Consumer experiences of shame in clinical encounters for breast cancer treatment. "Who do you think you are- Angelina Jolie?"

BACKGROUND

Shame is a powerful negative emotion that has the potential to affect health. Due to the intimate nature of breast cancer treatment and its impact on body image, it is hypothesised that shame may be experienced during treatment. The aim of this study was to explore shame experiences related to clinical encounters for breast cancer treatment.

METHODS

People with a lived experience of breast cancer were invited to anonymously share their stories of shame through an online survey. Using qualitative methodology, the stories were examined, and themes identified.

PARTICIPANTS

Participants were members of the consumer organisation Breast Cancer Network Australia.

RESULTS

Stories were contributed by 38 participants. Most (n = 28, 73.7 %) were >5 years post-diagnosis. Shame was experienced in a range of clinical settings (consulting rooms, wards, operating theatres, radiotherapy departments). They involved a different health professionals (oncologists, surgeons, nurses, radiation therapists, psychologists.) Five themes were identified: (1) Body shame (sub-themes: Naked/vulnerable and Weight), (2) Communication (subthemes: Lack of compassion/impersonal manner and Not listening), (3) Being blamed (subthemes: diagnosis and complications), (4) Feeling unworthy (subthemes: Burden to staff and Unworthy of care), (5) Judgement for treatment choices.

CONCLUSIONS

Shame can be experienced in a range of situations, from scrutiny of the naked body to comments from health professionals. The impact of these experiences is profound, and the feelings of shame are carried for many years. These findings can inform strategies to support consumers and educate health professionals with the aim of reducing harm related to cancer treatment.

Prevalence and outcomes of WPW pattern in the young: a report from a nationwide cardiac screening programme

Funding Acknowledgements

Type of funding sources: None.

Background

Individuals with accessory pathways, also referred as the Wolff-Parkinson-White pattern (WPWp), are usually asymptomatic and fatal arrhythmias may be the first presentation. Risk stratification is recommended, with electrophysiological study (EPS) being the gold standard. Catheter ablation offers a widely available, curative option, and provides incentive for screening, particularly in high-risk populations such as athletes.

Purpose

We sought to assess the prevalence, real-world clinical practice and outcomes of WPWp in young individuals identified through a nationwide cardiac screening programme.

Method

Between 2008 and 2018, 113,209 consecutive individuals (14 to 35 years old, 38% female) underwent cardiac screening with a health questionnaire, 12-lead electrocardiogram (ECG) and cardiology consultation. Individuals with suspected cardiac disease were referred for further investigations as necessary. Clinical outcomes were obtained via an online questionnaire and matched de-identified records from the Office of National Statistics database. Individuals were classified as elite athletes, non-elite athletes and non-athletes.

Results

A total of 214 (0.2%) individuals were referred for secondary evaluation with a suspected WPWp (Figure 1). Clinical outcomes were unavailable for 30 (14%) individuals. Follow-up confirmed an additional 13 individuals with a WPWp who were deemed to have normal investigations at screening, of which 8 (61%) had reported cardiovascular symptoms on their HQ and, in retrospect, 4 (30%) demonstrated subtle WPWp on their ECG. A WPWp was confirmed in 187 individuals (0.2%), of which 149 (80%) individuals were considered non-athletes, 114 (61%) reported cardiovascular symptoms, 116 (62%) underwent risk stratification with an EPS and 95 (43%) underwent catheter ablation. Report of palpitation was significantly greater in non-athletes than athletes (p=0.034). In asymptomatic individuals, those engaging in sports at elite level were more likely to be referred for an EPS (p=0.04). Four adverse cardiac events were reported over a follow up period of 7.4 years (IQR 4.9 to 9.2), including 3 individuals (16 years, 20 years, 40 years) with life-threatening arrhythmic events (LAE) requiring cardioversion, and 1 individual (20 years) with sudden cardiac death. Of these 4 individuals, only 1 with a LAE had undergone risk stratification with EPS.

Conclusions

The incidence of SCD in this young screened population was 0.72 per 1000 person-years. Clinical practice was variable and EPS was not offered to a significant proportion of patients, despite inadequate non-invasive risk stratification. The indication to EPS was driven by the athletic status in the asymptomatic individuals. The WPW syndrome may manifest with subtle ECG changes, posing a diagnostic challenge to interpreting physicians.

Mutational analysis of ProTx-I and the novel venom peptide Pe1b provide insight into residues responsible for selective inhibition of the analgesic drug target NaV1.7

Management of chronic pain presents a major challenge, since many currently available treatments lack efficacy and have problems such as addiction and tolerance. Loss of function mutations in the SCN9A gene lead to a congenital inability to feel pain, with no other sensory deficits aside from anosmia. SCN9A encodes the voltage-gated sodium (Na_V) channel 1.7 (Na_V1.7), which has been identified as a primary pain target. However, in developing Na_V1.7-targeted analgesics, extreme care must to be taken to avoid off-target activity on other Na_V subtypes that are critical for survival. Since spider venoms are an excellent source of Na_V channel modulators, we screened a panel of spider venoms to identify selective Na_V1.7 inhibitors. This led to identification of two novel Na_V modulating venom peptides (β/μ-theraphotoxin-Pe1a and β/μ-theraphotoxin-Pe1b (Pe1b) from the arboreal tarantula Phormingochilus everetti. A third peptide isolated from the tarantula Bumba pulcherrimaklaasi was identical to the well-known ProTx-I (β/ω-theraphotoxin-Tp1a) from the tarantula Thrixopelma pruriens. A tethered toxin (t-toxin)-based alanine scanning strategy was used to determine the Na_V1.7 pharmacophore of ProTx-I. We designed several ProTx-I and Pe1b analogues, and tested them for activity and Na_V channel subtype selectivity. Several analogues had improved potency against Na_V1.7, and altered specificity against other Na_V channels. These analogues provide a foundation for development of Pe1b as a lead molecule for therapeutic inhibition of Na_V1.7.

