Risk factors for loss to follow-up after traumatic injury: An updated view of a chronic problem

BACKGROUND

Loss to follow-up after traumatic injury occurs at rates of up to 47%. However, the most recent data are over a decade old, and recent changes in traumatic injury patterns necessitate an updated assessment of risk factors for loss to follow-up after trauma.

METHODS

We conducted a retrospective chart review of trauma admissions from January 1, 2018 to December 31, 2021. Categorical variables were compared using χ2 analyses, and continuous variables were analyzed using Mann-Whitney Wilcoxon tests. Multivariable logistic regression was used to adjust for relevant factors identified on unadjusted analysis.

RESULTS

Among 3,034 patients, overall loss to follow-up was 36.9%. Non-White patients, patients who underwent operations or non-surgical procedures, and patients discharged to rehabilitation facilities were more likely to have follow-up appointments within 30 days. Patients with substance use disorder and, among White patients, those with public insurance had higher loss to follow-up rates. Having a follow-up appointment scheduled with a primary care provider was the single most significant factor associated with attending a follow-up appointment.

CONCLUSION

Social determinants of health, such as insurance status and substance use disorder, are associated with loss of follow-up after trauma. Primary care appointments are associated with the highest attendance rates, supporting that all patients should be offered primary care appointments after traumatic injury.

Patients Lost to Follow-up After Injury: Who are They and What are Their Long-Term Outcomes?

INTRODUCTION

Trauma patients are at high risk for loss to follow-up (LTFU) after hospital discharge. We sought to identify risk factors for LTFU and investigate associations between LTFU and long-term health outcomes in the trauma population.

METHODS

Trauma patients with an Injury Severity Score ≥9 admitted to one of three Level-I trauma centers, 2015-2020, were surveyed via telephone 6 mo after injury. Univariate and multivariate analyses were performed to assess factors associated with LTFU and several long-term outcomes.

RESULTS

Of 3609 patients analyzed, 808 (22.4%) were LTFU. Patients LTFU were more likely to be male (71% versus 61%, P = 0.001), Black (22% versus 14%, P = 0.003), have high school or lower education (50% versus 42%, P = 0.003), be publicly insured (23% versus 13%, P < 0.001), have a penetrating injury (13% versus 8%, P = 0.006), have a shorter length of stay (3.64 d ± 4.09 versus 5.06 ± 5.99, P < 0.001), and be discharged home without assistance (79% versus 50%, P < 0.001). In multivariate analyses, patients who followed up were more likely to require assistance at home (6% versus 11%; odds ratio [OR] 2.23, 1.26-3.92, P = 0.005), have new functional limitations (11% versus 26%; OR 2.91, 1.97-4.31, P = < 0.001), have daily pain (30% versus 48%; OR 2.11, 1.54-2.88, P = < 0.001), and have more injury-related emergency department visits (7% versus 10%; OR 1.93, 1.15-3.22, P = 0.012).

CONCLUSIONS

Vulnerable populations are more likely to be LTFU after injury. Clinicians should be aware of potential racial and socioeconomic disparities in follow-up care after traumatic injury. Future studies investigating improvement strategies in follow-up care should be considered.

Characteristics of Litigations Involving Contact Dermatitis: An Exploratory Analysis

Background: Contact dermatitis (CD) is one of the most common skin disorders, occurring in >20% of patients worldwide. Estimated cost burden for CD in the United States approaches $1 billion annually. Objective: To describe characteristics of litigation among patients with CD. Methods: Westlaw legal database for U.S. lawsuits was queried for lawsuits between the years 1983 and 2021 containing the keywords "dermatitis or eczema." Each lawsuit associated with CD was analyzed by plaintiff demographics, verdict, prosecution reason, payouts, and allergen implicated. Results: Of 98 cases, 61 met the inclusion criteria. Verdicts issued favored plaintiffs (42.6%) more than defendants (32.8%) with the remaining cases decided through settlements. If payout occurred, the mean was $246,310 (standard deviation [SD] = $798,536), the median was $20,000 (Q1 = $8,500, Q3 = $88,725, interquartile range = $80,225). The top reason for litigation was toxic exposure (n = 38, 62.2%), and common contact allergens associated with lawsuits were latex (n = 4, 20%), surgical tape (n = 4, 20%), and beauty products (n = 4, 20%). Conclusion: Common allergens associated with lawsuits include latex, surgical tape, and beauty products. Most CD cases adjudicated in the United States since 1983 are associated with toxic exposures.

Determinants of long-term physical and mental health outcomes after intensive care admission for trauma survivors

INTRODUCTION

Collectively, studies from medical and surgical intensive care units (ICU) suggest that long-term outcomes are poor for patients who have spent significant time in an ICU. We sought to identify determinants of post-intensive care physical and mental health outcomes 6-12 months after injury.

METHODS

Adult trauma patients [ISS ≥9] admitted to one of three Level-1 trauma centers were interviewed 6-12 months post-injury to evaluate patient-reported outcomes. Patients requiring ICU admission ​≥ ​3 days ("ICU patients") were compared with those who did not require ICU admission ("non-ICU patients"). Multivariable regression models were built to identify factors associated with poor outcomes among ICU survivors.

RESULTS

2407 patients were followed [598 (25%) ICU and 1809 (75%) non-ICU patients]. Among ICU patients, 506 (85%) reported physical or mental health symptoms. Of them, 265 (52%) had physical symptoms only, 15 (3%) had mental symptoms only, and 226 (45%) had both physical and mental symptoms. In adjusted analyses, compared to non-ICU patients, ICU patients were more likely to have new limitations for ADLs (OR ​= ​1.57; 95% CI ​= ​1.21, 2.03), and worse SF-12 mental (mean Δ ​= ​-1.43; 95% CI ​= ​-2.79, -0.09) and physical scores (mean Δ ​= ​-2.61; 95% CI ​= ​-3.93, -1.28). Age, female sex, Black race, lower education level, polytrauma, ventilator use, history of psychiatric illness, and delirium during ICU stay were associated with poor outcomes in the ICU-admitted group.

