Costs of Physician Continuous Professional Development: A Systematic Review

PURPOSE

An essential yet oft-neglected step in cost evaluations is the selection of resources (ingredients) to include in cost estimates. The ingredients that most influence the cost of physician continuous professional development (CPD) are unknown, as are the relative costs of instructional modalities. This study's purpose was to estimate the costs of cost ingredients and instructional modalities in physician CPD.

METHOD

The authors conducted a systematic review in April 2020, searching MEDLINE, Embase, PsycInfo, and the Cochrane Library for comparative cost evaluations of CPD for practicing physicians. Two reviewers, working independently, screened articles for inclusion and extracted information on costs (converted to 2021 U.S. dollars) for each intervention overall, each ingredient, and each modality.

RESULTS

Of 3,338 eligible studies, 62 were included, enumerating costs for 86 discrete training interventions or instructional modalities. The most frequently reported ingredients were faculty time (25 of 86 interventions), materials (24), administrator/staff time (23), and travel (20). Ingredient costs varied widely, ranging from a per-physician median of $4 for postage (10 interventions) to $525 for learner time (13); equipment (9) and faculty time were also relatively expensive (median > $170). Among instructional modalities (≤ 11 interventions per modality), audit and feedback performed by physician learners, computer-based modules, computer-based virtual patients, in-person lectures, and experiences with real patients were relatively expensive (median > $1,000 per physician). Mailed paper materials, video clips, and audit and feedback performed by others were relatively inexpensive (median ≤ $62 per physician). Details regarding ingredient selection (10 of 62 studies), quantitation (10), and pricing (26) were reported infrequently.

CONCLUSIONS

Some ingredients, including time, are more important (i.e., contribute more to total costs) than others and should be prioritized in cost evaluations. Data on the relative costs of instructional modalities are insightful but limited. The methods and reporting of cost valuations merit improvement.

Temporal trends in comorbidity in adult elective hip and knee arthroplasty patients in England : a national population-based cohort study from the National Joint Registry

AIMS

Our main aim was to describe the trend in the comorbidities of patients undergoing elective total hip arthroplasties (THAs) and knee arthroplasties (KAs) between 1 January 2005 and 31 December 2018 in England.

METHODS

We combined data from the National Joint Registry (NJR) on primary elective hip and knee arthroplasties performed between 2005 and 2018 with pre-existing conditions recorded at the time of their primary operation from Hospital Episodes Statistics. We described the temporal trend in the number of comorbidities identified using the Charlson Comorbidity Index, and how this varied by age, sex, American Society of Anesthesiologists (ASA) grade, index of multiple deprivation, and type of KA.

RESULTS

We included 696,504 and 833,745 elective primary THAs and KAs respectively, performed for any indication. Between 2005 and 2018, the proportion of elective THA and KA patients with one or more comorbidity at the time of their operation increased substantially (THA: 20% to 38%, KA: 22% to 41%). This was driven by increases in four conditions: chronic obstructive pulmonary disease (COPD) (2018: ~17%), diabetes without complications (2018: THA 10%, KA 14%), myocardial infarction (2018: 4%), and renal disease (2018: ~8%). Notably, renal disease prevalence increased from < 1% in 2005 to ~8% in 2018.

CONCLUSION

Between 2005 and 2018 there were significant changes in the number of comorbidities recorded in patients having elective primary THAs and KAs. Renal disease is now one of the most prevalent comorbidities in this patient population. Future research should explore whether this comorbidity trend has increased the burden on other medical specialities to optimize these patients before surgery and to provide additional postoperative care.Cite this article: Bone Joint J 2022;104-B(9):1052-1059.

Entanglement between Muon and I>1/2 Nuclear Spins as a Probe of Charge Environment

We report on the first example of quantum coherence between the spins of muons and quadrupolar nuclei. We reveal that these entangled states are highly sensitive to a local charge environment and thus, can be deployed as a functional quantum sensor of that environment. The quantum coherence effect was observed in vanadium intermetallic compounds which adopt the A15 crystal structure, and whose members include all technologically pertinent superconductors. Furthermore, the extreme sensitivity of the entangled states to the local structural and electronic environments emerges through the quadrupolar interaction with the electric field gradient due to the charge distribution at the nuclear (I>1/2) sites. This case study demonstrates that positive muons can be used as a quantum sensing tool to also probe structural and charge-related phenomena in materials, even in the absence of magnetic degrees of freedom.

Quality of cost evaluations of physician continuous professional development: Systematic review of reporting and methods

INTRODUCTION

We sought to evaluate the reporting and methodological quality of cost evaluations of physician continuing professional development (CPD).

METHODS

We conducted a systematic review, searching MEDLINE, Embase, PsycInfo, and the Cochrane Database for studies comparing the cost of physician CPD (last update 23 April 2020). Two reviewers, working independently, screened all articles for inclusion. Two reviewers extracted information on reporting quality using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS), and on methodological quality using the Medical Education Research Study Quality Instrument (MERSQI) and a published reference case.

RESULTS

Of 3338 potentially eligible studies, 62 were included. Operational definitions of methodological and reporting quality elements were iteratively revised. Articles reported mean (SD) 43% (20%) of CHEERS elements for the Title/Abstract, 56% (34%) for Introduction, 66% (19%) for Methods, 61% (17%) for Results, and 66% (30%) for Discussion, with overall reporting index 292 (83) (maximum 500). Valuation methods were reported infrequently (resource selection 10 of 62 [16%], resource quantitation 10 [16%], pricing 26 [42%]), as were descriptions/discussion of the physicians trained (42 [68%]), training setting (42 [68%]), training intervention (40 [65%]), sensitivity analyses of uncertainty (9 [15%]), and generalizability (30 [48%]). MERSQI scores ranged from 6.0 to 16.0 (mean 11.2 [2.4]). Changes over time in reporting index (initial 241 [105], final 321 [52]) and MERSQI scores (initial 9.8 [2.7], final 11.9 [1.9]) were not statistically significant (p ≥ 0.08).

DISCUSSION

Methods and reporting of HPE cost evaluations fall short of current standards. Gaps exist in the valuation, analysis, and contextualization of cost outcomes.

Associations Between Physician Continuous Professional Development and Referral Patterns: A Systematic Review and Meta-Analysis

PURPOSE

Both overuse and underuse of clinician referrals can compromise high-value health care. The authors sought to systematically identify and synthesize published research examining associations between physician continuous professional development (CPD) and referral patterns.

METHOD

The authors searched MEDLINE, Embase, PsycInfo, and the Cochrane Database on April 23, 2020, for comparative studies evaluating CPD for practicing physicians and reporting physician referral outcomes. Two reviewers, working independently, screened all articles for inclusion. Two reviewers reviewed all included articles to extract information, including data on participants, educational interventions, study design, and outcomes (referral rate, intended direction of change, appropriateness of referral). Quantitative results were pooled using meta-analysis.

RESULTS

Of 3,338 articles screened, 31 were included. These studies enrolled at least 14,458 physicians and reported 381,165 referral events. Among studies comparing CPD with no intervention, 17 studies with intent to increase referrals had a pooled risk ratio of 1.91 (95% confidence interval: 1.50, 2.44; P < .001), and 7 studies with intent to decrease referrals had a pooled risk ratio of 0.68 (95% confidence interval: 0.55, 0.83; P < .001). Five studies did not indicate the intended direction of change. Subgroup analyses revealed similarly favorable effects for specific instructional approaches (including lectures, small groups, Internet-based instruction, and audit/feedback) and for activities of varying duration. Four studies reported head-to-head comparisons of alternate CPD approaches, revealing no clear superiority for any approach. Seven studies adjudicated the appropriateness of referral, and 9 studies counted referrals that were actually completed (versus merely requested).

