 32% had nutritional supplements prescribed and 36% (n=9) met criteria for referral to a dietician, of which 55%were referred. However, an additional 5 referrals were made to dietetics for patients who did not meet criteria, a 50% inappropriate referral rate.

PDSA cycle 1: increased nutritional assessment (85%), increased nutritional supplements prescribed (92%), decreased inappropriate referrals to dietetics (43%).

PDSA cycle 2: increased nutritional assessment & nutritional supplements prescribed (100%), increased inappropriate referrals to dietetics (80%).

Conclusions

The implementation of a nutrition pathway has led to increased identification and treatment of malnutrition, which has in addition improved accrual of the best practice tariff. However, greater number of inappropriate referrals have been made to dietetics. This is partly attributed to difficulty weighing patients on admission, and where no weight is inputted on the Malnutrition Universal Screening Tool a “High Risk” score is generated triggering a referral. We are now looking at alternative methods to obtaining a weight such a mid-upper arm circumference.

A case control study to determine the association between Perthes' disease and the recalled use of tobacco during pregnancy, and biological markers of current tobacco smoke exposure

AIMS

It is well established that there is a strong association between Perthes' disease and worsening socioeconomic deprivation. It has been suggested that the primary determinant driving this association is exposure to tobacco smoke. This study aimed to examine this hypothesis.

PATIENTS AND METHODS

A hospital case-control study (n = 149/146) examined the association between tobacco smoke exposure and Perthes' disease, adjusting for area-level socioeconomic deprivation. Tobacco smoke exposure was assessed by parental questionnaire of smoking habits during pregnancy, and by quantitative assay of current exposure using the urinary cotinine-creatinine ratio, which is a widely used and validated measure of tobacco smoke exposure.

RESULTS

The odds of Perthes' disease significantly increased with reported in utero exposure after adjustment for socioeconomic deprivation (maternal smoking odds ratio (OR) 2.06, 95% confidence interval (CI) 1.17 to 3.63; paternal smoking OR 2.09, 95% CI 1.26 to 3.46). The cotinine-creatinine ratio was significantly greater in cases, OR 1.63 (95% CI 1.09 to 2.43), suggesting a greater 'dose' of current tobacco exposure.

CONCLUSION

An association exists between tobacco smoke exposure and Perthes' disease but we remain unable to disentangle the association with socioeconomic deprivation. Cite this article: Bone Joint J 2017;99-B:1102-8.

Interdisciplinarity defines our identity as medical educators

This article was migrated. The article was marked as recommended. Medical education is a broad church. As a young interdisciplinary group of educationalists we discuss some aspects of the relevance of interdisciplinarity to medical education, using our own experiences as exemplars.

Accounts of Quitting among Older Ex-smokers with Smoking-related Disease

This article uses a discourse analytic method to explore how a sample of ex-smokers with smoking-related illness position themselves, and are positioned by, the language they use in their accounts of quitting. The article suggests that discursive constructions (having ‘no choice’ and getting ‘another chance’) used by the respondents position them in a way that constrains behaviour by closing down the option of smoking and/or opening up the possibility of change. In each telling, the respondents' (non-smoking) identities are confirmed anew and this affirmation may assist in sustaining the change and provide protection against relapse. Moreover, the article suggests that the development and exchange of these stories may contribute to the growth of shared beliefs about the experience of quitting, opening up the option of quitting for current smokers. In so doing, accounts of quitting provided by ex-smokers undermine or resist dominant social understandings that even among those highly motivated to stop smoking, quitting is a difficult, if not impossible, endeavour.

