The treatment effect of rivaroxaban on clot characteristics in patients who present acutely with first time deep vein thrombosis

BACKGROUND

The acute vascular disease deep vein thrombosis (DVT) requires oral anticoagulants to prevent progression. Monitoring therapeutic efficacy of direct oral anticoagulants (DOAC), including rivaroxaban, is problematic as no reliable test is available. Advances in rheometry have led to the development of a functional coagulation biomarker using Gel Point (GP) analysis which assesses clot structure formation. The biomarker measures incipient clot formation time (TGP) and quantifies fibrin clot structure in terms of fractal dimension (df).

OBJECTIVE

This study aimed to investigate clot structure formation in first time DVT and the effect of rivaroxaban treatment.

METHODS

This prospective observational cohort study measured the GP and standard laboratory markers at three sample points: pre-treatment and at 20 and 60 days following 15 mg BD and 20 mg OD rivaroxaban respectively.

RESULTS

Forty DVT patients (mean age 64 years [SD±14.8]; 23 males, 17 female) were recruited. The results show that DVT vs non-DVT patients did not have a significantly different GP profile (df: 1.72±0.06 vs 1.70±0.06 and TGP: 267±68 sec vs 262±73 sec) with both within the defined healthy index. In addition, rivaroxaban therapy increased TGP to 392 s (±135 s) after 20 days, and subsequently increased to 395 s (±194 s) at 60 days but did not significantly increase df (from 1.69±0.05 to 1.71±0.06).

CONCLUSIONS

The results indicate in this cohort of DVT patients there was no underlying hypercoagulable effect as determined by gel point analysis. Furthermore, the anticoagulant effect of rivaroxaban prolonged clotting, suggesting a protective effect against clot formation, without significantly reducing clot microstructural properties.

A case-control study of risk factors for wound infection in a colorectal unit

INTRODUCTION

Postoperative wound infections have been responsible for increasing morbidity and are associated with an increased use of hospital resources. Previous studies have identified several risk factors. However, most studies are outdated, and few relate to the era of enhanced recovery and laparoscopic surgery. This study investigated the association between patient and operative factors and the development of postoperative wound infections in colorectal surgery.

METHODS

Patients with documented wound infections or dehiscences were identified from a database of elective and emergency colorectal surgery. Patients with wound infections were matched by operation type to a control group of colorectal patients. Differences in patient and operative factors between case and control group were analysed using conditional logistic regression.

RESULTS

A total of 56 patients with wound infection were identified from 647 operations (8.6%). Fifty-seven per cent were emergency operations and eighty-eight per cent were performed as open surgery or as laparoscopic surgery converted to open. Forty per cent of patients had high ASA (American Society of Anesthesiologists) grades (3 or 4). Multivariate logistical regression showed that obese patients and those having open surgery had the highest risk of infections. The median postoperative hospital stay for patients with wound infections was twice as long as for those patients without wound infections.

CONCLUSIONS

Open surgery and obesity are independent risk factor for wound infections. An increase in laparoscopically performed operations and new strategies for managing wounds in obese patients may help to reduce the rate of wound infection.

Cronobacter species (formerly known as Enterobacter sakazakii) in powdered infant formula: a review of our current understanding of the biology of this bacterium

Cronobacter species (formerly known as Enterobacter sakazakii) are opportunistic pathogens that can cause necrotizing enterocolitis, bacteraemia and meningitis, predominantly in neonates. Infection in these vulnerable infants has been linked to the consumption of contaminated powdered infant formula (PIF). Considerable research has been undertaken on this organism in the past number of years which has enhanced our understanding of this neonatal pathogen leading to improvements in its control within the PIF production environment. The taxonomy of the organism resulted in the recognition of a new genus, Cronobacter, which consists of seven species. This paper presents an up-to-date review of our current knowledge of Cronobacter species. Taxonomy, genome sequencing, current detection protocols and epidemiology are all discussed. In addition, consideration is given to the control of this organism in the manufacturing environment, as a first step towards reducing the occurrence of this pathogen in PIF.

Development and testing of a theory-based behavioural change intervention: a pilot investigation in a nursery school in a deprived area of Scotland

OBJECTIVE

Investigate the effect of a theory-based intervention on oral-health knowledge, attitudes and behaviours of early years staff (EYS), parents and nursery children.

METHODS

Qualitative research with staff and parents from eight nurseries through interviews/focus groups. An intervention was developed and piloted using pre-posttest design.

CLINICAL SETTING

Nurseries in deprived communities in Dundee, Scotland.