CONCLUSIONS

Physical impairment and mental health symptoms following ICU stay are highly prevalent among injury survivors. Modifiable ICU-specific factors such as early liberation from ventilator support and prevention of delirium are potential targets for intervention.

Timeliness of Lung Cancer Care From the Point of Suspicious Image at an Urban Safety Net Hospital

BACKGROUND

Timeliness of care is an important metric for lung cancer patients, and care delays in the safety-net setting have been described. Timeliness from the point of the suspicious image is not well-studied. Herein, we evaluate time intervals in the workup of lung cancer at an urban, safety net hospital and assess for disparities by demographic and clinical factors.

PATIENTS AND METHODS

We performed a retrospective analysis of lung cancer patients receiving some portion of their care at Boston Medical Center between 2015 and 2020. A total of 687 patients were included in the final analysis. Median times from suspicious image to first treatment (SIT), suspicious image to diagnosis (SID), and diagnosis to treatment (DT) were calculated. Nonparametric tests were applied to assess for intergroup differences in time intervals.

RESULTS

SIT, SID, and DT for the entire cohort was 78, 34, and 32 days, respectively. SIT intervals were 87 days for females and 72 days for males (p < .01). SIT intervals were 106, 110, 81, and 41 days for stages I, II, III, and IV, respectively (p < .01). SID intervals differed between black (40.5) and Hispanic (45) patients compared to white (28) and Asian (23) patients (p < .05).

CONCLUSION

Advanced stage at presentation and male gender were associated with more timely treatment from the point of suspicious imaging while white and Asian were associated with more timely lung cancer diagnosis. Future analyses should seek to elucidate drivers of timeliness differences and assess for the impact of timeliness disparities on patient outcomes in the safety net setting.

The impact of 10-valent pneumococcal vaccine introduction on invasive disease in Fiji

BACKGROUND

In 2012, Fiji introduced the 10-valent pneumococcal conjugate vaccine (PCV10). We assessed the impact of PCV10 on invasive pneumococcal disease (IPD), probable bacterial or pneumococcal meningitis (PBPM), meningitis and sepsis 3-5 years post-introduction.

METHODS

Laboratory-confirmed IPD and PBPM cases were extracted from national laboratory records. ICD-10-AM coded all-cause meningitis and sepsis cases were extracted from national hospitalisation records. Incidence rate ratios were used to compare outcomes pre/post-PCV10, stratified by age groups: 1-23m, 2-4y, 5-9y, 10-19y, 20-54y, ≥55y. To account for different detection and serotyping methods in the pre-and post-PCV10 period, a Bayesian inference model estimated serotype-specific changes in IPD, using pneumococcal carriage and surveillance data.

FINDINGS

There were 423 IPD, 1,029 PBPM, 1,391 all-cause meningitis and 7,611 all-cause sepsis cases. Five years post-PCV10 introduction, IPD declined by 60% (95%CI: 37%, 76%) in children 1-23m months old, and in age groups 2-4y, 5-9y, 10-19y although confidence intervals spanned zero. PBPM declined by 36% (95%CI: 21%, 48%) among children 1-23 months old, and in all other age groups, although some confidence intervals spanned zero. Among children <5y of age, PCV10-type IPD declined by 83% (95%CI; 70%, 90%) and with no evidence of change in non-PCV10-type IPD (9%, 95%CI; -69, 43%). There was no change in all-cause meningitis or sepsis. Post-PCV10, the most common serotypes in vaccine age-eligible and non-age eligible people were serotypes 8 and 23B, and 3 and 7F, respectively.

INTERPRETATIONS

Our study demonstrates the effectiveness of PCV10 against IPD in a country in the Asia-Pacific of which there is a paucity of data.

FUNDING

This study was support by the Department of Foreign Affairs and Trade of the Australian Government and Fiji Health Sector Support Program (FHSSP). FHSSP is implemented by Abt JTA on behalf of the Australian Government.

POS0406 miRNAs DEREGULATED IN RESPONSE TO IL17A INHIBITORS IN PSORIATIC ARTHRITIS REGULATE GENE PRODUCTS IN Rho-GTPase PATHWAYS

Background:

Using transcriptomic data at initiation of therapy, we recently identified differentially expressed genes (DEGs) that separated IL-17Ai response from non-response1. Integration of cell-type-specific DEGs with protein-protein interactions (PPIs) and further comprehensive pathway enrichment analysis revealed Rho GTPase signaling pathway exhibited a strong signal specific to IL-17Ai response and particularly the genes, RAC1 and ROCKs.

Objectives:

To characterize microRNA (miR) profiles among IL-17Ai responders and non-responders, as it relates to RHO GTPase pathway.

Methods:

We interrogated 20 psoriatic arthritis (PsA) patients initiating IL-17Ai. Patients achieving at least low disease activity according to the Disease Activity Index for PsA (DAPSA) at three months were classified as responders. There were seven responders (35%) and thirteen non-responders (65%) in the IL-17Ai group, with biologic treatment naïve (bio-naïve) and previously-exposed (bio-exposed) patients exhibiting a 50% (4/8) and a 25% (3/12) response rate, respectively. For the miR analysis, CD4 positive T cells were isolated from peripheral blood mononuclear cells using DynabeadsTM CD4 beads (ThermoFisher). Total RNA was extracted from the CD4+ T cells using Lexogen’s Split RNA Extraction Kit (D-Mark Biosciences). Libraries were prepared from 200ng total RNA with the NEXTFLEX Small RNA-Seq Kit v3 with UDIs (Bioo Scientific) and sequenced on the Illumina NovaSeq 6000. Raw sequencing fastq data assessed the quality using FastQC. The miRDeep2 was used to trim the adapter, align and quantify human mature miRs from miRbase (Release 22). The abundance of miRs was converted to read counts per million, normalized and limma R package was used to identify pre- and post-differentially expressed miRs.

