Coccydynia: A Review of Anatomy, Causes, Diagnosis, and Treatment

» Coccydynia is a painful condition affecting many patients at the terminal caudal end of the spine.» An understanding of coccyx anatomy and variations of morphology is necessary for proper diagnosis. A multifactorial etiology for pain may be responsible for this clinical entity.» Several treatment options exist. Successful outcomes for patients depend on individual patient characteristics and the etiology of pain.

Posterior fossa microcystic meningioma mimicking an arachnoid cyst

Microcystic meningioma is an uncommon subtype of World Health Organization grade 1 meningiomas often associated with a shorter progression-free survival. Diagnosis through imaging alone can often be challenging due to atypical characteristics, especially when found in unexpected locations. Here, we present a 55-year-old woman who was diagnosed, based on imaging, with a posterior fossa arachnoid cyst 5 years prior after complaints of headaches and gait imbalance. After surgical resection of the "arachnoid cyst," the diagnosis of microcystic meningioma was made. This case report emphasizes the clinical importance and challenges associated with diagnosing microcystic meningiomas.

"How Will Medicaid Work Requirements Affect American Healthcare? A Look at What Past and Present Policy Tells Us"

Many social services have work requirements. Notably, Medicaid has no requirement that healthy, able-bodied beneficiaries work to receive benefits. There have been attempts at incorporating work requirement policies into several US states, but only a few have been implemented. The effect of work requirements has been studied in several other federally funded programs such as TANF, SNAP, and historically in the Civilian Corps created by Franklin Roosevelt. In general, these programs seem to have modest improvements in employment but are better when implemented with work supports which show improvement in employment and income. In this study, we examine the history of work requirements in Medicaid and other social programs to see which policies have the most effect on enrollment and employment.

Effect of common sedation agents on feline splenic size determined via ultrasonography

AIMS

To evaluate the effect of IM administration of three sedative drugs, acepromazine, alfaxalone and dexmedetomidine, in combination with morphine, on the size of the feline spleen using ultrasonography.

METHODS

Twenty-four client-owned cats undergoing elective de-sexing or minor procedures were recruited for a focused ultrasonographic examination of the spleen prior to and at 10, 20 and 30 minutes following administration of one of three randomly assigned IM sedation protocols: 0.05 mg/kg acepromazine (ACE group), 3 mg/kg alfaxalone (ALF group), or 10 μg/kg dexmedetomidine (DEX group), in combination with 0.5 mg/kg morphine. B-mode images of the spleen were collected and measured following a standardised protocol. Cardiorespiratory parameters and sedation score were also recorded. Mean thickness of the head, body and tail of the spleen for each group at 10, 20 and 30 minutes after drug administration was compared to baseline.

RESULTS

Mean splenic thickness increased over time in the ACE group (thickness of body at T0 = 8.9 (SE 2.1) mm and at T30 = 10.5 (SE 2.0) mm; p = 0.001) and the ALF group (thickness of body at T0 = 8.8 (SE 1.0) mm and at T30 = 10.3 (SE 1.7) mm; p = 0.022) but not in the DEX group (thickness of body at T0 = 8.6 mm (1.2) and at T30 = 8.9 mm (0.6); p = 0.67). Mean arterial blood pressure in the DEX group was significantly higher than in the other groups (p = 0.002). Sedation scores in the DEX group were consistently high for the entire period. However, the sedation score in the ACE group increased over 30 minutes (p = 0.007). Sedation score in the ALF group was highest at 10 minutes but gradually decreased over the following 20 minutes (p = 0.003).

CONCLUSIONS

Sedation with IM dexmedetomidine and morphine did not change splenic size, whereas acepromazine or alfaxalone and morphine increased it regardless of the degree of sedation.

CLINICAL RELEVANCE

Where splenomegaly is identified in a cat sedated with acepromazine or alfaxalone, the effects of the sedation protocol could be considered as a possible cause.

Health-related quality of life and social determinants of health following COVID-19 infection in a predominantly Latino population

BACKGROUND

As the COVID-19 pandemic evolves, more information is needed on its long-term impacts on health-related quality of life (HRQoL) and social determinants of health (SDoH). The aim of the study was to assess HRQoL and SDoH among a predominantly Latino population of COVID-19 survivors and to compare effects in Latinos versus non-Latinos.