CONCLUSIONS

Although between-study differences are large, CPD is associated with statistically significant changes in patient referral rates in the intended direction of impact. There are few head-to-head comparisons of alternate CPD interventions using referrals as outcomes.

Cost-effectiveness and Economic Benefit of Continuous Professional Development for Drug Prescribing: A Systematic Review

Importance

The economic impact of continuous professional development (CPD) education is incompletely understood.

Objective

To systematically identify and synthesize published research examining the costs associated with physician CPD for drug prescribing.

Evidence Review

MEDLINE, Embase, PsycInfo, and the Cochrane Database were searched from inception to April 23, 2020, for comparative studies that evaluated the cost of CPD focused on drug prescribing. Two reviewers independently screened all articles for inclusion and reviewed all included articles to extract data on participants, educational interventions, study designs, and outcomes (costs and effectiveness). Results were synthesized for educational costs, health care costs, and cost-effectiveness.

Findings

Of 3338 articles screened, 38 were included in this analysis. These studies included at least 15 659 health care professionals and 1 963 197 patients. Twelve studies reported on educational costs, ranging from $281 to $183 554 (median, $15 664). When economic outcomes were evaluated, 31 of 33 studies (94%) comparing CPD with no intervention found that CPD was associated with reduced health care costs (drug costs), ranging from $4731 to $6 912 000 (median, $79 373). Four studies found reduced drug costs for 1-on-1 outreach compared with other CPD approaches. Regarding cost-effectiveness, among 5 studies that compared CPD with no intervention, the incremental cost-effectiveness ratio for a 10% improvement in prescribing ranged from $15 390 to $437 027 to train all program participants. Four comparisons of alternative CPD approaches found that 1-on-1 educational outreach was more effective but more expensive than group education or mailed materials (incremental cost-effectiveness ratio, $18-$4105 per physician trained).

Conclusions and Relevance

In this systematic review, CPD for drug prescribing was associated with reduced health care (drug) costs. The educational costs and cost-effectiveness of CPD varied widely. Several CPD instructional approaches (including educational outreach) were more effective but more costly than comparators.

Costs and Economic Impacts of Physician Continuous Professional Development: A Systematic Scoping Review

PURPOSE

Nearly all health care professionals engage in continuous professional development (CPD), yet little is known about the cost and cost-effectiveness of physician CPD. Clarification of key concepts, comprehensive identification of published work, and determination of research gaps would facilitate application of existing evidence and planning for future investigations. The authors sought to systematically map study themes, methods, and outcomes in peer-reviewed literature on the cost and value of physician CPD.

METHOD

The authors conducted a scoping review, systematically searching MEDLINE, Embase, PsycInfo, and Cochrane Library databases for comparative economic evaluations of CPD for practicing physicians through April 2020. Two reviewers, working independently, screened all articles for inclusion. Three reviewers iteratively reviewed all included articles to inductively identify key features including participants, educational interventions, study designs, cost ingredients, and cost analyses. Two reviewers then independently reexamined all included articles to code these features.

RESULTS

Of 3,338 potentially eligible studies, 111 were included. Physician specialties included internal, family, or general medicine (80 studies [72%]), surgery (14 studies [13%]), and medicine subspecialties (7 studies [6%]). Topics most often addressed general medicine (45 studies [41%]) or appropriate drug use (37 studies [33%]). Eighty-seven studies (78%) compared CPD with no intervention. Sixty-three studies (57%) reported the cost of training, and 79 (71%) evaluated the economic impact (money saved/lost following CPD). Training cost ingredients (median 3 itemized per study) and economic impact ingredients (median 1 per study) were infrequently and incompletely identified, quantified, or priced. Twenty-seven studies (24%) reported cost-impact expressions such as cost-effectiveness ratio or net value. Nineteen studies (17%) reported sensitivity analyses.

CONCLUSIONS

Studies evaluating the costs and economic impact of physician CPD are few. Gaps exist in identification, quantification, pricing, and analysis of cost outcomes. The authors propose a comprehensive framework for appraising ingredients and a preliminary reference case for economic evaluations.

Review: More effective linkages between science and policy are needed to minimize the negative environmental impacts of livestock production

Animals form an integral part of our planetary ecosystem but balance is critical to effective ecosystem functioning as demand for livestock products has increased, greater numbers of domesticated livestock have created an imbalance and hence had a negative impact on a number of ecosystem services which means that life as we know it will become unsustainable. Policies and technology advances have helped to manage the impact but more needs to be done. The aim of this paper is to highlight ways in which better knowledge of animal science, and other disciplines, can both harness technology and inform policy to work towards a sustainable balance between livestock and the environment. Effective policies require simple, quantifiable indicators against which to set targets and monitor progress. Indicators are clear for water pollution, but more complex for biodiversity. Hence, more progress has been made with the former. It is not yet possible to measure the impacts of changes in livestock management on greenhouse gas emissions per se at a farm level and progress has been slower, although new technologies are emerging. With respect to land use, the simple indicator of area has been used, but total area is oversimplistic. Our analysis of land suitability and use highlights a relatively overlooked role of livestock in acting as a 'buffer' to use by-products and grains which do not meet the standards for processing by industry during years of inclement weather, which in the past has provided an 'insurance policy' for farmers. Since extreme weather events are increasing in frequency with climate change, this role for livestock may be more important in future. The conclusions of the review with respect to strengthening the links between research and policy are i) to encourage animal scientists to identify the relevant environmental indicators, work with the cutting edge experts developing technologies to measure these cost-effectively and across a range of relevant livestock systems and ii) to work with the feed industry to optimize diets not just in terms of least cost financially but also least 'cost' in terms of global carbon flux and engage in dialogue with the food industry and policy makers on regulations for grain quality.

Childhood Obesity: An Evidence-Based Approach to Family-Centered Advice and Support

The prevalence of childhood obesity continues to rise despite decades of clinical and public health efforts. Early identification of children at risk of developing obesity is essential using newer electronic health systems, which move beyond traditional growth charts to provide a wealth of information about body mass index and other relevant parameters such as social determinants of health and comorbid conditions. For children who already have obesity, there are several evidence-based strategies health care providers can use as they work with patients and families to mitigate the effects. First and foremost, providers should address the issue; unfortunately, weight is often not discussed in clinical practice. In addressing the issue, providers should support families through effective, positive relationships. Providers must be aware of their biases; their language should be appropriate and nonstigmatizing. Helpful interventions should focus on behavior, not weight, health, or appearance. Motivational interviewing may be used to promote healthful behaviors: supportive parenting, regular exercise, healthful food choices, minimal screen time, and optimal sleep. There is limited evidence for the efficacy of specific weight loss diets. Both medication and bariatric surgery are indicated for select adolescents who have severe disease unresponsive to behavioral management.

Irritable Bowel Syndrome: Questions and Answers for Effective Care

Irritable bowel syndrome (IBS) is a heterogeneous group of conditions related to specific biologic and cellular abnormalities that are not fully understood. Psychological factors do not cause IBS, but many people with IBS also have anxiety or depressed mood, a history of adverse life events, or psychosocial stressors. Physicians must understand the fears and expectations of patients and how they think about their symptoms and should also respond empathetically to psychosocial cues. Anxiety related to the unpredictability of symptoms may have a greater effect on quality of life than the symptoms themselves. Patients in generally good health who have ongoing or recurrent gastrointestinal symptoms and abnormal stool patterns most likely have IBS or another functional gastrointestinal disorder. Patients who meet symptom-based criteria and have no alarm features may be confidently diagnosed with few, if any, additional tests. Patients may not completely understand the diagnostic process; asking about expectations and carefully explaining the goals and limitations of testing leads to more effective care. There is no definitive treatment for IBS, and recommended treatments focus on symptom relief and improved quality of life. Trusting patient-physician interactions are essential to help patients understand and accept an IBS diagnosis and to actively engage in effective self-management.

