Patient-reported health outcomes of SARS-CoV-2-tested patients presenting to emergency departments: a propensity score-matched prospective cohort study

OBJECTIVE

This study aimed to compare the long-term physical and mental health outcomes of matched severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive and SARS-CoV-2-negative patients controlling for seasonal effects.

STUDY DESIGN

This was a retrospective cohort study.

METHODS

This study enrolled patients presenting to emergency departments participating in the Canadian COVID-19 Emergency Department Rapid Response Network. We enrolled consecutive eligible consenting patients who presented between March 1, 2020, and July 14, 2021, and were tested for SARS-CoV-2. Research assistants randomly selected four site and date-matched SARS-CoV-2-negative controls for every SARS-CoV-2-positive patient and interviewed them at least 30 days after discharge. We used propensity scores to match patients by baseline characteristics and used linear regression to compare Veterans RAND 12-item physical health component score (PCS) and mental health component scores (MCS), with higher scores indicating better self-reported health.

RESULTS

We included 1170 SARS-CoV-2-positive patients and 3716 test-negative controls. The adjusted mean difference for PCS was 0.50 (95% confidence interval [CI]: -0.36, 1.36) and -1.01 (95% CI: -1.91, -0.11) for MCS. Severe disease was strongly associated with worse PCS (β = -7.4; 95% CI: -9.8, -5.1), whereas prior mental health illness was strongly associated with worse MCS (β = -5.4; 95% CI: -6.3, -4.5).

CONCLUSION

Physical health, assessed by PCS, was similar between matched SARS-CoV-2-positive and SARS-CoV-2-negative patients, whereas mental health, assessed by MCS, was worse during a time when the public experienced barriers to care. These results may inform the development and prioritization of support programs for patients.

Growth and renal function dynamics of renal oncocytomas in patients on active surveillance

OBJECTIVES

To study the natural history of renal oncocytomas and address indications for intervention by determining how growth is associated with renal function over time, the reasons for surgery and ablation, and disease-specific survival.

PATIENTS AND METHODS

The study was conducted in a retrospective cohort of consecutive patients with renal oncocytoma on active surveillance reviewed at the Specialist Centre for Kidney Cancer at the Royal Free London NHS Foundation Trust (2012 to 2019). Comparison between groups was performed using Mann-Whitney U-tests and chi-squared tests. A mixed-effects model with a random intercept for patient was used to study the longitudinal association between tumour size and estimated glomerular filtration rate (eGFR).

RESULTS

Longitudinal data from 98 patients with 101 lesions were analysed. Most patients were men (68.3%) and the median (interquartile range [IQR]) age was 69 (13) years. The median (IQR) follow-up was 29 (26) months. Most lesions were small renal masses, and 24% measured over 4 cm. Over half (64.4%) grew at a median (IQR) rate of 2 (4) mm per year. No association was observed between tumour size and eGFR over time (P = 0.871). Nine lesions (8.9%) were subsequently treated. Two deaths were reported, neither were related to the diagnosis of renal oncocytoma.

CONCLUSION

Natural history data from the largest active surveillance cohort of renal oncocytomas to date show that renal function does not seem to be negatively impacted by growing oncocytomas, and confirms clinical outcomes are excellent after a median follow-up of over 2 years. Active surveillance should be considered the 'gold standard' management of renal oncocytomas up to 7cm.

Impact of the first surge of the COVID-19 pandemic on a tertiary referral centre for kidney cancer

Objective

To analyse the impact of the COVID‐19 pandemic on a centralized specialist kidney cancer care pathway.

Materials and Methods

We conducted a retrospective analysis of patient and pathway characteristics including prioritization strategies at the Specialist Centre for Kidney Cancer located at the Royal Free London NHS Foundation Trust (RFH) before and during the surge of COVID‐19.

