Simulating nitrogen balance in Canadian agricultural soils from 1981 to 2016

Agriculture produces food, fiber and biofuels for the world's growing population, however, agriculture can be a major contributor of nitrogen (N) losses including emissions of ammonia (NH₃), nitrous oxide (N₂O) and nitrate (NO₃^-) leaching and runoff. A Canadian Agricultural Nitrogen Budget for Reactive N (CANBNr) model was developed to estimate the soil N balance in 3487 soil landscape of Canada polygons from 1981 to 2016. The CANBNr model integrates NH₃ emission from fertilizers, manure from housing, storage and field, as well as direct/indirect N₂O emissions from fertilizers, manures, crop residues and soil organic matter. The NO₃^- leaching is estimated based on the residual soil N (RSN) at harvest and drainage derived with the DeNitrification-DeComposition (DNDC) model. From 1981 to 2016, the N input from fertilizer and N fixation increased at a greater rate than N removal in harvested crops in all provinces of Canada, resulting in an increase in the RSN and N losses. In 2016, the Prairie provinces had lower N losses (11.7 kg N ha^-1) from N₂O, NH₃ and NO₃^- compared with 43.2 kg N ha^-1 in central Canada, and 76.5 kg N ha^-1 in Atlantic Canada. However, the Prairie provinces had 84.3% of the total Canadian farmland (74.3% of the total Canadian N input), while central Canada had 12.9% of Canadian farmland (21.7% of the total Canadian N input). In the Prairie provinces, the total N₂O loss from fertilizer N ranged 4.4-8.6 Gg N whereas NH₃ loss ranged from 17.1 to 44.6 Gg N and these values were influenced by both emission intensity and total land area. Total N₂O losses from manure were highest in Alberta, Ontario and Quebec resulting in 4.8, 4.4, and 3.4 Gg N and NH₃ losses from manure were also highest in these 3 provinces at 61.1, 45.2 and 40.4 Gg N, respectively. Nitrate leaching was impacted by drainage volumes, soil type and N inputs. In the non-growing season, NO₃^- leaching losses (36-yr average) were 63.3 Gg in Ontario and 57.5 Gg N in Quebec compared with 20.8 Gg N for Ontario and 35.5 Gg N for Quebec in the growing season. In contrast, the Prairie provinces showed higher NO₃^- leaching in the growing season (23.1-37.4 Gg N) than in the non-growing season (10.4-13.7 Gg N). In summary, total fertilizer N increased the most over the 36 years in the Prairies which resulted in increased RSN and N leaching losses that will require further intervention.

Endogenous metabolism in endothelial and immune cells generates most of the tissue vitamin B3 (nicotinamide)

In mammals, nicotinamide (NAM) is the primary NAD precursor available in circulation, a signaling molecule, and a precursor for methyl-nicotinamide (M-NAM) synthesis. However, our knowledge about how the body regulates tissue NAM levels is still limited. Here we demonstrate that dietary vitamin B₃ partially regulates plasma NAM and NAM-derived metabolites, but not their tissue levels. We found that NAD de novo synthesis from tryptophan contributes to plasma and tissue NAM, likely by providing substrates for NAD-degrading enzymes. We also demonstrate that tissue NAM is mainly generated by endogenous metabolism and that the NADase CD38 is the main enzyme that produces tissue NAM. Tissue-specific CD38-floxed mice revealed that CD38 activity on endothelial and immune cells is the major contributor to tissue steady-state levels of NAM in tissues like spleen and heart. Our findings uncover the presence of different pools of NAM in the body and a central role for CD38 in regulating tissue NAM levels.

Cannabidiol Exposure During the Mouse Adolescent Period Is Without Harmful Behavioral Effects on Locomotor Activity, Anxiety, and Spatial Memory

Cannabidiol (CBD) is a non-intoxicating phytocannabinoid whose purported therapeutic benefits and impression of a high safety profile has promoted its increasing popularity. CBD’s popularity is also increasing among children and adolescents who are being administered CBD, off label, for the treatment of numerous symptoms associated with autism spectrum disorder, attention deficit hyperactivity disorder, anxiety, and depression. The relative recency of its use in the adolescent population has precluded investigation of its impact on the developing brain and the potential consequences that may present in adulthood. Therefore, there’s an urgency to identify whether prolonged adolescent CBD exposure has substantive impacts on the developing brain that impact behavioral and cognitive processes in adulthood. Here, we tested the effect of twice-daily intraperitoneal administrations of CBD (20 mg/kg) in male and female C57BL/6J mice during the adolescent period of 25–45 days on weight gain, and assays for locomotor behavior, anxiety, and spatial memory. Prolonged adolescent CBD exposure had no detrimental effects on locomotor activity in the open field, anxiety behavior on the elevated plus maze, or spatial memory in the Barnes Maze compared to vehicle-treated mice. Interestingly, CBD-treated mice had a faster rate of learning in the Barnes Maze. However, CBD-treated females had reduced weight gain during the exposure period. We conclude that prolonged adolescent CBD exposure in mice does not have substantive negative impacts on a range of behaviors in adulthood, may improve the rate of learning under certain conditions, and impacts weight gain in a sex-specific manner.

