An Emergency Department Quality Improvement Project for Intravenous Levetiracetam Administration

Background: Levetiracetam is a readily available, safe anticonvulsive medication. It is frequently administered as IV piggyback with a pump, carrier fluid, and tubing. The Established Status Epilepticus Treatment Trial demonstrated levetiracetam being similarly effective to previously used treatments in doses up to 4500 mg administered over 10 minutes. Objective: We sought to compare usage, cost, and waste of IV piggyback with IV push administration of levetiractam following implementation of an IV push protocol in an academic emergency department. Methods: A three-month review of levetiracetam administration was done following protocol implementation using IV push for initial treatment of benzodiazepine-refractory status epilepticus. The review quantified the number of IV push vs IV piggyback doses for all indications and evaluated cost of supplies necessary for administration. Results: During the study period, 137 patients received 142 doses of IV levetiracetam. Fifty-one doses (36%) were given as IV push rather than IV piggyback. The majority of doses 116 (82%) were 1000-2000 mg and 11 doses (8%) 3500-4500 mg. Estimated three-month savings with complete transition of IV piggyback to IV push would exceed $6000 just in our ED. The amount of sterile solution carrier fluid was also reduced and IV pump time freed. Conclusion: Implementation of an emergency department IV push levetiracetam protocol resulted in cost savings. Opportunities remain to improve clinical implementation practices. Medication administration represents one crucial target area where healthcare systems can implement policies to reduce waste and commit to climate-smart health care.

First Dark Matter Search Results from the LUX-ZEPLIN (LZ) Experiment

The LUX-ZEPLIN experiment is a dark matter detector centered on a dual-phase xenon time projection chamber operating at the Sanford Underground Research Facility in Lead, South Dakota, USA. This Letter reports results from LUX-ZEPLIN's first search for weakly interacting massive particles (WIMPs) with an exposure of 60 live days using a fiducial mass of 5.5 t. A profile-likelihood ratio analysis shows the data to be consistent with a background-only hypothesis, setting new limits on spin-independent WIMP-nucleon, spin-dependent WIMP-neutron, and spin-dependent WIMP-proton cross sections for WIMP masses above 9  GeV/c^{2}. The most stringent limit is set for spin-independent scattering at 36  GeV/c^{2}, rejecting cross sections above 9.2×10^{-48}  cm at the 90% confidence level.

Cystatin C as a biomarker for cardiorenal syndrome diseases quantitative diagnostics and monitoring via point-of-care

With heart failure (HF) and renal malfunction becoming global public health issues, there is an urgent need to monitor diseases at home or in the community. Point-of-care testing (POC) would shorten the patients waiting time compared with laboratory molecular analysis. This work evaluates two types of gold nanomaterials, and two assay protocols, to develop a lateral flow (LF) system for Cystatin C (CysC) quantification. Of the protocols, the 'delayed-release' shows the alleviation of the hook effects with 1% BSA running buffer (RB), albeit at increased complexity with three steps of washing. The standard method with sample dilution (1: 150 sample dilution for GNPs, and 1:10 sample dilution for GNRs) can ensure the clinical range detection of CysC as 1 mg/L with partial LF assays. GNPs have stronger optical signal intensity compared with GNRs and developed full LF assays with GNPs require 1:1.5 sample dilution in recombinant Cys C detection. The ideal sample dilution ratio is different for partial and full LF assays. Clinical Relevance- This work is the basis of future work that will use LF devices for human serum/plasma monitoring to assess kidney function related to heart failure during medication. The specificity, sensitivity, and limit of detection will be validated via a clinical trial before potential clinical use.

Gene characterization and expression of the γδ T cell co-receptor WC1 in sheep

Sheep are known to express the hybrid co-receptor/pattern recognition receptor WC1 on their γδ T cells but details of the ovine WC1 multigenic array and gene expression were unknown. Annotation of the sheep genome assembly (Oar_rambouillet_v1.0) yielded 15 complete and 42 partial WC1 genes predicted to code for six different protein structures. RT-PCR amplification of the most distal scavenger receptor cysteine rich (SRCR) domain known as a1, which serves as the gene signature, from genomic and cDNA templates verified the majority of annotated genes. As for cattle and goats, sheep a1 domain sequences included WC1.1 and WC1.2 types. A unique ovine gene, WC1-16, had multiple SRCR a-pattern domains in tandem similar to one found in goats. Intracytoplasmic domains of WC1 transcripts had splice variants that may affect signal transduction. The larger number of WC1 genes in sheep and differences in structures and splice variants relative to cattle could have implications in expression patterns and engagement of γδ T cells by pathogens or vaccine constructs.

Is Cutibacterium (previously Propionibacterium) acnes a potential pathogenic factor in the aetiology of the skin disease progressive macular hypomelanosis?

