Analysis of the economic burden of docusate sodium at a United States tertiary care center

OBJECTIVES

The primary objective was to determine the financial resources allocated to docusate at a representative U.S. tertiary care center. Secondary objectives included comparing docusate utilization between two tertiary care centers, and exploring alternative uses for the funds spent on docusate.

METHODS

The study population included all patients 18 years and older admitted to University Hospital in Newark, New Jersey. Every scheduled docusate prescription for the study population between January 1st, 2015 and December 31st, 2019 was collected. The annual total cost associated with docusate use per year was calculated. The 2015 data from this study and a 2015 McGill University Health Centre study were compared. Also, alternative uses for the money utilized on docusate were assessed.

RESULTS

Over the study period, 37,034 docusate prescriptions and 265,123 docusate doses were recorded. The average cost of prescribing docusate was $25,624.14 per year and $49.37 per hospital bed per year. A comparison between the 2015 data of University Hospital and McGill showed that McGill prescribed 107 doses and spent $10.09 more per hospital bed than University Hospital. Finally, alternative uses for the average yearly spending on docusate equated to 0.35 the salary of a nurse, 0.51 the salary of a secretary, 20.66 colonoscopies, 27.00 upper endoscopies, 186.71 mammograms, 1,399.37 doses of polyethylene glycol 3350, 3,826.57 doses of lactulose, or 4,583.80 doses of psyllium.

CONCLUSION

A single average size tertiary care hospital spent about $25,000 yearly on docusate despite its lack of clinical effectiveness. While this amount is small compared to an overall hospital budget, when considering likely comparable docusate use at the U.S's 6,090 hospitals, the economic burden of docusate becomes significant. The funds currently being used on docusate could be redirected to alternative, more cost-effective purposes.

Fetoscopic Laser Ablation for Twin-to-Twin Transfusion Syndrome: A 15-year Review of Perinatal Survival

Objective Twin to twin transfusion syndrome (TTTS) complicates 5-15% of monochorionic twin pregnancies and untreated is associated with a 90% mortality rate. The aim was to present the perinatal survival of patients with TTTS treated with laser ablation, by a national fetal medicine team. Methods This was a review of all cases of TTTS treated with fetoscopic laser ablation performed from March 2006 through to December 2020. All patients treated with fetoscopic laser were identified from the hospital database. The perinatal outcomes for the overall cohort and the individual Quintero stages were determined. Results A total of 155 cases of TTTS underwent fetoscopic laser ablation during the study period. The median gestational age at diagnosis was 19+1 weeks, with a mean growth discordance of 23.6%. The Quintero stage at diagnosis was: Stage 1 6.5% (10/155), Stage 2 49% (76/155), Stage 3 38.7% (60/155), Stage 4 5.8% (9/155). There was at least one survivor in 83.2% (129/155) of pregnancies, with dual survival in 52.9% (82/155). An increase in the rate of any survivor was observed from 75% (2006-2014) to 94% (2014-2020) (p<0.05). Dual survival decreased with increasing Quintero Stage (p<0.05). 80.6% (125/155) of pregnancies delivered prior to 34+6 weeks gestation. Conclusion Fetoscopic laser ablation is the recommended first line treatment for severe TTTS. We observed a survival rate of at least one twin in 83.2% pregnancies which is comparable to internationally published data on single-centre outcomes.

The Effects of Pre-Burn Center Intubation on Rates of Pneumonia, Early Extubation, and Death: A Systematic Review

Airway burns cause delayed collapse of airways due to airway edema. Transferring clinicians are trained to intubate at the first suspicion of airway collapse, which can lead to vague reasons for intubation such as "airway protection." Intubation, however, is not without risks, such as pneumonia and death. The objective of this research review is to compare pre-burn center intubations with those performed at burn centers and compare rates of pneumonia, mortality, and time to extubation. A systematic review of articles from MEDLINE and CINAHL Plus was performed to identify eligible trials and observational studies that compared pre-burn center intubations with those performed at burn centers between the years 2014 and 2018. Four studies met eligibility requirements. There were mixed results on the correlation of pre-burn center intubation with pneumonia and death; however, pre-burn center patients were more likely to have earlier extubation times, which points to potentially unnecessary intubations. Clinicians should be aware of the increased mortality and morbidity associated with intubation. Providers should use objective evidence-based tools such as the ABA (American Burn Association) and Denver criteria to determine the need for intubation to avoid unnecessary intubations and their potential complications.

