Stakeholders' perspectives and experiences of patient and public involvement (PPI) in clinical trials in maternal and neonatal healthcare: protocol for a qualitative evidence synthesis

BACKGROUND

Patient and public involvement (PPI) has the potential to improve the relevance of trial outcomes and improve participant recruitment within clinical trials. However, the literature on PPI approaches, outcomes, and attitudes towards PPI in specific clinical research areas is limited. We are interested to know the current approaches to and views of PPI within maternal and neonatal clinical trials, from the perspective and experience of involved stakeholders.

METHODS

A qualitative evidence synthesis (QES) of stakeholders' perspectives and experiences of PPI will be conducted. Stakeholders will include any individual involved in maternal or neonatal clinical trials with experience of PPI in the area or who expresses their views on PPI. The electronic bibliographic databases CINAHL, MEDLINE, PsycINFO, EMBASE, Web of Science and the Maternity and Infant Care (OVID) will be searched from inception. Qualitative studies, mixed-methods studies where the qualitative data can be extracted independently, and surveys with open-ended qualitative questions, will be included.

AIMS

The QES seeks to explore stakeholders', including PPI contributors, trial participants and guardians, and trial researchers, perspectives and experiences of PPI in maternal and neonatal clinical trials.

DISCUSSION

THE QES will provide an understanding of how PPI is understood, operationalised and experienced by stakeholders in maternal and neonatal clinical trials, with the aim of identifying good practice and areas for improvement. PROSPERO registration: CRD42023383878 (2 nd March 2023).

Stakeholders' perspectives and experiences of patient and public involvement (PPI) in clinical trials in maternal and neonatal healthcare: protocol for a qualitative evidence synthesis

BACKGROUND

Patient and public involvement (PPI) has the potential to improve the relevance of trial outcomes and improve participant recruitment within clinical trials. However, the literature on PPI approaches, outcomes, and attitudes towards PPI in specific clinical research areas is limited. We are interested to know the current approaches to and views of PPI within maternal and neonatal clinical trials, from the perspective and experience of involved stakeholders.

METHODS

A qualitative evidence synthesis (QES) of stakeholders' perspectives and experiences of PPI will be conducted. Stakeholders will include any individual involved in maternal or neonatal clinical trials with experience of PPI in the area or who expresses their views on PPI. The electronic bibliographic databases CINAHL, MEDLINE, PsycINFO, EMBASE, Web of Science and the Maternity and Infant Care (OVID) will be searched from inception. Qualitative studies, mixed-methods studies where the qualitative data can be extracted independently, and surveys with open-ended qualitative questions, will be included.

AIMS

The QES seeks to explore stakeholders', including PPI contributors, trial participants and guardians, and trial researchers, perspectives and experiences of PPI in maternal and neonatal clinical trials.

DISCUSSION

THE QES will provide an understanding of how PPI is understood, operationalised and experienced by stakeholders in maternal and neonatal clinical trials, with the aim of identifying good practice and areas for improvement. PROSPERO registration: CRD42023383878 (2 nd March 2023).

Physical health and comorbid anxiety and depression across the first year postpartum in Ireland (MAMMI study): A longitudinal population-based study

INTRODUCTION

Little is known of the associations between physical health issues and mental health issues such as anxiety, depression and comorbid anxiety and depression (CAD) occurring in the perinatal period.

METHODS

A longitudinal cohort study with 3009 first-time mothers giving birth in Ireland collected physical and mental health data in pregnancy and at 3, 6, 9 and 12 months postpartum. Mental health was measured using the depression and anxiety subscales of the Depression, Anxiety and Stress Scale. Experience of eight common physical health issues (e.g. severe headaches/migraines, back pain) were assessed in pregnancy, with an additional six assessed at each postpartum data collection point.

RESULTS

2.4 % of women reported depression alone in pregnancy and 4 % reported depression across the first postpartum year. Anxiety alone was reported by 3.0 % of women in pregnancy, and 2 % in the first year postpartum. Prevalence of comorbid anxiety/depression (CAD) was 1.5 % in pregnancy and almost 2 % postpartum. A higher proportion of women reporting, compared to women not reporting, postpartum CAD were younger, not partnered, not in paid employment in pregnancy, have fewer years of education, and had a caesarean birth. Extreme tiredness/exhaustion and back pain were the most common physical health issues in pregnancy and postpartum. Constipation, haemorrhoids, bowel issues, breast issues, infection and pain in the perineum or caesarean wound, pelvic pain and urinary tract infections were highest at three months postpartum and gradually decreased thereafter. Women reporting depression alone or anxiety alone were equivalent in terms of physical health issues. However, women without mental health symptoms reported significantly fewer physical health issues than women reporting depressive or anxiety symptoms alone or CAD at every time point. Women with CAD reported a significantly higher number of health issues than women reporting depression alone or anxiety alone at 9 and 12 months postpartum.

