Understanding the Impact of Symmetrical Substitution on the Photodynamics of Sinapate Esters Using Gas-Phase Ultrafast Spectroscopy

Two model biomimetic systems, ethyl sinapate (ES) and its symmetrical analogue, diethyl 2-(4-hydroxy-3,5-dimethoxybenzylidene)malonate (or diethyl sinapate, DES), are stripped to their core fundamentals through gas-phase spectroscopy to understand the underlying photophysics of photothermal materials. Following photoexcitation to the optically bright S1(ππ*) state, DES is found to repopulate the electronic ground state over 3 orders of magnitude quicker than its nonsymmetrical counterpart, ES. Our XMS-CASPT2 calculations shed light on the experimental results, revealing crucial differences in the potential energy surfaces and conical intersection topography between ES and DES. From this work, a peaked conical intersection, seen for DES, shows vital importance for the nonradiative ground-state recovery of photothermal materials. This fundamental comparative study highlights the potential impact that symmetrical substitution can have on the photodynamics of sinapate esters, providing a blueprint for future advancement in photothermal technology.

Perspectives of dairy employees at the beginning of the COVID-19 pandemic: A survey of health risks and educational needs

Our objective was to understand dairy employees' perceptions and educational needs at the onset of the COVID-19 pandemic. A bilingual (English and Spanish), anonymous survey targeted at dairy employees was circulated nationwide via university and allied industry media outlets. Responses (n = 63) from 11 states were received (May-Sep. 2020). Respondents worked in herds ranging from 50 to 40,000 animals in size. Dairy managers (33%) responded mostly to the English survey (52%), whereas entry-level workers (67%) chose the Spanish format (76%). Survey results highlighted different perspectives, educational needs, and preferred sources of information between English- and Spanish-speaking dairy workers. Overall, 83% of the respondents were somewhat concerned or very concerned about the COVID-19 pandemic. Respondents (51%) indicated that their main concern was "to bring the virus from work to home and make my family sick." Most dairy employees (83%) perceived that their employers were somewhat or very concerned about the pandemic. Respondents (65%) indicated that COVID-19 informative training was provided at the workplace, but training was more frequently undertaken among dairy managers (86%) than entry-level workers (53%). Most trainings (72%) were limited to posters on walls. The preferred means of information delivery was through in-person meetings at work (35%), with YouTube (29%) and on-demand videos (27%) as second and third options. The main source of information regarding the pandemic was social media (52%). Frequent handwashing (81%), limiting on-farm visits (70%), limiting agglomeration in break rooms (65%), hand sanitizer use (60%), and social distancing (60%) were the most common safety measures implemented at the workplace among the options given to respondents. Few respondents (38%) indicated that face-covering was required at work. Successful emergency plans on dairies should consider the outreach needs and preferences of dairy workers.

Perspective of dairy producers from California, Idaho, South Dakota, and Washington: Health and business implications of the COVID-19 pandemic during the second wave

The aim of this study was to document California, Idaho, South Dakota, and Washington dairy producers' perspectives on the health and business implications of COVID-19 during the pandemic second wave. Dairy producers were reached by a 14-question anonymous mail survey during June and July of 2020. We obtained 226 responses (response rate: 9.3% CA, 8.6% ID, 31.4%, and 10.0% WA). Responses were grouped by state (CA: 48.7%, ID: 15.9%, SD: 21.7%, or WA: 13.7%) and dairy size [based on number of cows; small (<100): 14.1%, medium (100-499): 27.7%, medium-large (500-1,999): 33.2%, or large (≥2,000): 25.0%]. Survey responses were summarized, and multiple correspondence analysis was used to map responses and identify data clusters. At the time of the survey, some respondents suspected (3%) or had confirmed (9%) COVID-19 cases on their premises. Respondents were somewhat or very concerned about the health (75%) and business (92%) implications associated with COVID-19. Producers were concerned about the health of their families, employees, and employees' families; having to reduce production; workforce shortage; limited goods availability; and lack of services. Producers perceived that their employees were somewhat or very concerned (74%) with the pandemic. There was COVID-19 safety information or training provided (78%) or intended (4%) in English (22%), Spanish (23%), or both (55%). The focus of training was as follows: how to remain healthy at work (91%) and at home (60%), what to do if a worker gets sick (77%), and sick leave information (54%). Nevertheless, 18% of the respondents answered that training was not going to be provided. The following control measures implemented: providing hand sanitizer or disinfectant wipes (78%), instruction on frequent hand-washing (76%), social distancing (59%), prevention of employee gatherings (54%), providing and requiring the use of face masks (49%), and limiting on-farm visitors (44%). Multiple correspondence analysis showed that concern with health risk and business impact of the COVID-19 pandemic, as well as mitigation and response strategies implemented, varied based on respondent's dairy size and state. The greatest concerns were reported by producers from California and large and medium-large dairies, whereas the fewest concerns were reported by producers from small dairies. Results from this survey highlighted the health and business concerns of dairy producers from California, Idaho, South Dakota, and Washington during the COVID-19 pandemic and the mitigation efforts adopted. In conclusion, mitigation measures were adopted by most dairy producers but in various degrees. Dairy industry service providers and educators were secondary educational resources during the pandemic; thus, future efforts toward centralized access to dairy specific bilingual educational materials are suggested.