Roundtable: arguments in support of using multi-parametric prostate MRI protocol

There is increasing evidence to suggest the value of bi-parametric prostate MRI to replace multi-parametric MRI, which includes the dynamic contrast enhancement (DCE) sequence. In this review, we discuss the value of DCE in select scenarios, specifically in resolving equivocal cases, improving the diagnostic accuracy in the inexperienced reader, rescuing exams in the settings of failed T2W and DWI, detecting biochemical recurrence, while imposing minimal to no risk to the patient with respect to IV gadolinium use, specifically group II agents.

Dysphagia presentation and management following COVID-19: an acute care tertiary centre experience

OBJECTIVES

As the pathophysiology of COVID-19 emerges, this paper describes dysphagia as a sequela of the disease, including its diagnosis and management, hypothesised causes, symptomatology in relation to viral progression, and concurrent variables such as intubation, tracheostomy and delirium, at a tertiary UK hospital.

RESULTS

During the first wave of the COVID-19 pandemic, 208 out of 736 patients (28.9 per cent) admitted to our institution with SARS-CoV-2 were referred for swallow assessment. Of the 208 patients, 102 were admitted to the intensive treatment unit for mechanical ventilation support, of which 82 were tracheostomised. The majority of patients regained near normal swallow function prior to discharge, regardless of intubation duration or tracheostomy status.

CONCLUSION

Dysphagia is prevalent in patients admitted either to the intensive treatment unit or the ward with COVID-19 related respiratory issues. This paper describes the crucial role of intensive swallow rehabilitation to manage dysphagia associated with this disease, including therapeutic respiratory weaning for those with a tracheostomy.

0679 Effects Of Cannabimimetic Enhancement On Subjective Sleep Quality And Function In Obstructive Sleep Apnea

Introduction

We previously reported that dronabinol a tetrahydrocannobinol, reduced the apnea hypopnea index (AHI) in patients with obstructive sleep apnea (OSA) in a dose-dependent manner. The aim of this report is to assess the effects of dronabinol on subjective sleep quality and daytime function in the Pharmacotherapy of Apnea by Cannabimimetic Enhancement (PACE) II trial.

Methods

By random assignment, 73 adults with moderate or severe OSA received either placebo (N = 25), 2.5 mg dronabinol (N = 21), or 10 mg dronabinol (N = 27) daily, 1 hour before bedtime for 6 weeks. Participants completed the Pittsburgh sleep quality index (PSQI) and Functional Outcomes of Sleep Questionnaire (FOSQ-10) at baseline and at the end of intervention.

Results

Between group comparisons were performed using a one-way ANOVA. At baseline, there were no significant difference between groups in the PSQI or FOSQ-10. When compared to placebo, the 10 mg group had a significant reduction in the global PSQI score (p=0.039). Paired t-test analysis showed, in comparison to the baseline, the subscale and total score of the FOSQ-10 were significantly increased (P=0.005); the global PSQI score, subjective sleep quality score, habitual sleep efficiency score and daytime dysfunction score were significantly reduced (p<0.001, p<0.001, p=0.024, p=0.007 respectively) in the 10 mg group, while no improvement was found in the 2.5 mg or placebo groups. Bivariate correlational analysis was used to identify the relationship between the changes of variables. Both ∆ global PSQI and ∆ total FOSQ were correlated with ∆ESS, but not with change in AHI or sleep parameters such as sleep stage percentage, sleep efficiency, arousal index, minutes of wake after sleep onset, time and duration of oxygen saturation below 90% percent.

Conclusion

These findings indicate that in addition to its ability to reduce the AHI, dronabinol can improve subjective sleep quality and daytime function in patients with moderate to severe OSA.

Support

This study was funded by National Institutes of Health, National Heart Lung and Blood Institute Grant Number UM1-HL112856 and National Center for Advancing Translational Sciences, Grant Numbers UL1TR001422 and UL1TR002003.