CONCLUSION

Reports of mental health symptoms are associated with higher physical health burden demonstrating a need for integrated approaches in mental and physical health care pathways in perinatal services.

Women's perspectives on resilience and research on resilience in motherhood: A qualitative study

PURPOSE

Definitional perspectives and operational approaches to the concept of resilience vary within the literature; however, little is known of women's opinions on current resilience research, or the philosophical and methodological directions women believe such research should take. This research explored women's perspectives on resilience research in the perinatal period and early motherhood and sought their opinions on the ways in which they believe research should be advanced.

METHODS

Following ethical approval, online interviews were conducted with 14 ethnically and socioeconomically diverse women who were mothers. Findings from a concept analysis on resilience in pregnancy and early motherhood, conducted by the authors, were shared with women before and during the interview. Interviews were organised in sections corresponding to the findings within the concept analysis' four philosophical (Epistemology, Linguistic, Logic, Pragmatic) principles and thematically analysed.

RESULTS

Epistemology-Women endorsed a dynamic process definition, and viewed resilience as influenced by multilevel, multisystemic processes. Linguistic-Women viewed words such as 'adaptation' and 'adjustment' as being more active and empowering than the term 'coping' in relation to motherhood. Logic-Women were resistant to the predominant operational conceptualisation of resilience as illness absence. Pragmatic-Women were wary of resilience research being used to reduce mental health support for other mothers and families.

CONCLUSIONS

Women provided constructive criticisms on the current state of resilience literature. Women suggested actionable ways in which research may be developed to better align with the epistemological and ethical approaches women want to see in resilience and maternal mental health research.

PATIENT OR PUBLIC CONTRIBUTION

Women who are mothers and participants in health research were consulted on their views of trends in mental health and resilience research in motherhood.

Resilience in the Perinatal Period and Early Motherhood: A Principle-Based Concept Analysis

A context-specific delineation of research approaches to resilience in the perinatal and early motherhood literature is currently lacking. A principle-based concept analysis was used to establish a description of how women's resilience is currently conceptualised and operationalised within empirical research in the perinatal period and early motherhood (defined as up to five-years postpartum). CINAHL, Medline, PsychInfo, EMBASE, ASSIA, Web of Science, Scielo, Maternity and Infant Care, the Cochrane Library, and the World Health Organization were systematically searched (January/February 2020 and March 2022). Fifty-six studies met the inclusion criteria. Analysis demonstrated interchangeable use of associated concepts such as 'coping', 'coping strategies', and 'adaptation'. Resilience was frequently operationalised as the absence of illness symptomatology, rather than the presence of mental well-being. Investigations of positive areas of functioning were predominately related to the mother's family role. There was limited qualitative exploration of women's perspectives. Recommendations for the pragmatic application of resilience research were not well developed. The narrow operationalisation of resilience by mental ill-health and parental role, and the distinct absence of women's perspectives, restricts the logical maturity and pragmatic application of the concept. Future research may benefit from exploration of women's insights on indicators that might best reflect positive functioning and resilience in this period.

764 ROCKWOOD CLINICAL FRAILTY SCALE TO PREDICT LENGTH OF STAY,INPATIENT MORTALITY & READMISSION RATE IN A COMMUNITY HOSPITAL SETTING

Introduction

Frailty is prevalent in elderly patients in acute medical wards. It is recognised that length of stay (LOS), inpatient mortality and readmission rates rise with increasing frailty. (Reference: Specialised Clinical Frailty Network: Clinical frailty Scale. 2018. https://www.scfn.org.uk/clinical-frailty-scale) The Rockwood clinical frailty scale (CFS) is a well-recognised and validated tool, which can be easily incorporated into the comprehensive geriatric assessment to identify the frailest patients and aid in clinical decision making. We collected data on elderly patients in a non-acute community setting to assess the relationship between degree of frailty and outcomes, in this subset of inpatients.

Methods

Data was collected on 200 patients admitted to a geriatrician led community hospital over an 8 month period. Patients were all transferred from the affiliated acute hospital site (both medical and surgical wards).Commonest acute diagnoses were: falls, fractures, infections, delirium and heart failure. Premorbid CFS was recorded and patients were divided into 2 groups: CFS ≤ 4: versus CFS ≥5, and outcomes compared to degree of frailty.

Results

Of 200 patients, aged ≥65 years, admitted from the acute hospital setting to the community hospital,28.5% had premorbid CFS ≤4,and 71.5% had premorbid CFS ≥5. Median LOS in the community hospital was 10 days in the less frail group compared to 13 days in the frailer group. One year emergency readmission rate was 58.5% in those with CFS ≤4,and 67% in those with CFS ≥5.