Dysphagia: Evaluation and Collaborative Management

Dysphagia is common but may be underreported. Specific symptoms, rather than their perceived location, should guide the initial evaluation and imaging. Obstructive symptoms that seem to originate in the throat or neck may actually be caused by distal esophageal lesions. Oropharyngeal dysphagia manifests as difficulty initiating swallowing, coughing, choking, or aspiration, and it is most commonly caused by chronic neurologic conditions such as stroke, Parkinson disease, or dementia. Symptoms should be thoroughly evaluated because of the risk of aspiration. Patients with esophageal dysphagia may report a sensation of food getting stuck after swallowing. This condition is most commonly caused by gastroesophageal reflux disease and functional esophageal disorders. Eosinophilic esophagitis is triggered by food allergens and is increasingly prevalent; esophageal biopsies should be performed to make the diagnosis. Esophageal motility disorders such as achalasia are relatively rare and may be overdiagnosed. Opioid-induced esophageal dysfunction is becoming more common. Esophagogastroduodenoscopy is recommended for the initial evaluation of esophageal dysphagia, with barium esophagography as an adjunct. Esophageal cancer and other serious conditions have a low prevalence, and testing in low-risk patients may be deferred while a four-week trial of acid-suppressing therapy is undertaken. Many frail older adults with progressive neurologic disease have significant but unrecognized dysphagia, which significantly increases their risk of aspiration pneumonia and malnourishment. In these patients, the diagnosis of dysphagia should prompt a discussion about goals of care before potentially harmful interventions are considered. Speech-language pathologists and other specialists, in collaboration with family physicians, can provide structured assessments and make appropriate recommendations for safe swallowing, palliative care, or rehabilitation.

Radiographer role extension in Oman - Current practice and future opportunities

INTRODUCTION

Radiographers in Oman are believed to be engaged with varying levels of role extension however the nature and extent of this currently unknown. The aim of this study was to investigate role extension for radiographers in Oman, and to evaluate radiographers and the radiologists' opinions and attitudes toward role extension.

METHODS

A cross sectional study of radiographers and radiologists at 13 major hospitals in Oman was used. A total of 189 radiographers and 77 radiologists were invited to complete a questionnaire seeking information on current and possible future role extension activities.

RESULTS

The overall response rate was 80.4% for radiographers and 63.6% for radiologists. Approximately half (53.3%) of the radiographer respondents reported they carry out examinations traditionally performed by radiologists (i.e. role extension); this was primarily in gastrointestinal and barium enema studies. Fewer (21%) reported being involved in image interpretation, most commonly in accident and emergency examinations. Forty percent of radiographers reported involvement in intravenous injections, most commonly for CT and intravenous urography procedures. Both radiographers and radiologists supported the involvement of radiographers in a range of examination types however responses vary within and between hospitals.

CONCLUSION

This study concluded that radiography role extension activities are widely implemented at hospitals in Oman and that radiographers have sufficient skills and education for participating in these activities.

IMPLICATIONS FOR PRACTICE

The involvement of radiographers in role extension activities is believed to be cost and time effective, improve teamwork and has potential for significant service delivery benefits.

Esophageal Motility Disorders

Esophageal motility disorders can cause chest pain, heartburn, or dysphagia. They are diagnosed based on specific patterns seen on esophageal manometry, ranging from the complete absence of contractility in patients with achalasia to unusually forceful or disordered contractions in those with hypercontractile motility disorders. Achalasia has objective diagnostic criteria, and effective treatments are available. Timely diagnosis results in better outcomes. Recent research suggests that hypercontractile motility disorders may be overdiagnosed, leading to unnecessary and irreversible interventions. Many symptoms ascribed to these disorders are actually due to unrecognized functional esophageal disorders. Hypercontractile motility disorders and functional esophageal disorders are generally self-limited, and there is considerable overlap among their clinical features. Endoscopy is warranted in all patients with dysphagia, but testing to evaluate for less common conditions should be deferred until common conditions have been optimally managed. Opioid-induced esophageal dysmotility is increasingly prevalent and can mimic symptoms of other motility disorders or even early achalasia. Dysphagia of liquids in a patient with normal esophagogastroduodenoscopy findings may suggest achalasia, but high-resolution esophageal manometry is required to confirm the diagnosis. Surgery and advanced endoscopic therapies have proven benefit in achalasia. However, invasive interventions are rarely indicated for hypercontractile motility disorders, which are typically benign and usually respond to lifestyle modifications, although pharmacotherapy may occasionally be needed.

Information and Decoherence in a Muon-Fluorine Coupled System

The unitary evolution of a quantum system preserves its coherence, but interactions between the system and its environment result in decoherence, a process in which the quantum information stored in the system becomes degraded. A spin-polarized positively charged muon implanted in a fluoride crystal realizes such a coherent quantum system, and the entanglement of muon and nearest-neighbor fluorine nuclear spins gives rise to an oscillatory time dependence of the muon polarization that can be detected and measured. Here we show that the decohering effect of more distant nuclear spins can be modelled quantitatively, allowing a very detailed description of the decoherence processes coupling the muon-fluorine "system" with its "environment," and allowing us to track the system entropy as the quantum information degrades. These results show how to precisely quantify the spin relaxation of muons implanted into quantum entangled states in fluoride crystals.

A new approach to comprehensively evaluate the morphological properties of the human femoral head: example of application to osteoarthritic joint

Osteoarthritis affects the morphological properties of the femoral head. The goal of this study was to develop a method to elucidate whether these changes are localised to discrete regions, or if the reported trends in microstructural changes may be identified throughout the subchondral bone of the human femoral head. Whole femoral heads extracted from osteoarthritic (n = 5) and healthy controls (n = 5) underwent microCT imaging 39 μm voxel size. The subchondral bone plate was virtually isolated to evaluate the plate thickness and plate porosity. The trabecular bone region was divided into 37 volumes of interest spatially distributed in the femoral head, and bone morphometric properties were determined in each region. The study showed how the developed approach can be used to study the heterogeneous properties of the human femoral head affected by a disease such as osteoarthritis. As example, in the superior femoral head osteoarthritic specimens exhibited a more heterogeneous micro-architecture, with trends towards thicker cortical bone plate, higher trabecular connectivity density, higher trabecular bone density and thicker structures, something that could only be observed with the newly developed approach. Bone cysts were mostly confined to the postero-lateral quadrants extending from the subchondral region into the mid trabecular region. Nevertheless, in order to generalise these findings, a larger sample size should be analysed in the future. This novel method allowed a comprehensive evaluation of the heterogeneous micro-architectural properties of the human femoral head, highlighting effects of OA in the superior subchondral cortical and trabecular bone. Further investigations on different stages of OA would be needed to identify early changes in the bone.