984 Changing the Management of Epistaxis in the Covid-19 Era

Aim

Epistaxis in the Covid pandemic is a concerning problem facing otolaryngologists due to high droplet concentration and increased virulence in nasal secretions. Furthermore, safe ambulation of patients reduces Covid exposure and preserves essential resources. This study assessed the implementation of ENT UK recommended altered epistaxis management during the Covid pandemic.

Method

Patients presenting to a medium-sized community hospital with unrelenting epistaxis had a rapid rhino (RR) inserted. Able patients were ambulated and given an appointment for RR removal. Previously all patients were admitted. A comparative retrospective analysis of patients referred with epistaxis was conducted using electronic care records from March – August 2019 versus the same period in 2020. Follow-up phone-call was also employed. Admissions, bed days, RR complications and patient satisfaction was assessed. Data was analysed student t-tests.

Results

A significant reduction in admissions (n = 91; P &lt; 0.001) and bed days (n = 104; P &lt; 0.001) was observed. Only 2 out of the 68 patients ambulated required medical assistance prior to their scheduled appointment (3%; P &lt; 0.001). The majority of patients were satisfied (91%) and reported no bleeding (94%). No RR dislodgement occurred (0%) and most patients were pleased to avoid admission (92%). 70% of patients reported severe pain following RR insertion.

Conclusions

Ambulation of patients presenting to ED with unrelenting epistaxis managed with RR insertion is a safe alternative to previous practice with few complications. Furthermore, patients are largely satisfied although reported severe pain post RR insertion needs addressed. Finally, this altered management reduces contact and preserves resources as our hospitals face overwhelming pressures.

MSTO1 mutations cause mtDNA depletion, manifesting as muscular dystrophy with cerebellar involvement

MSTO1 encodes a cytosolic mitochondrial fusion protein, misato homolog 1 or MSTO1. While the full genotype–phenotype spectrum remains to be explored, pathogenic variants in MSTO1 have recently been reported in a small number of patients presenting with a phenotype of cerebellar ataxia, congenital muscle involvement with histologic findings ranging from myopathic to dystrophic and pigmentary retinopathy. The proposed underlying pathogenic mechanism of MSTO1-related disease is suggestive of impaired mitochondrial fusion secondary to a loss of function of MSTO1. Disorders of mitochondrial fusion and fission have been shown to also lead to mitochondrial DNA (mtDNA) depletion, linking them to the mtDNA depletion syndromes, a clinically and genetically diverse class of mitochondrial diseases characterized by a reduction of cellular mtDNA content. However, the consequences of pathogenic variants in MSTO1 on mtDNA maintenance remain poorly understood. We present extensive phenotypic and genetic data from 12 independent families, including 15 new patients harbouring a broad array of bi-allelic MSTO1 pathogenic variants, and we provide functional characterization from seven MSTO1-related disease patient fibroblasts. Bi-allelic loss-of-function variants in MSTO1 manifest clinically with a remarkably consistent phenotype of childhood-onset muscular dystrophy, corticospinal tract dysfunction and early-onset non-progressive cerebellar atrophy. MSTO1 protein was not detectable in the cultured fibroblasts of all seven patients evaluated, suggesting that pathogenic variants result in a loss of protein expression and/or affect protein stability. Consistent with impaired mitochondrial fusion, mitochondrial networks in fibroblasts were found to be fragmented. Furthermore, all fibroblasts were found to have depletion of mtDNA ranging from 30 to 70% along with alterations to mtDNA nucleoids. Our data corroborate the role of MSTO1 as a mitochondrial fusion protein and highlight a previously unrecognized link to mtDNA regulation. As impaired mitochondrial fusion is a recognized cause of mtDNA depletion syndromes, this novel link to mtDNA depletion in patient fibroblasts suggests that MSTO1-deficiency should also be considered a mtDNA depletion syndrome. Thus, we provide mechanistic insight into the disease pathogenesis associated with MSTO1 mutations and further define the clinical spectrum and the natural history of MSTO1-related disease.