Conclusion(s)

Accurate recording of premorbid CFS in the non-acute hospital setting can be used to help predict patient outcomes. Used in conjunction with the CGA it is a tool that can aid decision making and prompt discussions with patients and/or families re advance care planning, specifically re suitability of transfer back to the acute hospital setting in the event of a decline in health.

Elite female athletes' experiences of symptoms of pelvic floor dysfunction: A systematic review

INTRODUCTION AND AIMS

Pelvic floor dysfunction (PFD) is a collection of signs, symptoms and conditions affecting the pelvic floor and urinary incontinence (UI) is the most common type of PFD. Recent systematic reviews have indicated a higher prevalence of UI among female athletes compared to their non-athletic counterparts. To date, no review has been undertaken to investigate female athletes' experiences of PFD. This review aims to offer insight and understanding, through aggregation, summary, synthesis and interpretation of findings from studies that report elite female athletes' experiences of symptoms of PFD.

METHODS

The review protocol was registered in PROSPERO in August 2020. A systematic search was conducted in Embase, MEDLINE (OVID), Cochrane Library, CINAHL, PsycINFO and Web of Science for studies published in the English language reporting elite female athletes' experiences of symptoms of PFD. This review included primary research studies that involved elite female athletes of any age or ethnicity.

RESULTS

Of the 1922 citations retrieved in the search, 32 studies met the methodological criteria for data extraction and analysis. Five main themes emerged: (1) triggers for symptoms of PFD; (2) strategies adopted by athletes to manage/mitigate symptoms of PFD; (3) impact on QOL/daily life; (4) impact on performance; (5) impact on emotions.

CONCLUSIONS

The findings of this review suggest a need to further explore the experiences of PFD among elite female athletes and it is suggested that future research should adopt qualitative methods or incorporate a qualitative component.

Oxytocin administration for induction and augmentation of labour in polish maternity units - an observational study

BACKGROUND

There is not enough data regarding practices and protocols on the dose of oxytocin administrated to women during labour. Empirical evidence indicates that compliance with the guidelines improves the quality of healthcare and reduces adverse effects. The study aimed to evaluate practices of oxytocin provision for labour induction and augmentation in two maternity units in Poland.

METHODS

The article presents a prospective observational study. Data from 545 (n = 545) labours was collected in two maternity units. First, the total dose (the total amount of oxytocin provided from the beginning in the labour ward until delivery including the III and IV stage of labour) and cumulative dose of oxytocin (the amount of oxytocin given until the birth of the neonate) administered to women during labour was calculated. Then, the relationship between the cumulative dose of oxytocin and short term perinatal outcomes (mode of delivery, use of epidural anaesthesia, Apgar scores, birth weight and postpartum blood loss) was analysed. Finally, the compliance of oxytocin supply during labour with national guidelines in the following five criteria: medium, start dose, escalation rate, interval, the continuation of infusion after established labour was examined.

RESULTS

The average cumulative dose of oxytocin administrated to women before birth was 4402 mU following labour induction and 2366 mU following labour augmentation. The actual administration of oxytocin deviated both from the unit and national guidelines in 93.6% of all observed labours (mainly because of continuation of infusion after established labour). We found no statistically significant correlation between the cumulative dose of oxytocin administered and mode of delivery, immediate postpartum blood loss or Apgar scores. There was no observed effect of cumulative dose oxytocin on short-term perinatal outcomes. The two units participating in the study had similar protocols and did not differ significantly in terms of total oxytocin dose, rates of induction and augmentation - the only observed difference was the mode of delivery.

CONCLUSIONS

The study showed no effect of the mean cumulative oxytocin dose on short-term perinatal outcomes and high rate of non-compliance of the practice of oxytocin administration for labour induction and augmentation with the national recommendations. Cooperation between different professional groups of maternity care providers should be considered in building national guidelines for maternity care.. Further studies investigating possible long-term effects of the meant cumulative dose of oxytocin and the reasons for non-compliance of practice with guidelines should be carried out.

Factors associated with maternal readmission to hospital, attendance at emergency rooms or visits to general practitioners within three months postpartum

While most women remain healthy after giving birth to their baby, others experience complications that require medical attention or readmission to hospital. However, data on maternal attendance for medical care postpartum or readmission to hospital are not collected or reported routinely in many countries so the extent of health problems experienced remain unknown. Collecting data on the proportion of women who seek medical care in the early postpartum period may deepen understanding of risk factors, the consequences for women, their families and the maternity care system and, ultimately, help identify preventative strategies and processes.