Gas, Bloating, and Belching: Approach to Evaluation and Management

Gas, bloating, and belching are associated with a variety of conditions but are most commonly caused by functional gastrointestinal disorders. These disorders are characterized by disordered motility and visceral hypersensitivity that are often worsened by psychological distress. An organized approach to the evaluation of symptoms fosters trusting therapeutic relationships. Patients can be reliably diagnosed without exhaustive testing and can be classified as having gastric bloating, small bowel bloating, bloating with constipation, or belching disorders. Functional dyspepsia, irritable bowel syndrome, and chronic idiopathic constipation are the most common causes of these disorders. For presumed functional dyspepsia, noninvasive testing for Helicobacter pylori and eradication of confirmed infection (i.e., test and treat) are more cost-effective than endoscopy. Patients with symptoms of irritable bowel syndrome should be tested for celiac disease. Patients with chronic constipation should have a rectal examination to evaluate for dyssynergic defecation. Empiric therapy is a reasonable initial approach to functional gastrointestinal disorders, including acid suppression with proton pump inhibitors for functional dyspepsia, antispasmodics for irritable bowel syndrome, and osmotic laxatives and increased fiber for chronic idiopathic constipation. Nonceliac sensitivities to gluten and other food components are increasingly recognized, but highly restrictive exclusion diets have insufficient evidence to support their routine use except in confirmed celiac disease.

Associations Among Practice Variation, Clinician Characteristics, and Care Algorithm Usage: A Multispecialty Vignette Study

The objective was to quantitatively evaluate clinician characteristics associated with unwarranted practice variation, and how clinical care algorithms influence this variation. Participants (142 physicians, 53 nurse practitioners, and 9 physician assistants in family medicine, internal medicine, and cardiology) described their management of 4 clinical vignettes, first based on their own practice (unguided), then using care algorithms (guided). The authors quantitatively estimated variation in management. Cardiologists demonstrated 17% lower variation in unguided responses than generalists (fold-change 0.83 [95% confidence interval (CI) 0.68, 0.97]), and those who agreed that practice variation can realistically be reduced had 16% lower variation than those who did not (fold-change 0.84 [CI, 0.71, 0.99]). A 17% reduction in variation was observed for guided responses compared with baseline (unguided) responses (fold-change 0.83 [CI, 0.76, 0.90]). Differences were otherwise similar across clinician subgroups and attitudes. Unwarranted practice variation was similar across most clinician subgroups. The authors conclude that care algorithms can reduce variation in management.

Silage review: Animal and human health risks from silage

Silage may contain several agents that are potentially hazardous to animal health, the safety of milk or other animal food products, or both. This paper reviews published literature about microbial hazards, plant toxins, and chemical hazards. Microbial hazards include Clostridium botulinum, Bacillus cereus, Listeria monocytogenes, Shiga toxin-producing Escherichia coli, Mycobacterium bovis, and various mold species. High concentrations of C. botulinum in silage have been associated with cattle botulism. A high initial concentration of C. botulinum spores in forage in combination with poor silage fermentation conditions can promote the growth of C. botulinum in silage. The elevated pH level that is generally associated with aerobic deterioration of silage is a major factor influencing concentrations of L. monocytogenes, Shiga toxin-producing E. coli, and molds in silage and may also encourage survival and growth of M. bovis, the bacterium that causes bovine tuberculosis. Soil is a major source of B. cereus spores in silage; growth of this bacterium in silage appears to be limited. Hazards from plant toxins include pyrrolizidine, tropane and tropolone alkaloids, phytoestrogens, prussic acid, and mimosine, compounds that exist naturally in certain plant species that may contaminate forages at harvesting. Another group of toxins belonging to this category are ergot alkaloids, which are produced by endophytic fungal species in forages such as tall fescue grass, sorghum, and ryegrass. Varying effects of ensiling on the degradation of these plant toxins have been reported. Chemical hazards include nitrate, nitrite, and toxic oxide gases of nitrogen produced from nitrate and high levels of butyric acid, biogenic amines, and ammonia. Chemical and microbiological hazards are associated with poorly fermented silages, which can be avoided by using proper silage-making practices and creating conditions that promote a rapid and sufficient reduction of the silage pH and prevent aerobic deterioration.

The risk of cardiac failure following metal-on-metal hip arthroplasty

AIMS

The aim of this study was to determine whether patients with metal-on-metal (MoM) arthroplasties of the hip have an increased risk of cardiac failure compared with those with alternative types of arthroplasties (non-MoM).

PATIENTS AND METHODS

A linkage study between the National Joint Registry, Hospital Episodes Statistics and records of the Office for National Statistics on deaths was undertaken. Patients who underwent elective total hip arthroplasty between January 2003 and December 2014 with no past history of cardiac failure were included and stratified as having either a MoM (n = 53 529) or a non-MoM (n = 482 247) arthroplasty. The primary outcome measure was the time to an admission to hospital for cardiac failure or death. Analysis was carried out using data from all patients and from those matched by propensity score.

RESULTS

The risk of cardiac failure was lower in the MoM cohort compared with the non-MoM cohort (adjusted hazard ratio (aHR) 0.901; 95% confidence interval (CI) 0.853 to 0.953). The risk of cardiac failure was similar following matching (aHR 0.909; 95% CI 0.838 to 0.987) and the findings were consistent in subgroup analysis.

CONCLUSION

The risk of cardiac failure following total hip arthroplasty was not increased in those in whom MoM implants were used, compared with those in whom other types of prostheses were used, in the first seven years after surgery. Cite this article: Bone Joint J 2018;100-B:20-7.

Refractive Eye Surgery: Helping Patients Make Informed Decisions About LASIK

A variety of refractive surgery techniques, which reshape the corneal stroma using laser energy, have been marketed as simple and safe alternatives to glasses or contact lenses. Laser-assisted in-situ keratomileusis (LASIK) is the most common of these procedures. Although there are few high-quality prospective studies of long-term outcomes, complications, or stability for refractive surgery procedures, there is at least general agreement that more than 90% of appropriately selected patients achieve excellent uncorrected distance vision. In addition to well-recognized contraindications (e.g., unstable refraction, pregnancy and lactation, chronic eye disease, systemic illness, corneal abnormalities), there are other conditions that warrant caution (e.g., excessively dry eyes, contact lens intolerance, chronic pain syndromes). Postoperative dry eye, which may in part represent a corneal neuropathy, usually resolves after six to 12 months but persists in up to 20% of patients. Up to 20% of patients may have new visual disturbances, particularly with night driving. Vision-threatening complications are rare. Intraocular lenses, implanted following cataract extraction, may be an alternative to LASIK in older patients. Although the overall dependence on corrective lenses is markedly reduced, many patients still require glasses or contact lenses after LASIK, particularly in low-light conditions and as they age. Most patients report satisfaction with the results. Family physicians can help patients make informed decisions by exploring their values, preferences, expectations, and tolerance of uncertainty and risk.

Rates of hip and knee joint replacement amongst different ethnic groups in England: an analysis of National Joint Registry data

OBJECTIVE

Despite a health care system that is free at the point of delivery, ethnic minorities may not always get care equitable to that of White patients in England. We examined whether ethnic differences exist in joint replacement rates and surgical practice in England.

DESIGN

373,613 hip and 428,936 knee National Joint Registry (NJR) primary replacement patients had coded ethnicity in Hospital Episode Statistics (HES). Age and gender adjusted observed/expected ratios of hip and knee replacements amongst ethnic groups were compared using indirect standardisation. Associations between ethnic group and type of procedure were explored and effects of demographic, clinical and hospital-related factors examined using multivariable logistic regression.

RESULTS

Adjusted standardised observed/expected ratios were substantially lower in Blacks and Asians than Whites for hip replacement (Blacks 0.33 [95% CI, 0.31-0.35], Asians 0.20 [CI, 0.19-0.21]) and knee replacement (Blacks 0.64 [CI, 0.61-0.67], Asians 0.86 % [CI, 0.84-0.88]). Blacks were more likely to receive uncemented hip replacements (Blacks 52%, Whites 37%, Asians 44%; P < 0.001). Black men and women aged <70 years were less likely to receive unicondylar or patellofemoral knee replacements than Whites (men 10% vs 15%, P = 0.001; women 6% vs 14%, P < 0.001). After adjustment for demographic, clinical and hospital-related factors, Blacks were more likely to receive uncemented hip replacement (OR 1.43 [CI, 1.11-1.84]).