PARTICIPANTS

111 children aged 3-5 years attending nursery, including 79 parents and 8 nursery staff.

INTERVENTIONS

Staff session targeted outcome expectancies, subjective norms and self-efficacy for tooth-brushing in nursery using information provision, modelling and goal-setting, followed by a three-week intervention. Parent-child dyads received a leaflet with instructions for goal-setting, planning and monitoring home brushing. Tooth-brushing self-monitoring materials (e.g. two-minute timer, diaries) were used and certificates provided in the nursery as rewards.

OUTCOME MEASURES

EYS knowledge, attitudes and behaviours were assessed before and after the intervention using self-report questionnaires. Parents completed interviews assessing beliefs about tooth-brushing and their children's tooth-brushing behaviour at baseline and post-intervention follow-up.

RESULTS

Significant improvements in staff knowledge, but not attitudes, self-efficacy, or nursery tooth-brushing were reported. Parent-child dyads completing the intervention were not more likely to report their child carried out twice-daily tooth-brushing at home. The intervention did not improve parents' intentions to brush their child's teeth twice a day or beliefs about the ease of twice-daily tooth-brushing.

CONCLUSION

Only past behaviour significantly predicted posttest brushing. Parents who found brushing easier at baseline were more likely to complete the intervention. Recommendations are made regarding implementing psychological theory and methods into oral-health interventions.

Comparison of outcomes after transplantation of peripheral blood stem cells versus bone marrow following an identical nonmyeloablative conditioning regimen

This is the first study to examine the outcomes in 54 patients with hematologic malignancies who received an HLA-matched related donor bone marrow (BM, n = 42) or GCSF-mobilized peripheral blood stem cells (PBSC, n = 12) following identical nonmyeloablative conditioning with the intention of induction of mixed chimerism (MC) followed by prophylactic donor leukocyte infusion (pDLI) to convert MC to full donor chimerism (FDC) and capture a graft-versus-tumor effect without clinical graft-versus-host disease (GVHD). Neutrophil and platelet recovery were faster and transfusion requirement was less in PBSC recipients (P < 0.05). A total of 48% of BMT recipients achieved FDC with a median conversion time of 84 days, including 13 following pDLI. In contrast, 83% (P = 0.04) in the PBSC group had spontaneous FDC at a median of 14 days, precluding the administration of pDLI. There was no significant difference in the incidences of acute or chronic GVHD, though the rates of chronic GVHD were considerably higher in PBSC group than in the BM group (6/7, 86% vs 10/24, 42%). CD4 and CD8 T-cell recovery was faster in PBSC recipients. In PBSC recipients, a higher number of CD34+ cells was associated with increased rates of severe, grade III-IV acute GVHD.

Myeloma responses and tolerance following combined kidney and nonmyeloablative marrow transplantation: in vivo and in vitro analyses

Six patients with renal failure due to multiple myeloma (MM) received simultaneous kidney and bone marrow transplantation (BMT) from HLA-identical sibling donors following nonmyeloablative conditioning, including cyclophosphamide (CP), peritransplant antithymocyte globulin and thymic irradiation. Cyclosporine (CyA) was given for approximately 2 months posttransplant, followed by donor leukocyte infusions. All six patients accepted their kidney grafts long-term. Three patients lost detectable chimerism but accepted their kidney grafts off immunosuppression for 1.3 to >7 years. One such patient had strong antidonor cytotoxic T lymphocyte (CTL) responses in association with marrow rejection. Two patients achieved full donor chimerism, but resumed immunosuppression to treat graft-versus-host disease. Only one patient experienced rejection following CyA withdrawal. He responded to immunosuppression, which was later successfully withdrawn. The rejection episode was associated with antidonor Th reactivity. Patients showed CTL unresponsiveness to cultured donor renal tubular epithelial cells. Initially recovering T cells were memory cells and were enriched for CD4+CD25+ cells. Three patients are in sustained complete remissions of MM, despite loss of chimerism in two. Combined kidney/BMT with nonmyeloablative conditioning can achieve renal allograft tolerance and excellent myeloma responses, even in the presence of donor marrow rejection and antidonor alloresponses in vitro.

Predicting outcome after appendicectomy

AIM

To validate an intraoperative appendicitis severity score (IASS) and examine outcome following emergency appendectomy.

METHODS

A prospective study was undertaken, enrolling consecutive patients undergoing emergency appendicectomy. Data were obtained independently on preoperative Alvarado scores, IASS (0-3: 0 no inflammation, 1 engorged appendix/no peritonitis, 2 peritoneal reaction/exudate or 3 evidence of perforation/abscess) and postoperative outcome parameters.