OBJECTIVE

To identify the factors associated with maternal rehospitalisation, attendance at emergency rooms or visits to general practitioners, the three main sources of medical services postpartum in Ireland, within the first three months postpartum.

STUDY DESIGN

A prospective cohort study, embedded in a larger maternal health and morbidity study, with 1668 nulliparous women recruited from two maternity hospitals in Ireland. Univariate and multivariable logistic regression analyses were used to explore associations with postpartum rehospitalisation, emergency room attendance and general practitioner visits within the first three months postpartum, for maternal health-related reasons.

RESULTS

Four percent (n = 66) of women were rehospitalised, 10% (n = 166) attended an emergency room, and 13.6% (n = 223) attended their general practitioner three or more times, regarding their own health. Women aged 24 years or less were more likely to attend their doctor (p = 0.02, AOR 2.13, 95% CI 1.08-4.21) compared to women aged 25-29 years, the reference category. Women who were obese or very obese were also more likely to attend their doctor three or more times (p = 0.01, AOR 1.79, 95% CI 1.15-2.79) and also more likely to attend an emergency room (p = 0.04, AOR 1.69, 95% CI 1.02-2.80) within three months postpartum, for their own health reasons.

CONCLUSION

Findings indicate that considerable proportions of women seek medical care from various healthcare sources postpartum. These medical visits are not routinely reported and point to the need for interventions regarding the care, management and services available to first-time mothers birthing in Ireland, with specific attention on preventative postpartum health.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Two-layered susceptibility vessel sign is associated with biochemically quantified thrombus red blood cell content

BACKGROUND AND PURPOSE

Better characterization of the thrombus could be useful to determine acute ischaemic stroke (AIS) aetiology and predict response to thrombolysis and endovascular therapy (EVT). To test the hypothesis that susceptibility vessel sign (SVS) on baseline magnetic resonance imaging (MRI) is related to red blood cell (RBC) content of AIS thrombi, the total haemoglobin contents (HbCs) of AIS thrombi retrieved by EVT from patients with or without SVS or two-layered SVS (TLSVS) were compared.

METHODS

Baseline MRI of 84 anterior AIS patients was reviewed by neuro-radiologists blinded to clinical and biochemical data. Thrombi from these patients were retrieved by EVT and analysed for HbC by quantitative enzyme-linked immunosorbent assay and measurement of haem concentration.

RESULTS

Susceptibility vessel sign and TLSVS were respectively observed in 85.7% and 50.0% of cases. The median HbC content was 253 µg/mg thrombus (interquartile range 177-333) and the median haem content was 219 µg/mg thrombus (131-264). Thrombus HbC and haem content were highly correlated with thrombus RBC content determined by flow cytometry (r = 0.94). Thrombi from patients with TLSVS weighed more [31.1 (16.5-68.3) mg vs. 17.7 (11.7-33.3) mg; P = 0.005] and had a higher HbC content [278 (221-331) µg/mg vs. 196 (139-301) µg/mg; P = 0.010] compared to thrombi from patients without TLSVS. There was no difference in thrombus weight or HbC content according to SVS status.

CONCLUSIONS

Our study shows that TLSVS is significantly associated with a higher thrombus weight and RBC content, as determined by quantitative assays.

Health economic analysis of a cluster-randomised trial (OptiBIRTH) designed to increase rates of vaginal birth after caesarean section

OBJECTIVE

To perform a health economic analysis of an intervention designed to increase rates of vaginal birth after caesarean, compared with usual care.

DESIGN

Economic analysis alongside the cluster-randomised OptiBIRTH trial (Optimising childbirth by increasing vaginal birth after caesarean section (VBAC) through enhanced women-centred care).

SETTING

Fifteen maternity units in three European countries - Germany (five), Ireland (five), and Italy (five) - with relatively low VBAC rates.

POPULATION

Pregnant women with a history of one previous lower-segment caesarean section; sites were randomised (3:2) to intervention or control.

METHODS

A cost-utility analysis from both societal and health-services perspectives, using a decision tree.

MAIN OUTCOME MEASURES

Costs and resource use per woman and infant were compared between the control and intervention group by country, from pregnancy recognition until 3 months postpartum. Based on the caesarean section rates, and maternal and neonatal morbidities and mortality, the incremental cost-utility ratios were calculated per country.

RESULTS

The mean difference in costs per quality-adjusted life years (QALYs) gained from a societal perspective between the intervention and the control group, using a probabilistic sensitivity analysis, was: €263 (95% CI €258-268) and 0.008 QALYs (95% CI 0.008-0.009 QALYs) for Germany, €456 (95% CI €448-464) and 0.052 QALYs (95% CI 0.051-0.053 QALYs) for Ireland, and €1174 (95% CI €1170-1178) and 0.006 QALYs (95% CI 0.005-0.007 QALYs) for Italy. The incremental cost-utility ratios were €33,741/QALY for Germany, €8785/QALY for Ireland, and €214,318/QALY for Italy, with a 51% probability of being cost-effective for Germany, 92% for Ireland, and 15% for Italy.