CONCLUSIONS

In England, hip and knee replacement rates and prosthesis type given differ amongst ethnic groups. Whether these reflect differences in clinical need or differential access to treatment requires urgent investigation.

Depression Screening, Diagnosis, and Treatment Across the Lifespan

This article focuses on six basic components of more effective depression care, emphasizing systems of team-based and collaborative care for diagnosis, monitoring, and follow-up. It also emphasizes the principles of stepped care and proactive and timely intensification of treatment, and discusses various augmentation strategies that all primary care providers could more readily employ.

Health Promotion in a Changing World: Preparing for the Genomics Revolution

All health professionals must become actively engaged in preparing for the genomics revolution. Healthy lifestyles will continue to be of utmost importance, and we must maintain a balance between health promotion activities and genomic-based tests and therapies. We must understand the specific changes likely to occur as advances in genomics are developed and applied to medicine, as well as their ethical, social, and legal implications. We must develop new, Web-based systems and new educational models to most appropriately incorporate these changes into routine practice. Finally, we must offer timely, useful advice and guidance to the public as well as to policymakers in order to maintain realistic expectations and to ensure adequate and balanced funding for health promotion initiatives and research.

Human breast cancer bone metastasis in vitro and in vivo: a novel 3D model system for studies of tumour cell-bone cell interactions

Bone is established as the preferred site of breast cancer metastasis. However, the precise mechanisms responsible for this preference remain unidentified. In order to improve outcome for patients with advanced breast cancer and skeletal involvement, we need to better understand how this process is initiated and regulated. As bone metastasis cannot be easily studied in patients, researchers have to date mainly relied on in vivo xenograft models. A major limitation of these is that they do not contain a human bone microenvironment, increasingly considered to be an important component of metastases. In order to address this shortcoming, we have developed a novel humanised bone model, where 1 × 10(5) luciferase-expressing MDA-MB-231 or T47D human breast tumour cells are seeded on viable human subchaodral bone discs in vitro. These discs contain functional osteoclasts 2-weeks after in vitro culture and positive staining for calcine 1-week after culture demonstrating active bone resorption/formation. In vitro inoculation of MDA-MB-231 or T47D cells colonised human bone cores and remained viable for <4 weeks, however, use of matrigel to enhance adhesion or a moving platform to increase diffusion of nutrients provided no additional advantage. Following colonisation by the tumour cells, bone discs pre-seeded with MDA-MB-231 cells were implanted subcutaneously into NOD SCID mice, and tumour growth monitored using in vivo imaging for up to 6 weeks. Tumour growth progressed in human bone discs in 80 % of the animals mimicking the later stages of human bone metastasis. Immunohistochemical and PCR analysis revealed that growing MDA-MB-231 cells in human bone resulted in these cells acquiring a molecular phenotype previously associated with breast cancer bone metastases. MDA-MB-231 cells grown in human bone discs showed increased expression of IL-1B, HRAS and MMP9 and decreased expression of S100A4, whereas, DKK2 and FN1 were unaltered compared with the same cells grown in mammary fat pads of mice not implanted with human bone discs.

Getting maintenance of certification to work: a grounded theory study of physicians' perceptions

IMPORTANCE

Despite general support for the goals of maintenance of certification (MOC), concerns have been raised about its effectiveness, relevance, and value.

OBJECTIVE

To identify barriers and enabling features associated with MOC and how MOC can be changed to better accomplish its intended purposes.

DESIGN, SETTING, AND PARTICIPANTS

Grounded theory focus group study of 50 board-certified primary care and subspecialist internal medicine and family medicine physicians in an academic medical center and outlying community sites.

EXPOSURES

Eleven focus groups.

MAIN OUTCOMES AND MEASURES

Constant comparative method to analyze transcripts and identify themes related to MOC perceptions and purposes and to construct a model to guide improvement.

RESULTS

Participants identified misalignments between the espoused purposes of MOC (eg, to promote high-quality care, commitment to the profession, lifelong learning, and the science of quality improvement) and MOC as currently implemented. At present, MOC is perceived by physicians as an inefficient and logistically difficult activity for learning or assessment, often irrelevant to practice, and of little benefit to physicians, patients, or society. To resolve these misalignments, we propose a model that invites increased support from organizations, effectiveness and relevance of learning activities, value to physicians, integration with clinical practice, and coherence across MOC tasks.

CONCLUSIONS AND RELEVANCE

Physicians view MOC as an unnecessarily complex process that is misaligned with its purposes. Acknowledging and correcting these misalignments will help MOC meet physicians' needs and improve patient care.

Systemic toxicity related to metal hip prostheses

INTRODUCTION

One in eight of all total hip replacements requires revision within 10 years, 60% because of wear-related complications. The bearing surfaces may be made of cobalt/chromium, stainless steel, ceramic, or polyethylene. Friction between bearing surfaces and corrosion of non-moving parts can result in increased local and systemic metal concentrations.

OBJECTIVES

To identify and systematically review published reports of systemic toxicity attributed to metal released from hip implants and to propose criteria for the assessment of these patients.

METHODS

Medline (from 1950) and Embase (from 1980) were searched to 28 February 2014 using the search terms (text/abstract) chrom* or cobalt* and [toxic* or intox* or poison* or adverse effect or complication] and [prosthes* or 'joint replacement' or hip or arthroplast*] and PubMed (all available years) was searched using the search term (("Chromium/adverse effects"[Mesh] OR "Chromium/poisoning"[Mesh] OR "Chromium/toxicity"[Mesh]) OR ("Cobalt/adverse effects"[Mesh] OR "Cobalt/poisoning"[Mesh] OR "Cobalt/toxicity"[Mesh])) AND ("Arthroplasty, Replacement, Hip"[Mesh] OR "Hip Prosthesis"[Mesh]). These searches identified 281 unique references, of which 23 contained original case data. Three further reports were identified from the bibliographies of these papers. As some cases were reported repeatedly the 26 papers described only 18 individual cases. Systemic toxicity. Ten of these eighteen patients had undergone revision from a ceramic-containing bearing to one containing a metal component. The other eight had metal-on-metal prostheses. Systemic toxicity was first manifest months and often several years after placement of the metal-containing joint. The reported systemic features fell into three main categories: neuro-ocular toxicity (14 patients), cardiotoxicity (11 patients) and thyroid toxicity (9 patients). Neurotoxicity was manifest as peripheral neuropathy (8 cases), sensorineural hearing loss (7) and cognitive decline (5); ocular toxicity presented as visual impairment (6). All these neurological features, except cognitive decline, have been associated with cobalt poisoning previously. Type of prosthesis and blood metal concentrations. Where blood or serum metal concentrations were reported (n = 17 for cobalt and n = 14 for chromium), the median cobalt concentration was 398 (range, 13.6-6521) μg/L and the median chromium concentration was 48 μg/L (in whole blood) (range, 4.1-221 μg/L including serum and blood values). Those patients reported to have systemic features who had received a metal-on-metal prosthesis (n = 8) had a median peak blood cobalt concentration of 34.5 (range, 13.6-398.6) μg/L; those with a metal-containing revision of a failed ceramic prosthesis (n = 10) had a median blood cobalt concentration of 506 (range, 353-6521) μg/L. Management. The most common treatment was removal of the metal-containing prosthesis, undertaken in all but 2 patients. This was usually associated with a fall in circulating cobalt concentration and improvement in some or all features. Clinical and toxicological assessment of systemic features. We propose the following criteria for assessing the likelihood that clinical features are related to cobalt toxicity: clinical effects consistent with the known neurological, cardiac, or thyroidal effects of cobalt, and for which any other explanation is less likely; increased blood cobalt concentrations (substantially higher than those in patients with well-functioning prostheses) several months after hip replacement; a fall in the blood cobalt concentration, usually accompanied by signs of improvement in features. When judged by these criteria, the systemic features in 10 of the reported cases are likely to be related to cobalt exposure from a metal-containing hip prosthesis.