P1548 Changes in left ventricular deformation with weight loss in obese adolescents with intellectual and developmental delays (IDD)

Funding Acknowledgements

AHA Career Development grant

Background

Adolescents with IDD have twice the prevalence of obesity as their typically developed peers, leading to frequent early obesity-related subclinical cardiac dysfunction, detected by strain echo. The effects of weight loss on cardiac deformation are unknown in this population.

Purpose

To evaluate early cardiac dysfunction in overweight IDD adolescents before and after a 6-month caloric restriction-weight loss program.

Methods

Subjects with IDD co-enrolling in a weight loss program were consented for this strain imaging study, excluding those with congenital heart disease. An echo measuring LVEF (bullet), 2D speckle longitudinal LV global strain (GLS) and strain rate (GLSr) from 3 apical views and global circumferential strain from a parasternal short axis view at the paps (GCS) was performed at baseline and 6 months. Analysis included paired T-test and regression analysis, p ≤ 0.05 significant.

Results

Overweight (5) and obese (15) adolescents (40% female) had baseline LV strain measurements that were mildly diminished with increased baseline body weight predicting diminished GLS (P = 0.034) and GCS (P = 0.046) on regression modeling. After 6 months, weight and BMI decreased significantly with improvements in GLS and GCS and non-significant trends towards improvement in GLSr and early diastolic global strain rate. BMI change at 6 months predicted change in GLS (p = 0.015) and GCS (p = 0.0087) on regression modeling. At baseline, LVEF and LV end-diastolic volume were normal with no change over 6 months (p &gt; 0.55).

Conclusions

Baseline abnormalities in LV deformation with preserved LVEF are present in this young, obese IDD population with improvements in BMI predicting those in GLS and GCS after a 6-month caloric restriction-weight loss program. These data provide compelling justification for larger studies in this population.

n Baseline (mean ± SD) 6-mo. follow up 0-6 mo. change p-value Age (years) 20 17.0 ± 2.0 17.5 ± 2.1 0.5 ± 0.1 Weight (kg) 20 86.9 ± 22.2 83.1 ± 22.7 -3.7 ± 5.9 0.014 BMI (kg/m&sup2;) 20 32.2 ± 5.3 30.4 ± 5.7 -1.8 ± 2.2 0.0031 GLS (%) 20 16.9 ± 1.6 19.2 ± 2.7 2.4 ± 2.0 0.00023 GLSr 20 1.15 ± 0.018 1.22 ± 0.18 0.06 ± 0.16 0.096 EaGLSr 20 1.83 ± 0.038 2.01 ± 0.46 0.18 ± 0.45 0.098 GCS (%) 20 19.1 ± 2.3 22.0 ± 2.6 2.82 ± 2.6 0.00019 LV deformation before and after weight loss. GLS, GLSr, and GCS are reported as positive values (absolute values). Body Mass Index (BMI); Early Diastolic Global Longitudinal Strain Rate (EaGLSr)

Leaveism in English and Welsh police forces: baseline reference values

Background

Leaveism is a recently coined term for alternative attendance behaviours to sickness absence and sickness presence. Initial studies suggest that leaveism might mask the true extent of sickness in organizations and represent a response to perceived job insecurity, the belief that sickness absence could harm promotion prospects, and low job gratification.

Aims

To generate baseline reference values for leaveism in English and Welsh police forces to facilitate benchmarking and risk-reduction activities.

Methods

Officers represented by the Police Federation of England and Wales contributed survey data on the incidence of three leaveism dimensions in the year to February 2016. We applied descriptive statistics to characterize leaveism and Pearson's χ2 tests to examine differences in incidence rates by socio- and occupational-demographic factors.

Results

Annual leave or rest days were used to take time off from work due to physical health complaints by 8499/14 451 (59%) of respondents and psychological health complaints by 5983/14 326 (42%) (dimension 1). Work was taken home that could not be completed in normal working hours by 7515/14 959 (50%) of respondents (dimension 2), and 5974/14 963 (40%) reported having worked while on annual leave in order to catch up with work (dimension 3). Incidence rates on dimensions 2 and 3 differed markedly by rank, with higher ranks reporting higher rates.