Pregnancy per artificial insemination during summer in lactating dairy cows after treatment with aspirin

Embryonic loss in cattle may be related to a hormonal imbalance resulting in alterations in timing of prostaglandin F_2α (PGF_2α) secretion around the time of maternal recognition of pregnancy. The objective of this study was to examine effects of aspirin (a PGF_2α inhibitor) on pregnancy per AI (P/AI), and progesterone (P₄), and pregnancy specific protein B (PSPB) concentrations in lactating dairy cows inseminated more than once after parturition. Fourteen days after second or subsequent AI (Day 0 = Day of AI), 556 cows were assigned randomly to aspirin (187.2 g total; n = 277) or control (n = 279) groups. Aspirin was administered orally on Day 14 and 15, and control cows were subjected to sham bolus administration. On Day 25, blood samples were collected from a subset of cows (n = 194) to quantify P₄ and PSPB, whereas pregnancy was determined in all cows at 35-42 days post-AI. Maximum daily ambient temperature ranged from 38-41 °C during the experiment. Mean parity, days in milk, and times bred before treatment (TBRD) did not differ between groups. There were no differences in P/AI between treatments (aspirin 21.6 % compared with control 27.5 %). Neither treatment, parity, TBRD, or any two-way interactions with treatment affected concentrations of P₄. Moreover, there were no effects (P > 0.50) of treatment, or treatment by TBRD interaction on serum PSPB concentrations. A tendency (P = 0.07) occurred for multiparous cows to have greater serum PSPB concentrations compared with primiparous cows. Mean serum PSPB concentrations tended (P = 0.07) to be greater for second or third TBRD compared to fourth and greater TBRD. These results provide evidence that aspirin administered during periods of heat stress after the second and subsequent AI post-partum during the summer months does not improve P/AI or alter P₄ and PSPB in lactating dairy cows.

Pregnancy outcomes are not improved by administering gonadotropin-releasing hormone at initiation of a 5-day CIDR-Cosynch resynchronization protocol for lactating dairy cows

Using a 5-d controlled internal drug-release (CIDR)-Cosynch resynchronization protocol, the objective of this study was to determine the effect of the initial GnRH injection on pregnancy per artificial insemination (P/AI) to the second artificial insemination in lactating Holstein dairy cows. On 37 ± 3 d (mean ± standard deviation) after the first artificial insemination, and upon nonpregnancy diagnosis (d 0 of the experiment), lactating cows eligible for a second artificial insemination (n = 429) were enrolled in a 5-d CIDR-Cosynch protocol. On d 0, all cows received a CIDR insert and were assigned randomly to receive the initial GnRH injection (GnRH; n = 226) of the protocol or no-GnRH (n = 203). Blood samples were collected from a sub-group of cows (n = 184) on d 0 and analyzed for progesterone (P4) concentration. On d 5, CIDR inserts were removed, and all cows received 1 injection of PGF_2α. On d 6 and 7, cows were observed once daily by employees for tail-chalk removal, and cows detected in estrus on d 6 or 7 received artificial insemination that day (EDAI), and did not receive the final GnRH injection. The remaining cows not detected in estrus by d 8 received GnRH and timed artificial insemination (TAI). Pregnancy status was confirmed by transrectal palpation of uterine contents at 37 ± 3 d (mean ± standard deviation) after the second artificial insemination. Eliminating the initial GnRH injection had no effect on P/AI compared with cows receiving GnRH (27 vs. 21%), respectively. Similarly, method of insemination (EDAI vs. TAI) and its interaction with treatment had no effect on P/AI. Primiparous cows had greater P/AI than multiparous cows (31 vs. 21%). Mean P4 concentrations (n = 184) at the initiation of the protocol did not differ between treatments (4.51 ± 0.35 ng/mL no-GnRH vs. 3.96 ± 0.34 ng/mL of GnRH). When P4 concentrations were categorized as high (≥1 ng/mL) or low (<1 ng/mL), P/AI tended to be greater for high P4 concentrations (n = 136) compared with low (n = 48) P4 concentrations (26 vs. 16%, respectively). No differences were observed in the proportion of cows with high or low P4 between treatments. Collectively, these results provide evidence that eliminating the initial GnRH in a 5-d CIDR-Cosynch resynchronization protocol for lactating dairy cows did not reduce P/AI in this study.