Progressive macular hypomelanosis (PMH) is a skin condition that normally causes symmetrically distributed hypopigmented macules on the front and back of the trunk, but rarely the face. To date, the pathophysiology of the condition is not well understood, but a role for the anaerobic skin bacterium Cutibacterium (previously Propionibacterium) acnes in the development of the disease has been proposed due to its sole presence within lesional, but not normal peri-lesional, skin. The success of antimicrobials in the treatment of PMH also provides circumstantial evidence that this association may be causal, although this is still to be proven. More recent culture and metagenomic typing studies indicate that strains of C. acnes subsp. elongatum (type III) may be important in the aetiology of the condition, which would help to explain why PMH does not normally affect the face since such strains are rarely present there, and why no association between this condition and acne vulgaris is found; acne appears to primarily involve type IA₁ strains from C. acnes subsp. acnes (type I). In this review, we summarize current knowledge on the relationship between C. acnes and PMH, and re-examine previous challenges to the view that the bacterium plays a role in the condition against the backdrop of newly emerged data.

Interactive website for head and neck cancer patients: Adherence and coping program to prevent dysphagia after radiation

INTRODUCTION

Pharyngeal and laryngeal cancers are highly curable; however survivors are at high risk for long-term dysphagia after radiation. To address lack of access to preventive care in community settings, we developed a responsive web-based application to help patients adhere to preventive swallowing exercises and cope with radiation side effects. We conducted an interim study analysis to determine website usage characteristics and to examine the effect size for future trials.

METHODS

Pharyngeal and laryngeal cancer patients were recruited for enrollment by speech language pathologists before primary radiation and introduced to the interactive website. The program (English and Spanish) features tracking logs for preventive exercises, instructional videos, patient stories and search features. Patients' self-reported swallowing function was assessed with the MD Anderson Dysphagia Inventory (MDADI) at baseline and at 6 months. Adherence to preventive exercises was assessed during the 10 week intervention. Number of unique website visits, total duration of website exposure, and rankings of the most popular webpages were calculated. Preliminary regression models were run using adherence and MDADI as outcomes.

RESULTS

Of the 160 enrolled, 96 had 10-week adherence data and 61 had 6-month MDADI data. The average age was 63 (SD = 12.26), 49.4% were from rural counties, 44% had a high school education or lower, and 42% reported annual income of $30,000 or less. The average number of visits was 5.49 (SD = 9.96) and the average total time spent with the website was 41.09 min (SD =88.48). Preliminary analyses indicated that number of unique visits to the website was independently associated with increased adherence to preventive exercises (p = .001-.008).

CONCLUSION

Our website showed significant effects in promoting adherence to swallowing exercises. However, our return visit rate showed that the platform needs improvement in navigability and usability for this older population undergoing challenging treatment in community settings with low resources.

Efficacy and safety of topical capsaicin for cannabinoid hyperemesis syndrome in the emergency department

Introduction: Cannabinoid hyperemesis syndrome (CHS) is a disorder of cyclic and recurrent nausea, vomiting, and abdominal pain associated with high-frequency and extended-duration marijuana use. Standard antiemetic therapy is often ineffective; however, capsaicin, an agonist of transient receptor potential vanilloid 1 (TRPV1), has shown promise in treating CHS.Methods: This retrospective cohort analysis evaluated the safety and efficacy of topical capsaicin for patients presenting with CHS. The primary outcome was to assess if utilization of capsaicin for ED management of CHS decreased ED length of stay (LOS) as compared to a visit without capsaicin. Secondary outcomes included a cost analysis, use of rescue therapies, and adverse events.Results: Forty-three patients met the inclusion criteria within the study period. ED LOS was reduced with capsaicin by a median of 22 minutes (201 vs. 179 min, p = 0.33). Patients received fewer additional medications if capsaicin was utilized (4 vs. 3 doses, p = 0.015), and 67% of visits where capsaicin was utilized required no further treatment prior to discharge. Additionally, opioid usage was less when utilizing capsaicin (166.5 vs. 69 mg OME). Forty-two percent of patients did not have a repeat CHS presentation to the ED after receiving capsaicin for an additional three months after the study period ended. Total medication cost was minimally more expensive (median difference of $3.26) in the capsaicin group. There were no significant adverse events reported with capsaicin.Conclusion: There was no significant difference in ED LOS when capsaicin was utilized for CHS. However, there was a decrease in total medications administered and a reduction in opioid requirements. While medication costs for capsaicin visits were minimally more expensive, the utility of capsaicin as an over-the-counter (OTC) product may empower at home therapy with OTC products, decreasing potentially unnecessary healthcare encounters and costs.

Healing experience for family caregivers after an intensive care unit death

OBJECTIVES

Family caregivers suffer a high burden of emotional and psychological distress following the death of a loved one in the intensive care unit and often struggle to heal in the weeks following their loss. The purpose of this hermeneutic phenomenological study was to describe and interpret the experience of healing for family caregivers six weeks following the death of a loved one in the ICU.