Conclusions

These sector-wide findings suggest that leaveism is a cause for concern. Further research is required to identify sector-specific causes of leaveism with a view to informing interventions to tackle the problem.

Organic waste as a sustainable feedstock for platform chemicals

Biorefineries have been established since the 1980s for biofuel production, and there has been a switch lately from first to second generation feedstocks in order to avoid the food versus fuel dilemma. To a lesser extent, many opportunities have been investigated for producing chemicals from biomass using by-products of the present biorefineries, simple waste streams. Current facilities apply intensive pre-treatments to deal with single substrate types such as carbohydrates. However, most organic streams such as municipal solid waste or algal blooms present a high complexity and variable mixture of molecules, which makes specific compound production and separation difficult. Here we focus on flexible anaerobic fermentation and hydrothermal processes that can treat complex biomass as a whole to obtain a range of products within an integrated biorefinery concept.

Effects of pneumoperitoneum and Trendelenburg position on intracranial pressure assessed using different non-invasive methods

BACKGROUND

The laparoscopic approach is becoming increasingly frequent for many different surgical procedures. However, the combination of pneumoperitoneum and Trendelenburg positioning associated with this approach may increase the patient's risk for elevated intracranial pressure (ICP). Given that the gold standard for the measurement of ICP is invasive, little is known about the effect of these common procedures on ICP.

METHODS

We prospectively studied 40 patients without any history of cerebral disease who were undergoing laparoscopic procedures. Three different methods were used for non-invasive estimation of ICP: ultrasonography of the optic nerve sheath diameter (ONSD); transcranial Doppler-based (TCD) pulsatility index (ICP_PI); and a method based on the diastolic component of the TCD cerebral blood flow velocity (ICP_FVd). The ONSD and TCD were measured immediately after induction of general anaesthesia, after pneumoperitoneum insufflation, after Trendelenburg positioning, and again at the end of the procedure.

RESULTS

The ONSD, ICP_FVd, and ICP_PI increased significantly after the combination of pneumoperitoneum insufflation and Trendelenburg positioning. The ICP_FVd showed an area under the curve of 0.80 [95% confidence interval (CI) 0.70-0.90] to distinguish the stage associated with the application of pneumoperitoneum and Trendelenburg position; ONSD and ICP_PI showed an area under the curve of 0.75 (95% CI 0.65-0.86) and 0.70 (95% CI 0.58-0.81), respectively.

CONCLUSIONS

The concomitance of pneumoperitoneum and the Trendelenburg position can increase ICP as estimated with non-invasive methods. In high-risk patients undergoing laparoscopic procedures, non-invasive ICP monitoring through a combination of ONSD ultrasonography and TCD-derived ICP_FVd could be a valid option to assess the risk of increased ICP.

Further Reductions in Road-Related Deaths and Injuries in Irish Children

The aim was to study road-related injuries and fatalities in under 15-year-olds in three time periods (1996-2000, 2004-2008 and 2009 -2013 respectively) to assess whether progress has been made via cross-sectoral efforts (legislation, public awareness campaigns and police enforcement) to reduce this injury toll in Ireland. For road traffic collisions where an injury has occurred, police assistance is required and at the time a detailed CT 68 form is completed by the attending police officer and sent to the Road Safety Authority for analysis. Details regarding the severity of injury, light and road conditions and safety measures such as seat belt or car restraint use, seat position and helmet use if a cyclist is involved are recorded. Injuries were sub-classified as fatalities, serious (detained in hospital, fractures, severe head injury, severe internal injuries or shock requiring treatment) or minor. All data for the three time periods was entered onto an SPSS database. A concerted national campaign re road safety media campaign allied to random breath testing, penalty points for driving offences, on the spot fines for speeding and greater police enforcement took place over the 17-year timeframe and continues to this day. When results were compared between the three cohorts, total injuries dropped from 5928 (1996-2000) to 3903 (2009-2013).Fatal injuries dropped from 163 to 43 with car occupant fatalities fell from 69 to 17 between 1996-2000 and 2009-2013. Serious injuries dropped from 347 in the first cohort to 201 in the third cohort. Minor injuries fell from 5,063 to 3,659 between first and last cohort. Pedestrian injuries dropped from 1719 to 1258 with pedestrian fatalities decreased from 61 (1996-2000) to 21 (2009-2013) and serious pedestrian injuries decreased from 261 down to 129. Cyclist fatalities saw the most significant fall (76%) with a dramatic reduction in fatalities from 25 down to 6. A national road safety campaign, greater police enforcement and a cultural change has seen road-related deaths and injuries in children drop very significantly (by over 70%) over the three time periods (spanning 1996 to 2013) and this campaign should continue.