Evaluation of a community based service for urgent psychiatric assessment

The Urgent Assessment Service (UAS) was set up to provide community based urgent psychiatric assessment to a range of referrers. The work of the service was assessed over a six month period. Results show that it was popular with a broad range of medical and non-medical professionals. Patients generally presented with depression or psychotic illnesses and those referred from non-medical sources were more likely to be suffering from schizophrenia and assessed as being at least as unwell as those referred by GPs and hospital based doctors. Rates or referral to hospital services were low with the vast majority of patients being referred back to their general practitioner after initial assessment and treatment.

Relative ADC and Location Differ between Posterior Fossa Pilocytic Astrocytomas with and without Gangliocytic Differentiation

BACKGROUND AND PURPOSE

Pilocytic astrocytomas, the most common posterior fossa tumors in children, are characterized by KIAA1549-BRAF fusions and shows excellent 5-year survival rates. Pilocytic astrocytoma with gangliocytic differentiation, a recently defined pilocytic astrocytoma variant that includes glial and neuronal elements similar to a ganglioglioma, may be distinguished from a classic ganglioglioma by molecular, radiologic, and histopathologic features. This study investigated whether imaging could distinguish posterior fossa pilocytic astrocytoma with and without gangliocytic differentiation.

MATERIALS AND METHODS

Preoperative MRIs (± CTs) of 41 children (age range, 7 months to 15 years; mean age, 7.3 ± 3.7 years; 58.5% male) with pilocytic astrocytoma with gangliocytic differentiation (n = 7) or pilocytic astrocytoma (n = 34) were evaluated; differences in tumor location, morphology, and minimum relative ADC between tumor types were compared (Wilcoxon rank sum test, Fisher exact test). Histopathology and BRAF fusion/mutation status were reviewed. Associations of progression-free survival with diagnosis, imaging features, and BRAF status were examined by Cox proportional hazards models.

RESULTS

Pilocytic astrocytoma with gangliocytic differentiation appeared similar to pilocytic astrocytoma but had lower minimum relative ADC (mean, 1.01 ± 0.17 compared with 2.01 ± 0.38 for pilocytic astrocytoma; P = .0005) and was more commonly located within midline structures (P = .0034). BRAF status was similar for both groups. Non-total resection (hazard ratio, 52.64; P = .0002), pilocytic astrocytoma with gangliocytic differentiation diagnosis (hazard ratio, 4.66; P = .0104), and midline involvement (hazard ratio, 3.32; P = .0433) were associated with shorter progression-free survival.

CONCLUSIONS

Minimum relative ADC and tumor location may be useful adjuncts to histopathology in differentiating pilocytic astrocytoma with gangliocytic differentiation from pilocytic astrocytoma. Shorter progression-free survival in pilocytic astrocytoma with gangliocytic differentiation is likely due to a propensity for involvement of midline structures and poor resectability.

Clinical, radiological, histological and molecular characteristics of paediatric epithelioid glioblastoma

AIMS

A few case series in adults have described the characteristics of epithelioid glioblastoma (e-GB), one of the rarest variants of this cancer. We evaluated clinical, radiological, histological and molecular characteristics in the largest series to date of paediatric e-GB.

METHODS

Review of clinical characteristics and therapy, imaging studies and histology was performed in patients younger than 22 years with e-GB seen at our institution over 15 years. Sequencing of hotspot mutations and fluorescence in situ hybridization of relevant genes were undertaken.

RESULTS

Median age at diagnosis of six patients was 7.6 years. Tumours originated in the cerebral cortex (n = 2) or diencephalon (n = 4). Three patients presented with acute, massive haemorrhage and three had leptomeningeal dissemination at diagnosis. Paediatric e-GB had the typical histological characteristics seen in adult tumours. Universal immunoreactivity for INI1 and lack of diverse protein expression were seen in all cases. One tumour had a chromosome 22q loss. Three tumours (50%) harboured a BRAF: p.V600E. One thalamic tumour had an H3F3A p.K27M. All patients received radiation therapy with (n = 3) or without chemotherapy (n = 3). All patients experienced tumour progression with a median survival of 169 days. One patient with nonmetastatic disease had early leptomeningeal progression. Two patients had symptomatic tumour spread outside the central nervous system (CNS) through a ventriculoperitoneal shunt. One additional patient had widespread metastases outside the CNS identified at autopsy.

CONCLUSIONS

Paediatric e-GBs are rare cancers with an aggressive behaviour that share histological and genetic characteristics with their adult counterparts. BRAF inhibition is a potential treatment for these tumours.