Psychological intervention (ConquerFear) for treating fear of cancer recurrence: mediators and moderators of treatment efficacy

PURPOSE

ConquerFear is an efficacious intervention for fear of cancer recurrence (FCR) that demonstrated greater improvements than an attention control (relaxation training) in a randomized controlled trial. This study aimed to determine mediators and moderators of the relative treatment efficacy of ConquerFear versus relaxation.

METHODS

One hundred and fifty-two cancer survivors completed 5 therapy sessions and outcome measures before and after intervention and at 6 months' follow-up. We examined theoretically relevant variables as potential mediators and moderators of treatment outcome. We hypothesized that metacognitions and intrusions would moderate and mediate the relationship between treatment group and FCR level at follow-up.

RESULTS

Only total FCR score at baseline moderated treatment outcome. Participants with higher levels of FCR benefited more from ConquerFear relative to relaxation on the primary outcome. Changes in metacognitions and intrusive thoughts about cancer during treatment partially mediated the relationship between treatment group and FCR.

CONCLUSIONS

These results show that ConquerFear is relatively more effective than relaxation for those with overall higher levels of FCR. The mediation analyses confirmed that the most likely mechanism of treatment efficacy was the reduction in unhelpful metacognitions and intrusive thoughts during treatment, consistent with the theoretical framework underpinning ConquerFear.

IMPLICATIONS FOR CANCER SURVIVORS

ConquerFear is a brief, effective treatment for FCR in cancer survivors with early-stage disease. The treatment works by reducing intrusive thoughts about cancer and changing beliefs about worry and is particularly helpful for people with moderate to severe FCR.

Applying Data Preprocessing Methods to Predict Premature Birth

Data mining and pattern classification tools have{enabled prediction of several medical outcomes with high levels of accuracy. This is due to the capability of handling large datasets, even those with missing values. Preterm birth (PTB) can have damaging long-term effects for infants and rates have been increasing over the last two decades worldwide. The purpose of this work was to investigate whether preprocessing methods, when applied to two different prenatal datasets, can improve prediction accuracy of our software tool to predict PTB. The primary software used within this work was R. The software was used to deal with missing values and class imbalances found in these two datasets. The results show that in comparison to our past work, we have managed to increase the performance of the prediction tool using the metrics of sensitivity, specificity, and ROC values.

NaV1.1 inhibition can reduce visceral hypersensitivity

Functional bowel disorder patients can suffer from chronic abdominal pain, likely due to visceral hypersensitivity to mechanical stimuli. As there is only a limited understanding of the basis of chronic visceral hypersensitivity (CVH), drug-based management strategies are ill defined, vary considerably, and include NSAIDs, opioids, and even anticonvulsants. We previously reported that the 1.1 subtype of the voltage-gated sodium (NaV; NaV1.1) channel family regulates the excitability of sensory nerve fibers that transmit a mechanical pain message to the spinal cord. Herein, we investigated whether this channel subtype also underlies the abdominal pain that occurs with CVH. We demonstrate that NaV1.1 is functionally upregulated under CVH conditions and that inhibiting channel function reduces mechanical pain in 3 mechanistically distinct mouse models of chronic pain. In particular, we use a small molecule to show that selective NaV1.1 inhibition (a) decreases sodium currents in colon-innervating dorsal root ganglion neurons, (b) reduces colonic nociceptor mechanical responses, and (c) normalizes the enhanced visceromotor response to distension observed in 2 mouse models of irritable bowel syndrome. These results provide support for a relationship between NaV1.1 and chronic abdominal pain associated with functional bowel disorders.

A Two Centre Observational Study of Simultaneous Pulse Oximetry and Arterial Oxygen Saturation Recordings in Intensive Care Unit Patients

The influence of variables that might affect the accuracy of pulse oximetry (SpO2) recordings in critically ill patients is not well established. We sought to describe the relationship between paired SpO2/SaO2 (oxygen saturation via arterial blood gas analysis) in adult intensive care unit (ICU) patients and to describe the diagnostic performance of SpO2 in detecting low SaO2 and PaO2. A paired SpO2/SaO2 measurement was obtained from 404 adults in ICU. Measurements were used to calculate bias, precision, and limits of agreement. Associations between bias and variables including vasopressor and inotrope use, capillary refill time, hand temperature, pulse pressure, body temperature, oximeter model, and skin colour were estimated. There was no overall statistically significant bias in paired SpO2/SaO2 measurements; observed limits of agreement were +/-4.4%. However, body temperature, oximeter model, and skin colour, were statistically significantly associated with the degree of bias. SpO2 <89% had a sensitivity of 3/7 (42.9%; 95% confidence intervals, CI, 9.9% to 81.6%) and a specificity of 344/384 (89.6%; 95% CI 86.1% to 92.5%) for detecting SaO2 <89%. The absence of statistically significant bias in paired SpO2/SaO2 in adult ICU patients provides support for the use of pulse oximetry to titrate oxygen therapy. However, SpO2 recordings alone should be used cautiously when SaO2 recordings of 4.4% higher or lower than the observed SpO2 would be of concern. A range of variables relevant to the critically ill had little or no effect on bias.

Using voltage-sensor toxins and their molecular targets to investigate NaV 1.8 gating

Voltage-gated sodium (Na_V ) channel gating is a complex phenomenon which involves a distinct contribution of four integral voltage-sensing domains (VSDI, VSDII, VSDIII and VSDIV). Utilizing accrued pharmacological and structural insights, we build on an established chimera approach to introduce animal toxin sensitivity in each VSD of an acceptor channel by transferring in portable S3b-S4 motifs from the four VSDs of a toxin-susceptible donor channel (Na_V 1.2). By doing so, we observe that in Na_V 1.8, a relatively unexplored channel subtype with distinctly slow gating kinetics, VSDI-III participate in channel opening whereas VSDIV can regulate opening as well as fast inactivation. These results illustrate the effectiveness of a pharmacological approach to investigate the mechanism underlying gating of a mammalian Na_V channel complex.