METHODS

Semi-structured telephone interviews were conducted with a purposive sample of twenty-four family caregivers six weeks following the death of their loved ones in the ICU. Qualitative analysis techniques were used to identify common themes central to the experience of healing across all interviews.

RESULTS

Seven themes were interpreted from the data: searching for clarity from a time of uncertainty; riding an emotional rollercoaster; seeking peace in one's decisions; moving forward with each new day; taking comfort in the memories; valuing layers of support; and discovering life on one's own.

CONCLUSION

By identifying and gaining an understanding of healing following the death of a loved one in the ICU, nursing and other healthcare providers have an opportunity to promote healing and positively impact family caregiver's bereavement.

Wireless chest wearable vital sign monitoring platform for hypertension

Hypertension, a silent killer, is the biggest challenge of the 21^st century in public health agencies worldwide [1]. World Health Organization (WHO) statistic shows that the mortality rate of hypertension is 9.4 million per year and causes 55.3% of total deaths in cardiovascular (CV) patients [2]. Early detection and prevention of hypertension can significantly reduce the CV mortality. We are presenting a wireless chest wearable vital sign monitoring platform. It measures Electrocardiogram (ECG), Photoplethsmogram (PPG) and Ballistocardiogram (BCG) signals and sends data over Bluetooth low energy (BLE) to mobile phone-acts as a gateway. A custom android application relays the data to thingspeak server where MATLAB based offline analysis estimates the blood pressure. A server reacts on the health of subject to friends & family on the social media - twitter. The chest provides a natural position for the sensor to capture legitimate signals for hypertension condition. We have done a clinical technical evaluation of prototypes on 11 normotensive subjects, 9 males 2 females.

Portable Cardiac Mapping Assessment of Acute Ischaemic Injury

A portable cardiac mapping system is used to improve the accuracy of diagnosis of acute ischaemic injury outside hospital. Patients presenting chest pain suggestive of myocardial infarction (Ml) were mapped by attendant medical personnel operating from a mobile coronary unit. These first Ml maps were compared against average normal maps using QRS and ST-T isointegral values. Discriminant function analysis performed on the parameters achieved a sensitivity of 90% and a specificity of 96%.

Does the Use of Volumetric Modulated Arc Therapy Reduce Gastrointestinal Symptoms after Pelvic Radiotherapy?

AIMS

Growing numbers of patients with cancer are surviving after treatment with pelvic radiotherapy. We evaluated the technique of volumetric modulated arc therapy (VMAT), which delivers a decreased dose to the organs at risk. We aimed to determine outcomes of this technique in terms of patient-reported acute toxicity and late effects and correlate the frequency of gastrointestinal symptoms with the volume of bowel receiving radiation dose.

MATERIALS AND METHODS

Patients who were to receive VMAT for gynaecological malignancy completed patient-reported outcomes at baseline, the end of treatment, 8 weeks and 1 year. The rates of patient-reported toxicity were correlated with the volume of bowel irradiated.

RESULTS

The frequencies of patient-reported gastrointestinal symptoms increased in the acute toxicity phase and tended to improve at 1 year, with the exception of faecal incontinence and rectal bleeding (P < 0.05). There was not a strong association between the volume of small bowel that was irradiated (P > 0.05 at all dose levels) and reported toxicity, suggesting that other factors are involved in the development of toxicity.

CONCLUSION

Although VMAT decreases the dose delivered to the small bowel, this does not translate into a reduction in patient-reported toxicity.

Extreme ocean acidification reduces the susceptibility of eastern oyster shells to a polydorid parasite

Ocean acidification poses a threat to marine organisms. While the physiological and behavioural effects of ocean acidification have received much attention, the effects of acidification on the susceptibility of farmed shellfish to parasitic infections are poorly understood. Here we describe the effects of moderate (pH 7.5) and extreme (pH 7.0) ocean acidification on the susceptibility of Crassostrea virginica shells to infection by a parasitic polydorid, Polydora websteri. Under laboratory conditions, shells were exposed to three pH treatments (7.0, 7.5 and 8.0) for 3- and 5-week periods. Treated shells were subsequently transferred to an oyster aquaculture site (which had recently reported an outbreak of P. websteri) for 50 days to test for effects of pH and exposure time on P. websteri recruitment to oyster shells. Results indicated that pH and exposure time did not affect the length, width or weight of the shells. Interestingly, P. websteri counts were significantly lower under extreme (pH 7.0; ~50% reduction), but not moderate (pH 7.5; ~20% reduction) acidification levels; exposure time had no effect. This study suggests that extreme levels - but not current and projected near-future levels - of acidification (∆pH ~1 unit) can reduce the susceptibility of eastern oyster shells to P. websteri infections.

Development and integration of a Surveillance Monitoring solution to provide earlier detection of the deteriorating patient

This paper presents recent improvement of a Wi-Fi based vital signs monitor used for in-hospital monitoring in medium-risk settings. Valuable insight into design strengths and weaknesses has been gained and device improvements have been confirmed with real-world use. Integration with intuitive central station software is considered with respect to balancing functionality and performance. Practical use of the early warning system in challenging clinical environments has enabled further understanding of the potential impact of the system. A tool to provide a convenient method of tracking patient condition and alerting on deterioration is offered.