METHODS

This cross-sectional study consisted of a survey (in English and Spanish) of COVID-19 survivors from December 2020 to July 2021. The study assessed sociodemographic data, clinical characteristics, and SDoH, consisting of 10 COVID-19-related concerns. The PROMIS-29 + 2 (PROPr) measure, which captures 8 HRQoL domains and a preference-based health utility, was used to assess HRQoL. Bivariate analyses included chi-square tests and t-tests. Generalized linear models were conducted for multivariable analyses.

RESULTS

Of 230 respondents (6.3% response rate), the mean [SD] age was 43.1 [14.3] years; 83.0% were Latino; the mean [SD] time since diagnosis was 8.1 [3.2] months; and 12.6% had a history of hospitalization with COVID-19. HRQoL scores were slightly worse than population norms on all domains, especially anxiety; the mean [SD] PROPr health utility was 0.36 [0.25]. Domain scores were similar by ethnicity except for cognitive function-abilities, where scores were lower in Latinos. Multivariable analyses revealed that: (1) financial concerns were associated with worse health utility, as well as worse scores on all 8 PROMIS domains; (2) interpersonal conflict was associated with worse health utility and worse scores on 6 of the 8 PROMIS domains (anxiety, depression, fatigue, sleep disturbance, social function, and pain interference); and (3) Latino ethnicity was only associated with 1 PROMIS domain (cognitive function-abilities) after controlling for covariates.

CONCLUSION

COVID-19 infection is associated with HRQoL decrements long after the acute infection, and financial concerns and interpersonal conflict are particularly associated with worse HRQoL.

Factors influencing oral cancer screening preferences in patients attending Tertiary Care University Oral Health Clinic

BACKGROUND

Understanding factors that influence patients' preferences towards oral cancer (OC) screening is imperative to provide high-quality evidence-based OC screening interventions that can be targeted for population-level uptake. This study determined adult patients' knowledge and awareness of OC, and how health behaviours influenced their preferences towards OC screening.

METHODS

This cross-sectional study used a 42-point questionnaire, between February and May 2020 using a combination of in-person and telephone interviews. Chi-square test and multiple logistic regression analysis were applied to confounding factors that returned statistical significance against OC knowledge and awareness. Significance of P < 0.05 was accepted.

RESULTS

Sixty-eight (38.6%) participants out of a total 176 had good knowledge of OC and 89 (50.6%) had good awareness. A total of 31.8% reported preference for OC screening by a general dental practitioner (GDP) over a general medical practitioner (GMP). Majority (72.7%) reported acceptance of OC screening at their next GDP visit. Ages 56-70 (OR = 0.357, 95% CI) and previous smokers (OR = 0.336, 95% CI) significantly influenced screening preferences. Knowledge of risk factors did not significantly influence OC screening preferences (χ²  = 3.178, P = 0.075).

CONCLUSIONS

Significant gaps in OC knowledge, screening and role of GDPs exist with smoking history and age influencing OC screening preferences.

Calcaneotibial screws for immobilisation of the tarsocrural joint of dogs in extension: effect of the angle of screw placement on the force to failure in a canine cadaveric model

AIMS

To compare the force to failure under axial loading of a calcaneotibial screw placed approximately perpendicular to the tibia with that of a screw placed perpendicular to the calcaneus, when used to immobilise the tarsus in an ex vivo canine model.

METHODS

Twelve pairs of cadaveric hindlimbs from large breed dogs, without orthopaedic or soft tissue disease, were prepared by transecting the limb at the level of the stifle and stripping the limbs of all musculature from the stifle to mid-metatarsus, including removal of the common calcaneal tendon from all limbs. The limbs in each pair were randomly assigned to receive a calcaneotibial screw placed perpendicular to the long axis of either the calcaneus (C group) or the tibia (T group) with the tarsus in full extension. The distal limb was potted in resin and the proximal tibia was pinned to allow biomechanical testing in compressive loading. Testing was performed to apply an axial load using a material testing machine in a proximodistal direction through the tibia, advancing at a rate of 10 mm/second. The force to failure was recorded in kN and compared between groups.

RESULTS

The median force to failure of the C group was 0.86 (min 0.50; max 1.64) kN which was higher than the T group which had a median force to failure of 0.74 (min 0.26, max1.05) kN (p = 0.004). All modes of failure were by screw pull-out.

CONCLUSIONS

A calcaneotibial screw placed at an angle approximately perpendicular to the long axis of the calcaneus, has a higher force to failure under axial loading than a calcaneotibial screw that is placed at an angle approximately perpendicular to the tibia, in a canine cadaveric model.