ICP Versus Laser Doppler Cerebrovascular Reactivity Indices to Assess Brain Autoregulatory Capacity

BACKGROUND

To explore the relationship between various autoregulatory indices in order to determine which approximate small vessel/microvascular (MV) autoregulatory capacity most accurately.

METHODS

Utilizing a retrospective cohort of traumatic brain injury patients (N = 41) with: transcranial Doppler (TCD), intracranial pressure (ICP) and cortical laser Doppler flowmetry (LDF), we calculated various continuous indices of autoregulation and cerebrovascular responsiveness: A. ICP derived [pressure reactivity index (PRx)-correlation between ICP and mean arterial pressure (MAP), PAx-correlation between pulse amplitude of ICP (AMP) and MAP, RAC-correlation between AMP and cerebral perfusion pressure (CPP)], B. TCD derived (Mx-correlation between mean flow velocity (FVm) and CPP, Mx_a-correlation between FVm and MAP, Sx-correlation between systolic flow velocity (FVs) and CPP, Sx_a-correlation between FVs and MAP, Dx-correlation between diastolic flow index (FVd) and CPP, Dx_a-correlation between FVd and MAP], and LDF derived (Lx-correlation between LDF cerebral blood flow [CBF] and CPP, Lx_a-correlation between LDF-CBF and MAP). We assessed the relationship between these indices via Pearson correlation, Friedman test, principal component analysis (PCA), agglomerative hierarchal clustering (AHC), and k-means cluster analysis (KMCA).

RESULTS

LDF-based autoregulatory index (Lx) was most associated with TCD-based Mx/Mx_a and Dx/Dx_a across Pearson correlation, PCA, AHC, and KMCA. Lx was only remotely associated with ICP-based indices (PRx, PAx, RAC). TCD-based Sx/Sx_a was more closely associated with ICP-derived PRx, PAx and RAC. This indicates that vascular-derived indices of autoregulatory capacity (i.e., TCD and LDF based) covary, with Sx/Sx_a being the exception, whereas indices of cerebrovascular reactivity derived from pulsatile CBV (i.e., ICP indices) appear to not be closely related to those of vascular origin.

CONCLUSIONS

Transcranial Doppler Mx is the most closely associated with LDF-based Lx/Lx_a. Both Sx/Sx-a and the ICP-derived indices appear to be dissociated with LDF-based cerebrovascular reactivity, leaving Mx/Mx-a as a better surrogate for the assessment of cortical small vessel/MV cerebrovascular reactivity. Sx/Sx_a cocluster/covary with ICP-derived indices, as seen in our previous work.

Occurrence of CPPopt Values in Uncorrelated ICP and ABP Time Series

OBJECTIVES

Optimal cerebral perfusion pressure (CPPopt) is a concept that uses the pressure reactivity (PRx)-CPP relationship over a given period to find a value of CPP at which PRx shows best autoregulation. It has been proposed that this relationship be modelled by a U-shaped curve, where the minimum is interpreted as being the CPP value that corresponds to the strongest autoregulation. Owing to the nature of the calculation and the signals involved in it, the occurrence of CPPopt curves generated by non-physiological variations of intracranial pressure (ICP) and arterial blood pressure (ABP), termed here "false positives", is possible. Such random occurrences would artificially increase the yield of CPPopt values and decrease the reliability of the methodology.In this work, we studied the probability of the random occurrence of false-positives and we compared the effect of the parameters used for CPPopt calculation on this probability.