Results:

We obtained 2,889 miRs. After removing miRs with low reads in >90% of samples, 1902 high quality miRs remained for further analysis. Using mirDIP v4.1 we identified gene targets for differential miRs, and focused on recently identified DEGs related to RHO GTPase pathway. The miRs on the left of the figure 1 are those deregulated in pre-treatment, and the miRs on the right of the figure 1 show the post-treatment deregulated miRs. hsa-miR-3691-5p and hsa-miR-3161 represent the miRs that were deregulated in both conditions. The red highlighted nodes represent the most connected miRs and genes; thus, representing miRs that are the most RHO-pathway centric regulators (hsa-miR-495-3p, 16-5p, 129-5p, 520h, 520g-3p), and genes representing the most strongly regulated RHO-pathway gene products (ROCK1, RHOQ, PFN2, TAOK1, DYNC1L12, MAPRE1, PAFAH1B1, ARHGAP5, MAPK1, CALM1, DIAPH2, PKN2, ITSN1).

Conclusion:

Pre- and post-treatment differential miRs related to IL-17Ai response regulate multiple genes from RHO GTPase pathway.

References:

[1]Rahmati S, O’Rielly DD, Li Q, Codner D, Dohey A, Jenkins K, Jurisica I, Gladman DD, Chandran V, Rahman P. Rho-GTPase pathways may differentiate treatment response to TNF-alpha and IL-17A inhibitors in psoriatic arthritis. Sci Rep. 2020 Dec 10;10(1):21703.

Figure 1.

Disclosure of Interests:

Proton Rahman Speakers bureau: AbbVie, Amgen, BMS, Celgene, Eli Lily, Janssen, Merck, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, BMS, Celgene, Eli Lily, Janssen, Merck, Novartis, Pfizer, UCB, Grant/research support from: Janssen, Novartis, Quan Li: None declared, Dianne Codner: None declared, Darren O’Rielly: None declared, Amanda Dohey: None declared, Kari Jenkins: None declared, Dafna D Gladman Speakers bureau: AbbVie, Amgen, BMS, Eli Lily, Galapagos, Gilead, Janssen, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, BMS, Eli Lily, Galapagos, Gilead, Janssen, Novartis, Pfizer, UCB, Grant/research support from: AbbVie, Amgen, Eli Lily, Janssen, Novartis, Pfizer, UCB, Vinod Chandran Speakers bureau: AbbVie, Amgen, BMS, Eli Lily, Janssen, Novartis, Pfizer, UCB, Paid instructor for: AbbVie, Amgen, BMS, Eli Lily, Janssen, Novartis, Pfizer, UCB, Grant/research support from: AbbVie, Amgen, Eli Lily, Employee of: Spousal Employment Eli Lilly, Igor Jurisica: None declared

OP0305 RHO-GTPASE PATHWAYS MAY DIFFERENTIATE RESPONDER AND NON-RESPONDERS TO TUMOUR NECROSIS FACTOR INHIBITOR (TNFI) AND INTERLEUKIN-17A INHIBITOR (IL-17AI) THERAPY IN PSORIATIC ARTHRITIS (PSA)

Background:

In PsA there is a pressing need to develop a coherent strategy for identifying initial and subsequent biologic responders. PsA patients present substantial heterogeneity in response to biologics, and molecular subtyping will help to identify the right patient for the right treatment.

Objectives:

To identify transcript profiles (biomarkers) that will select TNFi and IL-17Ai responders in PsA using baseline CD4+ cells; and elucidate novel signaling pathways relevant to biologic disease modifying antirheumatic drug (bDMARD) response using a systems biology approach.

Methods:

Consenting patients initiating TNFi agents (20 patients) or IL-17Ai agents (20 patients) with moderate-to-severe PsA were assessed with a comprehensive standardized protocol at baseline and at 3 months. Responder to bDMARDs was defined by Disease Activity index for PSoriatic Arthritis (DAPSA) score of less than 14 (low disease activity). Global transcript profiling was performed on all patients prior to initiation of and 3 months post bDMARDs. We mapped RNA-seq reads to the hg19 reference genome using STAR and quantified transcripts with Cufflinks. The transcripts per million (TPM) values were log-transformed for statistical analyses

Results:

The demographics of PsA patients for both treatment groups are presented (Table 1). Differentially expressed genes (DEGs) were identified using the limma tool for TNFi and IL-17Ai responders and non-responders (Figure 1) as well as DEGs that differentiated TNFi from IL-17Ai response and non-response. Integration of differential gene expression data with tissue-specific protein-protein interactions (IID version 2018-11) identified 117 and 132 DEGs between responders and non-responders to TNFi and IL-17Ai treatments, respectively. Comprehensive pathway enrichment analysis of these genes using pathDIP (v 4.1) revealed 576 (out of 5380) pathways enriched in 117 DEGs between responders and non-responders to TNFi, and 125 pathways enriched in 132 DEGs between responders and non-responders to IL-17Ai. Interestingly, while these two gene lists share only 17 genes, they have 79 enriched pathways in common suggesting potential effect of two different treatments on similar pathways but through different pathway members (Figure 2). Moreover, it suggests potential importance of the 17 shared genes in association with these pathways. Most of these pathways are related to innate and adaptive immune system, and to “osteoclast differentiation”. Among 46 pathways specific to response to IL-17Ai, multiple Rho-GTPase-related pathways were identified. It has been shown that experimental inhibition of ROCK2, a target of Rho-GTPase family is effective in psoriatic disease through regulation of IL-17/23/10, but not IL-6 and TNFα.