The tarantula toxin β/δ-TRTX-Pre1a highlights the importance of the S1-S2 voltage-sensor region for sodium channel subtype selectivity

Voltage-gated sodium (Na_V) channels are essential for the transmission of pain signals in humans making them prime targets for the development of new analgesics. Spider venoms are a rich source of peptide modulators useful to study ion channel structure and function. Here we describe β/δ-TRTX-Pre1a, a 35-residue tarantula peptide that selectively interacts with neuronal Na_V channels inhibiting peak current of hNa_V1.1, rNa_V1.2, hNa_V1.6, and hNa_V1.7 while concurrently inhibiting fast inactivation of hNa_V1.1 and rNa_V1.3. The DII and DIV S3-S4 loops of Na_V channel voltage sensors are important for the interaction of Pre1a with Na_V channels but cannot account for its unique subtype selectivity. Through analysis of the binding regions we ascertained that the variability of the S1-S2 loops between Na_V channels contributes substantially to the selectivity profile observed for Pre1a, particularly with regards to fast inactivation. A serine residue on the DIV S2 helix was found to be sufficient to explain Pre1a’s potent and selective inhibitory effect on the fast inactivation process of Na_V1.1 and 1.3. This work highlights that interactions with both S1-S2 and S3-S4 of Na_V channels may be necessary for functional modulation, and that targeting the diverse S1-S2 region within voltage-sensing domains provides an avenue to develop subtype selective tools.

Isolation of two insecticidal toxins from venom of the Australian theraphosid spider Coremiocnemis tropix

Sheep flystrike is caused by parasitic flies laying eggs on soiled wool or open wounds, after which the hatched maggots feed on the sheep flesh and often cause large lesions. It is a significant economic problem for the livestock industry as infestations are difficult to control due to ongoing cycles of larval development into flies followed by further egg laying. We therefore screened venom fractions from the Australian theraphosid spider Coremiocnemis tropix to identify toxins active against the sheep blowfly Lucilia cuprina, which is the primary cause of flystrike in Australia. This screen led to isolation of two insecticidal peptides, Ct1a and Ct1b, that are lethal to blowflies within 24 h of injection. The primary structure of these peptides was determined using a combination of Edman degradation and sequencing of a C. tropix venom-gland transcriptome. Ct1a and Ct1b contain 39 and 38 amino acid residues, respectively, including six cysteine residues that form three disulfide bonds. Recombinant production in bacteria (Escherichia coli) resulted in low yields of Ct1a whereas solid-phase peptide synthesis using native chemical ligation produced sufficient quantities of Ct1a for functional analyses. Synthetic Ct1a had no effect on voltage-gated sodium channels from the American cockroach Periplanata americana or the German cockroach Blattella germanica, but it was lethal to sheep blowflies with an LD₅₀ of 1687 pmol/g.

Molecular basis of the remarkable species selectivity of an insecticidal sodium channel toxin from the African spider Augacephalus ezendami

The inexorable decline in the armament of registered chemical insecticides has stimulated research into environmentally-friendly alternatives. Insecticidal spider-venom peptides are promising candidates for bioinsecticide development but it is challenging to find peptides that are specific for targeted pests. In the present study, we isolated an insecticidal peptide (Ae1a) from venom of the African spider Augacephalus ezendami (family Theraphosidae). Injection of Ae1a into sheep blowflies (Lucilia cuprina) induced rapid but reversible paralysis. In striking contrast, Ae1a was lethal to closely related fruit flies (Drosophila melanogaster) but induced no adverse effects in the recalcitrant lepidopteran pest Helicoverpa armigera. Electrophysiological experiments revealed that Ae1a potently inhibits the voltage-gated sodium channel BgNa_V1 from the German cockroach Blattella germanica by shifting the threshold for channel activation to more depolarized potentials. In contrast, Ae1a failed to significantly affect sodium currents in dorsal unpaired median neurons from the American cockroach Periplaneta americana. We show that Ae1a interacts with the domain II voltage sensor and that sensitivity to the toxin is conferred by natural sequence variations in the S1–S2 loop of domain II. The phyletic specificity of Ae1a provides crucial information for development of sodium channel insecticides that target key insect pests without harming beneficial species.

Binary architecture of the Nav1.2-β2 signaling complex

To investigate the mechanisms by which β-subunits influence Nav channel function, we solved the crystal structure of the β2 extracellular domain at 1.35Å. We combined these data with known bacterial Nav channel structural insights and novel functional studies to determine the interactions of specific residues in β2 with Nav1.2. We identified a flexible loop formed by (72)Cys and (75)Cys, a unique feature among the four β-subunit isoforms. Moreover, we found that (55)Cys helps to determine the influence of β2 on Nav1.2 toxin susceptibility. Further mutagenesis combined with the use of spider toxins reveals that (55)Cys forms a disulfide bond with (910)Cys in the Nav1.2 domain II pore loop, thereby suggesting a 1:1 stoichiometry. Our results also provide clues as to which disulfide bonds are formed between adjacent Nav1.2 (912/918)Cys residues. The concepts emerging from this work will help to form a model reflecting the β-subunit location in a Nav channel complex.