CLINICAL RELEVANCE

A temporary calcaneotibial screw is a common method of immobilising the tarsus in extension to protect primary repair of a common calcaneal tendon injury. Placing a calcaneotibial screw perpendicular to the calcaneus may be a more reliable option for immobilisation of the tarsus to protect a common calcaneal tendon repair compared to screws placed perpendicular to the tibia. However extrapolation of these results into a clinical setting requires caution.

OP0314 DOCK8 MUTATIONS IN COVID-19 AND MIS-C CYTOKINE STORM SYNDROME

Background:

We recently identified DOCK8 as a novel gene associated with cytokine storm syndrome (CSS)1. Heterozygous missense mutations in DOCK8 diminish NK cell lytic function and contribute to increased pro-inflammatory cytokine production (CSS). CSS is a potential complication of COVID-19 with severe consequences2. Children are at risk of a SARS-CoV-2 post-infectious CSS, multisystem inflammatory syndrome in children (MIS-C)3. Host genetic factors associated with COVID-19 CSS and MIS-C CSS are unknown.

Objectives:

The goals are to identify and functionally study rare mutations in DOCK8 in patients with SARS-CoV-2 COVID-19 and MIS-C.

Methods:

To date, 16 adult patients enrolled in a COVID-19 CSS clinical trial at UAB had whole genome sequencing. Four (25%) had rare heterozygous DOCK8 mutations (3 missense, 1 intronic). A COVID-19 CSS adult patient in Seattle also had a DOCK8 missense mutation. In addition, DOCK8 missense mutations were identified in five children (UAB & Northwell) hospitalized with MIS-C. DOCK8 mutations, or wild-type (WT) sequence controls, were introduced into human NK-92 cells by FOAMY virus transduction. WT and mutant DOCK8-expressing NK-92 cells were incubated with K562 target cells and compared for cytolysis and degranulation (CD107a).

Results:

One COVID-19 patient DOCK8 mutation (Gly523Arg) reduced NK cell degranulation by 30% and cytolysis by 23% (n=3) (Figure 1). Similar studies of 3 MIS-C patients with DOCK8 missense mutations (Arg899Trp, Ala2Thr, Pro687Leu) revealed up to 31% reduced NK cell degranulation and 48% reduction in cytolysis by 3 distinct mutations (n=3). Two-way ANOVA analysis revealed statistically significant (p<0.05) differences in NK cell degranulation and lysis for four unique DOCK8 mutations.

Conclusion:

Heterozygous DOCK8 missense mutations may contribute to severe COVID-19 and MIS-C CSS by partial dominant-negative effects yielding decreased NK cell cytolysis.

References:

[1]Schulert GS, Cron RQ. The genetics of macrophage activation syndrome. Genes Immun 2020:21:169-181.

[2] Cron RQ, Chatham WW. The rheumatologist’s role in COVID-19. J Rheumatol 2020:47:639-642.

[3]Reiff D, Mannion ML, Samuy N, Scalici P, Cron RQ. Distinguishing active pediatric COVID-19 from MIS-C. Pediatr Rheumatol Online J, in press.

Disclosure of Interests:

Randy Cron Consultant of: SOBI, Novartis, Pfizer, Sironax, Grant/research support from: SOBI, Mingce Zhang: None declared, Remy Cron: None declared, Devin Absher: None declared, John Bridges: None declared, Amanda Schnell: None declared, Pavan Bhatraju: None declared, Anshul Vagrecha: None declared, Shannon Lozinsky: None declared, Suchitra Acharya: None declared, Carolyn Levy: None declared, Winn Chatham Grant/research support from: SOBI.

The Relationship Between Approval of Violence and Intimate Partner Violence in College Students

Dating violence is a significant problem among college students. Using a sample of 248 male and 304 female college students, we explored whether or not male and female college students differed in their approval rates of male-to-female intimate partner violence (IPV) and female-to-male IPV. We also examined how approval of violence related to reports of physical, psychological, and sexual IPV perpetration and victimization. We found that both male and female college students had higher levels of approval of female-to-male IPV than male-to-female IPV. We also found that male students had higher levels of approval of male-to-female IPV and female-to-male IPV than did female students. We found that men who had higher levels of approval of female-to-male IPV were more likely to be perpetrators and victims of physical IPV and perpetrators of sexual IPV. Finally, we found that women who had higher levels of approval of female-to-male IPV were more likely to be victims of sexual and psychological IPV.