The lymph nodes draining the small intestine and colon are anatomically separate and immunologically distinct

Dendritic cells (DCs) in the small intestine (SI) and colon are fundamental to direct intestinal immune responses; they migrate to the mesenteric lymph nodes (MLNs) and prime T cells. We demonstrate anatomical segregation of lymphatic drainage from the intestine, specifically that DCs from the SI and colon migrate to different nodes within the MLN, here called the sMLN and cMLN. As a consequence, different frequencies of DC subsets observed in the SI and colon are reflected among the DCs in the sMLN and cMLN. Consistent with the SI's function in absorbing food, fed antigen is presented in the sMLN, but not in the cMLN. Furthermore, the levels of expression of CCR9 and α4β7 are increased on T cells in the sMLN compared with the cMLN. DCs from the cMLN and colon are unable to metabolize vitamin A to retinoic acid (RA); thus, DCs may contribute to the differential expression of tissue homing markers observed in the sMLN and cMLN. In summary, the sMLN and cMLN, and the DCs that migrate to these LNs are anatomically and immunologically separate. This segregation allows immune responses in the SI and colon to be controlled independently.

Long term temporal and spatial changes in the distribution of polychlorinated biphenyls and polybrominated diphenyl ethers in Scottish soils

Long term changes in polychlorinated biphenyl (PCB) and polybrominated diphenyl ether (PBDE) concentrations in soil from four transects across Scotland were measured in three surveys conducted between 1990 and 2007-9. Overall PCB level declined during this period (22.5 to 4.55 ng/g, p<0.001) but PBDEs increased (0.68 to 2.55 ng/g, p<0.001), reflecting the ban on PCB use in the 1980s while PBDE use increased until about 2004 when the use of penta-mix congener ceased in Europe. The proportion of lighter PCB congeners (28+52) present declined (p<0.001) primarily between 1990 and 1999. However, the proportion of lighter PBDE congeners (47+99) in the soil samples increased (p<0.01) from 1990 to 1999 and declined (p<0.001) thereafter, probably reflecting the introduction of legislation banning penta-BDE products and the degradation of lighter congeners and their translocation. PCBs were slightly higher in two southernmost transects but PBDE concentrations were significantly higher (p<0.001) in the two southern transects than in the two northern transects. This may reflect proximity to areas of high population and industrial activity. It is concluded that temporal and spatial changes in the distribution of PCBs and PBDEs reflect geography, physical processes and legislation.

Breast cancer after prophylactic mastectomy for Lobular Carcinoma-In-Situ (LCIS) - an unusual case

Bilateral risk reducing mastectomy results in the greatest breast cancer risk reduction but is an irreversible intervention. Total mastectomy can never remove all breast tissue and there is always a small risk of breast cancer. Regular follow up and surveillance is beneficial. We present the case of a 47-year-old woman who presented with axillary lymph node metastatic breast cancer after risk reducing mastectomy in which only Lobular Carcinoma-in-Situ (LCIS) was present on histopathology.

Legal impediments to data linkage

Large numbers of electronic health data collections have been accumulated by both government and non-government agencies and organisations. Such collections primarily assist with the management of health services and the provision of health care programs, with only a minority of these data collections also intended for research purposes. A number of constraints are placed on access to such data for the purposes of research, including data linkage. This article examines those factors arising from the intricacies of Australia's privacy legislation landscape which impede access to such collections. The relevant issues discussed include issues relating to the existence of multiple privacy and health privacy Acts, the recommendations made by the Australian Law Reform Commission in relation to the Privacy Act 1988 (Cth) and the constraints placed on the conduct of data-linkage research which arise from legislation that relates specifically to certain data collections.

Management of pain in children with burns

Burn injuries are common in children under 10 years of age. Thermal injury is the most common mechanism of injury and scalds account for >60% of such injuries. All children with burns will experience pain, regardless of the cause, size, or burn depth. Undertreated pain can result in noncompliance with treatment and, consequently, prolonged healing. It is acknowledged that the monitoring and reporting of pain in children with burns has generally been poor. Due to the adverse physiological and emotional effects secondary to pain, adequate pain control is an integral and requisite component in the management of children with burns. A multidisciplinary approach is frequently necessary to achieve a robust pain relief. Key to successful treatment is the continuous and accurate assessment of pain and the response to therapy. This clinical review article discusses the essential aspects of the pathophysiology of burns in children provides an overview of pain assessment, the salient principles in managing pain, and the essential pharmacodynamics of commonly used drugs in children with burn injuries. Both pharmacological and nonpharmacological treatment options are discussed, although a detailed review of the latter is beyond the scope and remit of this article.