A distinct sodium channel voltage-sensor locus determines insect selectivity of the spider toxin Dc1a

β-Diguetoxin-Dc1a (Dc1a) is a toxin from the desert bush spider Diguetia canities that incapacitates insects at concentrations that are non-toxic to mammals. Dc1a promotes opening of German cockroach voltage-gated sodium (Na_v) channels (BgNa_v1), whereas human Na_v channels are insensitive. Here, by transplanting commonly targeted S3b-S4 paddle motifs within BgNa_v1 voltage sensors into K_v2.1, we find that Dc1a interacts with the domain II voltage sensor. In contrast, Dc1a has little effect on sodium currents mediated by PaNa_v1 channels from the American cockroach even though their domain II paddle motifs are identical. When exploring regions responsible for PaNa_v1 resistance to Dc1a, we identified two residues within the BgNa_v1 domain II S1–S2 loop that when mutated to their PaNa_v1 counterparts drastically reduce toxin susceptibility. Overall, our results reveal a distinct region within insect Na_v channels that helps determine Dc1a sensitivity, aconcept that will be valuable for the design of insect-selective insecticides.

Nav1.1 modulation by a novel triazole compound attenuates epileptic seizures in rodents

Here, we report the discovery of a novel anticonvulsant drug with a molecular organization based on the unique scaffold of rufinamide, an anti-epileptic compound used in a clinical setting to treat severe epilepsy disorders such as Lennox-Gastaut syndrome. Although accumulating evidence supports a working mechanism through voltage-gated sodium (Nav) channels, we found that a clinically relevant rufinamide concentration inhibits human (h)Nav1.1 activation, a distinct working mechanism among anticonvulsants and a feature worth exploring for treating a growing number of debilitating disorders involving hNav1.1. Subsequent structure-activity relationship experiments with related N-benzyl triazole compounds on four brain hNav channel isoforms revealed a novel drug variant that (1) shifts hNav1.1 opening to more depolarized voltages without further alterations in the gating properties of hNav1.1, hNav1.2, hNav1.3, and hNav1.6; (2) increases the threshold to action potential initiation in hippocampal neurons; and (3) greatly reduces the frequency of seizures in three animal models. Altogether, our results provide novel molecular insights into the rational development of Nav channel-targeting molecules based on the unique rufinamide scaffold, an outcome that may be exploited to design drugs for treating disorders involving particular Nav channel isoforms while limiting adverse effects.

Animal toxins can alter the function of Nav1.8 and Nav1.9

Human voltage-activated sodium (Nav) channels are adept at rapidly transmitting electrical signals across long distances in various excitable tissues. As such, they are amongst the most widely targeted ion channels by drugs and animal toxins. Of the nine isoforms, Nav1.8 and Nav1.9 are preferentially expressed in DRG neurons where they are thought to play an important role in pain signaling. Although the functional properties of Nav1.8 have been relatively well characterized, difficulties with expressing Nav1.9 in established heterologous systems limit our understanding of the gating properties and toxin pharmacology of this particular isoform. This review summarizes our current knowledge of the role of Nav1.8 and Nav1.9 in pain perception and elaborates on the approaches used to identify molecules capable of influencing their function.

Dog bites: still a problem?

OBJECTIVE

To estimate the incidence of dog bites in the USA and compare it with similar estimates from 1994.

DESIGN

Nationally representative cross-sectional, list-assisted, random-digit-dialed telephone survey conducted during 2001-2003.

METHODS

Weighted estimates were generated from data collected by surveying 9684 households during 2001-2003 and compared with results from a similar survey conducted in 1994. Estimates for persons aged 15-17 years were extrapolated on the basis of rates for 10-14-year-olds.

RESULTS

Whereas the incidence of dog bites among adults remained relatively unchanged, there was a significant (47%) decline in the incidence of dog bites among children compared with that observed in the 1994 survey, particularly among boys and among those aged 0-4 years. Between 2001 and 2003, an estimated 4 521 300 persons were bitten each year. Of these, 885 000 required medical attention (19%). Children were more likely than adults to receive medical attention for a dog bite. Among adults, bite rates decreased with increasing age. Among children and adults, having a dog in the household was associated with a significantly increased incidence of dog bites, with increasing incidence also related to increasing numbers of dogs.

CONCLUSIONS

Dog bites continue to be a public health problem affecting 1.5% of the US population annually. Although comparison with similar data from 1994 suggests that bite rates for children are decreasing, there still appears to be a need for effective prevention programs.

Mutations in the FUS/TLS gene on chromosome 16 cause familial amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a fatal degenerative motor neuron disorder. Ten percent of cases are inherited; most involve unidentified genes. We report here 13 mutations in the fused in sarcoma/translated in liposarcoma (FUS/TLS) gene on chromosome 16 that were specific for familial ALS. The FUS/TLS protein binds to RNA, functions in diverse processes, and is normally located predominantly in the nucleus. In contrast, the mutant forms of FUS/TLS accumulated in the cytoplasm of neurons, a pathology that is similar to that of the gene TAR DNA-binding protein 43 (TDP43), whose mutations also cause ALS. Neuronal cytoplasmic protein aggregation and defective RNA metabolism thus appear to be common pathogenic mechanisms involved in ALS and possibly in other neurodegenerative disorders.

Debriefing after failed paediatric resuscitation: a survey of current UK practice

OBJECTIVES

Debriefing is a form of psychological "first aid" with origins in the military. It moved into the spotlight in 1983, when Mitchell described the technique of critical incident stress debriefing. To date little work has been carried out relating to the effectiveness of debriefing hospital staff after critical incidents. The aim of this study was to survey current UK practice in order to develop some "best practice" guidelines.

METHODS

This study was a descriptive evaluation based on a structured questionnaire survey of 180 lead paediatric and emergency medicine consultants and nurses, selected from 50 UK trusts. Questions collected data about trust policy and events and also about individuals' personal experience of debrief. Free text comments were analyzed using the framework method described for qualitative data.

RESULTS

Overall, the response rate was 80%. 62% said a debrief would occur most of the time. 85% reported that the main aim was to resolve both medical and psychological and emotional issues. Nearly all involve both doctors and nurses (88%); in over half (62%) other healthcare workers would be invited, eg, paramedics, students. Sessions are usually led by someone who was involved in the resuscitation attempt (76%). This was a doctor in 80%, but only 18% of responders said that a specifically trained person had led the session. Individuals' psychological issues would be discussed further on a one-to-one basis and the person directed to appropriate agencies. Any strategic working problems highlighted would be discussed with a senior member of staff and resolved via clinical governance pathways.