CONCLUSION

The OptiBIRTH intervention was likely to be cost-effective in Ireland and Germany.

TWEETABLE ABSTRACT

The OptiBIRTH intervention (to increase VBAC rates) is likely to be cost-effective in Germany and Ireland.

Mode of birth and postnatal health-related quality of life after one previous cesarean in three European countries

BACKGROUND

How a woman gives birth can affect her health-related quality of life (HRQoL). This study explored HRQoL at 3 months postpartum in women with a history of one previous cesarean in three European countries.

METHODS

A prospective longitudinal survey, embedded within a cluster randomized trial in three countries, exploring women's postnatal HRQoL up to 3 months postpartum. The Short-Form Six-Dimensions (SF-6D) was used to measure HRQoL, and multivariate analyses were used to examine the relationship with mode of birth.

RESULTS

Complete data were available from 880 women. Women with a spontaneous vaginal birth had the highest HRQoL scores, whereas women with an emergency repeat cesarean (P = .01) had the lowest. Postnatal readmission of the mother (P = .03), having public health insurance (P = .04), and a low antenatal HRQoL score (P < .01) contributes to poorer HRQoL scores. More specifically, women with a spontaneous vaginal birth had significantly higher HRQoL scores on the vitality dimension compared with women with an emergency repeat cesarean (P = .04).

CONCLUSIONS

In women with low-risk factors, repeat cesareans result in a poorer HRQoL compared with vaginal birth. When there are no contraindications for vaginal birth, women with a history of one previous cesarean should be encouraged to give birth vaginally rather than have an elective repeat cesarean.

Vaginal birth after caesarean versus elective repeat caesarean delivery after one previous caesarean section: a cost-effectiveness analysis in four European countries

BACKGROUND

The OptiBIRTH study incorporates a multicentre cluster randomised trial in 15 hospital sites across three European countries. The trial was designed to test a complex intervention aimed at improving vaginal birth after caesarean section (VBAC) rates through increasing women's involvement in their care. Prior to developing a robust standardised model to conduct the health economic analysis, an analysis of a hypothetical cohort was performed to estimate the costs and health effects of VBAC compared to elective repeat caesarean delivery (ERCD) for low-risk women in four European countries.

METHODS

A decision-analytic model was developed to estimate the costs and the health effects, measured using Quality Adjusted Life Years (QALYs), of VBAC compared with ERCD. A cost-effectiveness analysis for the period from confirmation of pregnancy to 6 weeks postpartum was performed for short-term consequences and during lifetime for long-term consequences, based on a hypothetical cohort of 100,000 pregnant women in each of four different countries; Belgium, Germany, Ireland and Italy. A societal perspective was adopted. Where possible, transition probabilities, costs and health effects were adapted from national data obtained from the respective countries. Country-specific thresholds were used to determine the cost-effectiveness of VBAC compared to ERCD. Deterministic and probabilistic sensitivity analyses were conducted to examine the uncertainty of model assumptions.

RESULTS

Within a 6-week time horizon, VBAC resulted in a reduction in costs, ranging from €3,334,052 (Germany) to €66,162,379 (Ireland), and gains in QALYs ranging from 6399 (Italy) to 7561 (Germany) per 100,000 women birthing in each country. Compared to ERCD, VBAC is the dominant strategy in all four countries. Applying a lifetime horizon, VBAC is dominant compared to ERCD in all countries except for Germany (probabilistic analysis, ICER: €8609/QALY). In conclusion, compared to ERCD, VBAC remains cost-effective when using a lifetime time.

CONCLUSIONS

In all four countries, VBAC was cost-effective compared to ERCD for low-risk women. This is important for health service managers, economists and policy makers concerned with maximising health benefits within limited and constrained resources.

Porphyrin derivatives as potent and selective blockers of neuronal Kv1 channels

Docking model of compound12into the homology model of Kv1.1.

Reliability of Repeated Measurements on Post-Burn Scars with Corneometer CM 825(®)

BACKGROUND/PURPOSE

The water content in burn scars, the parameter of stratum corneum water holding capacity, is an important feature in evaluation of biophysical properties of scars. Nevertheless, quantifiying this parameter is a challenge. In this study, the reliability of repeated water content measurements with Corneometer CM825(®) on (burn) scars was investigated.

METHODS

Intra-observer reliability, inter-observer reliability and day-by-day variability were examined on 30 scars by means of intra-class correlation coefficient (ICC) and within-subject coefficient of variation (WSCV). Bland-Altman plots with '95% limits of agreement' were constructed.