1151 Is Timing Of Light Exposure Different In Women With Chronic Migraine?

Introduction

Light avoidance is a common coping behavior of individuals with migraine headaches. It is not known whether timing of light exposure is different in individuals with chronic migraine (CM) compared to those without migraine and how this may relate to headache frequency and severity. We tested this by examining timing of the brightest and darkest light and headaches in women with chronic migraines and healthy controls.

Methods

Sixteen women with CM (mean age = 33.07) and 18 female healthy controls (HC; mean age = 32.22) completed daily ratings of headache severity (0-10, severity > 2 classified as headache) concurrent with light exposure measured by wrist actigraphy for approximately one month (M=28.00 days, range=21-36). Start time of each day’s 10-hour periods of maximum light (M10) and 5-hour periods of lowest light (L5) were calculated and averaged for each participant. T-tests and Cohen’s d effect sizes were used to compare groups. Pearson correlation coefficients were calculated to examine associations between M10/L5 timing and headache frequency and severity.

Results

M10 was earlier in the CM group compared to the HC group (07:42±00:47 vs. 08:50±00:58, t(32)=3.69, p=0.0008, d=1.08). The CM group exhibited non-significant trend towards earlier L5 compared to the HC group (12:26±00:48 vs. 01:07±01:03, t(32)=1.89, p=0.0723, d=0.62). Among individuals with CM, later M10 timing was associated with more severe average daily headache (r=0.60, p=0.0136) and more frequent headaches (r=0.55, p=0.0257). Later L5 timing was significantly associated with more severe average daily headache (r=0.66, p=0.0052) and showed a non-significant trend toward association with more frequent headaches (r=0.47, p=0.0686).

Conclusion

Timing of the greatest light exposure period was earlier in CM compared to HC. Within the CM group, those who had earlier light and dark periods reported lower headache severity and fewer days with headaches. These findings suggest the possibility of a role for the circadian system in chronic migraine.

Support

This study was supported by grant R21NS081088 from the National Institutes of Health.

Determination of Ochratoxin A in Currants, Raisins, Sultanas, Mixed Dried Fruit, and Dried Figs by Immunoaffinity Column Cleanup with Liquid Chromatography: Interlaboratory Study

An interlaboratory study was performed on behalf of the Food Standards Agency to evaluate the effectiveness of an affinity column cleanup liquid chromatographic (LC) method for the determination of ochratoxin A in a variety of dried fruit at European regulatory limits. To ensure homogeneity before analysis, laboratory samples are normally slurried with water in the ratio of 5 parts fruit to 4 parts water, and test materials in this form were used in the study. The test portion was extracted with acidified methanol. The extract was filtered, diluted with phosphate-buffered saline, and applied to an affinity column. The column was washed and ochratoxin A was eluted with methanol. Ochratoxin A was quantified by reversed-phase LC. The use of post-column pH shift to enhance the fluorescence of ochratoxin A by the addition of 1.1M ammonia solution to the column eluant is optional. Determination was by fluorescence. Currants, sultanas, raisins, figs, and mixed fruit (comprising dried pineapple, papaya, sultanas, prunes, dates, and banana chips), both naturally contaminated and blank (very low level), were sent to 24 collaborators in 7 European countries. Participants were asked to spike test portions of all test samples at a level equivalent to 5 ng/g ochra toxin A. Average recoveries ranged from 69 to 74%. Based on results for 5 naturally contaminated test samples (blind duplicates) the relative standard deviation for repeatability (RSDr) ranged from 4.9 to 8.7%, and the relative standard deviation for reproducibility (RSDR)rangedfrom14to28%. The method showed acceptable within-and be-tween-laboratory precision for all 5 matrixes, as evidenced by HORRAT values <1.3.

Physical Performance and Serum 25(OH)vitamin D Status in Community Dwelling Old Mobility Limited Adults: A Cross-Sectional Study

OBJECTIVES

To examine the potential association between serum 25(OH) vitamin D and the performance on the Short Physical Performance Battery (SPPB) including the sub-components; five repeated chair stands test, 4 meters walk test and balance in older mobility-limited community-dwelling men and women.

DESIGN

A cross sectional study was performed in American and Swedish subjects who were examined for potential participation in a combined exercise and nutrition intervention trial. Logistic regression analysis and linear regression analyses were performed to evaluate the association for 25(OH)D with the overall score on the SBBP, chair stand, gait speed and balance.

PARTICIPANTS

Community-dwelling (mean age 77.6 ± 5.3 years) mobility limited American (n=494) and Swedish (n=116) females (59%) and males.