Table 1.

Demographics of psoriatic arthritis (PsA) patients.

IL-17AiTNFiNumber of PsA patients2020Gender (% female)55%75%Mean Age (Years)55.9 (9.5)56.8 (7.9)Mean Disease Duration (Years)10.4 (6.9)7.3 (7.9)Mean DAPSA baseline38.8 (17.5)45.6 (28.9)Responders (%) (DAPSA <14)35%65%Biologic naïve (%)40%60%Figure 1.

PCA plots illustrating that DEGs of CD4+ cells can differentiate responders from non-responders when treated with:A.IL-17Ai; andB.TNFi.

Figure 2.

Over-represented terms in significantly enriched pathways considering DEGs between:A.IL-17i responders and non-responders (125 pathways);B.TNFi responders and non-responders (576 pathways).

Conclusion:

Integration of cell-specific transcriptomic data with protein networks represents a very promising strategy for identifying biologic responders and pathways involved in predicting response that may have identified the Rho-GTP pathway as a potential marker to guide the choice of biologic agents for individual patients.

Disclosure of Interests:

Sara Rahmati: None declared, Darren O’Rielly: None declared, Quan Li: None declared, Dianne Codner: None declared, Amanda Dohey: None declared, Kari Jenkins: None declared, Igor Jurisica Grant/research support from: IBM, Dafna D Gladman Grant/research support from: AbbVie, Amgen Inc., BMS, Celgene Corporation, Janssen, Novartis, Pfizer, UCB – grant/research support, Consultant of: AbbVie, Amgen Inc., BMS, Celgene Corporation, Janssen, Novartis, Pfizer, UCB – consultant, Vinod Chandran Grant/research support from: Abbvie, Celgene, Consultant of: Abbvie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lily, Janssen, Novartis, Pfizer, UCB, Employee of: Spouse employed by Eli Lily, Proton Rahman Grant/research support from: Janssen and Novartis, Consultant of: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, and Pfizer., Speakers bureau: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, Pfizer

Assessing surface water flood risk and management strategies under future climate change: Insights from an Agent-Based Model

Climate change and increasing urbanization are projected to result in an increase in surface water flooding and consequential damages in the future. In this paper, we present insights from a novel Agent Based Model (ABM), applied to a London case study of surface water flood risk, designed to assess the interplay between different adaptation options; how risk reduction could be achieved by homeowners and government; and the role of flood insurance and the new flood insurance pool, Flood Re, in the context of climate change. The analysis highlights that while combined investment in property-level flood protection and sustainable urban drainage systems reduce surface water flood risk, the benefits can be outweighed by continued development in high risk areas and the effects of climate change. In our simulations, Flood Re is beneficial in its function to provide affordable insurance, even under climate change. However, the scheme does face increasing financial pressure due to rising surface water flood damages. If the intended transition to risk-based pricing is to take place then a determined and coordinated strategy will be needed to manage flood risk, which utilises insurance incentives, limits new development, and supports resilience measures. Our modelling approach and findings are highly relevant for the ongoing regulatory and political approval process for Flood Re as well as for wider discussions on the potential of insurance schemes to incentivise flood risk management and climate adaptation in the UK and internationally.

The Effect of Propranolol on Glyceryltrinitrate-Induced Headache and Arterial Response

Prophylactic drug trials in migraine are long-lasting and expensive and require long-term toxicology information. A human migraine model would therefore be helpful in testing new drugs. Immediate headache and delayed migraine after glyceryltrinitrate (GTN) has been well characterized. We have recently shown that sodium valproate has prophylactic effect in the GTN model. Here we report our experience with propranolol in this model. Nineteen subjects with migraine without aura and 16 sex- and aged-matched healthy subjects were included in a two-centre randomized double-blind cross-over study. Fourteen migraine subjects and 14 healthy subjects completed the study and results from comparison of the 28 subjects are reported. Randomly propranolol 160 mg or placebo were each given daily for 14 days to both migraine and healthy subjects. A 20-min intravenous infusion of GTN 0.25 mg/kg per min was administered on a study day at the end of both pretreatment periods. Headache was registered for 12 h after GTN infusions. Its intensity was scored on a numerical verbal rating scale from 0 to 10. Fulfilment of International Headache Society (HIS) criteria was recorded for 24 h. Radial and superficial temporal artery diameters and blood velocity of both middle cerebral arteries were measured. All migraine subjects developed headache after GTN. No reduction of overall peak headache was found after propranolol (median 5, range 0-7) compared with placebo (median 5, range 0-10) ( P = 0.441). Eight of the 14 completing migraine subject developed IHS 1.1 migraine after GTN, two subjects on both days, three subjects only after placebo, and three subjects only after propranolol. No reduction of GTN-induced migraine was found after propranolol compared with placebo (5 vs. 5, P = 1.000). All healthy subjects developed headache after GTN. No reduction of overall peak headache was found after propranolol (median 2, range 1-5) compared with placebo (median 1, range 1-7) ( P = 0.315). Two subjects fulfilled IHS criteria 1.1 for migraine without aura after propranolol but not after placebo. The fulfilment was short lasting and did not require rescue medication. Headache after GTN was more pronounced in migraine subjects than in healthy subjects both with ( P = 0.003) and without pretreatment with propranolol ( P = 0.017). We found that 2 weeks of propranolol constricted the radial artery in healthy subjects but not in migraine subjects. GTN-induced vasodilatation abolished this difference. Mean maximum blood flow velocity in the middle cerebral artery was higher in healthy subjects than in migraine patients ( P = 0.003-0.033) and unaffected by propranolol. We observed no effect of propranolol on GTN-induced headache and migraine. This could indicate that GTN induces migraine at a deeper level of the pathophysiological cascade of migraine than the prophylactic effect of propranolol. Propranolol does not constrict cerebral arteries, which therefore cannot be part of its mechanism of action in migraine.