A case-control study of risk factors for death from 2009 pandemic influenza A(H1N1): is American Indian racial status an independent risk factor?

Historically, American Indian/Alaska Native (AI/AN) populations have suffered excess morbidity and mortality from influenza. We investigated the risk factors for death from 2009 pandemic influenza A(H1N1) in persons residing in five states with substantial AI/AN populations. We conducted a case-control investigation using pandemic influenza fatalities from 2009 in Alaska, Arizona, New Mexico, Oklahoma and Wyoming. Controls were outpatients with influenza. We reviewed medical records and interviewed case proxies and controls. We used multiple imputation to predict missing data and multivariable conditional logistic regression to determine risk factors. We included 145 fatal cases and 236 controls; 22% of cases were AI/AN. Risk factors (P 45 years vs. <18 years], pre-existing medical conditions (mOR 7·1), smoking (mOR 3·0), delayed receipt of antivirals (mOR 6·5), and barriers to healthcare access (mOR 5·3). AI/AN race was not significantly associated with death. The increased influenza mortality in AI/AN individuals was due to factors other than racial status. Prevention of influenza deaths should focus on modifiable factors (smoking, early antiviral use, access to care) and identifying high-risk persons for immunization and prompt medical attention.

Mutations in DDX3X Are a Common Cause of Unexplained Intellectual Disability with Gender-Specific Effects on Wnt Signaling

Intellectual disability (ID) affects approximately 1%-3% of humans with a gender bias toward males. Previous studies have identified mutations in more than 100 genes on the X chromosome in males with ID, but there is less evidence for de novo mutations on the X chromosome causing ID in females. In this study we present 35 unique deleterious de novo mutations in DDX3X identified by whole exome sequencing in 38 females with ID and various other features including hypotonia, movement disorders, behavior problems, corpus callosum hypoplasia, and epilepsy. Based on our findings, mutations in DDX3X are one of the more common causes of ID, accounting for 1%-3% of unexplained ID in females. Although no de novo DDX3X mutations were identified in males, we present three families with segregating missense mutations in DDX3X, suggestive of an X-linked recessive inheritance pattern. In these families, all males with the DDX3X variant had ID, whereas carrier females were unaffected. To explore the pathogenic mechanisms accounting for the differences in disease transmission and phenotype between affected females and affected males with DDX3X missense variants, we used canonical Wnt defects in zebrafish as a surrogate measure of DDX3X function in vivo. We demonstrate a consistent loss-of-function effect of all tested de novo mutations on the Wnt pathway, and we further show a differential effect by gender. The differential activity possibly reflects a dose-dependent effect of DDX3X expression in the context of functional mosaic females versus one-copy males, which reflects the complex biological nature of DDX3X mutations.

Survival in women with ovarian cancer with and without microsatellite instability

PURPOSE OF INVESTIGATION

Microsatellite instability (MSI) is a hallmark of defective mismatch repair and is present in approximately 20% of ovarian cancers. It is not known if the presence of MSI predicts survival in women with epithelial ovarian cancer.

MATERIALS AND METHODS

Cases of epithelial ovarian cancer were ascertained from a population-based study in Ontario and tumour samples were tested for MSI, using five MSI markers. Patients were divided into MSI-high and MSI-low/normal, according to National Cancer Institute criteria. The authors compared the prevalence of specific prognostic factors in the two subgroups, including age, grade, stage, and histology. They estimated the hazard ratio for death from ovarian cancer associated with MSI-high and with other prognostic factors using a multi-variate analysis.

RESULTS

A total of 418 ovarian cancer patients were included. One hundred and twenty-seven (19.7%) cancers were MSI- high. Subgroup analyses did not reveal any statistically significant differences for pathologic features associated with MSI status. No survival difference was seen according to MSI status.

CONCLUSIONS

The presence of MSI in ovarian cancer is not associated with survival.

National radon programmes and policies: the RADPAR recommendations

Results from epidemiological studies on lung cancer and radon exposure in dwellings and mines led to a significant revision of recommendations and regulations of international organisations, such as WHO, IAEA, Nordic Countries, European Commission. Within the European project RADPAR, scientists from 18 institutions of 14 European countries worked together for 3 y (2009-12). Among other reports, a comprehensive booklet of recommendations was produced with the aim that they should be useful both for countries with a well-developed radon programme and for countries with little experience on radon issues. In this paper, the main RADPAR recommendations on radon programmes and policies are described and discussed. These recommendations should be very useful in preparing a national action plan, required by the recent Council Directive 2013/59/Euratom.