CONCLUSIONS

Rarely, patients exposed to high circulating concentrations of cobalt from failed hip replacements develop neurological damage, hypothyroidism and/or cardiomyopathy, which may not resolve completely even after removal of the prosthesis. The greatest risk of systemic cobalt toxicity seems to result from accelerated wear of a cobalt-containing revision of a failed ceramic prosthesis, rather than from primary failure of a metal-on-metal prosthesis.

Value and process of curbside consultations in clinical practice: a grounded theory study

OBJECTIVES

To clarify the value and process of the curbside consultation and identify ways to optimize this activity.

PARTICIPANTS AND METHODS

We conducted 13 focus groups at an academic medical center and outlying community sites (September 2011 to January 2013), involving a purposive sample of 54 primary care and subspecialist internal medicine and family medicine physicians. Focus group discussions were transcribed and then analyzed using a constant comparative approach to identify benefits, liabilities, mechanisms, and potential improvements related to curbside consultations.

RESULTS

We developed a model describing the role and process of the curbside consultation. Focus group participants perceived that curbside consultations add particular value in offering immediate, individualized answers with bidirectional information exchange, and this in turn expedites patient care and elevates patient confidence. Despite the uncompensated interruption and potential risks, experts provide curbside consultations because they appreciate the honor of being asked and the opportunity to help colleagues, expedite patient care, and teach. Key decisions for the initiator (each reflecting a potential barrier) include whom to contact, how to contact that expert, and how to determine availability. Experts decide to accept a request on the basis of personal expertise, physical location, and capacity to commit time and attention. Participants suggested systems-level improvements to facilitate expert selection, clarify expert availability, enhance access to clinical information, and acknowledge the expert's effort.

CONCLUSIONS

Curbside consultations play an important role in enhancing communication and care coordination in clinical medicine, but the process can be further improved. Information technology solutions may play a key role.

Brain structure and function in patients after metal-on-metal hip resurfacing

BACKGROUND AND PURPOSE

Hip prostheses that use a metal-on-metal articulation expose the brain to elevated metal concentrations that, in acute excess due to prosthesis malfunction, is associated with neurologic damage, including visual and hearing loss and motor deficits. Here, we examined whether chronic exposure to lower elevated metal levels, typical of well-functioning prostheses, also affects brain structure and function.

MATERIALS AND METHODS

We compared brain volumes, metal deposition, and gray matter attenuation by MR imaging and clinical neurologic function in patients 8 years after receiving a metal-on-metal hip resurfacing versus a matched group of patients with the same duration exposure to a conventional hip prosthesis.

RESULTS

Twenty-nine patients (25 men; mean, age 59±7 years) after metal-on-metal hip resurfacing and 29 patients (25 men; 59±8 years) after total hip arthroplasty were compared. Whole blood cobalt and chromium concentrations were 5-10 times higher in the metal-on-metal hip resurfacing group (P<.0001). Occipital cortex gray matter attenuation tended to be lower (P<.005 uncorrected, P>.05 corrected), and the optic chiasm area tended to be lower (mean difference, -2.7 mm2; P=.076) in the metal-on-metal hip resurfacing group. Subgroup analyses in 34 patients (17 per group), after exclusion of primary ocular pathology, showed the same trend in gray matter attenuation in the occipital cortex and basal ganglia and a smaller optic chiasm in the metal-on-metal hip resurfacing group (mean difference, -3.9 mm2; P=.048). No other structural or functional differences were found between the groups.

CONCLUSIONS

Chronic exposure to metal-on-metal hip resurfacing is associated with subtle structural change in the visual pathways and the basal ganglia in asymptomatic patients.

Cannabinoid WIN-55,212-2 mesylate inhibits interleukin-1β induced matrix metalloproteinase and tissue inhibitor of matrix metalloproteinase expression in human chondrocytes

OBJECTIVE

Interleukin-1β (IL-1β) is involved in the up-regulation of matrix metalloproteinases (MMPs) leading to cartilage degradation. Cannabinoids are anti-inflammatory and reduce joint damage in animal models of arthritis. This study aimed to determine a mechanism whereby the synthetic cannabinoid WIN-55,212-2 mesylate (WIN-55) may inhibit cartilage degradation.

METHODS

Effects of WIN-55 were studied on IL-1β stimulated production of MMP-3 and -13 and their inhibitors TIMP-1 and -2 in human chondrocytes. Chondrocytes were obtained from articular cartilage of patients undergoing total knee replacement. Chondrocytes were grown in monolayer and 3D alginate bead cultures. Real-time polymerase chain reaction (PCR) was used to determine the gene expression of MMP-3, -13, TIMP-1 and -2 and Enzyme Linked Immunosorbent Assay (ELISA) to measure the amount of MMP-3 and MMP-13 protein released into media. Immunocytochemistry was used to investigate the expression of cannabinoid receptors in chondrocyte cultures.

RESULTS

Treatment with WIN-55 alone or in combination with IL-1β, decreased or abolished MMP-3, -13, TIMP-1 and -2 gene expression in human chondrocyte monolayer and alginate bead cultures in both a concentration and time dependent manner. WIN-55 treatment alone, and in combination with IL-1β, reduced MMP-3 and -13 protein production by chondrocytes cultured in alginate beads. Immunocytochemistry demonstrated the expression of cannabinoid receptors in chondrocyte cultures.

CONCLUSION

Cannabinoid WIN-55 can reduce both basal and IL-1β stimulated gene and protein expression of MMP-3 and -13. However WIN-55 also decreased basal levels of TIMP-1 and -2 mRNA. These actions of WIN-55 suggest a mechanism by which cannabinoids may act to prevent cartilage breakdown in arthritis.

Features of effective medical knowledge resources to support point of care learning: a focus group study

OBJECTIVE

Health care professionals access various information sources to quickly answer questions that arise in clinical practice. The features that favorably influence the selection and use of knowledge resources remain unclear. We sought to better understand how clinicians select among the various knowledge resources available to them, and from this to derive a model for an effective knowledge resource.

METHODS

We conducted 11 focus groups at an academic medical center and outlying community sites. We included a purposive sample of 50 primary care and subspecialist internal medicine and family medicine physicians. We transcribed focus group discussions and analyzed these using a constant comparative approach to inductively identify features that influence the selection of knowledge resources.

RESULTS

We identified nine features that influence users' selection of knowledge resources, namely efficiency (with sub-features of comprehensiveness, searchability, and brevity), integration with clinical workflow, credibility, user familiarity, capacity to identify a human expert, reflection of local care processes, optimization for the clinical question (e.g., diagnosis, treatment options, drug side effect), currency, and ability to support patient education. No single existing resource exemplifies all of these features.

CONCLUSION

The influential features identified in this study will inform the development of knowledge resources, and could serve as a framework for future research in this field.