Implementation of a national school-based Human Papillomavirus (HPV) vaccine campaign in Fiji: knowledge, vaccine acceptability and information needs of parents

Background

In 2008 Fiji implemented a nationwide Human Papillomavirus (HPV) vaccine campaign targeting all girls aged 9–12 years through the existing school-based immunisation program. Parents of vaccine-eligible girls were asked to provide written consent for vaccination. The purpose of this study was to describe parents’ knowledge, experiences and satisfaction with the campaign, the extent to which information needs for vaccine decision-making were met, and what factors were associated with vaccine consent.

Methods

Following vaccine introduction, a cross-sectional telephone survey was conducted with parents of vaccine-eligible girls from randomly selected schools, stratified by educational district. Factors related to vaccine consent were explored using Generalised Estimating Equations.

Results

There were 560 vaccine-eligible girls attending the participating 19 schools at the time of the campaign. Among these, 313 parents could be contacted, with 293 agreeing to participate (93.6 %). Almost 80 % of participants reported having consented to HPV vaccination (230/293, 78.5 %). Reported knowledge of cervical cancer and HPV prior to the campaign was very low. Most respondents reported that they were satisfied with their access to information to make an informed decision about HPV vaccination (196/293, 66.9 %). and this was very strongly associated with provision of consent. Despite their young age, the vaccine-eligible girls were often involved in the discussion and decision-making. Most consenting parents were satisfied with the campaign and their decision to vaccinate, with almost 90 % indicating they would consent to future HPV vaccination. However, negative media reports about the vaccine campaign created confusion and concern. Local health staff were cited as a trusted source of information to guide decision-making. Just over half of the participants who withheld consent cited vaccine safety fears as the primary reason (23/44, 52.3 %).

Conclusion

This is the first reported experience of HPV introduction in a Pacific Island nation. In a challenging environment with limited community knowledge of HPV and cervical cancer, media controversy and a short lead-time for community education, Fiji has implemented an HPV vaccine campaign that was largely acceptable to the community and achieved a high level of participation. Community sensitisation and education is critical and should include a focus on the local health workforce and the vaccine target group.

The role of surgical therapy for pulmonary vein atresia in childhood

The outcome for children with pulmonary vein atresia has been historically poor. This report describes clinical outcomes after surgical treatment of primary and secondary pulmonary vein atresia. All patients undergoing surgery for pulmonary vein atresia at Children's Hospital Boston from 1 January 2005 to 1 January 2009 were identified. The data available for analysis included demographic characteristics, findings based on cardiac catheterization and other imaging, clinical information, operative surgical intervention, and pulmonary vein histology. The study-specific information included the calculated number of atretic pulmonary veins as well as surgical interventions performed during the study period. The study end points included successful relief of pulmonary vein atresia, recurrence of pulmonary atresia or stenosis, overall pulmonary vein disease progression, and patient survival. A total of 16 patients with one or more pulmonary vein atresias were identified in the cardiac surgery registry database. Of these 16 patients, 5 had primary pulmonary atresia, and 11 had secondary atresia after repair of anomalous pulmonary venous drainage. Surgical recanalization of atretic pulmonary veins was achieved for more than 80% of the patients. At the most recent follow-up assessment, 7 (44%) of the 16 patients had recurrence of atresia. Five of the patients had development of new atresia in other previously healthy pulmonary veins. The median follow-up period was 4 months for primary and 17 months for secondary pulmonary vein atresia. The three main predictors of pulmonary vein disease progression after surgery were the presence of underlying lung disease (P = 0.036), prematurity (P = 0.035), and a history of recurrent pulmonary vein atresia. The overall mortality rate for the patients with primary or secondary pulmonary vein atresia was 56% at the most recent follow-up assessment (100% for the patients with primary vein atresia and 36% for the patients with secondary vein atresia).

CONCLUSIONS

Surgical recanalization of pulmonary vein atresia is possible, but prognosis remains poor. Recurrence of atresia can take place as early as a few months in the presence of underlying lung disease, prematurity, or history of recurrent pulmonary vein atresia. Further research is needed to identify mechanisms for attaining and sustaining pulmonary vein patency after surgery.

Compliance with postoperative instructions: a telephone survey of 750 day surgery patients

Patients undergoing day surgical procedures are given postoperative instructions not to drink alcohol, drive vehicles or make important decisions for 24 h. They are also advised to have a responsible adult stay with them at home overnight. Seven hundred and fifty patients were telephoned at 24 h postoperatively to determine their compliance with these instructions. Four per cent of patients drove vehicles, 1.8% consumed alcohol, while one patient made an important decision. A higher proportion of patients (5%) drove after general anaesthesia than regional anaesthesia or intravenous sedation (2.4%). The percentage of patients consuming alcohol was similar in both groups (1.8% vs. 1.9%). Four per cent of patients had no one staying with them overnight despite being accompanied out of the hospital. Patient compliance with instructions to not drink alcohol, drive or make important decisions may be improved by physician reinforcement of instructions and patient education.

A review of the updated European Best Practice Guidelines for the Management of Anaemia in Patients with Chronic Renal Failure

The management of anaemia of Chronic Kidney Disease (CKD) has progressed significantly during the last decade. Research studies show that effective treatment of anaemia in adult patients with CKD can reduce cardiovascular complications slow progression of renal failure, and improve quality of life. To ensure adult patients receive optimum care, evidence-based practice and recognised guidelines and management strategies are needed to help reduce variations in clinical practice. In 1999 a working party of European Nephrologists developed the European Best Practice Guidelines (EBPG) for Management of Anaemia in Patients with Chronic Renal Failure to address this issue. Since the publication of the guidelines in 1999, over 3,000 papers relating to anaemia in CKD, have been published, many of which have significant implications for the practice of anaemia management. To ensure that the most up to date scientific evidence is available to those who manage anaemia in CKD the guidelines were revised in 2004. These guidelines, look at the anaemia management of adults with CKD and do not include guidelines for children.