Demonstrating the accuracy of an in-hospital ambulatory patient monitoring solution in measuring respiratory rate

This paper presents clinical testing conducted to evaluate the accuracy of Aingeal, a wireless in-hospital patient monitor, in measuring respiration rate via impedance pneumography. Healthy volunteers were invited to simultaneously wear a CE Marked Aingeal vital signs monitor and a capnograph, the current gold standard in respiration rate measurement. During the test, participants were asked to undergo a series of defined breathing protocols which included normal breathing, paced breathing between 8-23 breaths per minute (bpm) and a recovery period following moderate exercise. Statistical analysis of the data collected shows a mean difference of -0.73, a standard deviation of 1.61, limits of agreement of -3.88 and +2.42 bpm and a P-value of 0.22. This testing demonstrates comparable performance of the Aingeal device in measuring respiration rate with a well-accepted and widely used alternative method.

Efficacy of an educational intervention on family physicians' risk assessment and management of colorectal cancer

We developed a point-of-care tool indicating risk categories for colorectal cancer (CRC) based on family history (FH) and management recommendations tailored to risk. The study objective was to determine if this CRC Risk Triage/Management Too would enable family physicians (FPs) to appropriately triage and make screening and genetics referral recommendations for patients with CRC FH. Baseline questionnaires were mailed to a random sample of FPs in Ontario and Newfoundland, Canada. Participants were asked to use the tool for 3 months and then complete a follow-up questionnaire. The primary outcomes were correct responses to questions regarding CRC risk category, screening method, starting age, frequency, and decision to refer to genetics, for eight clinical vignettes. The study was completed by 75/121 (62 %) participating FPs. Most (77 %) agreed they routinely recommended fecal occult blood testing for average risk patients age ≥50. This did not change significantly following the intervention. There was a significant increase in confidence in CRC risk assessment (52 % pre; 88 % post; p < 0.001), correct management recommendations for patients with CRC FH (51 % pre; 84 % post; p < 0.001), and improvement in total mean scores on outcome measures for all vignettes. Most (90 %) agreed the tool would improve practice. Receipt of the CRC Risk Triage/Management Tool was associated with improvement in FPs' CRC risk assessment, screening, and genetics referral recommendations for clinical vignettes. This demonstrates the value of point-of-care tools and illustrates a process for development, evaluation, and dissemination of tools needed by FPs if potential impacts of genomic advances are to be achieved.

Review article: the assessment and management of chronic severe gastrointestinal dysmotility in adults

BACKGROUND

The characterisation and management of chronic severe gastrointestinal (GI) dysmotility are challenging. It may cause intestinal failure requiring home parenteral nutrition (HPN).

AIMS

To review the presentation, aetiology, characterisation, management and outcome of chronic severe GI dysmotility, and to suggest a pragmatic management algorithm.

METHODS

PubMed search was performed up to December 2012 using appropriate search terms, restricted to human articles and reviewed for relevance. Segmental dysmotility, acute ileus, functional syndromes and non-English articles were excluded. Evidence and recommendations were evaluated using the GRADE system.

RESULTS

In total, 721 relevant articles were reviewed. A coherent and definitive picture is hampered by overlapping classification systems using multi-modal characterisation methods, subject to pitfalls and some requiring further validation. The literature is confined to case series with no randomised trials. Fewer than 20% undergo full thickness jejunal biopsy, which are otherwise labelled idiopathic. However, in studies with up to 80% biopsy rates, neuromuscular abnormalities may be found in 90%. Between 14% and 50% will require HPN, comprising 8-14% of all HPN patients, of which 2/3 are primary/idiopathic and 1/3 secondary, with scleroderma being the leading secondary cause. Ten-year  mortality ranges from 13% to 35% and is worst in elderly scleroderma patients. Management includes limited treatments for secondary causes, prokinetics, symptom palliation, psychological support, nutrition, hydration and judicious surgery.

CONCLUSIONS

Severe dysmotility often remains idiopathic. It is rarely possible to alter disease trajectory; consequently, prognosis may be poor. Multi-disciplinary teams in a specialist setting can improve outcomes. Graded recommendations are enumerated and a pragmatic algorithm is suggested.

Development of a ubiquitous clinical monitoring solution to improve patient safety and outcomes

This paper highlights the main findings of an integrated and ubiquitous remote wireless based vital signs monitoring solution as trialed in a clinical setting. Results demonstrate the feasibility of utilising a Wi-Fi based solution to monitor early-warning signs such as impedance-based respiration rate changes, heart rate/ECG events, temperature, and motion analysis in a clinical setting and act as an early warning system.

Colestyramine slows gastric emptying of liquids and reduces appetite in healthy subjects

BACKGROUND

There is evidence to suggest that the particulate resin colestyramine, a bile acid sequestrant formerly used as a cholesterol-lowering agent, enhances secretion of the gut hormone cholecystokinin (CCK). Established physiological actions of CCK include inhibition of gastric emptying and induction of satiation. This study evaluated the hypothesis that colestyramine, which is luminally retained, would slow gastric emptying of liquids and suppress appetite in humans.