Prenatal inflammation enhances antenatal corticosteroid-induced fetal lung maturation

Respiratory complicˆations are the major cause of morbidity and mortality among preterm infants, which is partially prevented by the administration of antenatal corticosteroids (ACS). Most very preterm infants are exposed to chorioamnionitis, but short- and long-term effects of ACS treatment in this setting are not well defined. In low-resource settings, ACS increased neonatal mortality by perhaps increasing infection. We report that treatment with low-dose ACS in the setting of inflammation induced by intraamniotic lipopolysaccharide (LPS) in rhesus macaques improves lung compliance and increases surfactant production relative to either exposure alone. RNA sequencing shows that these changes are mediated by suppression of proliferation and induction of mesenchymal cellular death via TP53. The combined exposure results in a mature-like transcriptomic profile with inhibition of extracellular matrix development by suppression of collagen genes COL1A1, COL1A2, and COL3A1 and regulators of lung development FGF9 and FGF10. ACS and inflammation also suppressed signature genes associated with proliferative mesenchymal progenitors similar to the term gestation lung. Treatment with ACS in the setting of inflammation may result in early respiratory advantage to preterm infants, but this advantage may come at a risk of abnormal extracellular matrix development, which may be associated with increased risk of chronic lung disease.

Updating exposure assessment for skin sensitization quantitative risk assessment for fragrance materials

In 2008, a proposal for assessing the risk of induction of skin sensitization to fragrance materials Quantitative Risk Assessment 1 (QRA1) was published. This was implemented for setting maximum limits for fragrance materials in consumer products. However, there was no formal validation or empirical verification after implementation. Additionally, concerns remained that QRA1 did not incorporate aggregate exposure from multiple product use and included assumptions, e.g. safety assessment factors (SAFs), that had not been critically reviewed. Accordingly, a review was undertaken, including detailed re-evaluation of each SAF together with development of an approach for estimating aggregate exposure of the skin to a potential fragrance allergen. This revision of QRA1, termed QRA2, provides an improved method for establishing safe levels for sensitizing fragrance materials in multiple products to limit the risk of induction of contact allergy. The use of alternative non-animal methods is not within the scope of this paper. Ultimately, only longitudinal clinical studies can verify the utility of QRA2 as a tool for the prevention of contact allergy to fragrance materials.

Effect of insulation with bubble wrap and an absorbent pad on heat loss in anaesthetised cats

Aims: To evaluate the efficacy of insulating the limbs and thorax of cats with a combination of bubble wrap and an absorbent, plastic-lined pad in reducing heat loss during ovariohysterectomy. Methods: A preliminary study was performed to compare heat loss of 1 L bags of Hartmann's solution heated to 38°C which were either wrapped in two layers of bubble wrap and an absorbent pad (n = 6) or were unwrapped (n = 6). Bags were allowed to cool in a temperature-controlled room and the temperature of the bags was measured every 10 minutes for 60 minutes. The clinical study, included 16 intact female cats undergoing ovariohysterectomy. The cats were premedicated with I/M morphine and either medetomidine or dexmedetomidine, and anaesthesia was induced with I/V propofol and maintained with isoflurane in 100% oxygen. Cats were randomly assigned to either the treatment group (n = 8) whose limbs and thorax wrapped with two layers of bubble wrap and an absorbent pad immediately after induction, or the control group (n = 8) which were unwrapped. Body temperature (measured with an oesophageal temperature probe), heart rate, respiratory rate, mean arterial pressure and partial pressure of end-tidal CO₂ were recorded immediately after induction (T _start), before surgery started (T _surgery), and at the end of isoflurane administration (T _end). The times from T _end to extubation, from T _end to when the cat could maintain sternal recumbency and from T _end to when the cat was able to stand, were also recorded. Results: In the preliminary study of heat loss by fluid bags, the mean temperature at 60 minutes was higher in wrapped bags (35.4 (SD 0.2)°C) compared to unwrapped bags (33.0 (SD 0.3)°C; p < 0.01). For cats undergoing ovariohysterectomy, mean body temperature of wrapped cats was higher than that of unwrapped cats both at T _surgery (36.0 (SE 0.3) vs. 34.5 (SE 0.3)°C; p = 0.001) and at T _end (37.2 (SE 0.5) vs. 36.0 (SE 0.5)°C; p = 0.01). Wrapped cats regained the ability to stand more rapidly that unwrapped cats (26.4 (SE 5.8) vs. 47.0 (SE 5.8) minutes p = 0.01). Conclusions: Wrapping the limbs and thorax of cats undergoing ovariohysterectomy in a combination of bubble wrap and absorbent pads reduced heat loss, which in turn improved recovery time from general anaesthesia. Clinical relevance: This inexpensive and practical method may reduce perioperative hypothermia, in cats undergoing abdominal surgery.