MATERIALS AND METHODS

To simulate the occurrence of false-positives, uncorrelated ICP and ABP time series were generated by destroying the relationship between the waves in real recordings. The CPPopt algorithm was then applied to these new series and the number of false-positives was counted for different values of the algorithm's parameters.

RESULTS

The percentage of CPPopt curves generated from uncorrelated data was demonstrated to be 11.5%.

CONCLUSION

This value can be minimised by tuning some of the calculation parameters, such as increasing the calculation window and increasing the minimum PRx span accepted on the curve.

Non-invasive Monitoring of Intracranial Pressure Using Transcranial Doppler Ultrasonography: Is It Possible?

Although intracranial pressure (ICP) is essential to guide management of patients suffering from acute brain diseases, this signal is often neglected outside the neurocritical care environment. This is mainly attributed to the intrinsic risks of the available invasive techniques, which have prevented ICP monitoring in many conditions affecting the intracranial homeostasis, from mild traumatic brain injury to liver encephalopathy. In such scenario, methods for non-invasive monitoring of ICP (nICP) could improve clinical management of these conditions. A review of the literature was performed on PUBMED using the search keywords 'Transcranial Doppler non-invasive intracranial pressure.' Transcranial Doppler (TCD) is a technique primarily aimed at assessing the cerebrovascular dynamics through the cerebral blood flow velocity (FV). Its applicability for nICP assessment emerged from observation that some TCD-derived parameters change during increase of ICP, such as the shape of FV pulse waveform or pulsatility index. Methods were grouped as: based on TCD pulsatility index; aimed at non-invasive estimation of cerebral perfusion pressure and model-based methods. Published studies present with different accuracies, with prediction abilities (AUCs) for detection of ICP ≥20 mmHg ranging from 0.62 to 0.92. This discrepancy could result from inconsistent assessment measures and application in different conditions, from traumatic brain injury to hydrocephalus and stroke. Most of the reports stress a potential advantage of TCD as it provides the possibility to monitor changes of ICP in time. Overall accuracy for TCD-based methods ranges around ±12 mmHg, with a great potential of tracing dynamical changes of ICP in time, particularly those of vasogenic nature.

Non-invasive assessment of intracranial pressure

Monitoring of intracranial pressure (ICP) is invaluable in the management of neurosurgical and neurological critically ill patients. Invasive measurement of ventricular or parenchymal pressure is considered the gold standard for accurate measurement of ICP but is not always possible due to certain risks. Therefore, the availability of accurate methods to non-invasively estimate ICP has the potential to improve the management of these vulnerable patients. This review provides a comparative description of different methods for non-invasive ICP measurement. Current methods are based on changes associated with increased ICP, both morphological (assessed with magnetic resonance, computed tomography, ultrasound, and fundoscopy) and physiological (assessed with transcranial and ophthalmic Doppler, tympanometry, near-infrared spectroscopy, electroencephalography, visual-evoked potentials, and otoacoustic emissions assessment). At present, none of the non-invasive techniques alone seem suitable as a substitute for invasive monitoring. However, following the present analysis and considerations upon each technique, we propose a possible flowchart based on the combination of non-invasive techniques including those characterizing morphologic changes (e.g., repetitive US measurements of ONSD) and those characterizing physiological changes (e.g., continuous TCD). Such an integrated approach, which still needs to be validated in clinical practice, could aid in deciding whether to place an invasive monitor, or how to titrate therapy when invasive ICP measurement is contraindicated or unavailable.

Intraoperative non invasive intracranial pressure monitoring during pneumoperitoneum: a case report and a review of the published cases and case report series