CONCLUSIONS

Little is currently known about the benefits of debriefing hospital staff after critical incidents such as failed resuscitation. Debriefing is, however, widely practised and the results of this study have been used to formulate some best practice guidelines while awaiting evidence from further studies.

Things that go beep: experience with an ED guideline for use of a handheld metal detector in the management of ingested non-hazardous metallic foreign bodies

OBJECTIVES

To review compliance with our emergency department (ED) guideline on the imaging of ingested non-hazardous metallic foreign bodies in children, investigate adverse outcomes, and make suggestions for improving the guideline.

METHODS

Retrospective analysis of patients presenting in a 3 year period to a paediatric ED with a history of possible metallic foreign body (MFB) ingestion, who were managed according to an ED guideline.

RESULTS

We identified 430 episodes of possible MFB ingestion, of which 422 were eligible for inclusion in the study. Compliance with the guideline was 77.8% with no significant adverse events. The exclusion of symptoms as a criterion for x ray results in a reduction in the x ray rate of 56% in the symptomatic group with no increase in adverse events.

CONCLUSION

A handheld metal detector (HMD) can be safely and reliably used in lieu of plain radiography to investigate children with a history of MFB ingestion, irrespective of symptoms and without incurring any significant adverse events.

Non-fatal horse related injuries treated in emergency departments in the United States, 2001-2003

OBJECTIVE

To characterise and provide nationally representative estimates of persons with non-fatal horse related injuries treated in American emergency departments.

METHODS

The National Electronic Injury Surveillance System All Injury Program (NEISS-AIP) is a stratified probability sample comprising 66 hospitals. Data on injuries treated in these emergency departments are collected and reported. NEISS-AIP data on all types (horseback riding and otherwise) of non-fatal horse related injuries from 2001 to 2003 were analysed.

RESULTS

An estimated 102,904 persons with non-fatal horse related injuries (35.7 per 100,000 population) were treated in American emergency departments each year from 2001 to 2003 inclusive. Non-fatal injury rates were higher for females (41.5 per 100,000) than for males (29.8 per 100,000). Most patients were injured while mounted on a horse (66.1%), commonly from falling or being thrown by the horse; while not mounted, injuries most often resulted from being kicked by the horse. The body parts most often injured were the head/neck region (23.2%), lower extremity (22.2%), and upper extremity (21.5%). The most common principal diagnoses were contusions/abrasions (31.4%) and fractures (25.2%). For each year that was studied, an estimated 11 502 people sustained traumatic brain injuries from horse related incidents. Overall, more than 11% of those injured were admitted to hospital.

CONCLUSIONS

Horse related injuries are a public health concern not just for riders but for anyone in close contact with horses. Prevention programmes should target horseback riders and horse caregivers to promote helmet use and educate participants about horse behaviour, proper handling of horses, and safe riding practices.

Roller coaster related fatalities, United States, 1994--2004

OBJECTIVE

To determine the number of fatalities related to roller coasters and examine factors common to multiple incidents.

METHODS

A case was defined as the death of a person, which was associated with a roller coaster in the United States between 15 May 1994 and 14 May 2004. Cases were identified from four

DATA SOURCES

(1) Consumer Product Safety Commission, (2) Lexis-Nexis, (3) Medline, and (4) Safer parks.

RESULTS

Forty people, ranging in age from 7 to 77 years, were killed in 39 separate incidents. Twenty nine (73%) deaths occurred among roller coaster patrons. Eleven fatalities resulted from external causes related to injuries from falls or collisions. Eighteen people died from medical conditions that might have been caused or exacerbated by riding a roller coaster; 15 were the result of intracranial hemorrhages or cardiac problems. Eleven (28%) deaths involved employees; all were caused by injuries.

CONCLUSIONS

Approximately four deaths annually in the United States are associated with roller coasters. Prevention of roller coaster fatalities is dependent on establishing an effective surveillance system for amusement ride injuries, engineering rides to better protect both patrons and employees, improving training and supervision of employees regarding safety precautions, and posting cautionary notices near roller coasters for people with specified medical conditions. Further research is needed on roller coaster related deaths resulting from intracranial hemorrhages and cardiac problems.

Injuries from paintball game related activities in the United States, 1997-2001

OBJECTIVE

To quantify and characterize injuries resulting from paintball game related activities among persons >/=7 years in the United States.

SETTING

Hospitals included in the National Electronic Injury Surveillance System (NEISS); these are composed of a stratified probability sample of all hospitals in the United States with emergency departments.

METHODS

Using NEISS, non-fatal injury data for paintball game related injury cases from 1997-2001 were obtained from emergency department records. Participation estimates used to calculate injury rates were obtained from a yearly survey funded by the National Sporting Goods Association.

RESULTS

An estimated 11 998 persons >/=7 years with paintball game related injuries were treated in emergency departments from 1997-2001, with an annual average rate of 4.5 per 10 000 participants (95% confidence interval 3.3 to 5.7). The paintball game related injury rate was highest for 18-24 year olds (4.9 per 10 000 participants) and most injuries (94.0%) occurred among males. Almost 60% of all injured persons >/=7 years were treated for paintball pellet wounds of which most were to the eye. While 76.9% of injured persons ages 7-17 years were treated for paintball pellet wounds, almost 40% of those >/=18 years were treated for injuries resulting from overexertion or a fall. Lower extremity injuries were also common (23.0%), mostly from overexertion. Most injured persons (95.5%) were treated and released.

CONCLUSIONS

As paintball games become more popular, efforts are needed to increase training, enforce rules, and educate participants about how to stay safe, such as wearing protective eye gear, when engaged in paintball games at home, in a public area, or in a sports field.