RESULTS

Results revealed excellent ICC values (ICCintra  = 0.985; ICCinter  = 0.984) with relatively low WSCV (WSCVintra  = 6.3%; WSCVinter  = 10.6%) for respectively intra- and inter-observer reliability. However, the Bland-Altman plot showed that more than 5% of differences were expected to exceed 4 a.u., the limit of what has been defined as a clinically acceptable difference. Results for day-by-day variability showed good ICC value (ICCday-by-day  = 0.849) and higher WSCV (WSCVday-by-day  = 20.5%).

CONCLUSION

The Corneometer CM825(®) is an objective and sensitive instrument for water content measurements. On the basis of our results, we concluded that the instrument can be used in clinical trials, but only under very strict conditions with standardized test protocol, preferably in combination with the evaluation of other physiological parameters.

An integrated pressure and pathway approach to the spatial analysis of groundwater nitrate: a case study from the southeast of Ireland

Excess nitrogen in soil, aquatic and atmospheric environments is an escalating global problem. Eutrophication is the principal threat to surface water quality in the Republic of Ireland. European Union Water Framework Directive (2000/60/EC) water quality status assessments found that 16% of Irish groundwater bodies were 'at risk' of poor status due to the potential deterioration of associated estuarine and coastal water quality by nitrate from groundwater. This paper presents a methodology for evaluating pressure and pathway parameters affecting the spatial distribution of groundwater nitrate, investigated at a regional scale using existing national spatial datasets. The potential for nitrate transfer to groundwater was rated based on the introduced concepts of Pressure Loading and Pathway Connectivity Rating, each based on a combination of selected pressure and pathway parameters respectively. In the region studied, the South Eastern River Basin District of Ireland, this methodology identified that pathway parameters were more important than pressure parameters in understanding the spatial distribution of groundwater nitrate. Statistical analyses supported these findings and further demonstrated that the proportion of poorly drained soils, arable land, karstic flow regimes, regionally important bedrock aquifers and high vulnerability groundwater within the zones of contribution of the monitoring points are statistically significantly related to groundwater nitrate concentrations. Soil type was found to be the most important parameter. Analysis of variance showed that a number of the pressure and pathway parameters are interrelated. The parameters identified by the presented methodology may provide useful insights into the best way to manage and mitigate the influence of nitrate contamination of groundwater in this region. It is suggested that the identification of critical source areas based on the identified parameters would be an appropriate management tool, enabling planning and enforcement resources to be focussed on areas which will yield most benefit.

Bladder afferent sensitivity in wild-type and TRPV1 knockout mice

Understanding bladder afferent pathways may reveal novel targets for therapy of lower urinary tract disorders such as overactive bladder syndrome and cystitis. Several potential candidate molecules have been postulated as playing a significant role in bladder function. One such candidate is the transient receptor potential vanilloid 1 (TRPV1) ion channel. Mice lacking the TRPV1 channel have altered micturition thresholds suggesting that TRPV1 channels may play a role in the detection of bladder filling. The aim of this study was therefore to investigate the role of TRPV1 receptors in controlling bladder afferent sensitivity in the mouse using pharmacological receptor blockade and genetic deletion of the channel. Multiunit afferent activity was recorded in vitro from bladder afferents taken from wild-type (TRPV+/+) mice and knockout (TRPV1-/-) mice. In wild-type preparations, ramp distension of the bladder to a maximal pressure of 40 mmHg produced a graded increase in afferent activity. Bath application of the TRPV1 antagonist capsazepine (10 mum) caused a significant attenuation of afferent discharge in TRPV1+/+ mice. Afferent responses to distension were significantly attenuated in TRPV1-/- mice in which sensitivity to intravesical hydrochloric acid (50 mm) and capsaicin (10 microm) were also blunted. Altered mechanosensitivity occurred in the absence of any changes in the pressure-volume relationship during filling indicating that this was not secondary to a change in bladder compliance. Single-unit analysis was used to classify individual afferents into low-threshold and high-threshold fibres. Low threshold afferent responses were attenuated in TRPV1-/- mice compared to the TRPV1+/+ littermates while surprisingly high threshold afferent sensitivity was unchanged. While TRPV1 channels are not considered to be mechanically gated, the present study demonstrates a clear role for TRPV1 in the excitability of particularly low threshold bladder afferents. This suggests that TRPV1 may play an important role in normal bladder function.

Detection and recovery rates achieved using direct plate and enrichment/immunomagnetic separation methods for Escherichia coli O157:H7 in minced beef and on bovine hide

AIMS

To assess the detection and recovery rates achieved with commonly used cultural methods for the enumeration and recovery of Escherichia coli O157:H7 from minced beef and bovine hide.