Insulin-like Growth Factor 1 Supports a Pulmonary Niche that Promotes Type 3 Innate Lymphoid Cell Development in Newborn Lungs

Type 3 innate lymphoid cells (ILC3s) are critical for lung defense against bacterial pneumonia in the neonatal period, but the signals that guide pulmonary ILC3 development remain unclear. Here, we demonstrated that pulmonary ILC3s descended from ILC precursors that populated a niche defined by fibroblasts in the developing lung. Alveolar fibroblasts produced insulin-like growth factor 1 (IGF1), which instructed expansion and maturation of pulmonary ILC precursors. Conditional ablation of IGF1 in alveolar fibroblasts or deletion of the IGF-1 receptor from ILC precursors interrupted ILC3 biogenesis and rendered newborn mice susceptible to pneumonia. Premature infants with bronchopulmonary dysplasia, characterized by interrupted postnatal alveolar development and increased morbidity to respiratory infections, had reduced IGF1 concentrations and pulmonary ILC3 numbers. These findings indicate that the newborn period is a critical window in pulmonary immunity development, and disrupted lung development in prematurely born infants may have enduring effects on host resistance to respiratory infections.

92 Relocation in Care Homes (RICH) Study: The Experience of Different Stakeholders

Introduction

In the UK, care homes in unsuitable older buildings are closing. Involuntary relocation is associated with increased mortality and negative emotions among residents. Extensive planning can mitigate this. The aim was to understand the experience of a planned relocation between two care homes.

Methods

In the UK, care homes in unsuitable older buildings are closing. Involuntary relocation is associated with increased mortality and negative emotions among residents. Extensive planning can mitigate this. The aim was to understand the experience of a planned relocation between two care homes.

Results

Seven themes were identified and organised under three stages: pre-move (communication and involvement; preparation for the move; and attitudes towards the move), day-of-the-move (organisation of the move), and post-move (environmental change and impact; staff organisation and management; and settling in). Family and staff members reported that the pre-move information provided was inconsistent and staff did not feel involved in the planning and design process. Pre-move visits and staff and family support were beneficial for residents’ preparation for the move. All participants expressed sadness about the closure, and reported apprehension about moving. The moving day felt disorganised and stressful to staff who had to spread between the two homes. Post-move, the new care home was perceived by many participants as a ‘hotel’ rather than a home. Its larger size and confusing layout impacted negatively on residents and staff. New staff and changes in management structure were perceived by the different stakeholders to cause increased staff workload. Residents adjusted variably to the new home, with family support and staff continuity of care proving to be facilitators.

Conclusions

Despite extensive planning, relocation and adjustment was challenging. Recommendations for future relocations include: increasing involvement of staff in the planning and design of the home; ensuring consistent communication and organising staff rotas to maintain continuity of care.

The duration of fetal antenatal steroid exposure determines the durability of preterm ovine lung maturation

BACKGROUND

Antenatal corticosteroids (ACS) are the standard of care for maturing the fetal lung and improving outcomes for preterm infants. Antenatal corticosteroid dosing remains nonoptimized, and there is little understanding of how different treatment-to-delivery intervals may affect treatment efficacy. The durability of a lung maturational response is important because the majority of women treated with antenatal corticosteroids do not deliver within the widely accepted 1- to 7-day window of treatment efficacy.

OBJECTIVE

We used a sheep model to test the duration of fetal exposures for efficacy at delivery intervals from 1 to 10 days.

MATERIALS AND METHODS

For infusion studies, ewes with single fetuses were randomized to receive an intravenous bolus and maintenance infusion of betamethasone phosphate to target 1-4 ng/mL fetal plasma betamethasone for 36 hours, with delivery at 2, 4 ,or 7 days posttreatment or sterile saline solution as control. Animals receiving the clinical treatment were randomised to receive either a single injection of 0.25 mg/kg with a 1:1 mixture of betamethasone phosphate + betamethasone acetate with delivery at either 1 or 7 days posttreatment, or 2 treatments of 0.25 mg/kg betamethasone phosphate + betamethasone acetate spaced at 24 hours (giving ∼48 hours of fetal steroid exposure) with delivery at 2, 5, 7, or 10 days posttreatment. Negative control animals were treated with saline solution. All lambs were delivered at 121 ± 3 days gestational age and ventilated for 30 minutes to assess lung function.