MEASUREMENTS

The SPPB (0-12 points) includes chair stand (s), gait speed (m/s) and a balance test. Mobility limitation i.e., SPPB score ≤ 9 was an inclusion criterion. A blood sample was obtained to measure serum 25(OH)vitamin D concentrations.

RESULTS

No clear association of 25(OH)D with SPPB scores was detected either when 25(OH)D was assessed as a continuous variable or when categorized according to serum concentrations of <50, 50-75 or <75 nmol/L. However, when analyzing the relationship between 25(OH)D and seconds to perform the chair stands, a significant quadratic relationship was observed. Thus, at serum levels of 25(OH)D above 74 nmol/L, higher concentrations appeared to be advantageous for the chair stand test, whereas for serum levels below 74 nmol/L this association was not observed.

CONCLUSION

This cross- sectional study lacked clear association between serum 25(OH)D and physical performance in mobility limited adults. A potentially interesting observation was that at higher serum levels of 25(OH)D a better performance on the chair stand test was indicated.

Secondary contact and asymmetrical gene flow in a cosmopolitan marine fish across the Benguela upwelling zone

The combination of oceanographic barriers and habitat heterogeneity are known to reduce connectivity and leave specific genetic signatures in the demographic history of marine species. However, barriers to gene flow in the marine environment are almost never impermeable which inevitably allows secondary contact to occur. In this study, eight sampling sites (five along the South African coastline, one each in Angola, Senegal and Portugal) were chosen to examine the population genetic structure and phylogeographic history of the cosmopolitan bluefish (Pomatomus saltatrix), distributed across a large South-east Atlantic upwelling zone. Molecular analyses were applied to mtDNA cytochrome b, intron AM2B1 and 15 microsatellite loci. We detected uncharacteristically high genetic differentiation (F_ST 0.15-0.20; P<0.001) between the fish sampled from South Africa and the other sites, strongly influenced by five outlier microsatellite loci located in conserved intergenic regions. In addition, differentiation among the remaining East Atlantic sites was detected, although mtDNA indicated past isolation with subsequent secondary contact between these East Atlantic populations. We further identified secondary contact, with unidirectional gene flow from South Africa to Angola. The directional contact is likely explained by a combination of the northward flowing offshore current and endogenous incompatibilities restricting integration of certain regions of the genome and limiting gene flow to the south. The results confirm that the dynamic system associated with the Benguela current upwelling zone influences species distributions and population processes in the South-east Atlantic.

Harnessing Teams and Technology to Improve Outcomes in Infants With Single Ventricle

Infants with single ventricle require staged cardiac surgery, with stage I typically performed shortly after birth, stage II at 4 to 6 months of age, and stage III at 3 to 5 years of age. There is a high risk of interstage mortality and morbidity after infants are discharged from the hospital between stages I and II. Traditional home monitoring requires caregivers to record measurements of weight and oxygen saturation into a binder and requires families to assume a surveillance role. We have developed a tablet PC-based solution that provides secure and nearly instantaneous transfer of patient information to a cloud-based server, with the capacity for instant alerts to be sent to the caregiver team. The cloud-based IT infrastructure lends itself well to being able to be scaled to multiple sites while maintaining strict control over the privacy of each site. All transmitted data are transferred to the electronic medical record daily. The system conforms to recently released Food and Drug Administration regulation that pertains to mobile health technologies and devices. Since this platform was developed in March 2014, 30 patients have been monitored. There have been no interstage deaths. The experience of care providers has been unanimously positive. The addition of video has added to the use of the monitoring program. Of 30 families, 23 expressed a preference for the tablet PC over the notebook, 3 had no preference, and 4 preferred the notebook to the tablet PC.

Atomic Layer Epitaxy of h-BN(0001) Multilayers on Co(0001) and Molecular Beam Epitaxy Growth of Graphene on h-BN(0001)/Co(0001)

The direct growth of hexagonal boron nitride (h-BN) by industrially scalable methods is of broad interest for spintronic and nanoelectronic device applications. Such applications often require atomically precise control of film thickness and azimuthal registry between layers and substrate. We report the formation, by atomic layer epitaxy (ALE), of multilayer h-BN(0001) films (up to 7 monolayers) on Co(0001). The ALE process employs BCl3/NH3 cycles at 600 K substrate temperature. X-ray photoelectron spectroscopy (XPS) and low energy electron diffraction (LEED) data show that this process yields an increase in h-BN average film thickness linearly proportional to the number of BCl3/NH3 cycles, with BN layers in azimuthal registry with each other and with the Co(0001) substrate. LEED diffraction spot profile data indicate an average BN domain size of at least 1900 Å. Optical microscopy data indicate the presence of some domains as large as ∼20 μm. Transmission electron microscopy (TEM) and ambient exposure studies demonstrate macroscopic and microscopic continuity of the h-BN film, with the h-BN film highly conformal to the Co substrate. Photoemission data show that the h-BN(0001) film is p-type, with band bending near the Co/h-BN interface. Growth of graphene by molecular beam epitaxy (MBE) is observed on the surface of multilayer h-BN(0001) at temperatures of 800 K. LEED data indicate azimuthal graphene alignment with the h-BN and Co(0001) lattices, with domain size similar to BN. The evidence of multilayer BN and graphene azimuthal alignment with the lattice of the Co(0001) substrate demonstrates that this procedure is suitable for scalable production of heterojunctions for spintronic applications.