METHODS AND RESULTS

Minced beef and bovine hide were inoculated with varying concentrations (log(10) 1.58-2.58 CFU g(-1) and log(10) 2.42-4.49 CFU 100 cm(2) respectively) of E. coli O157:H7 and recovered using a direct plate method or an enrichment/immunomagnetic separation (IMS) method and then plated onto SMAC or SMAC-CT in both cases. The direct plate method detected the pathogen consistently from minced beef samples with an average recovery of 69.2-91.2%. From faecal material on the bovine hide the recovery of the pathogen ranged from 1.80 to 64.5% with fresh faeces depending on the inocula while from dried faeces on hide the results ranged from no recovery at all to 25.1%. Enrichment/IMS recovered E. coli O157:H7 at all inocula levels tested in minced beef while the pathogen was only detected consistently at an average inocula level of log(10) 2.73 CFU 100 cm(2) from fresh faeces and log(10) 4.49 CFU 100 cm(2) from dried faeces on bovine hide.

CONCLUSIONS

The direct count enumeration method for E. coli O157:H7 underestimated the numbers of pathogens present. The enrichment/IMS procedure consistently detected the pathogen from minced beef but did not always detect E. coli O157:H7 from faeces on bovine hide.

SIGNIFICANCE AND IMPACT OF THE STUDY

Overall this study highlights that any microbial data, used in either predictive microbiology or risk assessment, must take account of the sensitivity and associated performance of the methods employed, in order to make an accurate reflection of the true microbiology of the examined sample.

Solution-phase, parallel synthesis and pharmacological evaluation of acylguanidine derivatives as potential sodium channel blockers

Solution-phase synthesis of various acylguanidine derivatives and the evaluation of a small library of compounds as potential sodium channel blockers are described.

Wheelchair propulsion biomechanics: implications for wheelchair sports

The aim of this article is to provide the reader with a state-of-the-art review on biomechanics in hand rim wheelchair propulsion, with special attention to sport-specific implications. Biomechanical studies in wheelchair sports mainly aim at optimising sport performance or preventing sport injuries. The sports performance optimisation question has been approached from an ergonomic, as well as a skill proficiency perspective. Sports medical issues have been addressed in wheelchair sports mainly because of the extremely high prevalence of repetitive strain injuries such as shoulder impingement and carpal tunnel syndrome. Sports performance as well as sports medical reflections are made throughout the review. Insight in the underlying musculoskeletal mechanisms of hand rim wheelchair propulsion has been achieved through a combination of experimental data collection under realistic conditions, with a more fundamental mathematical modelling approach. Through a synchronised analysis of the movement pattern, force generation pattern and muscular activity pattern, insight has been gained in the hand rim wheelchair propulsion dynamics of people with a disability, varying in level of physical activity and functional potential. The limiting environment of a laboratory, however, has hampered the drawing of sound conclusions. Through mathematical modelling, simulation and optimisation (minimising injury and maximising performance), insight in the underlying musculoskeletal mechanisms during wheelchair propulsion is sought. The surplus value of inverse and forward dynamic simulation of hand rim stroke dynamics is addressed. Implications for hand rim wheelchair sports are discussed. Wheelchair racing, basketball and rugby were chosen because of the significance and differences in sport-specific movement dynamics. Conclusions can easily be transferred to other wheelchair sports where movement dynamics are fundamental.

Psychological distress, social support, and disease activity in patients with inflammatory bowel disease

OBJECTIVES

The objectives of this study were to compare the psychological status of patients in active and inactive disease states, to assess social support, and to identify correlates of psychological distress in patients with inflammatory bowel disease (IBD).

METHODS

This cross-sectional study was conducted in 200 patients (mean age 36.7 yr [SD = 14.8], 119 [59.5%] female) with long-standing IBD who were seen in tertiary care. Psychosocial assessments included psychological distress (Symptom Checklist-90R), social support (Social Support Questionnaire-6), perceived stress (Perceived Stress Scale-10), and recent minor stressful events (Weekly Stress Inventory). Disease activity was assessed with the Harvey Bradshaw Index.

RESULTS

Patients reported higher levels of satisfaction with social support and smaller network sizes compared with normative values. Using multiple linear regression, the independent correlates of psychological distress (p = 0.0001; adjusted R2 = 0.62) were as follows: active disease (p = 0.0234), less time since diagnosis (p = 0.0012), and greater number (p = 0.0001) and impact of stressful events (p = 0.0003). A statistically significant interaction term (p = 0.0171) revealed that the relationship between psychological distress and perceived stress changes depending on the level of satisfaction with social support. For patients with low levels of perceived stress, satisfaction with social support did not affect levels of psychological distress. However, for patients who experienced moderate to high levels of perceived stress, high satisfaction with social support decreased the level of psychological distress.