How midwives tailor health information used in antenatal care

OBJECTIVE

to examine the informal approaches taken by midwives and other antenatal staff to adapt health communication to the needs of their patients, as well as their perception of the barriers faced when trying to provide tailored health promotion.

DESIGN

qualitative research methods (participant observation, individual and group interviews) were utilised to gain an understanding of how media and communication resources were used in practice within the study hospital.

SETTING

a major metropolitan teaching hospital located in the Northern suburbs of Adelaide, South Australia.

PARTICIPANTS

individual semi-structured interviews with antenatal staff (n=8) were combined with group interviews (n=2; total number of staff=13), and observational research.

FINDINGS

midwives and other antenatal staff use a range of strategies to meet the perceived health literacy level of their patients. However, their attempts to tailor health information to individual needs are frequently based on incomplete information about patients' health literacy, may be inconsistent in delivery and content and are seldom assessed to determine whether communication has been understood or led to patient behaviour change.

KEY CONCLUSIONS

midwives fully recognise the need to adapt standard printed materials to meet the diverse health literacy needs of patients but lack the resources required to evaluate whether these adaptations have positive effect.

IMPLICATIONS FOR PRACTICE

midwives' commitment to improving health communication provides a latent resource that institutions can build on to improve health outcomes for patients with low health literacy. This requires improvements in health communication training, willingness to use a range of validated instruments for measuring health literacy, and commitment to use of innovative approaches to health promotion where these have been shown to have a positive impact on health behaviours.

Pregnant women’s use of information and communications technologies to access pregnancy-related health information in South Australia

This paper examines how pregnant women living in South Australia use information and communication technologies (ICTs), principally Internet and mobile phones, to access pregnancy-related information. It draws on 35 semistructured interviews conducted as part of the ‘Health-e Baby’ project, a qualitative study designed to assess the information needs and ICT preferences of pregnant women cared for at a South Australian metropolitan teaching hospital. Our research shows that although ICTs offer exciting possibilities for health promotion and the potential for new forms of communication, networking and connection, we cannot assume the effectiveness of communicating through such channels, despite near universal levels of ICT access. In turn, this highlights that if e-mediated health promotion is to be effective, health promoters and practitioners need to better understand ICT access, usage and content preferences of their clients.

Removal of TSE agent from plasma products manufactured in the United Kingdom

BACKGROUND AND OBJECTIVES

The outbreak of vCJD in the UK leads to concern regarding the potential for human-to-human transmission of this agent. Plasma-derived products such as albumin, immunoglobulin and coagulation factors were manufactured by BPL from UK plasma up until 1999 when a switch to US plasma was made. In the current study, the capacity of various manufacturing processes that were in use both prior to and after this time to remove the TSE agent was tested.

MATERIALS AND METHODS

Small-scale models of the various product manufacturing steps were developed. Intermediates were spiked with scrapie brain extract and then further processed. Samples were assayed for the abnormal form of prion protein (PrP(SC) ) by Western blotting, and the reduction in the amount of scrapie agent determined.

RESULTS

Many of the manufacturing process steps produced significant reduction in the scrapie agent. Particularly effective were steps such as ethanol fractionation, depth filtration, ion-exchange and copper chelate affinity chromatography. Virus retentive filters, of nominal pore size 15 or 20 nm, removed >3 log. The total cumulative reduction capacity for individual products was estimated to range from 7 to 14 log. In the case of factor VIII (8Y), the total removal was limited to 3 log.

CONCLUSION

All the processes showed a substantial capacity to remove the TSE agent. However, this was more limited for the intermediate purity factor VIII 8Y which included fewer manufacturing steps.

Computed tomography appearance of mandibular para-radicular third molar radiolucencies

OBJECTIVES

Mandibular para-radicular third molar radiolucencies (MPRs) were first described in 2004 by Bohay et al (Bohay RN, Mara TW, Sawula KW, Lapointe HJ. A preliminary radiographic study of mandibular para-radicular third molar radiolucencies. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004; 98: 97-101) as a well-defined oval radiolucency surrounded by a thin sclerotic border located immediately distal to the mandibular third molar roots. Bohay et al's analysis was undertaken using panoramic radiographs. The purpose of this study was to confirm Bohay et al's findings on panoramic radiographs and to identify and document the appearance of MPRs on cross-sectional CT.

METHODS

Panoramic films and CT images of the lower third molar regions from 143 patients were reviewed.

RESULTS

MPR was identified on panoramic film in 12 patients with a total of 14 MPRs. A number of factors were recorded from panoramic films and CT.