Joint working with hospice teams: a renal collaborative approach

There are over 600 million people in the world aged 60 years and over. This figure is expected to double by 2025 and to reach 2 billion by 2050 (1). Population ageing is characteristically accompanied by an increase in the burden of chronic non-communicable diseases such as diabetes, cardiovascular disease, cancers and renal failure. As a consequence, pressures on health systems worldwide will increase (1). Data produced by the National Renal Workforce Planning Group in 2002 (2), predicted that the demand for renal replacement therapy (RRT) will continue to rise beyond 2010 for many reasons one of those being demographic changes with an aging population. This will also have an impact on the numbers of patients predicted to commence dialysis and transplantation (Table 1). With this higher projection of patients requiring RRT, there is a need to look at new ways of working.

Competence to give informed consent in acute psychosis is associated with symptoms rather than diagnosis

To investigate the association between competence to give informed consent to treatment, specific symptomology and diagnostic category, 110 inpatients diagnosed with DSM-IV acute schizophrenia (n = 64), schizoaffective disorder (n = 25) and bipolar affective disorder (n = 21) were interviewed using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) and the Positive and Negative Syndrome Scale (PANSS). Results indicated no significant difference in competence between the three disorders. Elevated positive, cognitive and excitement PANSS factor scores had lower MacCAT-T scores. Further analyses indicated symptoms that impair cognition; particularly, conceptual disorganisation and poor attention were most consistently related to poor performance on competence tests.

Consent and anaesthetic risk

The incidences of mortality and morbidity associated with anaesthesia were reviewed. Most of the published incidences for common complications of anaesthesia vary considerably. Where possible, a realistic estimate of the incidence of each morbidity has been made, based on the best available data. Perception of risk and communication of anaesthetic risk to patients are discussed. The incidences of anaesthetic complications are compared with the relative risks of everyday events, using a community cluster logarithmic scale, in order to place the risks in perspective when compared with other complications and with the inherent risks of surgery. Documentation of these risks and discussion with patients should allow them to be better informed of the relative risks of anaesthetic complications. Depending on specific comorbidities and the severity of operation, these risks associated with anaesthesia may increase for any one individual.

The Prudhoe Cognitive Function Test, a scale to assess cognitive function in adults with Down's syndrome: inter-rater and test-retest reliability

BACKGROUND

The Prudhoe Cognitive Function Test (PCFT) was designed to measure cognitive function in subjects with all degrees of intellectual disability (ID) and to be administered by non-specialist raters. The aim of the present study was to measure the test-retest and inter-rater reliability of the PCFT.

METHODS

Three raters, one a specialist and two non-specialists, administered the PCFT to 14 subjects with Down's syndrome on two occasions separated by 4 weeks.

RESULTS

The intra-class correlation coefficients (ICCs) between the rater pairs (n=3) were 0.99, 0.99 and 0.98 (P<0.01). Floor effects were recorded for two items. The ICC for test-retest reliability was 0.99 (P<0.01).

CONCLUSIONS

The PCFT is a highly reliable instrument when used by either specialist or non-specialist raters. It has excellent temporal stability.

AWARENESS OF ANAEMIA IN DIABETES PATIENTS

Although the link between diabetes and anaemia has been firmly established in the renal world, patients with diabetes and healthcare workers in this field are clearly failing to recognise many of the common symptoms of anaemia, a key indicator for renal disease. By forging links and instigating an exchange of information, renal health care workers can work with their colleagues in diabetes to raise awareness of the important benefits arising from the early diagnosis and treatment of the anaemia related to kidney disease.

Eicosapentaenoic acid and arachidonic acid: collaboration and not antagonism is the key to biological understanding

Much of the literature on omega-3 and omega-6 fatty acids suggests that desirable effects of omega-3 fatty acids are in part related to depletion of arachidonic acid (AA). However, in rats and humans, we have found that low doses of EPA actually elevate membrane AA phospholipid concentrations. In patients with schizophrenia, treatment with eicosapentaenoic acid (EPA) produced clinical improvement, but that improvement was greater at a dose of 2 g/day than at 4 g/day. The improvement was not significantly correlated with changes in either EPA or docosahexaenoic acid (DHA) but was highly significantly positively correlated with rises in red cell membrane AA. We suggest that elevation of concentrations of both AA and EPA in cell membranes may be important for health.

A survey of professional satisfaction among Canadian anesthesiologists

PURPOSE

To assess overall job satisfaction among Canadian anesthesiologists and examine contributing factors.

METHODS

A confidential postal survey of all active members of the Canadian Anesthesiologists Society was conducted in 1998. Demographics, anesthesia practice, overall job satisfaction, anesthetic assistance, and perceived surgeons' and public attitudes towards anesthesiologists were collected.

RESULTS

Of 1659 surveys sent, 946 were returned (57% response rate). Seventy-five percent of the respondents were male and 25% female. Staff comprized 91%, residents 9%. The average working week was 59 +/- 11.9 hr. Seventy-five percent of respondents reported overall job satisfaction. Job satisfaction was associated with intellectual stimulation, good quality of care and interaction with patients. Dissatisfaction stemmed from treatment from the provincial government, hospital politics and long hours. Job satisfaction was associated with satisfaction with the level of operating room (OR) assistance, perceived high surgical regard and public image. Residents were more satisfied than staff anesthesiologists. Overall satisfaction was not affected by age, gender, region of practice, type of hospital or clinical work.