Localization of VGLUT3, the vesicular glutamate transporter type 3, in the rat brain

We have recently identified a third subtype of glutamate vesicular transporter (VGLUT) named VGLUT3. In the present study, we provide a detailed account of the regional and cellular distributions of VGLUT3 in the rat brain, using specific nucleotide probes and antisera. The distribution of VGLUT3 protein was compared with that of the other vesicular transporters (VGLUT1 and VGLUT2). All the areas expressing VGLUT3 also contain high levels of VGLUT1 and -2 proteins, but, at a finer level of analysis, the distribution of the three subtypes differs. Unlike VGLUT1 and -2, VGLUT3 expression is limited to discrete cell populations. Neurons containing VGLUT3 transcript are essentially observed in the caudate-putamen, the olfactory tubercle, the nucleus accumbens, the hippocampus, the interpeduncular nucleus and the dorsal and medial raphe nuclei. More scattered populations of VGLUT3 expressing neurons are found in the cerebral cortex. The distribution of the VGLUT3 protein, as determined with specific antisera, overlaps with that of the transcript in the caudate-putamen, olfactory tubercles, hippocampus, cortex, interpeduncular nucleus, and raphe nuclei, suggesting that VGLUT3 is essentially present in local projection neurons in these regions. Microscopic examination reveals staining of terminals and perikarya. Furthermore, co-localization studies indicate that VGLUT3 is present in GABAergic interneurons in the hippocampus, as well as in the interpeduncular nucleus. However, other regions, such as the substantia nigra (pars compacta), the ventral tegmental area, and the parabigeminal nucleus, receive a dense VGLUT3 terminal labeling although they do not contain VGLUT3 expressing neurons. In these regions, VGLUT3 immunoreactivity may be present in terminals of long projecting neurons. This subclass of glutamatergic afferents differs from other "classical" excitatory terminals that express VGLUT1 or VGLUT2. The distribution of VGLUT3 in the rat brain suggests an unsuspected function of vesicular glutamate transport in subsets of interneurons and in neuromodulatory neurons.

Impact of age and duration on sight–threatening retinopathy in South Asians and Caucasians attending a diabetic clinic

AIMS

To examine diabetic retinopathy in Asians and Caucasians attending a hospital diabetic clinic and to evaluate the impact of the significant risk factors on the probability of sight-threatening retinopathy.

METHODS

A total of 500 diabetic patients (268 Asians, 232 Caucasians) who attended a diabetic clinic within a defined time period were examined for severity of diabetic retinopathy. The existence of sight-threatening retinopathy (STR) was compared in the two groups. Significant risk factors such as age, duration and hypertension were analysed against the probability of STR in each of the two races.

RESULTS

Asians demonstrated significantly higher rates of STR. Univariate analysis showed age, duration, race, gender, and insulin-requiring status to be significantly associated with STR. Multivariate logistic regression showed a significant association of STR with race, age and duration of diabetes, with no significant interaction effects between variables. The logistic regression model predicted STR in Asians to be matched to that in Caucasians by a 12.5-year difference factor; that is, Caucasians were older by 12.5 years or had a 12.5-year longer duration than Asians for the same level of STR.

CONCLUSIONS

After adjusting for age and duration of diabetes, the probability of STR in Asian diabetic patients attending the diabetic clinics in Bradford is significantly higher than that in Caucasians (odds ratio=3.184, P<0.05). The impact of age and duration was significantly higher in patients of South Asian origin compared to Caucasians.

Differential ranking of causes of fatal versus non-fatal injuries among US children

OBJECTIVE

Leading causes of fatal and non-fatal injury among US children aged <15 years were compared.

METHOD

A descriptive study was conducted using nationally representative data on injury related deaths (National Vital Statistics System) and on non-fatal injury related emergency department visits (IEDV; National Electronic Injury Surveillance System-All Injury Program). Data were accessed using a publicly available web based system.

RESULTS

Annually, an estimated 7100000 pediatric IEDV and 7400 injury deaths occurred. The overall non-fatal to fatal ratio (NF:F) was 966 IEDV:1 death. Among deaths, the leading causes were motor vehicle traffic occupants (n = 1700; NF:F = 150:1), suffocations (n = 1037; NF:F = 14:1), and drownings (n = 971, NF:F = 6:1). Among non-fatal injuries, falls (estimated 2400000) and struck by/against (estimated 1800000) were the most common causes, but substantially less lethal (NF:F = 19000:1 and 15000:1, respectively).

CONCLUSIONS

The leading causes of pediatric fatal and non-fatal injuries differed substantially. This study indicates the need for consideration of common causes of non-fatal injury, especially falls.

Prevention of knee injuries in sports. A systematic review of the literature

AIM

We reviewed evidence regarding risk factors associated with incidence of knee injuries both to assess the effectiveness of prevention strategies, and to offer evidence-based recommendations to physicians, coaches, trainers, athletes, and researchers.

METHODS

We searched electronic data bases without language restriction for the years 1966 - September 1, 2001, identified citations from reference sections of research papers retrieved, contacted experts in the field, and searched the Cochrane Collaboration. Of the 328 citations identified, we emphasized the results from the 13 reports that compared alternative methods to prevent knee injury and assessed the methodologic quality of these reports using a standardized instrument.

RESULTS

Five studies addressed the effectiveness of bracing in football players; these studies showed no consistent evidence of benefit. Two studies comparing alternative cleat designs and a controlled study testing the effects of adjustments in the ski boot/binding system were difficult to interpret because of inadequate reporting of methodology. Six prospective studies that addressed the impact of conditioning and training showed promise of proprioception and neuromuscular training for protection against knee injury. We identified serious flaws in study design, control of bias, and statistical methods; the median quality scores ranged from 11 to 56 (out of 100).