Tools in the assessment of sarcopenia

This review provides a framework for the development of an operational definition of sarcopenia and of the potential end points that might be adopted in clinical trials among older adults. While the clinical relevance of sarcopenia is widely recognized, there is currently no universally accepted definition of the disorder. The development of interventions to alter the natural history of sarcopenia also requires consensus on the most appropriate end points for determining outcomes of clinical importance which might be utilized in intervention studies. We review current approaches to the definition of sarcopenia and the methods used for the assessment of various aspects of physical function in older people. The potential end points of muscle mass, muscle strength, muscle power, and muscle fatigue, as well as the relationships between them, are explored with reference to the availability and practicality of the available methods for measuring these end points in clinical trials. Based on current evidence, none of the four potential outcomes in question is sufficiently comprehensive to recommend as a uniform single outcome in randomized clinical trials. We propose that sarcopenia may be optimally defined (for the purposes of clinical trial inclusion criteria as well as epidemiological studies) using a combination of measures of muscle mass and physical performance. The choice of outcome measures for clinical trials in sarcopenia is more difficult; co-primary outcomes, tailored to the specific intervention in question, may be the best way forward in this difficult but clinically important area.

Decision-making for ecosystem-based management: evaluating options for a krill fishery with an ecosystem dynamics model

Decision-makers charged with implementing ecosystem-based management (EBM) rely on scientists to predict the consequences of decisions relating to multiple, potentially conflicting, objectives. Such predictions are inherently uncertain, and this can be a barrier to decision-making. The Convention on the Conservation of Antarctic Marine Living Resources requires managers of Southern Ocean fisheries to sustain the productivity of target stocks, the health and resilience of the ecosystem, and the performance of the fisheries themselves. The managers of the Antarctic krill fishery in the Scotia Sea and southern Drake Passage have requested advice on candidate management measures consisting of a regional catch limit and options for subdividing this among smaller areas. We developed a spatially resolved model that simulates krill-predator-fishery interactions and reproduces a plausible representation of past dynamics. We worked with experts and stakeholders to identify (1) key uncertainties affecting our ability to predict ecosystem state; (2) illustrative reference points that represent the management objectives; and (3) a clear and simple way of conveying our results to decision-makers. We developed four scenarios that bracket the key uncertainties and evaluated candidate management measures in each of these scenarios using multiple stochastic simulations. The model emphasizes uncertainty and simulates multiple ecosystem components relating to diverse objectives. We summarize the potentially complex results as estimates of the risk that each illustrative objective will not be achieved (i.e., of the state being outside the range specified by the reference point). This approach allows direct comparisons between objectives. It also demonstrates that a candid appraisal of uncertainty, in the form of risk estimates, can be an aid, rather than a barrier, to understanding and using ecosystem model predictions. Management measures that reduce coastal fishing, relative to oceanic fishing, apparently reduce risks to both the fishery and the ecosystem. However, alternative reference points could alter the perceived risks, so further stakeholder involvement is needed to identify risk metrics that appropriately represent their objectives.

Abstract 54: The SAQ-7: A Short Version of the Seattle Angina Questionnaire

Background: The Seattle Angina Questionnaire (SAQ) is a well-validated and widely used 19-item instrument that measures patient-reported symptoms, function and quality of life for patients with coronary artery disease. We sought to develop a shortened version to reduce response burden and facilitate greater use within busy clinical environments.