Non-invasive measurement of ICP (nICP) can be warranted in patients at risk for developing increased ICP during pneumoperitoneum (PP). Our aim was to assess available data on the application of nICP monitoring during these procedures and to present a patient assessed with an innovative combination of noninvasive tools. Literature review of nICP assessment during PP did not find any studies comparing different methods intraprocedurally and only few studies of any nICP monitoring were available: transcranial Doppler (TCD) studies used the pulsatility index (PI) as an estimator of ICP and failed to detect a significant ICP increase during PP, whereas two out of three optic nerve sheath diameter (ONSD) studies detected a statistically significant ICP increase. In the case study, we describe a 52 year old man with a high grade thalamic glioma who underwent urgent laparoscopic cholecystectomy. Considering the high intraoperative risk of developing intracranial hypertension, he was monitored through parallel ONSD ultrasound measurement and TCD derived formulae (flow velocity diastolic formula, FVdnICP, and PI). ONSD and FVdnICP methods indicated a significant ICP increase during PP, whereas PI was not significantly increased. Our experience, combined with the literature review, seems to suggest that PI might not detect ICP changes in this context, however we indicate a possible interest of nICP monitoring during PP by means of ONSD and of TCD derived FVdNICP, especially for patients at risk for increased ICP.

Influence of high altitude on cerebral blood flow and fuel utilization during exercise and recovery

We examined the hypotheses that: (1) during incremental exercise and recovery following 4-6 days at high altitude (HA) global cerebral blood flow (gCBF) increases to preserve cerebral oxygen delivery (CDO2) in excess of that required by an increasing cerebral metabolic rate of oxygen ( CM RO2); (2) the trans-cerebral exchange of oxygen vs. carbohydrates (OCI; carbohydrates = glucose + ½lactate) would be similar during exercise and recovery at HA and sea level (SL). Global CBF, intra-cranial arterial blood velocities, extra-cranial blood flows, and arterial-jugular venous substrate differences were measured during progressive steady-state exercise (20, 40, 60, 80, 100% maximum workload (Wmax)) and through 30 min of recovery. Measurements (n = 8) were made at SL and following partial acclimatization to 5050 m. At HA, absolute Wmax was reduced by ∼50%. During submaximal exercise workloads (20-60% Wmax), despite an elevated absolute gCBF (∼20%, P < 0.05) the relative increases in gCBF were not different at HA and SL. In contrast, gCBF was elevated at HA compared with SL during 80 and 100% Wmax and recovery. Notwithstanding a maintained CDO2 and elevated absolute CM RO2 at HA compared with SL, the relative increase in CM RO2 was similar during 20-80% Wmax but half that of the SL response (i.e. 17 vs. 27%; P < 0.05 vs. SL) at 100% Wmax. The OCI was reduced at HA compared with SL during 20, 40, and 60% Wmax but comparable at 80 and 100% Wmax. At HA, OCI returned almost immediately to baseline values during recovery, whereas at SL it remained below baseline. In conclusion, the elevations in gCBF during exercise and recovery at HA serve to maintain CDO2. Despite adequate CDO2 at HA the brain appears to increase non-oxidative metabolism during exercise and recovery.

The influence of key clinical practices on the knowledge of first year doctors about the patients under their care

AIMS

In 2009 in the United Kingdom the 48-h working week was introduced for junior doctors. To comply with this traditional working practices have changed. This study aims to assess how much first year (FY1) doctors know about the acute surgical patients they manage and how this is influenced by changes in key working practices.

METHODS

Surgical FY1s working in NHS hospitals answered 16 clinical questions about a standard acute surgical patient under their care 48 h after admission. Scores were analysed according to how long the FY1 had been looking after the patient, whether they had clerked the patient in, attended the post take ward round (PTWR), used a handover sheet to answer the questions and had sole or shared responsibility for the patient.

RESULTS

Two hundred and seventy-four FY1s (92% response rate) from 36 hospitals were surveyed. The overall median score was 11/16 (inter-quartile range 8-13). Only 8.4% (23/274) FY1s had clerked in the patient and 58.4% (160/274) had attended the PTWR. Clerking patients and attending the PTWR resulted in significantly higher test scores compared to FY1s who did not perform these activities (p = < 0.001 and 0.001 respectively). The scores of the 67.2% who used a handover sheet were significantly lower than those who did not (p = 0.001). Having sole or shared responsibility and duration of care made no significant difference (p = 0.143 and p = 0.458 respectively)

CONCLUSIONS

The results demonstrate that junior doctors' knowledge of their patients is significantly enhanced when they have the opportunity to perform the admission clerking and attend the PTWR. Because of working hours' restrictions this is now rare. Although use of handover sheets appears to ensure that certain key facts immediately related to the current admission are passed on, it is associated with significantly poorer wider knowledge of the patient.