Results

On 18 March 2020 all elective surgery was halted at RFH to redeploy resources and staff for the COVID‐19 surge. Prioritizing of patients according to European Association of Urology guidance was introduced. Clinics and the specialist multidisciplinary team (SMDT) meetings were maintained with physical distancing, kidney surgery was moved to a COVID‐protected site, and infection prevention measurements were enforced. During the 7 weeks of lockdown (23 March to 10 May 2020), 234 cases were discussed at the SMDT meetings, 53% compared to the 446 cases discussed in the 7 weeks pre‐lockdown. The reduction in referrals was more pronounced for small and asymptomatic renal masses. Of 62 low‐priority cancer patients, 27 (43.5%) were deferred. Only one (4%) COVID‐19 infection occurred postoperatively, and the patient made a full recovery. No increase in clinical or pathological upstaging could be detected in patients who underwent deferred surgery compared to pre‐COVID practice.

Conclusion

The first surge of the COVID‐19 pandemic severely impacted diagnosis, referral and treatment of kidney cancer at a tertiary referral centre. With a policy of prioritization and COVID‐protected pathways, capacity for time‐sensitive oncological interventions was maintained and no immediate clinical harm was observed.

Emotional demands, compassion and mental health in social workers

BACKGROUND

Compassion, described as the act of providing care based on empathy, dignity and respect, is intrinsic to effective health and social care. Although delivering compassionate care has wide-ranging benefits for service users, more insight is needed into its effects on health and social care professionals. The emotional demands of 'helping' work can engender compassion fatigue that may impair well-being, whereas compassion satisfaction and feelings of compassion towards the self could be protective.

AIMS

To examine the effects (direct and indirect) of compassion satisfaction, compassion fatigue and self-compassion on mental health in a cohort of social workers.

METHODS

We used validated scales to measure emotional demands, compassion satisfaction and fatigue, and self-compassion and the General Health Questionnaire-12 to assess mental health. We tested the main and moderating effects of emotional demands and the three facets of compassion using hierarchical regression analysis.

RESULTS

The study sample comprised 306 social workers (79% female). Participants who reported higher levels of compassion satisfaction and self-compassion tended to report better mental health, whereas compassion fatigue was a significant risk factor for well-being. The models explained 44-53% of the variance in mental health symptoms. We found some evidence that compassion satisfaction and self-compassion buffer the negative effects of emotional demand on mental health, contributing 2 and 3%, respectively, to the incremental variance.

CONCLUSIONS

Our findings suggest that evidence-based interventions are needed to reduce compassion fatigue and enhance compassion satisfaction and self-compassion in social care work. We consider ways to accomplish this using targeted interventions.

Renal tumor biopsy to reduce overtreatment of renal oncocytomas

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Background: Up to 30% of renal masses are benign tumours, the most common of which is renal oncocytomas (RO). Our practice is to offer renal tumour biopsy (RTB) for small renal masses (SRM; ≤4cm) as part of a multi-disciplinary pathway. Our objective was to determine whether RTB influenced the management of RO. Methods: Retrospective descriptive analysis of the management of all sporadic cases with a histological diagnosis of RO (biopsy or surgical) at a high-volume tertiary centre from January/2012 to June/2019. Results: 170 patients (66% male; median age 67 years; median age-related Charlson comorbidity index 3) were diagnosed with 177 RO (median size 36mm). 70% (124) of RO were diagnosed using tumour biopsy (median size 33mm), of which 116 (93.4%) embarked on active surveillance (AS; 101) or watchful waiting (15). 53 (30%) RO were diagnosed after surgical excision (median size 50mm; 15 partial and 38 radical nephrectomies), of which 4 lesions were initially managed with AS. Median follow-up on AS was 20 months (2 to 84 months), with a median decrease in estimated glomerular filtration rate of 3 ml/min/1.73m2 over this period. 79% of RO on AS were SRMs. Median overall lesion size change was 1.1mm/year during follow up. Overall 62.6% of lesions grew, a quarter of which at a rate >5mm/year. Nine cases of RO on AS changed to intervention due to lesion growth or patient choice. No metastases were reported in the whole cohort. Three patients on AS died (stroke, respiratory arrest secondary to food inhalation, and unknown cause). One patient who had had surgical excision of RO died of unknown cause. Conclusions: Surgical risks for benign renal lesions are not different to those taken for renal cell carcinoma. RTB reduces the use of unnecessary surgery and its incumbent morbidity for benign renal lesions, such as RO. AS is a safe management option for patients with RO and can be used to reduce overtreatment-associated harm.