CONCLUSIONS

These findings suggest that strategies aimed at improving social support can have a favorable impact on psychological distress and, ultimately, can improve health outcomes in patients with IBD.

2-Amino-5-chloro-1,3-benzoxazol-3-ium 2-(3,4-dichlorophenoxy)acetate

The 1:1 organic salt of the title compound, C(7)H(6)ClN(2)O(+). C(8)H(5)Cl(2)O(3)(-) or [(2-ABOX)(3,4-D)], comprises the two constituent molecules associated by an R(2)(2)(8) graph-set interaction through the carboxylate group of 3,4-D across the protonated N/N sites of 2-ABOX [N.O 2.546 (3) and 2.795 (3) A]. Cation/anion pairs associate across an inversion centre forming discrete tetramers via an additional three-centre hydrogen-bonding association from the latter N amino proton to a phenoxy O atom [N.O 3.176 (3) A] and a carboxylate O atom [N.O 2.841 (3) A]. This formation differs from the polymeric hydrogen-bonded chains previously observed for adduct structures of 2-ABOX with carboxylic acids.

QTc interval (cardiac repolarization): lengthening after meals

Weight reduction, either by dietary or surgical means, is associated with prolongation of the heart rate corrected QT interval (QTc = QT/R-R0.5) and, on occasion, sudden death. Screening subjects with obesity before weight loss for prolonged QTc intervals is an accepted practice, although at present, there are no guidelines for whether subjects should be fasting before electrocardiogram (EKG) evaluation. The aim of this study was to test the hypothesis that EKG QTc interval duration is independent of meal ingestion. The hypothesis was tested in 11 healthy subjects who ingested a 500-kcal formula meal. A small decrease in absolute QT interval and a steady decline in R-R interval were observed for up to 60 minutes after formula ingestion. The QTc interval increased above baseline at 15 minutes (p < 0.007) after meal, a change that persisted for the 1-hour postmeal observation period. Spectral analysis of EKG R-R intervals (low-/high-frequency amplitude ratio) indicated a change in cardiac autonomic flow after meal ingestion. The QTc interval did not lengthen and R-R low-/high-frequency amplitude ratio remained unchanged in eight subjects evaluated in a similar manner but in whom isovolumic amounts of water replaced the meal. These observations suggest that (1) cardiac repolarization changes with fasting and feeding, (2) the QTc interval is influenced by meal intake, and (3) the autonomic nervous system may play a role in meal-related QTc changes. These findings have implications for the evaluation of patients with obesity before starting and during weight loss treatment.

Beckwith-Wiedemann syndrome: dental management

Beckwith-Wiedemann syndrome (BWS) comprises multiple congenital anomalies with a risk of childhood tumours. Macroglossia is the most common manifestation. Two cases are presented to illustrate the importance of early referral and the role of preventive dentistry.

Activation of glutamatergic neurotransmission by ketamine: a novel step in the pathway from NMDA receptor blockade to dopaminergic and cognitive disruptions associated with the prefrontal cortex

Subanesthetic doses of ketamine, a noncompetitive NMDA receptor antagonist, impair prefrontal cortex (PFC) function in the rat and produce symptoms in humans similar to those observed in schizophrenia and dissociative states, including impaired performance of frontal lobe-sensitive tests. Several lines of evidence suggest that ketamine may impair PFC function in part by interacting with dopamine neurotransmission in this region. This study sought to determine the mechanism by which ketamine may disrupt dopaminergic neurotransmission in, and cognitive functions associated with, the PFC. A thorough dose-response study using microdialysis in conscious rats indicated that low doses of ketamine (10, 20, and 30 mg/kg) increase glutamate outflow in the PFC, suggesting that at these doses ketamine may increase glutamatergic neurotransmission in the PFC at non-NMDA glutamate receptors. An anesthetic dose of ketamine (200 mg/kg) decreased, and an intermediate dose of 50 mg/kg did not affect, glutamate levels. Ketamine, at 30 mg/kg, also increased the release of dopamine in the PFC. This increase was blocked by intra-PFC application of the AMPA/kainate receptor antagonist, 6-cyano-7-nitroquinoxaline-2,3-dione CNQX. Furthermore, ketamine-induced activation of dopamine release and impairment of spatial delayed alternation in the rodent, a PFC-sensitive cognitive task, was ameliorated by systemic pretreatment with AMPA/kainate receptor antagonist LY293558. These findings suggest that ketamine may disrupt dopaminergic neurotransmission in the PFC as well as cognitive functions associated with this region, in part, by increasing the release of glutamate, thereby stimulating postsynaptic non-NMDA glutamate receptors.