Methods: We used data from 4 U.S. multicenter longitudinal cohorts studies (2 PCI: n=1,507 and 2,206; 2 AMI: n=2,487 and 4,340) to develop and validate a short version of the SAQ. We included items from the Physical Limitation, Angina Frequency and Quality of Life scales, which directly measure patients’ current health status. We conducted parallel analyses for 3 distinct clinical scenarios (stable CAD, peri-PCI, acute MI). In development cohorts, we used equidistant item-total correlation methods to identify items that best correlated with their respective full-version score across the entire range of scores. We also considered item response variability and missingness in choosing between similarly performing items. Using the selected items, we calculated summary scores for each of the 3 scales, and an overall summary score as the average of the 3 scale scores. (As in the full SAQ, scores were rescaled so that 0 denotes the worst and 100 the best possible health status.) Finally, in independent validation cohorts, we conducted a range of analyses to investigate the validity, reproducibility, and responsiveness of the short-version scores.

Results: We identified 7 items that tracked strongly with their corresponding full-version scores (3 of 9 Physical Limitation items; 2 of 2 Angina Frequency items; 2 of 3 Quality of Life items). These items were consistently identified across all 3 clinical scenarios. Correlations between the resulting short-version and full-version scores were excellent (r=0.95 to 1.00), and missing rates were the same or lower for all scores. In validation studies, the SAQ-7 demonstrated strong performance comparable to the full SAQ (Table).

Conclusions: The SAQ-7 is a valid, reproducible, responsive instrument for assessing disease-specific health status among patients with coronary artery disease, with properties and performance similar to the full SAQ but with a substantially reduced response burden.

Abstract 248: The KCCQ-12: A Short Version of the Kansas City Cardiomyopathy Questionnaire

Background: The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a well-validated and widely used 23-item instrument that measures patient-reported symptoms, function and quality of life for patients with heart failure. We sought to develop a shortened version to reduce response burden and facilitate greater use within busy clinical environments.

Methods: We used data from 2 multicenter randomized trials (EVEREST: n=2,005; EPHESUS: n=1,616) and one multicenter outpatient cohort study (n=547) to develop and validate a short version of the KCCQ. We included items from the Physical Limitation, Symptoms, Quality of Life and Social Limitation scales, which directly measure patients’ current health status. In development cohorts, we used equidistant item-total correlation methods to identify items that best correlated with their respective full-version score across the entire range of scores. We considered item response variability and missingness in choosing between similarly performing items. Using the selected items, we calculated summary scores for each of the 4 scales, and an overall summary score as the average of the 4 scale scores. (As in the full KCCQ, scores were rescaled so that 0 denotes the worst and 100 the best possible health status.) Finally, in independent validation cohorts, we conducted a range of analyses to investigate the validity, reproducibility, and responsiveness of the short-version scores.

Results: We identified 12 items that tracked strongly with their corresponding full-version scores (3 of 6 Physical Limitation items; 4 of 8 Symptom items; 2 of 3 Quality of Life items; 2 of 3 Social Limitation items). Correlations between the resulting short-version and full-version scores was excellent (r=0.92 to 0.99), and missing rates were the same or lower for all scores. In validation studies, the KCCQ-12 demonstrated strong performance comparable to the full KCCQ (Table).

Conclusions: The KCCQ-12 is a valid, reproducible, responsive instrument for assessing disease-specific health status among patients with heart failure, with properties and performance similar to the full KCCQ but with a substantially reduced response burden.

Students' perception of a problem-based learning scenario in dental nurse education

BACKGROUND

In July 2008, The General Dental Council implemented mandatory registration for Dental Nurses in the United Kingdom, recognising them as legally responsible for patient care. As dentistry comes to terms with the impact registration has on dental nurses, sustained advances in the teaching of students in other healthcare disciplines demonstrate the way in which the role of pedagogy in dental nurse education has been underdeveloped. In an attempt to see dental nursing stand in line with other progressive healthcare professionals, the authors have implemented Problem-Based Learning (PBL) into a dental nurse program in NHS Education for Scotland, Glasgow.

AIM

The aim of the research is to assess the perceptions of dental nurse students with regard to participation in active learning.

MATERIALS AND METHODS

The study is facilitated by a short PBL package which offers introductory exposure to this method of learning. A qualitative approach has been taken to gather experiential data using a questionnaire. Thematic analysis took place to reveal emergent themes.

RESULTS

Analysis reveals that the participants found PBL to be an enjoyable experience that could be valuable in the acquisition of deep knowledge and improved patient care. The participants raised concerns with regard to confidence in their own knowledge acquisition in PBL sessions and highlighted a need for improved feedback.

DISCUSSION AND CONCLUSION

While the participants enjoyed the self directed nature of PBL, it is important to note that the need for facilitator guidance was considered imperative, especially where the students had little or no experience of PBL, as in this study.

Impact of a prison triage system on injuries seen in emergency departments

OBJECTIVES

1) To describe injuries experienced by the male prisoner population in the Kingston, Ontario area, and to compare them with those observed in the general population; and 2) to compare the incidence and patterns of prisoner injuries seen in emergency departments (EDs) before and after the introduction of a prison injury triage system.