METHODS

Nine healthy volunteers consumed 500 mL liquid test meals containing 4 g colestyramine, 12 g colestyramine, or control (water alone), on three occasions, in a randomized order. The effect of colestyramine on gastric emptying was determined non-invasively using the (13) C-acetate breath test, and appetite and other gut-centered sensations were rated using visual analog scale questionnaires.

KEY RESULTS

Colestyramine dose dependently slowed liquid gastric emptying compared with control (water) (4 g vs control, ∼20% reduction, P < 0.05; 12 g vs control, ∼35% reduction, P < 0.01). Colestyramine also significantly reduced hunger (4 g vs control, ∼20% reduction, P < 0.01), and the amount of food participants felt able to eat (12 g vs control, ∼32% reduction, P < 0.001), but increased bloating (both doses, P < 0.05), with no effect on ratings of nausea.

CONCLUSIONS & INFERENCES

This study provides the first evidence that colestyramine significantly slows liquid gastric emptying and reduces appetite in healthy humans. Colestyramine therefore presents an attractive gut-brain signaling research tool in that it is not absorbed and thus lacks potentially confounding postabsorptive effects. Furthermore, with clear effects on gastric emptying and appetite, colestyramine now merits consideration as a trial therapeutic strategy for appetite suppression and weight loss.

Intimate partner abuse and suicidality: a systematic review

Research has demonstrated an association between intimate partner abuse and suicidality, presenting a serious mental health issue. However, studies have differed widely in the samples and methods employed, and in the depth of the investigation. Given the level of heterogeneity in the literature, this systematic review examines, for the first time, the nature of the relationship between intimate partner abuse and suicidality. The three main psychological and medical databases (PsychInfo 1887-March 2011; Medline, 1966-March 2011; Web of Knowledge 1981-March 2011) were searched. Thirty-seven papers on the topic of intimate partner abuse and suicidality were found. With only one exception, all of the studies found a strong and consistent association between intimate partner abuse and suicidality. Significantly, this relationship held irrespective of study design, sample and measurement of abuse and suicidality, thus demonstrating a consistently strong relationship between intimate partner abuse and suicidality. This review highlights that intimate partner abuse is a significant risk factor for suicidal thoughts and behaviours, which has important clinical implications.

Patients' knowledge of pregnancy-related issues in inflammatory bowel disease and validation of a novel assessment tool ('CCPKnow')

BACKGROUND

Inflammatory bowel diseases (IBD) require complex therapeutic decisions and life choices concerning pregnancy, but little is known about patient's knowledge of IBD and its treatment before and during pregnancy.

AIM

To develop a novel tool (Crohn's and Colitis Pregnancy Knowledge Score 'CCPKnow') to assess knowledge of pregnancy-related issues in IBD. The validated tool was then applied to determine knowledge in patients.

METHOD

Discriminate ability of 'CCPKnow' was validated in four groups with different levels of IBD knowledge. Reliability and readability were tested by Cronbach-α and Flesch-Kencaid. Construct validity was subsequently assessed against general IBD knowledge (CCKnow) in 145 women with IBD. Associations between patient factors and knowledge were studied.

RESULTS

Median CCPKnow scores differed significantly between the validation groups (P < 0.001). CCPKnow displayed excellent internal consistency, reliability (Cronbach-α 0.94), readability (reading age 9 years) and close correlation with CCKnow (Spearman's ρ 0.64; P < 0.001). Of 145 patients, 44.8% had poor, 27.6% adequate, 17.3% good and only 10.3% very good knowledge. Better knowledge was associated with Caucasian ethnicity, higher income, having a partner, having children, Crohn's and Colitis Association membership, longer disease duration and Crohn's disease.

CONCLUSIONS

Crohn's and Colitis Pregnancy Knowledge Score, a novel knowledge assessment tool of pregnancy and IBD, demonstrated excellent test characteristics. We found that nearly half of the women with IBD had poor knowledge, identifying a pressing need for better education.

Why is the sex gap in feelings of depression wider in high gender equity countries? The effect of children on the psychological well-being of men and women

This study uses data from 23 countries in the World Values Survey and the National Survey of Families and Households and finds that the sex gap in feelings of depression is wider in high gender equity societies even though overall levels of feelings of depression are lower. Using hierarchical logistic modeling, we find that the sex difference in feelings of depression is wider in high gender equity societies because children increase depression for women in high gender equity societies, while they reduce depression for women without paid employment in low gender equity societies. There is little difference in the effect of children on feelings of depression for men across societies.