Effect of hypoxia on the dynamic response of hyperaemia in the contracting human calf muscle

Although systemic hypoxia increases the muscle hyperaemic response during 'steady-state' exercise, its effect on the dynamic characteristics of this response is not clear. In the present study, we first established that hypoxia increases the steady-state hyperaemic response at low workloads during calf exercise. To study dynamic aspects of this response, eight subjects performed eight exercise trials while breathing a normoxic (fractional inspired O(2) = 0.2094) or hypoxic gas mixture (fractional inspired O(2) = 0.105). Subjects performed intermittent contractions (1 s) of the calf muscle at 20% maximal voluntary contraction, and the leg blood flow (LBF), leg vascular conductance (LVC) and EMG activities of the triceps surae muscles were measured during each contraction-relaxation period (3 s). The LBF and LVC responses were averaged for each subject and fitted using a four-phase, exponential growth and decay function. Hypoxia evoked significant increases in the change in LBF (15%) and LVC (23%) from the start to the end of exercise, as well as the amplitude of the rapid growth phase of LBF and LVC (21%). Similar, but non-significant, effects on the amplitude of the slow growth phase of LBF (P = 0.08) and LVC (P = 0.10) were observed. By contrast, hypoxia had no effect on temporal parameters of these growth phases, parameters defining the decay phases or EMG activities. These results suggest that the effect of hypoxia on exercise hyperaemia is targeted at the rapid and perhaps the slow growth phase of the response, and is not mediated by a change in the level of muscle activation.

Progress in reducing road-related deaths and injuries in Irish children

The aim was to study road-related injuries and fatalities in under 15 year olds in two time periods (1996-2000 and 2004-2008 inclusive) to assess whether progress has been made via cross-sectoral efforts to reduce this injury toll in Ireland. For pedestrian and car-related accidents, police assistance is required and at the time a detailed CT 68 form is completed by the attending officer and sent to the Road Safety Authority for analysis. Details re the severity of injury, light and road conditions and safety measures such as seat belt or car restraint use, seat position and helmet use if a cyclist were recorded. Injuries were sub-classified as fatalities, serious (detained in hospital, fractures, severe head injury, severe internal injuries or shock requiring treatment) or minor. All data for the two time periods was entered onto an SPSS database. A concerted national campaign re road safety media campaign allied to random breath testing, penalty points for driving offences, on the spot fines for speeding and far greater police enforcement took place between the two time frames and continues to this day. When looked at as most likely estimates of death ratios the results were found to be statistically significant with an overall p value of < 0.0001 CI [0.39, 0.69]. When broken down into specific age ranges all were significant apart from the 0-3 age range with a p value of 0.69 CI [0.26, 1.1]. The most significant changes were found in the 7-9 years, 10-12 and 13-15 year age ranges with p values of < 0.0001, 0.0002 and 0.0007 respectively. When results were compared between the two cohorts, car occupant fatalities between both groups dropped by 36%. Pedestrian injuries dropped from 1719 to 1232, pedestrian fatalities decreased by almost 50% as did serious pedestrian injuries from 261 down to 129. Cyclist fatalities saw the most significant fall (76%) with a dramatic reduction in cyclist injuries from 25 down to 6 (63%). The 13-15 year old age group had the highest mortality and morbidity in both cohorts. Documented restraint use was less than 70% in both cohorts. A national road safety campaign, greater police enforcement and a cultural change has seen road-related injuries in children drop very significantly (by 50%) over the two time periods and this campaign should continue.

Obstetric outcome with low molecular weight heparin therapy during pregnancy

This was a prospective study of women attending a combined haematology/obstetric antenatal clinic in the National Maternity Hospital (2002-2008). Obstetric outcome in mothers treated with low molecular weight heparin (LMWH) was compared to the general obstetric population of 2006. There were 133 pregnancies in 105 women. 85 (63.9%) received prophylactic LMWH and 38 (28.6%) received therapeutic LMWH in pregnancy. 10 (7.5%) received postpartum prophylaxis only. The perinatal mortality rate was 7.6/1000 births. 14 (11.3%) women delivered preterm which is significantly higher than the hospital population rate (5.7%, p<0.05). Despite significantly higher labour induction rates (50% vs 29.2% p<0.01), there was no difference in CS rates compared to the general hospital population (15.4% vs 18.9%, NS). If carefully managed, these high-risk women can achieve similar vaginal delivery rates as the general obstetric population.