DESIGN

A chart review.

SETTING

The catchment area surrounding 2 hospital-based EDs in Kingston, Ontario, which includes 8 federal and provincial prisons for adult males.

OBSERVATIONS

Injuries to male prisoners (ages 18-75 years) who were treated in the ED during 1996-98 were compared with injuries to the general male population of the same age range. An on-site emergency care triage system was introduced to area prisons in 1993. Prisoner injuries seen in the ED during 1996-98 were compared with those seen during a similar period prior to the introduction of the triage system (1981-84). Available comparators included patient demographics, disposition, intent and nature of injury, the need for surgery, and lengths of hospital stay.

RESULTS

148 prisoner injuries were identified for 1996-98. Prisoner injuries seen in the ED were relatively severe when compared with the general male population, as indicated by the higher frequency of fractures (31.8% prisoner vs. 13.4% general, p < 0.001), blunt head injuries (10.1% vs. 2.2%, p < 0.001), hospital admissions (42.6% vs. 4.1%, p < 0.001) and deaths (2.7% vs. 0.6%, p < 0.001). Since the introduction of the triage system there has been a reduction in the rate of prisoner injuries seen in local hospital EDs (6.1/100/yr [before] vs. 1.6/100/yr [after], p < 0.001). There has been an increase in the relative severity of prisoner injuries seen in the EDs as indicated by the increased hospital admission rate (42.6% vs. 22.7%, p < 0.001), increased rate of surgical intervention (27.7% vs. 12.1%, p < 0.001), and increased length of hospital stay (4.0 days vs. 2.1 days, p < 0.05). The mortality rate has remained low and unchanged (0.7% vs. 1.1%, p = 0.99).

CONCLUSIONS

The introduction of the new triage system appeared to be associated with a decrease in the total number of ED visits by prisoners. The relative acuity of prisoner injuries seen in the EDs appeared to increase following introduction of the triage system.

Abstract P328: Complete vs. ‘Culprit’ Only Revascularization in STEMI Patients With Multivessel Coronary Artery Disease: Practice Patterns, Predictors of Complete Revascularization and Impact on Health Status Outcomes

BACKGROUND One third of patients presenting with acute ST segment elevation myocardial infarction (STEMI) are found to have multivessel coronary artery disease (MVD). Several studies have described clinical outcomes after culprit only compared to complete revascularization. Little is known about the health status benefits of these competing strategies.

METHODS The 26-center TRIUMPH registry was used to identify STEMI pts with MVD. CR was defined as revascularization of all significant coronary stenoses ≥70%. Numerous demographic and clinical factors were tested for their independent association with CR using multivariable, hierarchical Poisson regression models. The association of CR with 1-year mortality, and disease-specific and generic health status as assessed by the Seattle Angina Questionnaire (SAQ) and SF-12 Physical Component Scores (SF-12 PCS) were evaluated using hierarchical multivariable models.

RESULTS Among the 664 STEMI pts with MVD (mean age 58 yrs, 74% male, 25% diabetic, 2.4 ± 0.7 mean diseased vessels), 231 (35%) underwent CR and 433 (65%) had ‘culprit’ revascularization. Among CR pts, 28 (12.1%) had CABG. Of the CR patients treated with PCI 71 (30.7%) occurred concurrent with primary reperfusion while the remainder were staged. Independent predictors of CR included greater number of diseased vessels (RR 1.33, 95% CI 1.17-1.51), LAD culprit (RR 0.63, 95% CI 0.48-0.81), and acute heart failure (RR 1.65, 95% CI 1.10-2.48). An inverse-U shaped relationship between age and CR was present, with pts age 50 most likely and young and old less likely to receive CR. At 1 year, CR was not associated with mortality [2.6% vs. 3.2%, p=0.66) and angina [30.6% vs. 25.9%, p=0.278], but was associated with improved health status - a 4.7 point increase in SAQ quality of life score (95%CI 0.53 - 8.84, p=0.03) and a trend in SF-12 PCS score (2 point increase, 95% CI 0.19 - 4.24, p=0.07).

CONCLUSION CR during the index hospitalization for STEMI is common. While CR was not associated with improved 1 year survival, it was associated with improved health status. These patient centered benefits should be considered in future guidelines recommendations.

Can morphine still be considered to be the standard for treating chronic pain? A systematic review including pair-wise and network meta-analyses

OBJECTIVE

For chronic pain treatment many health care authorities consider morphine to be the reference standard for strategic decisions in pain therapy. Although morphine's effectiveness is clear and its cost is low, it's unclear whether morphine should remain the first choice or reference treatment.