CONCLUSION

Structured training programs that emphasize neuromuscular and proprioceptive training offer encouraging evidence for the prevention of knee injuries. However, flaws in study design and implementation have limited the effectiveness of work in this field. A rigorously implemented research program is needed to address this critically important sports medicine problem.

Sports and recreation related injury episodes in the US population, 1997-99

OBJECTIVE

To characterize sports and recreation related (SR) injury episodes in the US population. SR activities are growing in popularity suggesting the need for increased awareness of SR injuries as a public health concern for physically active persons of all ages in the US population.

SETTING

The National Health Interview Survey (NHIS) is a face-to-face household survey conducted yearly by the National Center for Health Statistics, part of the Centers for Disease Control and Prevention. Demographic and health data are collected from a nationally representative sample of the civilian, non-institutionalized population residing in the US.

METHODS

Medically attended injury events reported in the 1997-99 Injury Section of the NHIS were categorized according to the associated sport or recreational activity using a classification scheme based on the International Classification of External Causes of Injury system. Episodes where the injured person received any type of medical attention (that is, medical advice or treatment) from any health care provider were used to report the incidence, severity, and nature of SR injuries sustained by US citizens.

RESULTS

Annually, an estimated seven million Americans received medical attention for SR injuries (25.9 injury episodes per 1000 population). For 5-24 year olds, this national estimate was about 42% higher than estimates based on SR injuries seen only in emergency departments over a similar time frame. The highest average annual SR injury episode rates were for children ages 5-14 years (59.3 per 1000 persons) and persons aged 15-24 years (56.4 per 1000 persons). The SR injury episode rate for males was more than twice the rate for females. The age adjusted injury rate for whites was 1.5 times higher than for blacks (28.8 v 19.0 per 1000 population). Basketball was the most frequently mentioned SR activity when the injury episode occurred, with a rate of about four injury events per 1000 population. Strains and sprains accounted for 31% of injury episodes. An estimated 1.1 million SR episode related injuries involve the head or neck region, of which 17% were internal head injuries. The most common mechanisms of injury were struck by/against (34%), fall (28%), and overexertion (13%).

CONCLUSION

As physical activity continues to be promoted as part of a healthy lifestyle, SR injuries are becoming an important public health concern for both children and adults. Prevention efforts aimed at reducing SR injuries through targeting high risk activities, places of occurrence, activity, risk behaviors, and use of protective devices need to go beyond focusing on children and also consider physically active adults.

Optometric glaucoma referrals--measures of effectiveness and implications for screening strategy

The effectiveness of disease screening is conventionally evaluated using the epidemiological indices of sensitivity and specificity, which measure the association between screening test results and final diagnoses of all the patients screened. The effectiveness of optometric glaucoma referrals cannot be measured using such indices because diagnoses are obtained only on patients who are referred, while the true disease status of those not referred remains unknown. Instead, glaucoma referral effectiveness has been evaluated using measures of 'detection rate'--the proportion of those screened who are correctly referred, and 'referral accuracy'--the proportion of those referred who are correctly referred occurrence. Examination of these operational measures shows that their obtainable values and, hence, their interpretation are influenced by the total proportions of diseased and referred patients, one or both of which will generally be unavailable in evaluating samples of referrals. On the other hand, if valid estimates of these proportions can be obtained from other sources, it is possible to rescale detection rate and referral accuracy to take account of them. This rescaling produces a pair of weighted kappa coefficients, chance-corrected measures of association between referral and diagnosis, which provide a better indication of true referral effectiveness than other measures. An important consequence of this approach is that it provides a clear quantitative illustration of the need for a dual strategy to improve the overall quality of optometric glaucoma screening; widespread adoption of more comprehensive modes of screening to improve accuracy, together with a significant increase in the total numbers of patients screened to improve detection. In order for detection rates to reach desirable levels, the total number of referrals in any sub-population of patients must match or exceed the number of patients with disease. This analysis confirms quantitatively that which is intuitively obvious; not only that glaucoma awareness and uptake of screening opportunities must be encouraged in all patients over 40 years of age, but also that the older and/or more at risk patients are, the greater is their need to take advantage of glaucoma screening.

Merkel cell carcinoma of the skin

BACKGROUND

Neuroendocrine/Merkel cell carcinoma (MCC) of the skin is an uncommon tumour. Currently, there are only limited data available on the natural history, prognostic factors, and patient management of MCC.

OBJECTIVES

To review our experience and build the largest database from the literature.

METHODS

Twenty-eight cases from the London Regional Cancer Center were combined with 633 cases obtained from the literature searched in English, French, German, and Chinese for the years 1966 to 1998. The database included age, sex, initial disease status at presentation to the clinic, site of primary, any coexisting disease, any previous irradiation, sizes of primary/nodal/distant metastases, management details, and final disease status. A new modified staging system was used: stage Ia (primary disease only, size > 2 cm), stage Ib (primary disease only, size > 2 cm); stage II (regional nodal disease), and stage III (beyond regional nodes and/or distant disease).

RESULTS

Age > 65 years, male sex, size of primary > 2 cm, truncal site, nodal/distant disease at presentation, and duration of disease before presentation (< or =3 months) were poor prognostic factors. Surgery was the initial treatment of choice and it significantly improved overall survival (p =.004).

CONCLUSIONS

We identified poor prognostic factors that may necessitate more aggressive treatment. The suggested staging system, incorporating primary tumour size, accurately predicted outcomes.

Breeds of dogs involved in fatal human attacks in the United States between 1979 and 1998

OBJECTIVE

To summarize breeds of dogs involved in fatal human attacks during a 20-year period and to assess policy implications.

ANIMALS

Dogs for which breed was reported involved in attacks on humans between 1979 and 1998 that resulted in human dog bite-related fatalities (DBRF).