Barriers and decisions when answering clinical questions at the point of care: a grounded theory study

IMPORTANCE

Answering clinical questions affects patient-care decisions and is important to continuous professional development. The process of point-of-care learning is incompletely understood.

OBJECTIVE

To understand what barriers and enabling factors influence physician point-of-care learning and what decisions physicians face during this process.

DESIGN

Focus groups with grounded theory analysis. Focus group discussions were transcribed and then analyzed using a constant comparative approach to identify barriers, enabling factors, and key decisions related to physician information-seeking activities.

SETTING

Academic medical center and outlying community sites.

PARTICIPANTS

Purposive sample of 50 primary care and subspecialist internal medicine and family medicine physicians, interviewed in 11 focus groups.

RESULTS

Insufficient time was the main barrier to point-of-care learning. Other barriers included the patient comorbidities and contexts, the volume of available information, not knowing which resource to search, doubt that the search would yield an answer, difficulty remembering questions for later study, and inconvenient access to computers. Key decisions were whether to search (reasons to search included infrequently seen conditions, practice updates, complex questions, and patient education), when to search (before, during, or after the clinical encounter), where to search (with the patient present or in a separate room), what type of resource to use (colleague or computer), what specific resource to use (influenced first by efficiency and second by credibility), and when to stop. Participants noted that key features of efficiency (completeness, brevity, and searchability) are often in conflict.

CONCLUSIONS AND RELEVANCE

Physicians perceive that insufficient time is the greatest barrier to point-of-care learning, and efficiency is the most important determinant in selecting an information source. Designing knowledge resources and systems to target key decisions may improve learning and patient care.

Use of kernel-based Bayesian models to predict late osteolysis after hip replacement

We studied the relationship between osteolysis and polyethylene wear, age at surgery, body mass index and height in 463 subjects (180 osteolysis and 283 controls) after cemented Charnley total hip arthroplasty (THA), in order to develop a kernel-based Bayesian model to quantitate risk of osteolysis. Such tools may be integrated into decision-making algorithms to help personalize clinical decision-making. A predictive model was constructed, and the estimated posterior probability of the implant failure calculated. Annual wear provided the greatest discriminatory information. Age at surgery provided additional predictive information and was added to the model. Body mass index and height did not contain valuable discriminatory information over the range in which observations were densely sampled. The robustness and misclassification rate of the predictive model was evaluated by a five-times cross-validation method. This yielded a 70% correct predictive classification of subjects into osteolysis versus non-osteolysis groups at a mean of 11 years after THA. Finally, the data were divided into male and female subsets to further explore the relationship between wear rate, age at surgery and incidence of osteolysis. The correct classification rate using age and wear rate in the model was approximately 66% for males and 74% for females.

Fully automatic segmentation of the proximal femur using random forest regression voting

Extraction of bone contours from radiographs plays an important role in disease diagnosis, preoperative planning, and treatment analysis. We present a fully automatic method to accurately segment the proximal femur in anteroposterior pelvic radiographs. A number of candidate positions are produced by a global search with a detector. Each is then refined using a statistical shape model together with local detectors for each model point. Both global and local models use Random Forest regression to vote for the optimal positions, leading to robust and accurate results. The performance of the system is evaluated using a set of 839 images of mixed quality. We show that the local search significantly outperforms a range of alternative matching techniques, and that the fully automated system is able to achieve a mean point-to-curve error of less than 0.9 mm for 99% of all 839 images. To the best of our knowledge, this is the most accurate automatic method for segmenting the proximal femur in radiographs yet reported.

Transcriptomic analysis identifies candidate genes and functional networks controlling the response of porcine peripheral blood mononuclear cells to mitogenic stimulation

It is difficult to obtain phenotypic data on disease susceptibility directly from swine in an industry setting. The magnitude of the proliferative response of peripheral blood mononuclear cells (PBMC) to the T cell mitogen concanavalin A (Con A) has long been used as an indirect measure of the responsiveness of the immune system to antigenic stimulation. This trait is known to exhibit moderate heritability in swine, but little is known about the identity of the genes that control the response. In this study, we carried out a time-course microarray experiment to measure gene expression at 3 different stages (3, 20, and 68 h) poststimulation of PBMC with Con A. A total of 46, 452, and 418 differentially expressed (DifEx) genes were identified at each time point, respectively. Expression changes for a subset of these genes were subsequently confirmed by real-time PCR. Functional annotation analyses of the microarray results successfully identified sets of genes involved in processes associated with multiple aspects of cell division, such as DNA and protein synthesis, and control of mitosis. However, the discovery of genes that controlled the response of PBMC to mitogen was limited with this approach, because the drastic changes in the transcriptional program necessitated by cells undergoing division masked changes in smaller immune response gene sets. Pathway and network analyses that focused on immune cells proved to be a more effective strategy for the identification of genes that coordinate aspects of the mitogenic response that are specific to PBMC. The cytokine gene IL15 was shown to be central to the highest scoring network at 20 h and affect the expression of 16 other DifEx genes, including some genes known to regulate T cell activation, such as IL7R, JUN, TNFRSF9, and ZAP70. The IL15 gene maps to a previously identified QTL interval for immune responsiveness to Con A on SSC 8, which also contains the related IL2 gene. At 68 h, a distinct downregulation of major histocompatibility complex class II antigen presentation genes was observed. Overall, the gene expression profile of the Con A-stimulated porcine PBMC points to a Th(1) bias in immune activation. Further work is required to determine whether polymorphisms linked to genes identified in this study affect this immune response trait in pig populations and whether the trait itself correlates with decreased susceptibility to intracellular pathogens in swine.

A preliminary study of complementary and alternative medicine (CAM) practitioners in Singapore

OBJECTIVES

To investigate the profile and health attitudes of complementary and alternative medicine (CAM) practitioners in Singapore.

DESIGN AND SETTING

A descriptive survey with convenience and snowball sampling were used. An anonymous self-administered survey was sent to 130 practitioners found in publicly accessible online practitioner registers, groups, and directories practicing CAM modalities from April 2010 to October 2010.

MAIN OUTCOME MEASURES

Participants' demographics, business structure, and attitudes towards health, CAM and orthodox medicine (OM).

RESULTS

Response rate was 32%. The data suggest that the typical CAM practitioner in Singapore is a middle-aged female who specialises in more than one CAM modality. Almost half (45%) of the participants possessed a degree and massage is the most commonly practiced modality. Participants practiced an average of 2-3 therapies and group-practice size ranged from 2 to 15 practitioners. Most participants (69%) experienced a radical change in job type to become a CAM practitioner and their previous employment suggests a slightly middle-class profile. The cost and duration of initial consultation and treatment ranged from SG$20 to SG$345 and 30-120min, respectively. The most common source of CAM information was seminars/lectures/workshops (76%). Communication and referral between CAM and orthodox medicine practitioners are high (>70%). Participants perceived CAM to be more suitable for disease prevention than treatment of serious medical conditions.

CONCLUSIONS

This study provides important base-line data that will help future researchers explore further Singaporean CAM practitioners' business aspirations, and attitudes towards regulation and integration with OM.

Patient self-assessment factors predictive of persistent depressive symptoms 6 months after enrollment in collaborative care management

BACKGROUND

Collaborative care management (CCM) is effective for improving depression outcomes. However, a subset of patients will still have symptoms after 6 months. This study sought to determine whether routinely obtained baseline clinical, demographic, and self-assessment variables would predict which patients endorse persistent depressive symptoms (PDS) after 6 months. By estimating the relative risk associated with the patient variables, we aimed to outline the combinations of factors predictive of PDS after CCM enrollment.