Efficacy and safety of leuprolide acetate 6-month depot for suppression of testosterone in patients with prostate cancer

Background:

This open-label study evaluated the efficacy and safety of a new leuprolide acetate 45 mg 6-month depot formulation in 151 men with prostate cancer who received 2 intramuscular injections administered 24 weeks apart.

Methods:

The primary efficacy measurement was the proportion of patients achieving suppression of serum testosterone to ⩽50 ng dl⁻¹ from week 4 through week 48. Adverse events (AEs) and hormonal and safety laboratory values were monitored.

Results:

The primary efficacy end point was achieved in 93.4% of subjects (95% confidence interval (89.2%, 97.6%)). There were nine escapes from testosterone suppression during the study, none of which were accompanied by a rise in PSA. By week 4, mean testosterone concentration was suppressed below castrate levels to 15.9 ng dl⁻¹; suppression was maintained for the entire 24-week duration of each depot injection. No mean increase in testosterone was observed after the second injection. Mean PSA levels were maintained below 3 ng ml⁻¹ from week 14 through the 48-week treatment period. The most frequent AE was flushing (58.3%). Injection site reactions were reported in 24.5% of patients.

Conclusions:

Leuprolide acetate 45 mg 6-month depot demonstrated rapid and sustained testosterone suppression through 12 months and was well tolerated. This 6-month leuprolide acetate depot will decrease the number of annual injections in the treatment of prostate cancer.

Kinome siRNA-phosphoproteomic screen identifies networks regulating AKT signaling

To identify regulators of intracellular signaling we targeted 541 kinases and kinase-related molecules with siRNAs and determined their effects on signaling with a functional proteomics reverse phase protein array (RPPA) platform assessing 42 phospho and total proteins. The kinome wide screen demonstrated a strong inverse correlation between phosphorylation of AKT and MAPK with 115 genes that when targeted by siRNAs demonstrated opposite effects on MAPK and AKT phosphorylation. Network based analysis identified the MAPK subnetwork of genes along with p70S6K and FRAP1 as the most prominent targets that increased phosphorylation of AKT, a key regulator of cell survival. The regulatory loops induced by the MAPK pathway are dependent on TSC2 but demonstrate a lesser dependence on p70S6K than the previously identified FRAP1 feedback loop. The siRNA screen also revealed novel bi-directionality in the AKT and GSK3 interaction, whereby genetic ablation of GSK3 significantly blocks AKT phosphorylation, an unexpected observation as GSK3 has only been predicted to be downstream of AKT. This method uncovered novel modulators of AKT phosphorylation and facilitated the mapping of regulatory loops.

Role of mammography in the triple assessment of single-quadrant breast symptoms

Background

Most women over the age of 35 years referred to a breast clinic have single-quadrant symptoms and undergo mammography (MMG) as part of the triple assessment of these. A proportion of these women has no abnormality clinically or on ultrasonography (P1 U1). The aim of this study was to assess the additional contribution of MMG in diagnosing cancer in patients with P1 U1 findings and to consider whether it is safe to be more selective when requesting MMG.

Methods

Over a 2-year interval the clinical and radiological details of women whose single-quadrant breast symptoms were assessed as P1 U1, and who were then sent for MMG, were entered into a database. The results of further investigations initiated by a non-benign MMG report were recorded, and the patients reviewed to establish how many cancers were diagnosed purely by MMG and whether these were located at the site of symptoms.

Results

There were 454 women in the study group, representing 17·5 per cent of all new referrals. Twenty-one patients (4·6 per cent) were recalled following a non-benign MMG result, ten of whom required image-guided biopsy. Cancer was diagnosed in three patients (0·7 per cent of the study group), located in the contralateral breast in two women and a different ipsilateral quadrant in one.

Conclusion

MMG in this subset of patients did not increase the cancer detection rate at the site of symptoms and therefore constituted screening. The rationale for requesting MMG in these patients, and indeed for applying the triple assessment rule, should be reconsidered.