RESULTS

Preterm lambs delivered at 1 or 2 days post-antenatal corticosteroid treatment had significant improvements in lung maturation for both intravenous and single-dose intramuscular treatments. After 2 days, the efficacy of 36-hour betamethasone phosphate infusions was lost. The single dose of 1:1 betamethasone phosphate + betamethasone acetate also was ineffective at 7 days. In contrast, animals treated with 2 doses had significant improvements in lung maturation at 2, 5, and 7 days, with treatment efficacy reduced by 10 days.

CONCLUSION

In preterm lambs, the durability of antenatal corticosteroids treatment depends on the duration of fetal exposure and is independent of the intravenous or intramuscular maternal route of administration. For acute 24- to 48-hour posttreatment deliveries, a 24-hour fetal antenatal corticosteroids exposure was sufficient for lung maturation. A fetal exposure duration of at least 48 hours was necessary to maintain long-term treatment durability. A single-dose ACS treatment should be sufficient for women delivering within <48 hours of antenatal corticosteroids treatment.

Plasma NT-proBNP and Cell-Free DNA Concentrations after Prolonged Strenuous Exercise in Working Farm Dogs

BACKGROUND

Plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentration is increased in dogs with myocardial dysfunction, and cell-free DNA (cfDNA) increases in numerous disease states. In humans, both of these biomarkers can be altered after endurance exercise.

OBJECTIVE

To investigate the effect of prolonged strenuous exercise on circulating NT-proBNP and cfDNA concentrations in working farm dogs.

ANIMALS

Six healthy, privately owned working farm dogs (4 Huntaways and 2 heading dogs) from the same hill country farm in New Zealand.

METHODS

Prospective, nonrandomised cohort study. Venous blood samples were collected before and after the dogs worked over 4 days. Plasma NT-proBNP concentrations were measured by a commercially available ELISA assay and cfDNA concentrations were determined by fluorometry without prior DNA extraction.

RESULTS

The baseline (before work, Day 1) median plasma NT-proBNP concentration was 664 pmol/L. A linear mixed-effects model showed that work increased plasma NT-proBNP concentrations by 101 ± 9% (P < 0.001), but with each consecutive day of work, NT-proBNP concentrations declined by 16 ± 4% (P < 0.001). The baseline median plasma cfDNA concentration was 653 ng/mL, and plasma cfDNA concentrations increased by 138 ± 45 ng/mL after work (P = 0.004).

CONCLUSIONS AND CLINICAL IMPORTANCE

The plasma concentration of NT-proBNP in healthy Huntaways and heading dogs after work can exceed the upper limit of the reference range. Results in dogs sampled on the day of prolonged strenuous exercise should be interpreted with caution. Plasma concentrations of cfDNA also increase with exercise, but further studies are needed to establish reference ranges in healthy dogs.

The effect of harness racing on the heart rate of professional harness racing drivers

Despite the size of the industry and the large amounts of money wagered on horses, little attention has been focused on the fitness of drivers of Standardbred harness racehorses. The purpose of this study was to describe the drivers’ pre-race, post-race and maximal heart rate response to multiple racing during a night of harness racing. Heart rate (HR), subjective measures of race difficulty and physical work effort, and race results were collected from eight professional Standardbred harness drivers during an official race meeting. Drivers were fitted with HR monitors prior to the start of the first race and data were continuously logged until the end of the last race. During the race meeting the drivers displayed a high mean heart rate 145±21 beats per minute. The heart rate profile during a single race demonstrated an early peak, a moderate level baseline and then increased again as the drivers took the last turn to the finish line. The best predictor of workload effort during the race was peak HR. The primary variables in explaining peak HR were final placing, horse difficulty, and pre-race HR. These data indicate that the physical work required to maintain driver position and the external stimuli associated with positioning the horse for a placing produce significant cardiovascular stress.

Achieving dignity for older people with dementia in hospital

The quality of care for people with dementia in general hospital settings has attracted widespread concern. While organisation-wide strategies are needed to address many of the issues, the nursing role is critical to articulating and promoting good practice. This article focuses on promoting dignity for older people with dementia and offers a number of strategies to help individual nurses and nursing teams reflect on and promote good practice.