Protocol for a feasibility study of a cohort embedded randomised controlled trial comparing phron paring reatment (NEST) for small renal masses

INTRODUCTION

Small renal masses (SRMs; ≤4 cm) account for two-thirds of new diagnoses of kidney cancer, the majority of which are incidental findings. The natural history of the SRM seems largely indolent. There is an increasing concern regarding surgical overtreatment and the associated health burden in terms of morbidity and economy. Observational data support the safety and efficacy of percutaneous cryoablation but there is an unmet need for high-quality evidence on non-surgical management options and a head-to-head comparison with standard of care is lacking. Historical interventional trial recruitment difficulties demand novel study conduct approaches. We aim to assess if a novel trial design, the cohort embedded randomised controlled trial (RCT), will enable carrying out such a comparison.

METHODS AND ANALYSIS

Single-centre prospective cohort study of adults diagnosed with SRM (n=200) with an open label embedded interventional RCT comparing nephron sparing interventions. Cohort participants will be managed at patient and clinicians' discretion and agree with longitudinal clinical data and biological sample collection, with invitation for trial interventions and participation in comparator control groups. Cohort participants with biopsy-proven renal cell carcinoma eligible for both percutaneous cryoablation and partial nephrectomy will be randomly selected (1:1) and invited to consider percutaneous cryoablation (n=25). The comparator group will be robotic partial nephrectomy (n=25). The primary outcome of this feasibility study is participant recruitment. Qualitative research techniques will assess barriers and recruitment improvement opportunities. Secondary outcomes are participant trial retention, health-related quality of life, treatment complications, blood transfusion rate, intensive care unit admission and renal replacement requirement rates, length of hospital stay, time to return to pre-treatment activities, number of work days lost, and health technologies costs.

ETHICS AND DISSEMINATION

Ethical approval has been granted (UK HRA REC 19/EM/0004). Study outputs will be presented and published.

TRIAL REGISTRATION

ISRCTN18156881; Pre-results.

Risk factors for transplant renal artery stenosis after live donor transplantation

Background

Renal transplant surgeons are making increasing use of live donor kidneys with multiple renal arteries. This study aimed to identify independent risk factors for the development of transplant renal artery stenosis (TRAS) in the modern era of complex arterial reconstruction for multiple vessels.

Methods

Multivariable logistic regression analysis with a stepwise variable deletion model was used to identify risk factors for the development of TRAS in a consecutive series of live donor kidney transplants.

Results

Of 506 kidney transplants, 19 (3·8 per cent) had evidence of significant TRAS on CT angiography. Functional TRAS, defined by improvement in BP control or renal function after correction of a stenosis by angioplasty, occurred in 13 of 506 patients (2·6 per cent). Independent risk factors for TRAS were: use of an explanted internal iliac artery graft from the recipient (odds ratio (OR) 4·95; P = 0·020) and total ischaemia time (OR 1·82; P = 0·010). TRAS was associated with a lower 5-year allograft survival rate (79 versus 88·7 per cent; P = 0·020) but only one graft loss was attributed directly to TRAS. The 5-year allograft survival rate after internal iliac artery grafting was 86 per cent.

Conclusion

Although use of an internal iliac artery graft is an independent risk factor for TRAS after live donor kidney transplantation, this technique is still a useful option for complex arterial reconstruction.

Assessment of Palliative Care Needs in Hospital Settings in Rwanda

Background: Rwanda is among the first African countries with a palliative care (PC) policy and implementation plan. A partnership with the Ministry of Health (MoH) through the Rwanda Biomedical Centre (RBC) and the University of Edinburgh has supported an integrated approach including expanding the evidence base. Aim: To assessing the need for (PC) to inform policy, service delivery and training. Methods: A point prevalence PC needs assessment was conducted in nine public hospitals (referral, provincial and district). A records census identified those with life-limiting illness (LLI) who were then invited to participate by interview. The assessment tool included the APCA African POS, POS S, WHO performance status and demographic information. Results: 608 case notes were reviewed, 152 eligible and 124 completed assessment. 25% of all patients admitted had LLI, of which 99.2% had evidence of unmet need determined by at least one score on the APCA POS ≥ 3. Diagnoses 29% cancer, 29% cardiovascular disease, 16.9% end-stage organ failure and 13.7% HIV. Symptoms with greatest impact; nausea and vomiting (34.7%) and pain (32.3%). 63.7% with WHO performance status 4 or 5. 8.1% seen by existing PC services. Conclusion: Although the MoH and RBC are making bold steps toward developing PC in Rwanda, there remains a significant amount of unmet PC needs. Meeting this need requires recognition of the scope of PC needs beyond cancer, feedback to the hospitals and health care workers, thinking strategically how to further strengthen the health system and further capacity building and training.