RESULTS

There were 149 patients identified with a mean age of 20.7 years. There was no association between Alvarado score and length of hospital stay, septic complication, patient sex or duration of symptoms (p>0.05). IASS was found to be an independent risk factor for septic complication, wound infection (p<0.05) and length of hospital stay (p<0.001). There was no correlation between preoperative duration of symptoms or time until surgery and intraoperative score.

CONCLUSIONS

This simple scoring system can identify patients more likely to suffer morbidity following emergency appendicectomy. Specifically, this system identifies patients who have a high risk of sepsis and therefore could be of use when comparing healthcare performance.

Early intervention for relapse in schizophrenia: results of a 12-month randomized controlled trial of cognitive behavioural therapy

BACKGROUND

The paper describes a randomized controlled trial of targeting cognitive behavioural therapy (CBT) during prodromal or early signs of relapse in schizophrenia. We hypothesized that CBT would result in reduced admission and relapse, reduced positive and negative symptoms, and improved social functioning.

METHOD

A total of 144 participants with schizophrenia or a related disorder were randomized to receive either treatment as usual (TAU) (N = 72) or CBT+TAU (N = 72). Participants were prospectively followed up between entry and 12 months.

RESULTS

At 12 months, 11 (15.3%) participants in the CBT group were admitted to hospital compared to 19 (26.4%) of the TAU group (hazard ratio = 0.53, P = 0.10, 95% CI 0.25, 1.10). A total of 13 (18.1%) participants in CBT relapsed compared to 25 (34.7%) in TAU (hazard ratio = 0.47, P < 0O05, 95% CI 0.24, 0.92). In addition, the CBT group showed significantly greater improvement in positive symptoms, negative symptoms, global psychopathology, performance of independent functions and prosocial activities.

CONCLUSIONS

The study provides evidence for the feasibility and effectiveness for targeting CBT on the appearance of early signs of relapse in schizophrenia. The results are discussed in context of the study's methodological limitations.

Challenges, benefits and pitfalls of the independent laboratory process

During 1998 Sydney's drinking water supply system experienced three contamination events in quick succession. These events were revealed by routine monitoring, which indicated the presence of large numbers of Cryptosporidium and Giardia in raw and treated water. Questions were raised regarding the validity of the results produced by Sydney Water's laboratory, Australian Water Technology. In response to the incident a NSW Government Inquiry was carried out which made a range of recommendations, one of which was that "A suitably qualified independent laboratory should be established to provide accurate data for regulatory authorities." The NSW Department of Health (DOH) was given the responsibilty for interpretation and implementation of this recommendation. The role of Independent Laboratory was awarded to the Australian Water Quality Centre (AWQC) and monthly program of duplicate sample analysis was established. The implementation of the program and interpretation of the results have provided a challenge for all parties involved. A protocol was developed which defined conditions under which differences in results from the two laboratories were to be investigated. Over the time period of the Independent Laboratory process there has been only one occasion where a difference between results, as defined by the protocol, has been seen. The process has provided additional assurance of quality control procedures for the laboratories. The future role of the process will need to be readdressed in light of the results of the previous 18 months and as changes in the area of testing methodologies occur.

Effects of hyperbaric (6 ATA) pressure on voluntary and evoked skeletal muscle contractile properties

The objective of this study was to investigate the effect of 6 atmospheres of pressure (ATA) on plantar flexors' (PF) voluntary force and activation, force-frequency characteristics, and rate of torque development (RTD). Eight subjects performed PF isometric contractions. Muscle activation was monitored by electromyographic (EMG) activity (PF and dorsiflexors) and the interpolated twitch technique (ITT). Maximal evoked contractions of the PF were elicited at 1, 2, 3, 5, 10, 20, and 40 Hz. PF RTD was calculated with maximal voluntary, 1 and 40 Hz contractions. Hyperbaric pressures significantly decreased PF voluntary torque; 6.2%, ITT activation; 2.8% with a trend for a 19.1% decrease in EMG (p = 0.1). There were no significant differences in the dorsiflexors/PF EMG ratio. One Hz torque was potentiated 15.7% with an increased absolute RTD of 12.8%, but no change in relative RTD. The results suggested hyperbaric-induced decreases in PF activation contributed to voluntary torque loss. A lack of torque reduction with higher frequency tetanic stimulation (2-40 Hz) suggested that 6 ATA does not impair myofilament kinetics, whereas twitch potentiation may include changes in excitation-contraction coupling.