Long-term measurements of thoron, its airborne progeny and radon in 205 dwellings in Ireland

Long-term (circa 3 months) simultaneous measurements of indoor concentrations of thoron gas, airborne thoron progeny and radon were made using passive alpha track detectors in 205 dwellings in Ireland during the period 2007-09. Thoron progeny concentrations were measured using passive deposition monitors designed at the National Institute of Radiological Sciences (NIRS), Japan, whereas thoron gas concentrations were measured using Raduet detectors (Radosys, Budapest). Radon concentrations were measured in these dwellings by means of NRPB/SSI type alpha track radon detectors as normally used by the Radiological Protection Institute of Ireland (RPII). The concentration of thoron gas ranged from <1 to 174 Bq m(-3) with an arithmetic mean (AM) of 22 Bq m(-3). The concentration of radon gas ranged from 4 to 767 Bq m(-3) with an AM of 75 Bq m(-3). For radon, the estimated annual doses were 0.1 (min), 19.2 (max) and 1.9 (AM) mSv y(-1). The concentration of thoron progeny ranged from <0.1 to 3.8 Bq m(-3) [equilibrium equivalent thoron concentration (EETC)] with an AM of 0.47 Bq m(-3) (EETC). The corresponding estimated annual doses were 2.9 (max) and 0.35 (mean) mSv y(-1). In 14 or 7% of the dwellings, the estimated doses from thoron progeny exceeded those from radon.

The captive husbandry and reproduction of the pink-eared turtle (Emydura victoriae) at Perth Zoo

In 1997, Perth Zoo acquired six pink-eared turtles (Emydura victoriae) from the wild for display in the reptile facility. There is very little documented information on pink-eared turtles in captivity. This article looks at the reproductive biology, ecology, behavior, diet, and captive husbandry of the species. Eight clutches of eggs were documented over a 2-year period with an average clutch size of 10 eggs. Egg size was recorded with three clutches incubated to hatching. Ten hatchlings were maintained for a growth and development study. Measurements of weight, carapace length, width, height, and plastron length were recorded weekly for about 12 months, and then monthly for approximately 2 years. The data were analyzed and showed positive growth curves in all animals. Sexual dimorphism was observed after 20 weeks and sexual maturity in males observed after 2 years.

The impact of prophylactic salpingo-oophorectomy on menopausal symptoms and sexual function in women who carry a BRCA mutation

OBJECTIVE

Prophylactic salpingo-oophorectomy is recommended to women who carry a BRCA1 or BRCA2 mutation to reduce the risks of breast, ovarian and fallopian tube cancer. We measured the impact of prophylactic salpingo-oophorectomy on menopausal symptoms and sexual functioning in women with a BRCA mutation.

METHODS

Women who underwent prophylactic salpingo-oophorectomy between October 1, 2002 and June 26, 2008 for a known BRCA1 or BRCA2 mutation were invited to participate. Participants completed questionnaires before prophylactic surgery and again one year after surgery. Measures of sexual functioning and menopausal symptoms before and after surgery were compared. Satisfaction with the decision to undergo prophylactic salpingo-oophorectomy was evaluated.

RESULTS

114 women who underwent prophylactic surgery completed questionnaires before and one year after surgery. Subjects who were premenopausal at the time of surgery (n=75) experienced a significant worsening of vasomotor symptoms (hot flashes, night sweats and sweating) and a decline in sexual functioning (desire, pleasure, discomfort and habit). The increase in vasomotor symptoms and the decline in sexual functioning were mitigated by HRT, but symptoms did not return to pre-surgical levels. HRT decreased vaginal dryness and dyspareunia; however, the decrease in sexual pleasure was not alleviated by HRT. Satisfaction with the decision to undergo prophylactic salpingo-oophorectomy remained high regardless of increased vasomotor symptoms and decreased sexual function.

CONCLUSIONS

Women who undergo prophylactic salpingo-oophorectomy prior to menopause experience an increase in vasomotor symptoms and a decrease in sexual functioning. These symptoms are improved by HRT, but not to pre-surgical levels.

An overview of thoron and its progeny in the indoor environment

An account is given of the behaviour of thoron and its progeny in the indoor environment. Emphasis is placed on the spatial distribution of these radionuclides in room air and on their interactions with indoor aerosols. How these aspects of thoron and progeny behaviour give rise to special problems for measuring them and assessing their radiological impact are described. Descriptions and comparisons are given of a range of thoron and progeny measurement techniques both passive and active. Recent progress in thoron dosimetry is described as well as compared with radon dosimetry. The results of some indoor thoron and progeny surveys carried out in different countries in recent years are given. As an example of this a summary account is presented of a recently concluded survey of thoron and its airborne progeny in over 200 houses in Ireland.

The genetic basis of colorectal cancer in a population-based incident cohort with a high rate of familial disease

BACKGROUND AND AIMS

Colorectal cancer (CRC) is the second most frequent cancer in developed countries. Newfoundland has the highest incidence of CRC in Canada and the highest rate of familial CRC yet reported in the world. To determine the impact of mutations in known CRC susceptibility genes and the contribution of the known pathways to the development of hereditary CRC, an incident cohort of 750 patients with CRC (708 different families) from the Newfoundland population was studied.