CONCLUSIONS

Job satisfaction among anesthesiologists is significantly associated with intellectual stimulation, quality of care, interaction with the patients, treatment from the provincial government, hospital politics, working hours, OR assistance and perceived attitude of surgeons. Improving these contributing factors may lead to higher job satisfaction.

A study comparing hyoscine hydrobromide and glycopyrrolate in the treatment of death rattle

This study looked at the efficacy of drug treatment in managing death rattle in a 30-bedded specialist palliative care unit. The study was conducted in two phases. In the first, patients received hyoscine hydrobromide as the antimuscarinic; glycopyrrolate was used in the second phase. The patients in the two phases were well matched for diagnosis, age, sex and duration of death rattle. A noise score scale of 0-3 was used, which was separately validated using a verbal rating scale and noise-meter readings. Noise scores were taken at the start; 30 min after an antimuscarinic drug was administered; an hour after the initial injection if a repeat dose was given at 30 min; and 4-hourly thereafter. Drug charts of all patients with death rattle were analysed to ascertain the amount of each drug given and the cost. The incidence of death rattle was 44% in phase I, and 36% in phase II. The percentage of patients with reduced noise scores 30 min after one injection of hyoscine was significantly greater than after one dose of glycopyrrolate (56% vs 27%, P = 0.002). The need for a second injection after 30 min was less using hyoscine (33% vs 50%, P = 0.03). There was no statistically significant difference in improvement at 1 h, or at the last recorded score before death. A comparison of the cost of drug treatment using hyoscine or glycopyrrolate was made, and the potential reduction in cost per patient in the glycopyrrolate group was largely offset by increased expenditure on other drugs, especially diamorphine, midazolam and levomepromazine. The results of this study suggest that: (1) glycopyrrolate 0.2 mg is less effective at reducing death rattle than hyoscine hydrobromide 0.4 mg when assessed at 30 min, (2) the use of glycopyrrolate may lead to an increased need for other sedative or anti-emetic medication such as diamorphine, midazolam or levomepromazine, and (3) the cost benefit of using glycopyrrolate over hyoscine hydrobromide is a small part of the total drug budget, and may be less than anticipated due to the increased need of these other drugs.

Post-operative recovery: day surgery patients' preferences

Due to the growing importance of quality assurance and cost containment in healthcare, eliciting patients' preferences for post-operative outcomes may be a more economical and reliable method of assessing quality. Three hundred and fifty-five day surgery patients completed a pre-operative written questionnaire to identify patients' preferences for avoiding 10 particular post-operative symptoms: pain, nausea, vomiting, disorientation, shivering, sore throat, drowsiness, gagging on the tracheal tube, thirst and a normal outcome. The two scoring methods used to evaluate preferences were priority ranking and relative value scores. The effects of age, gender, previous health status, type of surgery and previous experience of anaesthesia on patients' preferences were also examined. Avoiding post-operative pain, gagging on the tracheal tube and nausea and vomiting are major priorities for day-case patients. Anaesthetists should take patients' preferences into consideration when developing guidelines and planning anaesthetic care.

The spectrum of irritant-induced asthma: sudden and not-so-sudden onset and the role of allergy

A retrospective investigation of 86 asthmatic subjects defined clinical features of irritant-induced asthma and assessed the contributory role of an allergic predisposition. Three categories of asthma were evaluated: (1) occupational asthma due to a sensitizer (11 subjects, 13%); (2) irritant-induced asthma (54 persons, 63%); and (3) not occupational/environmental exposure-related asthma (21 subjects, 24%). Two distinct clinical presentations of irritant-induced asthma emerged: the first was sudden onset (29 subjects) and the second was not so sudden in onset (25 subjects). Sudden-onset, irritant-induced asthma was analogous to the reactive airways dysfunction syndrome. Clinical manifestations began immediately or within a few hours (always within 24 h) following an accidental, brief, and massive exposure. In contrast, for the not-so-sudden-onset asthma subjects, the causative irritant exposure was not brief, usually not massive, continued for > 24 h, and the initiation of asthma took longer to evolve. Eighty-eight percent of individuals with not-so-sudden irritant-induced asthma displayed an atopy/allergy status (p < 0.01). Some of the atopy/allergy subjects with presumed new-onset asthma were found to have suffered preexisting asthma that had been clinically quiescent for at least 1 year before the triggering exposure (16 persons). We conclude that preexisting allergic/atopy and/or preexisting asthma were significant contributors to the pathogenesis of not-so-sudden, irritant-induced asthma and emphasizes a critical interaction between environmental and host factors in the pathogenesis of asthma.

Evaluation of platelet activation and platelet-neutrophil aggregates in ponies with alimentary laminitis

OBJECTIVES

To determine whether platelets are hyperaggregable or form platelet-neutrophil aggregates during the prodromal stages of acute laminitis of ponies.

ANIMALS

Healthy adult ponies: 8 experimental and 6 control.

PROCEDURES

Acute laminitis was induced by oral administration of corn starch and wood flour to 8 ponies, and indices of platelet activation were evaluated. Blood samples were collected before and at 4, 8, 12, 24, 28, and 32 hours after carbohydrate administration, and PCV, total plasma protein concentration, platelet count, activated clotting time, whole blood recalcification time, spontaneous platelet aggregation, ex vivo platelet aggregation responses, and platelet-neutrophil aggregates were determined. When lameness was first detected, ponies were euthanatized and arteriography and histologic examination of hooves were performed.

RESULTS

Carbohydrate overload was associated with hyperaggregability of platelets throughout the prodromal stages of laminitis and increased numbers of platelet-neutrophil aggregates. Reduction of blood supply to affected hooves was variable, and blood clots were found in 6 of 11 laminitis-affected hooves.

CONCLUSIONS

Platelets were hyperaggregable throughout the prodromal stages of carbohydrate-induced laminitis and formed platelet-neutrophil aggregates. Platelet-neutrophil aggregates may initiate or contribute to development of acute laminitis.