METHODS

We retrospectively reviewed 1,110 adult primary care patients with the diagnosis of major depressive disorder enrolled in a CCM program and evaluated those with PDS (defined as patient health questionnaire-9score ≥10) 6 months after enrollment.

RESULTS

At baseline, an increased depression severity, worsening symptoms of generalized anxiety, an abnormal screening on the mood disorder questionnaire (MDQ) and the diagnosis of recurrent episode of depression were independent predictors of PDS. A patient with severe, recurrent depression, an abnormal MDQ screen, and severe anxiety at baseline had a predicted 42.1% probability of PDS at 6 months. In contrast, a patient with a moderate, first episode of depression, normal MDQ screen, and no anxiety symptoms had a low probability of PDS at 6.6%.

CONCLUSIONS

This study identified several patient self-assessment scores and clinical diagnosis that markedly predicted the probability of PDS 6 months after diagnosis and enrollment into CCM. Knowledge of these high-risk attributes should alert the clinician to monitor select patients more closely and consider altering therapy appropriately.

Quality pork genes and meat production

Functional genomics, including analysis of the transcriptome and proteome, provides new opportunities for understanding the molecular processes in muscle and how these influence its conversion to meat. The Quality Pork Genes project was established to identify genes associated with variation in different aspects of raw material (muscle) quality and to then develop genetic tools that could be utilized to improve this quality. DNA polymorphisms identified in the porcine PRKAG3 and CAST genes illustrate the impact that such tools can have in improving meat quality. The resources developed in Quality Pork Genes provide the basis for identifying more of these tools.

Depression remission after six months of collaborative care management: role of initial severity of depression in outcome

Aim The impact of initial severity of depression on the rate of remission has not been well studied. The hypothesis for this study was that increased depression severity would have an inverse relationship on clinical remission at six months while in collaborative care management. Participants The study cohort was 1128 primary care patients from a south-eastern Minnesota practice and was a longitudinal retrospective chart review analysis. Results Clinical remission at six months was less likely in the severe depression group at 29.6% compared with 36.9% in the moderately severe group and 45.6% in the moderate depression group (P < 0.001). Multivariate analysis of a sub-group demonstrated that increased initial anxiety symptoms (odds ratio [OR] 0.9645, 95% confidence interval [CI] 0.9345-0.9954, P = 0.0248) and an abnormal screening for bipolar disorder (OR 0.4856, 95% CI 0.2659-0.8868, P = 0.0187) predicted not achieving remission at six months. A patient with severe depression was significantly less likely to achieve remission at six months (OR 0.6040, 95% CI 0.3803-0.9592, P = 0.0327) compared with moderate depression, but not moderately severe depression (P = 0.2324). There was no statistical difference in the adjusted means of the PHQ-9 score for those patients who were in remission at six months. However, in the unremitted patients, the six-month PHQ-9 score was significantly increased by initial depression severity when controlling for all other variables. Conclusion Multivariate analysis in our study demonstrated that patients with severe depression have a decreased OR for remission at six months compared with moderate depression. Also, there was a significant increase in the six-month PHQ-9 score for those unremitted patients in the severe vs. moderate depression groups.

The effect of Leptospermum petersonii essential oil on Candida albicans and Aspergillus fumigatus

A variety of assays were utilized to determine the effects of Leptospermum petersonii essential oil on both Candida albicans and Aspergillus fumigatus. Hyphal morphology, susceptibility of spheroplasts and uptake of propidium iodide following exposure to the oil suggest that the mode of action of L. petersonii essential oil is through direct disturbance of the fungal cell membrane. Data also confirms that the volatile component of the oil is highly antifungal, independent of direct contact between the liquid oil and the fungal membrane. The degree of inhibition was greater when fungi were directly exposed to oil volatiles compared to pre-inoculation exposure of oil volatiles into the agar. It is likely that the essential oil volatiles are acting both directly and indirectly on the fungi to produce growth inhibition.

Insights into the genetic architecture of osteoarthritis from stage 1 of the arcOGEN study

Objectives

The genetic aetiology of osteoarthritis has not yet been elucidated. To enable a well-powered genome-wide association study (GWAS) for osteoarthritis, the authors have formed the arcOGEN Consortium, a UK-wide collaborative effort aiming to scan genome-wide over 7500 osteoarthritis cases in a two-stage genome-wide association scan. Here the authors report the findings of the stage 1 interim analysis.

Methods

The authors have performed a genome-wide association scan for knee and hip osteoarthritis in 3177 cases and 4894 population-based controls from the UK. Replication of promising signals was carried out in silico in five further scans (44 449 individuals), and de novo in 14 534 independent samples, all of European descent.

Results

None of the association signals the authors identified reach genome-wide levels of statistical significance, therefore stressing the need for corroboration in sample sets of a larger size. Application of analytical approaches to examine the allelic architecture of disease to the stage 1 genome-wide association scan data suggests that osteoarthritis is a highly polygenic disease with multiple risk variants conferring small effects.

Conclusions

Identifying loci conferring susceptibility to osteoarthritis will require large-scale sample sizes and well-defined phenotypes to minimise heterogeneity.

Long-term outcome of a cementless, hemispherical, press-fit acetabular component: survivorship analysis and dose-response relationship to linear polyethylene wear

Between 1988 and 1998 we implanted 318 total hip replacements (THRs) in 287 patients using the Plasmacup (B. Braun Ltd, Sheffield, United Kingdom) and a conventional metal-on-polyethylene articulation. The main indications for THR were primary or secondary osteoarthritis. At follow-up after a mean 11.6 years (7.6 to 18.4) 17 patients had died and 20 could not be traced leaving a final series of 280 THRs in 250 patients. There were 62 revisions (22.1%) in 59 patients. A total of 43 acetabular shells (15.4%) had been revised and 13 (4.6%) had undergone exchange of the liner. The most frequent indications for revision were osteolysis and aseptic loosening, followed by polyethylene wear. The mean Kaplan-Meier survival of the Plasmacup was 91% at ten years and 58% at 14 years. Osteolysis was found around 36 (17.1%) of the 211 surviving shells. The median annual rate of linear wear in the surviving shells was 0.12 mm/year and 0.25 mm/year in those which had been revised (p < 0.001). Polyethylene wear was a strong independent risk factor for osteolysis and aseptic loosening. The percentage of patients with osteolysis increased proportionately with each quintile of wear-rate. There is a high late rate of failure of the Plasmacup. Patients with the combination of this prosthesis and bearing should be closely monitored after ten years.

Antifungal activity of Leptospermum petersonii oil volatiles against Aspergillus spp. in vitro and in vivo

OBJECTIVES

This study investigates the volatile (vapour) component of an essential oil derived from the Australian native Leptospermum petersonii as a potential treatment for aspergillosis.

METHODS

The in vitro antifungal effects of the volatiles were assayed by a variety of methods. In vitro mammalian cell toxicity of the oil and the oil volatiles was also determined prior to animal testing. Efficacy of the volatiles in vivo was assessed using a murine model.

RESULTS

L. petersonii oil volatiles were found to be potent inhibitors of fungal growth in vitro, with fungicidal activity displayed following short exposure times (< or =1 h). No significant mammalian cell toxicity was found to be associated with the volatiles. In the absence of treatment, Aspergillus fumigatus infection of animals resulted in an increase in inflammatory cell counts and high fungal burden within the lung tissue. Chitin levels in treated animals were significantly reduced compared with control animals. No viable fungi could be recovered from animals that had completed the treatment regimen.

CONCLUSIONS

The significant reduction in fungal burden in the lungs of infected animals by the volatiles of L. petersonii oil was larger than that reported for conventional antifungal drugs of choice.