METHODS

Microsatellite instability (MSI) testing was performed on tumours, together with immunohistochemistry analysis for mismatch repair (MMR) genes. Where indicated, DNA sequencing and multiplex ligation-dependent probe amplifications of MMR genes and APC was undertaken. DNA from all patients was screened for MUTYH mutations. The presence of the BRAF variant, p.V600E, and of MLH1 promoter methylation was also tested in tumours.

RESULTS

4.6% of patients fulfilled the Amsterdam criteria (AC), and an additional 44.6% fulfilled the revised Bethesda criteria. MSI-high (MSI-H) was observed in 10.7% (n=78) of 732 tumours. In 3.6% (n=27) of patients, CRC was attributed to 12 different inherited mutations in six known CRC-related genes associated with chromosomal instability or MSI pathways. Seven patients (0.9%) carried a mutation in APC or biallelic mutations in MUTYH. Of 20 patients (2.7%) with mutations in MMR genes, 14 (70%) had one of two MSH2 founder mutations. 17 of 28 (61%) AC families did not have a genetic cause identified, of which 15 kindreds fulfilled the criteria for familial CRC type X (FCCTX).

CONCLUSIONS

Founder mutations accounted for only 2.1% of cases and this was insufficient to explain the high rate of familial CRC. Many of the families classified as FCCTX may have highly penetrant mutations segregating in a Mendelian-like manner. These families will be important for identifying additional CRC susceptibility loci.

Thoron: its metrology, health effects and implications for radon epidemiology: a summary of roundtable discussions

A roundtable discussion was made at the end of the workshop. All the presentations were summarised in this discussion. It involved measurement techniques, quality assurance and dose assessment and health effects of thoron and its progeny. In particular, major epidemiological studies may be affected by thoron interference in radon measurements. Since their data are not sufficient when compared with that of radon, further efforts in thoron studies will be needed.

Children's participation in health research: from objects to agents?

BACKGROUND

In the UK, there is a growing recognition of the need to include children's accounts in research on paediatric health care. This paper seeks to examine ways in which children have been included in health-related studies to identify strengths and weaknesses.

METHODS

Key empirical based studies were identified via comprehensive searches of academic literature databases to exemplify research practices related to three ways of engaging with children in health-related research. These three approaches are summarized as research on children, with children and by children.

RESULTS

Research on children engages with adult 'authorities', such as parents and medical professionals. This approach allows some access to children including those understood as hard-to-reach: for example, pre-speech infants, or children with complex developmental disabilities. Research with children includes children as respondents to engage directly with their own understandings. This may be achieved alongside adult representatives, or by focusing only on the children themselves. Research by children encourages children to participate in the research process itself. This may occur across any, or indeed, every stage from design to dissemination to enable children to set the agenda themselves. Each of the three approaches has strengths and weaknesses, and involves some form of adult-mediation.

CONCLUSION

Inclusion of children's perspectives can be achieved, at varying levels, in each approach (on, with and by) examined here. Although claims to authority around including children's perspectives may appear to hold more credence when children have directly participated in the research, there may be times when this is neither possible nor appropriate. Researchers are challenged to be open and reflexive about ways in which children are engaged with, incorporated in and represented across the many stages of research. Whichever approach is taken, ethical issues and notions of equity remain problematic. This point holds particular resonance for ways in which ethics around children may be considered in National Health Service ethics governance processes.

Practice parameter: pharmacologic treatment of spasticity in children and adolescents with cerebral palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society

OBJECTIVE

To evaluate published evidence of efficacy and safety of pharmacologic treatments for childhood spasticity due to cerebral palsy.

METHODS

A multidisciplinary panel systematically reviewed relevant literature from 1966 to July 2008.

RESULTS

For localized/segmental spasticity, botulinum toxin type A is established as an effective treatment to reduce spasticity in the upper and lower extremities. There is conflicting evidence regarding functional improvement. Botulinum toxin type A was found to be generally safe in children with cerebral palsy; however, the Food and Drug Administration is presently investigating isolated cases of generalized weakness resulting in poor outcomes. No studies that met criteria are available on the use of phenol, alcohol, or botulinum toxin type B injections. For generalized spasticity, diazepam is probably effective in reducing spasticity, but there are insufficient data on its effect on motor function and its side-effect profile. Tizanidine is possibly effective, but there are insufficient data on its effect on function and its side-effect profile. There were insufficient data on the use of dantrolene, oral baclofen, and intrathecal baclofen, and toxicity was frequently reported.

RECOMMENDATIONS

For localized/segmental spasticity that warrants treatment, botulinum toxin type A should be offered as an effective and generally safe treatment (Level A). There are insufficient data to support or refute the use of phenol, alcohol, or botulinum toxin type B (Level U). For generalized spasticity that warrants treatment, diazepam should be considered for short-term treatment, with caution regarding toxicity (Level B), and tizanidine may be considered (Level C). There are insufficient data to support or refute use of dantrolene, oral baclofen, or continuous intrathecal baclofen (Level U).