Home-Based Care Practitioners: A Strategy for Continuum of Care for Very Ill Patient

Background: Rwanda Ministry of Health in collaboration with partners has initiated an innovative initiative named Home Based Care Practitioners (HBCPs) to respond to the burden of long-term hospitalization for end of life patients. Aim: The program aims at providing home-based care to accompany patients and their families in their home, reduce unnecessary pain and suffering for those with chronic or terminal conditions, provide counseling to the patients and their families, early diagnosis of NCDs and improve awareness on prevention of NCDs risk factors and effectively refer them to either health facilities or community-based resources that can be of further help. Methods: The HBCPs is implemented into phases; phase one has started with a pilot of 200 HBCPs in 100 cells surrounding nine provincial and referral hospitals of Rwanda; 2 practitioners for both gender in each cell, with a criteria of completion at least secondary school. They have undergone a training of 120 credits (900 hours), equivalent of four months for theory and two months of practice. After training they have been deployed into the community with a supervision of health centers in collaboration with hospitals and Rwanda Biomedical Center. Results: During the implementation period of 6 months, 1663 NCDs patients have been transferred from health facility (OPD) to HBCPs for routine follow-up, 482 palliative care patients have been reported on end of life care by HBCPs, there is a remarkable linkage between facilities and community care ensured by supervisory relationship between health services providers and home based care practitioners, long-term admission has reduced the cost for the family and the facility due to the discharge of care from hospital to home. Conclusion: In a limited setting of social and economic cost of providing frivolous care in an expensive hospital for chronic or terminal conditions that would be better managed through treatment or palliative care at home (or less acute setting) home based care effort can better meet the needs of Rwandans at the community level and has started to show the efficiency in providing quality care to people in need of palliative care.

Evaluation of Clinical Prognostic Factors and Further Delineation of the Effect of Mesenteric Fibrosis on Survival in Advanced Midgut Neuroendocrine Tumours

BACKGROUND

Small intestinal neuroendocrine tumours (SI NETs) represent 30-50% of small bowel neoplasms and often present at an advanced stage. To date, there is relatively limited literature regarding prognostic factors affecting overall survival (OS) in stage IV disease. In addition, the prevalence of mesenteric fibrosis (MF) in SI NETs and its effect on OS have not been sufficiently explored in the literature.

AIM

The primary aim of this study was to perform a large-scale survival analysis in an institutional cohort of 387 patients with metastatic (stage IV) SI NETs. The secondary aim was to provide epidemiological information regarding the prevalence of MF and to evaluate its effect on OS.

RESULTS

The median OS was 101 months (95% CI 84, 118). Age > 65 years, mesenteric metastases with and without desmoplasia, liver metastases, carcinoid heart disease (CHD) and bone metastases were associated with a significantly shorter OS, while primary tumour resection was predictive of a longer OS. The benefit of surgical resection was limited to symptomatic patients. MF was present in approximately 50% of patients with mesenteric lymphadenopathy. Elevated urinary 5-HIAA levels correlated strongly with the presence of CHD (p < 0.001) and to a lesser extent (p = 0.02) with MF. MF and CHD did not usually co-exist, suggesting that different mechanisms are likely to be involved in the development of these fibrotic complications.

CONCLUSIONS

This study has identified specific prognostic factors in a large cohort of 387 patients with advanced SI NETs and has provided useful epidemiological data regarding carcinoid-related fibrotic complications.