Survey of surgical experience during training in obstetrics and gynaecology in the UK

The 2002 RCOG survey of training reported that the percentage of obstetric and gynaecology trainees who class their operative training as good or very good has declined from 45% in 1995, to 39% in 2002; reduction in years of training and number of working hours may have further impact on the surgical experience. In this study, we have attempted to assess the level of surgical confidence reported by senior and recently accredited trainees in obstetrics and gynaecology in the UK via an anonymised postal questionnaire. A total of 103 replies were received from 202 questionnaires. Some 99% of the respondents said they felt competent to carry out a simple total abdominal hysterectomy; 61.2% could confidently dissect the ureter and 55.3% could repair major damage to the bladder. However, when managing major obstetric haemorrhage, only 44.6% of respondents felt confident to perform a caesarean hysterectomy; 27.1% could dissect the ureter and 41.7% could apply a B-Lynch suture to the uterus. The level of competence increased with seniority and also with additional time spent in research, subspecialty training or other specialties. There appears to be an appropriate level of confidence in carrying out gynaecological surgical procedures by senior trainees and new consultants. However, surprisingly few respondents were confident in performing any surgical procedure necessary in the management of major obstetric haemorrhage. This may have serious implications in the provision of out of hours senior cover for maternity units in the future.

Short communication: A review of the management by hysterectomy of 25 cases of gestational trophoblastic tumours from March 1993 to January 2006

We reviewed 25 cases of gestational trophoblastic tumours referred for surgical management from Charing Cross Hospital (the London centre for gestational trophoblastic disease [GTD]) over a 13-year period. The operation performed was total abdominal hysterectomy, with lymph node sampling in 9/25 (36%) women and bilateral salpingo-oophorectomy in 11/25 (44%) women. Radical hysterectomy and unilateral parametrectomy was required in 3/25 (12%) women. Three of 25 (12%) women failed to survive, i.e. the overall rate of survival was 88%. Management by hysterectomy of primary drug-resistant and relapse cases of GTD is a useful and safe adjunct to chemotherapy.

Toxicological comments to the discussion about REACH

It is the ultimate goal of the intended REACH process (Registration, Evaluation and Authorization of Chemicals) of the European Union to identify substances of hazardous properties and to evaluate the risks of human and environmental exposure. During the last few months there has been a controversial discussion as to what extent in vitro studies and consideration of structure activity relationship provide sufficient information to waive repeated exposure studies. Industry as well as certain regulatory agencies or NGOs support this approach and propose that repeated dose studies may only be required beyond 100 t/a. From a toxicological point of view it has to be stressed that this discussion primarily considers the cost reduction and protection of animals, whereas protection of human health and the environment are secondary. In vitro studies only allow identification of specific hazardous properties which can be detected by the specific test system. Moreover, appropriate information on the dose response of adverse effects, identification of thresholds and NOELs that are essential for risk characterization cannot be obtained from these studies. Consequently, identification of all relevant hazardous properties and endpoints of adverse effects can only be determined in the intact animal by repeated dose studies such as 28-day or 90-day studies. In the absence of such information the hazard identification is incomplete and there is no basis for appropriate risk assessment of human exposure. Thus, any waiving of repeated dose studies in animals bears the probability of unforeseen effects in case of acute or continuous human exposure. From this the undersigning European Toxicologists conclude: 1. The intention of REACH is to identify hazardous properties in order that a reliable risk assessment can be made and measures taken to deal with chemicals posing a significant risk. 2. The recent debate has centered on ways in which the well established in vivo methods for risk assessment can be bypassed. 3. The evidence that the available alternatives would support such replacement is weak. Progress to improve their value for risk assessment purposes is bound to be slow because the issues are very complex. As a group of European Toxicologists we strongly support the need for more research support in these areas, but we believe that over claims for progress is damaging their development. 4. Under the circumstances only two options are available: to reduce very substantially the estimation of hazard and risk with inevitable adverse consequences for human health and environmental protection, or to continue the existing methods until properly validated new methods are available.