CLINICAL RELEVANCE

Anti-platelet therapy may be useful for treatment of acute alimentary laminitis in horses.

The development and testing of a competency-focused psychiatric nursing clinical evaluation instrument

This article presents the development of a competency-focused psychiatric clinical evaluation instrument for the junior year of a baccalaureate program. Initially, 80 competencies were identified and categorized into six subscales. Competency achievement was measured by the Bondy Criterion Matrix (1983). Pilot setting generated an overall alpha (alpha) of 0.89 with item reliabilities ranging from 0.16 to 0.95. Testing of the revised Psychiatric Nursing Performance Appraisal Instrument (PsychNPAI) with another group of students (N = 51) generated an overall alpha = 0.96. Subscale alphas ranged from 0.82 to 0.92. These clinical subscales correlated significantly with related aspects of the didactic content in the course. The National League for Nursing Psychiatric Achievement Test correlated significantly with the overall course grade but not with PsychNPAI. The faculty and students perceive that the PsychNPAI clarifies expected outcomes and increases confidence in performance appraisal.

In vivo and in vitro biotransformation of the lithium salt of gamma-linolenic acid by three human carcinomas

Lipid metabolism has been considered recently as a novel target for cancer therapy. In this field, lithium gamma-linolenate (LiGLA) is a promising experimental compound for use in the treatment of human tumours. In vivo and in vitro studies allowed us to assess the metabolism of radiolabelled LiGLA by tumour tissue and different organs of the host. In vitro studies demonstrated that human pancreatic (AsPC-1), prostatic (PC-3) and mammary carcinoma (ZR-75-1) cells were capable of elongating GLA from LiGLA to dihomo-gamma-linolenic acid (DGLA) and further desaturating it to arachidonic acid (AA). AsPC-1 cells showed the lowest delta5-desaturase activity on DGLA. In the in vivo studies, nude mice bearing the human carcinomas were given Li[1-(14)C]GLA (2.5 mg kg(-1)) by intravenous injection for 30 min. Mice were either sacrificed after infusion or left for up to 96 h recovery before sacrifice. In general, the organs showed a maximum uptake of radioactivity 30 min after the infusion started (t = 0). Thereafter, in major organs the percentage of injected radioactivity per g of tissue declined below 1% 96 h after infusion. In kidney, brain, testes/ovaries and all three tumour tissues, labelling remained constant throughout the experiment. The ratio of radioactivity in liver to tumour tissues ranged between 16- and 24-fold at t = 0 and between 3.1- and 3.7-fold at 96 h. All tissues showed a progressive increase in the proportion of radioactivity associated with AA with a concomitant decrease in radiolabelled GLA as the time after infusion increased. DGLA declined rapidly in liver and plasma, but at a much slower rate in brain and malignant tissue. Seventy-two hours after the infusion, GLA was only detected in plasma and tumour tissue. The sum of GLA + DGLA varied among tumour tissues, but it remained 2-4 times higher than in liver and plasma. In brain, DGLA is the major contributor to the sum of these fatty acids. Data showed that cytotoxic GLA and DGLA, the latter provided either by the host or by endogenous synthesis, remained in human tumours for at least 4 days.

Simulating Secondary Succession of Elk Forage Values in a Managed Forest Landscape, Western Washington

Modern timber management practices often influence forage production for elk (Cervus elaphus) on broad temporal and spatial scales in forested landscapes. We incorporated site-specific information on postharvesting forest succession and forage characteristics in a simulation model to evaluate past and future influences of forest management practices on forage values for elk in a commercially managed Douglas fir (Pseudotsuga menziesii, PSME)-western hemlock (Tsuga heterophylla, TSHE) forest in western Washington. We evaluated future effects of: (1) clear-cut logging 0, 20, and 40% of harvestable stands every five years; (2) thinning 20-year-old Douglas fir forests; and (3) reducing the harvesting cycle from 60 to 45 years. Reconstruction of historical patterns of vegetation succession indicated that forage values peaked in the 1960s and declined from the 1970s to the present, but recent values still were higher than may have existed in the unmanaged landscape in 1945. Increased forest harvesting rates had little short-term influence on forage trends because harvestable stands were scarce. Simulations of forest thinning also produced negligible benefits because thinning did not improve forage productivity appreciably at the stand level. Simulations of reduced harvesting cycles shortened the duration of declining forage values from approximately 30 to 15 years. We concluded that simulation models are useful tools for examining landscape responses of forage production to forest management strategies, but the options examined provided little potential for improving elk forages in the immediate future.KEY WORDS:Cervus elaphus; Elk; Forage; Forest management; Modeling; Secondary succession

Plasma membrane phospholipid fatty acid composition of cultured skin fibroblasts from schizophrenic patients: comparison with bipolar patients and normal subjects

Recent studies have found lower red cell plasma membrane contents and composition of the long chain polyunsaturated essential fatty acid derivatives, particularly arachidonic acid and docosahexaenoic acid, in a subgroup of chronic schizophrenic patients. These fatty acids are particularly enriched in the brain. Red blood cell levels of fatty acids are influenced by diet, medications, and other factors. Cell plasma membrane compositions of arachidonic and docosahexaenoic acids were therefore examined in cultured skin fibroblasts from 12 schizophrenic patients, 8 of whom were drug-naive and in a first episode of psychosis, 6 bipolar patients, and 8 normal control subjects. Docosahexaenoic acid as well as total n-3 essential fatty acid contents were significantly lower in cell lines from schizophrenic patients than in cell lines from bipolar patients and normal subjects, with no difference between the latter two groups. Arachidonic acid levels did not differ across the groups. The essential fatty acid profile observed is consistent with deficient delta-4 desaturase activity in schizophrenic patients.