Intermuscle differences in activation

The objective of this study was to investigate differences within individual subjects in the ability to activate the quadriceps, plantar flexors (PF), dorsiflexors (DF), and elbow flexors (EF) during isometric contractions. Twelve male subjects performed submaximal and maximal voluntary isometric contractions, and maximal tetanic contractions were also induced by electrical stimulation. The interpolated twitch technique was used to gauge the extent of muscle inactivation or inability to produce maximum force. Measurements included torque output, absolute and relative rate of force development (RFD), and percentage of muscle inactivation. The quadriceps exceeded all other muscle groups in voluntary and tetanic torque output, voluntary absolute RFD, and absolute and relative tetanic RFD. The quadriceps also exceeded the PF and DF in voluntary relative RFD and had greater muscle inactivation (15.5%) than the EF (5.0%), PF (5.0%), and DF (1.3%). Although the higher RFD may suggest a higher percentage of type II fibers in the quadriceps, their higher threshold of recruitment leads to greater difficulty in fully activating the quadriceps.

Comparison of interpolation and central activation ratios as measures of muscle inactivation

The objective of this study was to investigate different methods of estimating muscle inactivation, derived from single and multiple voluntary contractions. Ten subjects performed maximal and submaximal leg extensor contractions to determine an interpolation (IT) or central activation ratio (CAR). A superimposed evoked force was compared with the force output of either a voluntary (CAR) or resting evoked contraction (IT ratio), or the ratios were inserted into regression equations (linear, polynomial, exponential). Linear-regression estimates of CAR using doublets and tetanus provided physiologically inaccurate values. Whereas IT ratios using doublets (IT-doublet) and tetanus (IT-tetanus) had a significant difference in only one interaction, IT-tetanus and CAR using a tetanus (CAR-tetanus) estimates provided the most extensive correlation within and between measures. Thus, tetanic stimulation superimposed upon single maximal or multiple contractions seems to provide the most valid measure of muscle inactivation when using the interpolated-twitch technique.

The interaction of perceived maternal and paternal parenting styles and their relation with the psychological distress and offending characteristics of incarcerated young offenders

A shortened form of the Parental Bonding Instrument (PBI) (Pederson, 1994) was used to examine the relationship between parenting styles and the psychological distress and offending patterns of a group of young male offenders held in custody in Scotland. High levels of psychological distress were linked with low parental care, but there was no association between psychological distress and parental control. Parental care was not a distinguishing factor in offending patterns, although high paternal control was linked with a younger age of first arrest. When interactions of paternal and maternal parenting styles were examined, young offenders who perceived poor parenting (i.e. neglectful parenting or affectionless control) from both parents had the highest levels of psychological distress overall.

Case-control study of GP attendance rates by suicide cases with or without a psychiatric history

BACKGROUND

Targets for reduction in suicide deaths have been set against a background of an increasing number of people committing suicide. It is often assumed that a reduction can be effected by increasing the detection in primary care of patients at risk. This presupposes that there are indicators that enable suicide risk to be detected reliably.

AIM

To compare the characteristics of those who commit suicide with an age- and sex-matched control group in terms of level of general practitioner attendance, diagnosis and pharmacological treatment of mental illness, and to compare those suicides with and without a psychiatric history in terms of general practitioner attendance and history of pharmacological treatment.

METHOD

From a total of 48 deaths attributed to suicide and undetermined causes in the Forth Valley in 1993, general practice case notes were located for 41. Live controls were matched to index cases by age, sex and practice. Information on consultations, referrals to secondary care, medication and diagnoses in the previous 10 years was extracted from general practice and, for suicides, psychiatric case notes.

RESULTS

Over the 10-year period, suicide patients attended their general practitioner at a higher level than control subjects. However, the number of suicide patients who attended their general practitioner in the month before their death did not differ in comparison with control subjects over a similar period. Suicide cases, in comparison with control subjects, were more likely to have received a psychiatric diagnosis from their general practitioner, been prescribed psychotropic medication and received referral to specialist mental health services. Those suicide patients with a psychiatric history had a significantly higher number of general practitioner consultations than those without a psychiatric history in four out of the five years preceding death. Those suicide patients without a psychiatric history did not differ significantly from control subjects on any of the variables assessed.