Myeloid protein tyrosine phosphatase 1B (PTP1B) deficiency protects against atherosclerotic plaque formation in the ApoE-/- mouse model of atherosclerosis with alterations in IL10/AMPKα pathway

Objective

Cardiovascular disease (CVD) is the most prevalent cause of mortality among patients with Type 1 or Type 2 diabetes, due to accelerated atherosclerosis. Recent evidence suggests a strong link between atherosclerosis and insulin resistance due to impaired insulin receptor (IR) signaling. Moreover, inflammatory cells, in particular macrophages, play a key role in pathogenesis of atherosclerosis and insulin resistance in humans. We hypothesized that inhibiting the activity of protein tyrosine phosphatase 1B (PTP1B), the major negative regulator of the IR, specifically in macrophages, would have beneficial anti-inflammatory effects and lead to protection against atherosclerosis and CVD.

Methods

We generated novel macrophage-specific PTP1B knockout mice on atherogenic background (ApoE^−/−/LysM-PTP1B). Mice were fed standard or pro-atherogenic diet, and body weight, adiposity (echoMRI), glucose homeostasis, atherosclerotic plaque development, and molecular, biochemical and targeted lipidomic eicosanoid analyses were performed.

Results

Myeloid-PTP1B knockout mice on atherogenic background (ApoE^−/−/LysM-PTP1B) exhibited a striking improvement in glucose homeostasis, decreased circulating lipids and decreased atherosclerotic plaque lesions, in the absence of body weight/adiposity differences. This was associated with enhanced phosphorylation of aortic Akt, AMPKα and increased secretion of circulating anti-inflammatory cytokine interleukin-10 (IL-10) and prostaglandin E2 (PGE₂), without measurable alterations in IR phosphorylation, suggesting a direct beneficial effect of myeloid-PTP1B targeting.

Conclusions

Here we demonstrate that inhibiting the activity of PTP1B specifically in myeloid lineage cells protects against atherosclerotic plaque formation, under atherogenic conditions, in an ApoE^−/− mouse model of atherosclerosis. Our findings suggest for the first time that macrophage PTP1B targeting could be a therapeutic target for atherosclerosis treatment and reduction of CVD risk.

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PTP1B inhibition as therapy for atherosclerosis/cardiovascular disease is proposed.

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Myeloid-PTP1B mice on ApoE^−/− background (ApoE^−/−/LysM-PTP1B) were generated.

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ApoE^−/−/LysM-PTP1B had improved glucose homeostasis with no body weight differences.

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ApoE^−/−/LysM-PTP1B had lower lipids and protection against atherosclerotic plaques.

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Protection was via a PGE₂/IL-10/AMPKα mechanism.

The relationships between golf and health: a scoping review

OBJECTIVE

To assess the relationships between golf and health.

DESIGN

Scoping review.

DATA SOURCES

Published and unpublished reports of any age or language, identified by searching electronic databases, platforms, reference lists, websites and from consulting experts.

REVIEW METHODS

A 3-step search strategy identified relevant published primary and secondary studies as well as grey literature. Identified studies were screened for final inclusion. Data were extracted using a standardised tool, to form (1) a descriptive analysis and (2) a thematic summary.

RESULTS AND DISCUSSION

4944 records were identified with an initial search. 301 studies met criteria for the scoping review. Golf can provide moderate intensity physical activity and is associated with physical health benefits that include improved cardiovascular, respiratory and metabolic profiles, and improved wellness. There is limited evidence related to golf and mental health. The incidence of golfing injury is moderate, with back injuries the most frequent. Accidental head injuries are rare, but can have serious consequences.

CONCLUSIONS

Practitioners and policymakers can be encouraged to support more people to play golf, due to associated improved physical health and mental well-being, and a potential contribution to increased life expectancy. Injuries and illnesses associated with golf have been identified, and risk reduction strategies are warranted. Further research priorities include systematic reviews to further explore the cause and effect nature of the relationships described. Research characterising golf's contribution to muscular strengthening, balance and falls prevention as well as further assessing the associations and effects between golf and mental health are also indicated.

The relationship and effects of golf on physical and mental health: a scoping review protocol

INTRODUCTION

Golf is a sport played in 206 countries worldwide by over 50 million people. It is possible that participation in golf, which is a form of physical activity, may be associated with effects on longevity, the cardiovascular, metabolic and musculoskeletal systems, as well as on mental health and well-being. We outline our scoping review protocol to examine the relationships and effects of golf on physical and mental health.