CONCLUSIONS

This study confirmed the findings of Bohay et al and concluded that the relative lucent appearance on panoramic radiographs can be explained by the presence of one or a combination of factors: (i) an area of decreased density in trabecular bone, (ii) thinning of the inner surface of the buccal cortex, (iii) thinning of the inner surface of the lingual cortex or (iv) a depression in the external surface of the lingual cortex.

Targeting parents for the treatment of pediatric obesity in boys with Duchenne muscular dystrophy: a case series

Obesity is a major public health concern in children. Obesity occurs frequently in boys with Duchenne muscular dystrophy (DMD), complicating treatment and impairing functioning. Parent-focused interventions to facilitate weight loss have been successful in other pediatric samples but have not been studied with this population. The current investigation examined the feasibility and potential efficacy of parent-focused treatment to improve healthy eating and physical activity of parents and eating and weight in their sons with DMD. Three families participated in this case series. Resulting changes in body weight among boys with DMD were an outcome variable. Findings indicate inconsistent changes in boys' weight, decreases in parent weight, increases in healthy foods available in the home, and increases in children's perceived quality of life. Participant ratings of treatment suitability and satisfaction were generally favorable. These preliminary findings support the use of parent-focused psychoeducation for the treatment of obesity in children with DMD.

Community-based treatment for chronic hepatitis C in drug users: high rates of compliance with therapy despite ongoing drug use

BACKGROUND

Chronic hepatitis C infection is common in drug users. Treatment of injectors is possible under controlled conditions, but many have not yet been included in treatment programmes as there are concerns about their ability to comply with therapy. It is not known which factors influence compliance.

AIM

To examine the hypothesis that active drug users would comply with anti-viral therapy if treatment was delivered in a convenient manner.

METHODS

We established a community-based treatment programme and offered anti-viral therapy to all drug users who wanted it. Few pre-treatment requirements were imposed and, by design, compliance with therapy was reviewed after 50 patients had completed treatment.

RESULTS

Of the 441 patients who were known to be HCV RNA positive and attended the specialist addiction services during the period of this study, eighty three patients considered therapy. Twenty patients did not undergo treatment: 14 declined and 6 had medical conditions that precluded it. In 60 episodes (58 patients) where treatment had been completed, compliance was greater than 80% and homelessness, active illicit drug use and pre-treatment antidepressant therapy were not associated with noncompliance. In 25 of 49 treatment episodes that were assessed 6 months after treatment cessation, a sustained virological response (51%) was seen.

CONCLUSION

Active drug users using illicit drugs can be successfully treated in community-based clinics.

Polysomnographic measures of sleep moderate the relationship between depression and pain

8526

Background: We explored the effects of polysomnographic measures of nocturnal sleep on depression and pain in advanced cancer patients taking opioids. Methods: The sample included 72 subjects (solid tumor, Stages III/IV) with a mean age of 55.9 (9.1); 39 were male. All were taking opioids. Subjects underwent ambulatory polysomnography for 48 hours in their homes. Nocturnal sleep parameters included total sleep time (minutes); sleep efficiency (SE; %); sleep latency (SL; minutes); rapid-eye-movement sleep latency (REML; minutes); the percentages (%) of non-rapid eye movement (NREM) Stages 1, 2, and slow wave sleep (SWS, 3 & 4), and REM sleep; and the number of awakenings > 60 seconds. Subjects kept an opioid diary, data from which were converted into a mean hourly morphine equivalent dose (HMED). Subjects also completed the Brief Pain Inventory (BPI) and the Beck Depression Inventory (BDI). Descriptive, correlation, and regression procedures were used for data analysis. Results: Subjects had a mean nocturnal sleep period of 400.1 ± 97.4 minutes. The SL was normal at 26.5 ± 42.6 minutes but the SE was low (77.5 ± 13.2%). Most sleep was light NREM Stages 1 and 2 with decreased amounts of deep SWS (0.3 ± 2.7%) and REM sleep (14.4 ± 8.5%). The REML was prolonged at 149.1 ± 105.1 minutes. The mean BPI scores for pain intensity and interference were 4.4 ± 1.4 and 5.0 ± 2.1, respectively. The mean BDI score was 13.7 ± 7.9. The average HMED was .59 ± .1. Controlling for age and gender, regression analyses revealed that SWS and REM sleep moderated the relationship between depression and pain. Those with more SWS had lower depression levels in spite of higher pain intensity (t = -2.8, p = .007) while those with more REM sleep had lower depression levels despite higher pain interference (t = -2.0, p = .045). Controlling for pain intensity and interference, HMED was positively associated with Stage 1 % (r = .36, p = .001) and the number of nocturnal awakenings > 60 seconds (r = .28, p = .019). Conclusions: Opioids may lighten and disrupt sleep altering sleep cycle progression. The resulting decrements in SWS and REM sleep may lead to increased depression and enhanced pain. Consideration of the timing and dosing of opioids in relationship to nocturnal sleep may decrease depression and subsequently optimize pain management.