Integrin beta1 is required for the invasive behaviour but not proliferation of squamous cell carcinoma cells in vivo

Integrin β1 is both overexpressed and in an ‘active’ conformation in vulval squamous cell carcinomas (VSCCs) compared to matched normal skin. To investigate the significance of integrin β1 deregulation we stably knocked-down integrin β1 expression in the VSCC cell line A431. In vitro analysis revealed that integrin β1 is required for cell adhesion, cell spreading and invasion. However, integrin β1 is not required for cell growth or activation of FAK and ERK signalling in vitro or in vivo. Strikingly, while control tumours were able to invade the dermis, integrin β1 knockdown tumours were significantly more encapsulated and less invasive.

Corticosterone Responses of Grey‐Faced Petrels (Pterodroma macroptera gouldi) Are Higher during Incubation than during Other Breeding Stages

We report the results of the first field study examining seasonal changes in corticosterone responses of typically long-lived birds of the order Procellariiformes. In particular, we examined whether grey-faced petrels Pterodroma macroptera gouldi showed changes in circulating baseline corticosterone concentrations and corticosterone responses to a standardized handling protocol across the breeding season. Such changes have been associated with changes in body condition and variations in energy demands on adult birds through the breeding season. During early incubation, males were in significantly better condition than females that had just completed laying, whereas during late incubation, males were in significantly poorer condition than females. In spite of these differences, there was no significant difference in baseline corticosterone concentrations between sexes or among birds at different reproductive stages. However, we detected significant differences in corticosterone responses associated with a standardized handling protocol at different stages through the breeding season. Responses were significantly greater during incubation compared with the prelay period and late chick rearing. Body condition was weakly and negatively correlated with maximum and total integrated corticosterone level, indicating that some of the individual variability in stress corticosterone responses could be explained by variation in body condition. However, the largest stress response occurred during late incubation and was independent of sex, although males were in relatively poor condition and females in relatively good condition. This period coincided with the breeding stage in which energy constraints on individual adults were higher than at other periods of the reproductive cycle and birds may be physiologically primed for extended fasts.

Mucinous epithelial ovarian cancer: a separate entity requiring specific treatment

PURPOSE

Invasive mucinous carcinoma of the ovary (mucinous epithelial ovarian cancer [mEOC]) is a histologic subgroup of epithelial ovarian cancer (EOC). Chemotherapy for mEOC is chosen according to guidelines established for EOC. The purpose of this study is to determine whether this is appropriate.

PATIENTS AND METHODS

Women with advanced mEOC (International Federation of Gynecology and Obstetrics stage III or IV) who underwent first-line platinum-based chemotherapy were compared with women with other histologic subtypes of EOC in a case-controlled study.

RESULTS

Eighty-one patients (27 cases, 54 controls) treated with platinum-based regimens were analyzed. The response rates for cases and controls were 26.3% (95% CI, 9.2% to 51.2%) and 64.9% (95% CI, 47.5% to 79.8%), respectively (P=.01). The odds ratio for complete or partial response to chemotherapy for mEOC was 0.19 (95% CI, 0.06 to 0.66; P=.009) compared with other histologic subtypes of EOC. Median progression-free survival was 5.7 months (95% CI, 1.9 to 9.6 months) versus 14.1 months (95% CI, 12.0 to 16.2 months; P<.001) and overall survival was 12.0 months (95% CI, 8.0 to 15.6 months) versus 36.7 months (95% CI, 25.2 to 48.2 months; P<.001) for cases and controls, respectively. The hazard ratio for progression and death was 2.94 (95% CI, 1.71 to 5.07; P<.001) and 3.08 (95% CI, 1.69 to 5.6; P<.001), respectively, for mEOC patients as compared with controls.

CONCLUSION

Patients with advanced mEOC have a poorer response to platinum-based first-line chemotherapy compared with patients with other histologic subtypes of EOC, and their survival is worse. Specific alternative therapeutic approaches should be sought for this group of patients, perhaps involving fluorouracil-based chemotherapy.

Ethical relationships in paediatric emergency medicine: moving beyond the dyad

Most areas of health-services research concentrate on a dyadic relationship between doctor and patient. In paediatric emergency medicine it may be necessary to focus on a more complicated relationship because the parents of the child play an important role in the delivery of medical services. This paper discusses the ethical principles in paediatric emergency medicine from the perspective of five disciplines: health economics, paediatrics, medical ethics, law and mental health. The general consensus is that the traditional dyadic model is inadequate and that a more complicated relationship is needed for the paediatric emergency setting, such as triadic, multiple-dyadic or polyadic. Such models allow the inclusion of the parents and possibly other family members, medical providers and community members. If the paediatric setting is considered in such a framework, it may be possible to deliver a more socially beneficial medical service.