PROCEDURE

Data for human DBRF identified previously for the period of 1979 through 1996 were combined with human DBRF newly identified for 1997 and 1998. Human DBRF were identified by searching news accounts and by use of The Humane Society of the United States' registry databank.

RESULTS

During 1997 and 1998, at least 27 people died of dog bite attacks (18 in 1997 and 9 in 1998). At least 25 breeds of dogs have been involved in 238 human DBRF during the past 20 years. Pit bull-type dogs and Rottweilers were involved in more than half of these deaths. Of 227 reports with relevant data, 55 (24%) human deaths involved unrestrained dogs off their owners' property, 133 (58%) involved unrestrained dogs on their owners' property, 38 (17%) involved restrained dogs on their owners' property, and 1 (< 1%) involved a restrained dog off its owner's property.

CONCLUSIONS

Although fatal attacks on humans appear to be a breed-specific problem (pit bull-type dogs and Rottweilers), other breeds may bite and cause fatalities at higher rates. Because of difficulties inherent in determining a dog's breed with certainty, enforcement of breed-specific ordinances raises constitutional and practical issues. Fatal attacks represent a small proportion of dog bite injuries to humans and, therefore, should not be the primary factor driving public policy concerning dangerous dogs. Many practical alternatives to breed-specific ordinances exist and hold promise for prevention of dog bites.

Police enforcement as part of a comprehensive bicycle helmet program

BACKGROUND

Bicycle-related head injuries cause >150 deaths and 45 000 nonfatal injuries among children in the United States annually. Although bicycle helmets are highly effective against head injury, only 24% of US children regularly wear one. Georgia mandated bicycle helmet use for children, effective July 1993. During that summer, 1 rural Georgia community passed an ordinance instructing police officers to impound the bicycle of any unhelmeted child. We evaluated the effect of active police enforcement of this ordinance, combined with a helmet giveaway and education program.

METHODS

During April 1997, approximately 580 children in kindergarten through grade 7 received free helmets, fitting instructions, and safety education. Police then began impounding bicycles of unhelmeted children. We conducted an observational study, unobtrusively observing helmet use just before helmet distribution, several times during the next 5 months, and once 2 years later.

RESULTS

Before the program began, none of 97 observed riders wore a helmet. During the next 5 months, helmet use among 358 observed children averaged 45% (range: 30%-71%), a significant increase in all race and gender groups. In contrast, adult use did not change significantly. Police impounded 167 bicycles during the study, an average of 1 per day. Two years after program initiation, 21 of 39 child riders (54%) were observed wearing a helmet.

CONCLUSIONS

Without enforcement, the state and local laws did not prompt helmet use in this community, yet active police enforcement, coupled with helmet giveaways and education, was effective and lasting.

Chemotherapy in neuroendocrine/Merkel cell carcinoma of the skin: case series and review of 204 cases

PURPOSE

To study the use of chemotherapy for Merkel cell carcinoma (MCC) of the skin.

PATIENTS AND METHODS

Twenty-five cases of MCC were treated at the London Regional Cancer Center between 1987 and 1997. Thirteen cases treated with chemotherapy were reviewed with 191 cases from the literature.

RESULTS

At presentation, 24 patients had localized skin lesions (stage I) and one had locoregional involvement (stage II). Among the nine cases with recurrent nodal disease, six had chemotherapy as a component of salvage treatment. They were all free of disease at a median of 19 months (range, 12 to 37 months). In contrast, two patients who had salvage radiotherapy alone died of disease. Overall survival (OS) and disease-free survival (DFS) were 59% and 43%, respectively, at two years. Median OS and DFS were 29 months (range, 1 to 133 months) and 9 months (range, 1 to 133 months), respectively. Nodal disease developed in 12 (50%) of 24 patients with stage I disease, and distant metastases developed in six (25%) of 24. Including those from the literature, there were 204 cases treated with chemotherapy. Cyclophosphamide/doxorubicin (or epirubicin)/vincristine combination +/- prednisone was the most commonly used chemotherapy regimen (47 cases), with an overall response rate of 75.7% (35.1% complete, 35. 1% partial, and 5.4% minor responses). Etoposide/cisplatin (or carboplatin) was the next most commonly used regimen (27 cases), with an overall response rate of 60% (36% complete and 24% partial responses). The difference in response rate was not statistically significant (P =.19). Among the 204 cases, there were seven (3.4%) toxic deaths.

CONCLUSION

Chemoradiation for locally recurrent or advanced disease may be an option for patients with a good performance status.

Cognitive-behaviour therapy as a treatment for irritable bowel syndrome: a pilot study

OBJECTIVE

The irritable bowel syndrome (IBS) is a chronic and often disabling functional bowel disorder. Psychological treatments, in particular cognitive and behavioural interventions, have been shown to be effective for this disorder. The aim of this study was to test the efficacy of a cognitive-behaviour program.

METHOD

Eight participants (seven female, one male) aged between 24 and 71 years, with a diagnosis of IBS according to the Rome criteria, were recruited from among the gastroenterology outpatients at Nepean Hospital, in Sydney, Australia. Participants were administered pretreatment on measures of psychological function and bowel symptom severity. Following a 2-week baseline period, participants began a structured psychological treatment comprising eight sessions of cognitive-behaviour therapy. Throughout treatment, participants maintained daily records of symptom severity and completed homework assignments to ensure treatment compliance. The pretreatment assessment measures were repeated 1 week post-treatment.

RESULTS

After treatment, five of the eight patients no longer met the Rome diagnostic criteria for IBS. There was no significant reduction in bowel symptom frequency. There were, however, significant improvements in the distress and disability associated with bowel symptoms. Anxiety and depression were also significantly reduced.

CONCLUSIONS

Cognitive-behaviour therapy reduced the distress and disability associated with IBS, but not the frequency of bowel symptoms. This supports the proposed cognitive model for IBS, and cognitive-behaviour therapy appears to have its effect by altering the cognitive response to visceral hypersensitivity.