No significant financial relationships to disclose.

A series of systematic reviews to inform a decision analysis for sampling and treating infected diabetic foot ulcers

OBJECTIVES

To review systematically the evidence on the performance of diagnostic tests used to identify infection in diabetic foot ulcers (DFUs) and of interventions to treat infected DFUs. To use estimates derived from the systematic reviews to create a decision analytic model in order to identify the most effective method of diagnosing and treating infection and to identify areas of research that would lead to large reductions in clinical uncertainty.

DATA SOURCES

Electronic databases covering period from inception of the database to November 2002.

REVIEW METHODS

Selected studies were assessed against validated criteria and described in a narrative review. The structure of a decision analytic model was derived for two groups of patients in whom diagnostic tests were likely to be used.

RESULTS

Three studies that investigated the performance of diagnostic tests for infection on populations including people with DFUs found that there was no evidence that single items on a clinical examination checklist were reliable in identifying infection in DFUs, that wound swabs perform poorly against wound biopsies, and that semi-quantitative analysis of wound swabs may be a useful alternative to quantitative analysis. However, few people with DFUs were included, so it was not possible to tell whether diagnostic performance differs for DFUs relative to wounds of other aetiologies. Twenty-three studies investigated the effectiveness (n = 23) or cost-effectiveness (n = 2) of antimicrobial agents for DFUs. Eight studied intravenous antibiotics, five oral antibiotics, four different topical agents such as dressings, four subcutaneous granulocyte colony stimulating factor (G-CSF), one evaluated oral and topical Ayurvedic preparations and one compared topical sugar versus antibiotics versus standard care. The majority of trials were underpowered and were too dissimilar to be pooled. There was no strong evidence for recommending any particular antimicrobial agent for the prevention of amputation, resolution of infection or ulcer healing. Topical pexiganan cream may be as effective as oral antibiotic treatment with ofloxacin for the resolution of local infection. Ampicillin and sulbactam were less costly than imipenem and cilastatin, a growth factor (G-CSF) was less costly than standard care and cadexomer iodine dressings may be less costly than daily dressings. A decision analytic model was derived for two groups of people, those for whom diagnostic testing would inform treatment--people with ulcers which do not appear infected but whose ulcer is not progressing despite optimal concurrent treatment--and those in whom a first course of antibiotics (prescribed empirically) have failed. There was insufficient information from the systematic reviews or interviews with experts to populate the model with transition probabilities for the sensitivity and specificity of diagnosis of infection in DFUs. Similarly, there was insufficient information on the probabilities of healing, amputation or death in the intervention studies for the two populations of interest. Therefore, we were unable to run the model to inform the most effective diagnostic and treatment strategy.

CONCLUSIONS

The available evidence is too weak to be able to draw reliable implications for practice. This means that, in terms of diagnosis, infection in DFUs cannot be reliably identified using clinical assessment. This has implications for determining which patients need formal diagnostic testing for infection, on whether empirical treatment with antibiotics (before the results of diagnostic tests are available) leads to better outcomes, and on identifying the optimal methods of diagnostic testing. With respect to treatment, it is not known whether treatment with systemic or local antibiotics leads to better outcomes or whether any particular agent is more effective. Limited evidence suggests that both G-CSF and cadexomer iodine dressings may be less expensive than 'standard' care, that ampicillin/sulbactam may be less costly than imipenem/cilastatin, and that an unlicensed cream (pexiganan) may be as effective as oral ofloxacin. Further research is needed to ascertain the characteristics of infection in people with DFUs that influence healing and amputation outcomes, to determine whether detecting infection prior to treatment offers any benefit over empirical therapy, and to establish the most effective and cost-effective methods for detecting infection, as well as the relative effectiveness and cost-effectiveness of antimicrobial interventions for DFU infection.

A multicenter, randomized, dose-finding study of gamma intracoronary radiation therapy to inhibit recurrent restenosis after stenting

OBJECTIVES

The objective of this double-blind, randomized study was to determine the safety and efficacy of intracoronary radiation therapy (ICRT) with a dose of 17 Gray (Gy) compared to the currently recommended dose prescription of 14 Gy for the treatment of in-stent restenosis within bare metal stents.