RESEARCH DESIGN AND METHODS

We performed a systematic review to evaluate the evidence available to support the position of morphine as the reference standard for step III opioids based on efficacy and tolerability outcomes.

RESULTS

The search yielded 5,675 titles and 56 studies were included. Considerable heterogeneity precluded pair-wise meta-analysis on change of pain intensity and no difference between morphine and other opioids were found for tolerability outcomes. The network meta-analysis showed no statistically significant difference in change of pain intensity between morphine and oxycodone, methadone and oxymorphone. Compared to morphine, patients using buprenorphine are more likely to discontinue treatment due to lack of effect (OR 2.32, 95% CI 1.37 to 3.95). Patients using methadone are more likely to discontinue due to adverse events (OR 3.09, 95% CI 1.14 to 8.36), whereas this risk is decreased for patients using fentanyl (OR 0.29, 95% CI 0.17 to 0.50) or buprenorphine (OR 0.30, 95% CI 0.16 to 0.53). The most important limitation of this review is that the included studies are heterogeneous with regard to study population and intervention, which may affect the pooled effect estimates. The main strength is that we only included parallel RCTs, the strongest design for intervention studies.

CONCLUSIONS

The current evidence is moderate, both in respect to the number of directly comparative studies and in the quality of reporting of these studies. No clear superiority in efficacy and tolerability of morphine over other opioids was found in pair-wise and network analyses. Based on these results, a justification for the placement of morphine as the reference standard for the treatment of severe chronic pain cannot be supported.

Epidemiology of chronic pain and its treatment in The Netherlands

BACKGROUND

Chronic pain is common&semi; however, good epidemiological data are scarce. Such information can help all the involved stakeholders to make responsible decisions about health budgets and prioritisation. This study aims to provide best-evidence epidemiological information about chronic pain in the Netherlands.

METHODS

We performed a systematic search which yielded 16,619 references, 119 Dutch studies were relevant. We selected at least three studies per question that provided the most recent, representative and valid data.

RESULTS

The prevalence of moderate to severe general chronic pain among Dutch adults was estimated at 18%. This prevalence was 27% and 55% for any cancer pain. Up to 74% of patients with general or non-cancer chronic pain get treated&semi; this percentage is little higher for patients with cancer pain. A substantial proportion of the patients receive drug treatment for their pain, mainly NSAIDs, but also non-pharmacological interventions for pain are being used. Up to 43% of the chronic non-cancer pain patients report not receiving treatment and up to 79% of the patients believe their pain is inadequately treated. All studies reported a detrimental effect of chronic pain on quality of life, activities of daily living and mental health. Chronic pain is also associated with direct and indirect medical costs, and patients may have decreased income and additional out-of pocket expenses.

CONCLUSION

Chronic pain occur s frequently, has a negative impact on the patient and society and treatment may not always be adequate. Chronic pain should be seen as an important public health problem deserving more attention of Dutch healthcare workers and policy makers.

Porphyromonas gingivalis mutY is involved in the repair of oxidative stress-induced DNA mispairing

The ability for DNA mismatch repair, after oxidative stress-induced DNA damage, is critical for the persistence of Porphyromonas gingivalis in the inflammatory environment of the periodontal pocket. Our previous report demonstrated that, in contrast to other organisms, the repair of oxidative stress-induced DNA damage involving 8-oxo-7,8-dihydroguanine (8-oxoG) may occur by a yet-to-be described mechanism in P. gingivalis. 8-oxoG does not block DNA replication; rather, it mispairs with adenine, which can be repaired by the MutY glycosylase. To determine the function of the P. gingivalis MutY homologue in DNA repair, it was insertionally inactivated using the ermF-ermAM antibiotic cassette and used to create a mutY-deficient mutant (FLL147) by allelic exchange mutagenesis. FLL147 had an increased rate of spontaneous mutation and was more sensitive to hydrogen peroxide compared with the wild-type W83 strain. DNA oligomers containing a site-specific 8-oxoG:A mispair was repaired similarly in both the P. gingivalis mutY-defective mutant and wild-type strains. The P. gingivalis mutY homologue was shown to complement the mutY mutation in Escherichia coli. In a gel mobility shift assay, the purified recombinant MutY is able to bind an oligo containing an 8-oxoG:A mispair. Taken together, MutY may play the expected role in oxidative stress resistance in P. gingivalis. However, there may exist other redundant mechanism(s) for the removal of 8-oxoG:A mismatch in this organism.