The effect of poisoned and notional vaccinated buffers on possum (Trichosurus vulpecula) movements: minimising the risk of bovine tuberculosis spread from forest to farmland

Context. Vaccination of brushtail possums (Trichosurus vulpecula) has been proposed as a cost-effective alternative to lethal control for preventing potentially bovine tuberculosis (Tb)-infected possums from crossing forested buffer zones that abut farmland. Aim. Evaluation of these two management option requires an estimation of the buffer width required to reduce the risk of disease spread to an acceptable level. Methods. The movements of two groups of adult and subadult possums were monitored for up to 12 months in the Kaimanawa Range, North Island of New Zealand, using GPS technology. One group was in untreated forest immediately adjacent to a recently poisoned forest buffer, and the second group was 2 km further into untreated forest, which mimicked a vaccinated buffer with no reduction in possum abundance. Key results. Close to the poisoned buffer, where the initial population density was 0.49–1.45 ha–1, adult possum home ranges averaged 10.2 ha in the summer immediately after control and 9.5 ha in the following winter. Two kilometres into the untreated forest, where the density was >3 ha–1, the corresponding values were only 3.5 ha and 2.8 ha. Over the first 6 months of monitoring, a ~350-m wide poisoned buffer would have contained 95% of movements by adult possums, as well as movements by most individuals, but a ~150-m wide vaccinated buffer would have been as effective. Equivalent results for the subsequent 6-month period were ~450 m and ~200 m for poisoned and vaccinated buffers, respectively. Movements by possums were not biased in the direction of the population ‘vacuum’ created by the poisoning operation. When subadult possums were included in the analysis, buffer widths of ~500–600 m for both poisoning and vaccination would be required to contain 95% of new den site locations. Conclusions and implications. Detailed data on possum movements provide a means for agencies managing Tb to specify the width of a buffer, subject to an acceptable level of risk that it could be breached by a potentially infected possum. As well as depending on the width of a treated buffer, the final cost-effectiveness of vaccination compared with poisoning will depend on the relative cost of applying the two control techniques, and the frequency of application required either to prevent Tb from establishing (in the case of vaccination) or to suppress possum density (in the case of lethal control).

Quantum chemical investigations of charge-transfer interactions in relation to the electronic theory of cancer

The results of ab initio 'supermolecule' calculations of the charge transfer between formamide and methylglyoxal, dimethylglyoxal and ethylglyoxal are compared for several different relative conformations of the constituent molecules. The extent and sign of the charge transfer is similar for all three molecules; the ketoaldehyde acts as an electron acceptor only for the stacked conformation. Similar calculations on alpha-hydroxytetronic acid as a model for ascorbic acid show that it can act as either an acceptor from formamide or a donor to glyoxal.

Prevalence of type-specific HPV infection by age and grade of cervical cytology: data from the ARTISTIC trial

Human papillomavirus (HPV) infection causes cervical cancer and premalignant dysplasia. Type-specific HPV prevalence data provide a basis for assessing the impact of HPV vaccination programmes on cervical cytology. We report high-risk HPV (HR-HPV) type-specific prevalence data in relation to cervical cytology for 24 510 women (age range: 20–64; mean age 40.2 years) recruited into the ARTISTIC trial, which is being conducted within the routine NHS Cervical Screening Programme in Greater Manchester. The most common HR-HPV types were HPV16, 18, 31, 51 and 52, which accounted for 60% of all HR-HPV types detected. There was a marked decline in the prevalence of HR-HPV infection with age, but the proportion due to each HPV type did not vary greatly with age. Multiple infections were common below the age of 30 years but less so between age 30 and 64 years. Catch-up vaccination of this sexually active cohort would be expected to reduce the number of women with moderate or worse cytology by 45%, but the number with borderline or mild cytology would fall by only 7%, giving an overall reduction of 12% in the number of women with abnormal cytology and 27% in the number with any HR-HPV infection. In the absence of broader cross-protection, the large majority of low-grade and many high-grade abnormalities may still occur in sexually active vaccinated women.