CONCLUSION

For those people committing suicide who do not have a psychiatric history and whose consultation patterns do not differ from the norm, it is difficult to suggest how general practitioners might improve their detection of relevant suicidal risk factors. For those patients with a psychiatric history who commit suicide, until we have more detailed information regarding the specific content of general practitioner's consultations before death and how these differed from other consultations of the deceased, then it is premature to assume that general practitioners are failing to identify indicators of impending suicide.

Transcortical and cervical magnetic stimulation with recording of the diaphragm

Transcortical and cervical magnetic stimulation is a potential method of examining the central inspiratory pathway to phrenic motor neurons. The reliability and accuracy of this technique were studied. We performed magnetic stimulations of the cortex and cervical spinal cord with recording from both hemidiaphragms in 35 normal subjects using two different stimulation coils (90-mm circular coil and 70-mm figure-of-eight coil). Needle electrode recordings and ultrasound real-time documentation in 2 subjects excluded volume-conducted contaminations from adjacent chest wall and abdominal muscles. The effect of diaphragmatic facilitation (stimulation at the end of a deep breath) on latency, and amplitude were compared to the effect of hypothenar muscle facilitation. Normal ranges were established for: latency; central motor conduction time; amplitude; amplitude ratio between between peripheral and both cortical and cervical amplitude; and excitability threshold. The latencies were similar for both coils. The amplitudes were significantly higher, and excitability thresholds significantly lower for the 90-mm circular coil, indicating that this coil is preferable for transcortical diaphragmatic stimulations. The effect of facilitation was greater for hypothenar than diaphragmatic recordings. There was excellent right-left agreement for all measurements. Transcortical and cervical magnetic stimulation with recording from the diaphragm can be used routinely to diagnose and monitor patients with impaired central respiratory drive.

Human hydatidosis in New South Wales and the Australian Capital Territory, 1987-1992

OBJECTIVE

To determine the prevalence of human hydatidosis in New South Wales and the Australian Capital Territory.

METHODS

Data on human hydatid infection occurring between 1987 and 1992 were collected retrospectively from 25 hospitals and 13 health services in New South Wales and four hospitals in the Australian Capital Territory. Mean annual prevalences of human hydatidosis were determined for shires in eastern New South Wales and data on infection in immigrants and Australian-born patients were compared.

RESULTS

321 patients were diagnosed with hydatid disease, 1987-1992; 195 were new cases and 117 readmissions (nine cases were not identified as new or recurrent). Most patients lived in the eastern half of New South Wales (which includes the Australian Capital Territory), half in rural areas and half in the major coastal cities. Most Australian-born rural patients lived in 39 shires in the north-eastern and south-eastern Tablelands. Sixty per cent of the patients in major cities were born overseas.

CONCLUSIONS

Hydatid infection occurs more commonly in south-eastern Australia than the official figures suggest. In rural areas of the north-eastern and south-eastern Tablelands hydatid infection is of public health importance. The national notification system must be improved and control campaigns alerting the public to the dangers of hydatid infection promoted.

Initial experience with single lead VDD system. Case study

A single pass lead with dual chamber electrode system, designed for atrial and ventricular sensing and ventricular pacing (VDD), was implanted in a 63-year-old man with a history of syncope and second degree atrioventricular (AV) block. Intact VDD pacing function was confirmed at rest and during treadmill exercise. There were no postoperative complications. A single pass lead system that allows VDD mode pacing in patients with symptomatic AV block and competent sinus node function offers several advantages over traditional two lead dual chamber systems. These advantages include enhanced atrial sensing due to a differentially processed signal reliable for P wave detection and effective for rejection of far field ventricular signals, lowered cost and reduced implant time.

Börjeson-Forssman-Lehmann syndrome: clinical manifestations and gene localization to Xq26-27

We have studied 7 males in one family with mild/moderate intellectual handicap, long thick ears, deep-set eyes, small testes, and post pubertal gynecomastia. The affected males and some of the heterozygous females also had tapering fingers and short, widely spaced flexed toes. The pedigree demonstrates X-linked recessive inheritance. The clinical manifestations are similar to those described in the Börjeson-Forssman-Lehmann (BFL) syndrome but differ in the degree of mental handicap and the absence of "dwarfism" and microcepaly. This milder manifestation may represent either phenotypic or genotypic variation. DNA marker studies demonstrated linkage to the DXS86, DXS51, and F9 cluster at Xq26-q27. The maximum lod score was 2.1 with DXS51, at theta = 0.0. Definite recombinants were observed between DXS10 (at Xq26 but proximal to DXS86), DXS105 (at Xq27 but distal to F9), and BFL. Thus, the regional localization for BFL is Xq26-q27 between DXS10 and DXS105.