METHODS AND ANALYSIS

Best practice methodological frameworks suggested by Arksey and O'Malley, Levac et al and the Joanna Briggs Institute will serve as our guide, providing clarity and rigour. A scoping review provides a framework to (1) map the key concepts and evidence, (2) summarise and disseminate existing research findings to practitioners and policymakers and (3) identify gaps in the existing research. A three-step search strategy will identify reviews as well as original research, published and grey literature. An initial search will identify suitable search terms, followed by a search using keyword and index terms. Two reviewers will independently screen identified studies for final inclusion.

DISSEMINATION

We will map key concepts and evidence, and disseminate existing research findings to practitioners and policymakers through peer-reviewed and non-peer reviewed publications, conferences and in-person communications. We will identify priorities for further study. This method may prove useful to examine the relationships and effects of other sports on health.

Inducible liver-specific knockdown of protein tyrosine phosphatase 1B improves glucose and lipid homeostasis in adult mice

AIMS/HYPOTHESIS

Protein tyrosine phosphatase 1B (PTP1B) is a key negative regulator of insulin signalling. Hepatic PTP1B deficiency, using the Alb-Cre promoter to drive Ptp1b deletion from birth in mice, improves glucose homeostasis, insulin sensitivity and lipid metabolism. The aim of this study was to investigate the therapeutic potential of decreasing liver PTP1B levels in obese and insulin-resistant adult mice.

METHODS

Inducible Ptp1b liver-specific knockout mice were generated using SA-Cre-ER(T2) mice crossed with Ptp1b floxed (Ptp1b(fl/fl)) mice. Mice were fed a high-fat diet (HFD) for 12 weeks to induce obesity and insulin resistance. Tamoxifen was administered in the HFD to induce liver-specific deletion of Ptp1b (SA-Ptp1b(-/-) mice). Body weight, glucose homeostasis, lipid homeostasis, serum adipokines, insulin signalling and endoplasmic reticulum (ER) stress were examined.

RESULTS

Despite no significant change in body weight relative to HFD-fed Ptp1b(fl/fl) control mice, HFD-fed SA-Ptp1b(-/-) mice exhibited a reversal of glucose intolerance as determined by improved glucose and pyruvate tolerance tests, decreased fed and fasting blood glucose and insulin levels, lower HOMA of insulin resistance, circulating leptin, serum and liver triacylglycerols, serum NEFA and decreased HFD-induced ER stress. This was associated with decreased glycogen synthase, eukaryotic translation initiation factor-2α kinase 3, eukaryotic initiation factor 2α and c-Jun NH2-terminal kinase 2 phosphorylation, and decreased expression of Pepck.

CONCLUSIONS/INTERPRETATION

Inducible liver-specific PTP1B knockdown reverses glucose intolerance and improves lipid homeostasis in HFD-fed obese and insulin-resistant adult mice. This suggests that knockdown of liver PTP1B in individuals who are already obese/insulin resistant may have relatively rapid, beneficial therapeutic effects.

Type 1 diabetes structured education: What are the core self-management behaviours?

AIMS

Study aims were to (1) describe and compare the way diabetes structured education courses have evolved in the UK, (2) identify and agree components of course curricula perceived as core across courses and (3) identify and classify self-care behaviours in order to develop a questionnaire assessment tool.

METHODS

Structured education courses were selected through the Type 1 diabetes education network. Curricula from five courses were examined and nine educators from those courses were interviewed. Transcripts were analysed using framework analysis. Fourteen key stakeholders attended a consensus meeting, to identify and classify Type 1 diabetes self-care behaviours.

RESULTS

Eighty-three courses were identified. Components of course curricula perceived as core by all diabetes educators were: carbohydrate counting and insulin dose adjustment, hypoglycaemia management, group work, goal setting and empowerment, confidence and control. The broad areas of self-management behaviour identified at the consensus meeting were carbohydrate counting and awareness, insulin dose adjustment, self-monitoring of blood glucose, managing hypoglycaemia, managing equipment and injection sites; and accessing health care. Specific self-care behaviours within each area were identified.

CONCLUSIONS

Planned future work will develop an updated questionnaire tool to access self-care behaviours. This will enable assessment of the effectiveness of existing structured education programmes at producing desired changes in behaviour. It will also help people with diabetes and their healthcare team identify areas where additional support is needed to initiate or maintain changes in behaviour. Provision of such support may improve glycaemia and reduce diabetes-related complications and severe hypoglycaemia.