BACKGROUND

While gamma ICRT for in-stent restenosis has been proven efficacious, the optimal dose is unknown, and radiation failure due to recurrent neointimal hyperplasia remains a significant clinical problem for some patients. A higher radiation dose may improve outcomes, but may potentially increase adverse events.

METHODS

Following coronary intervention, 336 patients with in-stent restenosis were randomly assigned to receive ICRT with either 14 Gy or 17 Gy at 2 mm from an 192-iridium source.

RESULTS

At 8-month follow up, fewer patients in the 17 Gy group underwent target lesion revascularization (TLR = 15.2% versus 27.2%; p = 0.01), target vessel revascularization (21.3% versus 33.1%; p = 0.02), or reached the composite endpoint of death, myocardial infarction, thrombosis, or TLR (17.1% versus 28.4%; p = 0.02). There were no differences in late thrombosis or mortality between treatment groups. There was a strong trend toward reduced in-lesion late loss (0.36 +/- 0.63 mm vs. 0.51 +/- 0.64 mm; p = 0.09) and a significantly lower rate of binary restenosis (23.9% versus 38.1%; p = 0.031) in the high dose group.

CONCLUSIONS

Gamma ICRT with 17 Gy is safe and, compared to 14 Gy, reduces recurrent stenosis and clinical events at 8-month follow up. An increase in the currently recommended gamma radiation dose prescription from 14 Gy to 17 Gy should be strongly considered.

Systematic review of antimicrobial treatments for diabetic foot ulcers

BACKGROUND

Foot ulcers in diabetes are associated with increased mortality, illness and reduced quality of life. Ulcer infection impairs healing and antimicrobial interventions may cure infection, aid healing and reduce amputation rates.

OBJECTIVES

To systematically review the evidence for antimicrobial interventions for foot ulcers in diabetes.

METHODS

We searched 16 databases, 11 Internet sites, three books, conference proceedings, a journal and bibliographies in November 2002. We included randomized controlled trials (RCTs) or controlled clinical trials (CCTs).

RESULTS

Twenty-three studies investigated the effectiveness or cost-effectiveness of antimicrobial agents: intravenous antibiotics (n = 8); oral antibiotics (n = 5); topical antimicrobials (n = 4); subcutaneous granulocyte-colony stimulating factor (G-CSF) (n = 4); Ayurvedic preparations (n = 1): and sugar vs. antibiotics vs. standard care (n = 1). The trials were small and too dissimilar to be pooled. There is no strong evidence for any particular antimicrobial agent for the prevention of amputation, resolution of infection, or ulcer healing. Pexiganan cream may be as effective as oral ofloxacin for resolution of infection. Ampicillin and sulbactam cost less than imipenem/cilastatin, G-CSF cost less than standard care and cadexomer iodine dressings may cost less than daily dressings.

CONCLUSIONS

The evidence is too weak to recommend any particular antimicrobial agent. Large studies are needed of the effectiveness and cost-effectiveness of antimicrobial interventions.

STAT3 is activated in a subset of the Ewing sarcoma family of tumours

STAT3 is an oncogene that regulates critical cellular processes and whose constitutive activation has been demonstrated to correlate with biological and clinical features in many types of human malignancy. In this study, STAT3 activation was assessed in the Ewing sarcoma family of tumours (ESFT), which is characterized by fusion of the EWS gene with one of several Ets transcription factors, most commonly EWS-FLI1. STAT3 activation was assessed by immunohistochemistry using a monoclonal antibody specific for tyrosine(705)-phosphorylated STAT3 (pSTAT3(tyr705)) and a tissue microarray containing 49 paraffin-embedded ESFT tumours with known EWS translocations. Twenty-five (51%) tumours were pSTAT3(tyr705)-positive, as defined by more than 10% tumour cell immunostaining. STAT3 activation correlated with tumour site at presentation, with pSTAT3(tyr705)-negative ESFT involving axial sites predominantly (p = 0.008). Notably, among 31 patients who presented with localized disease, high-level STAT3 activation correlated with better overall survival (p = 0.02). STAT3 activation was not directly related to EWS-FLI1 expression, since EWS-FLI1 transfection did not result in STAT3 activation. Furthermore, detailed molecular analysis indicated that STAT3 activation may be seen with EWS-FLI1 or EWS-ERG and appears to be independent of EWS-FLI1 fusion type. In conclusion, STAT3 activation is present in approximately half of ESFT and correlates with clinical features. The role of STAT3 activation in ESFT pathogenesis seems to be independent of the type of EWS/Ets translocation.