The Tayside insulin management course: an effective education programme in type 1 diabetes

AIMS

The Tayside insulin management (TIM) course is an intensive insulin management programme for adults with type 1 diabetes. The aim was to assess its effectiveness.

METHODS

Haemoglobin A1c (HbA1c) and body mass index (BMI) from individuals with type 1 diabetes were collected 3 months before, and 6 and 24 months after the programme. The programme involved a full day of education per week for 4 weeks in a row. Quality of life was assessed using the standardised Audit of Diabetes-Dependent Quality of Life (ADDQoL) questionnaire completed both before and 3 months after the course. Subjects were also asked to complete a pre- and postcourse questionnaire gathering information about aspects of their diabetes management. In addition, individual satisfaction with course content and delivery was recorded.

RESULTS

Participants had a median reduction in haemoglobin A1c (HbA1c) of 4 mmol/mol (0.4%) after 6 months and 5 mmol/mol (0.5%) 2 years after the course (p < 0.001). Mean daily dose of short-acting insulin decreased from 31.5 (1.9) units to 27.3 (1.9, p < 0.001). There was no significant change in BMI. There was an improvement in all 18 domains of the ADDQoL questionnaire. There was a decrease in hypoglycaemia unawareness from 34.3 ± 47.8% of patients to 8.6 ± 28% (p < 0.001), and a decrease in self-reported lipohypertrophy from 27.8% to 11.1% (p = 0.001). There was a significant reduction in the mean number of diabetic ketoacidosis and severe hypoglycaemic episodes. The number of blood glucose checks changed from 2.8 ± 2.1 to 3.2 ± 1.1 (p = 0.058) per day. Participant satisfaction with all aspects of course content and delivery was high.

CONCLUSIONS

TIM is an effective intensive education programme for patients with type 1 diabetes.

Pilot project and evaluation of delivering diabetes work-based education using video conferencing

CONTEXT

Diabetes is a chronic long-term disease with an increasing incidence. There is a need to increase access to effective care and to ensure such care is delivered as locally as possible. The geographical spread of NHS Highland Scotland presents additional challenges to ensuring a skilled workforce given education is normally work-based tuition and assessment. The aim of this pilot project was to deliver teleconferenced diabetes training to healthcare and allied healthcare professionals who provide basic level care for, and management of, people with diabetes and to evaluate this training.

ISSUE

Work-based diabetes education was designed to be delivered by a diabetes educator through videoconferencing or face to face (F2F) for healthcare professionals in peripheral settings in the Scottish Highlands region over two half-days. The education covered theoretical and practical training in diabetes. The evaluation of the project was through post-course questionnaires and assessment instruments to capture views of the content and delivery mode, as well as student performance.

LESSONS LEARNED

Feedback from participants indicated that the educational content was relevant and that the use of videoconferencing (VC) could provide accessibility to training where distance, cost and other issues may make access difficult. Student performance on the assessment instruments did not differ between those who received the training through video conferencing and those who received the training through F2F delivery. Video conferencing can counteract the difficulties of accessing training for clinical peripherally based professionals. Training through VC did not compromise student acquisition of learning outcomes. Feedback indicates that VC can reduce the interactive nature of the learning and teaching experience.

Sexual coercion prior to imprisonment: prevalence, demographic and behavioural correlates

Little is known about experiences of sexual coercion among prisoners prior to incarceration. Prisoner populations are routinely excluded from national surveys of sexual health which also tend to under-represent marginalized groups. We surveyed 2351 randomly selected men and women, aged 18–64 years, in New South Wales and Queensland prisons who participated in a computer-assisted telephone interview. Around 60% of women and 14% of men self-reported having been sexually coerced prior to incarceration, with 60% of these experiences occurring before the age of 16 years. Factors independently associated with a self-reported history of sexual coercion were: homosexual and bisexual identity, being unable to work, separated marital status, higher level of education (among women), having been paid for sex, a past sexually transmissible infection (among men), drug use (among women) and a history of mental health problems. Prior sexual coercion was associated with unwanted sexual contact and physical assault while in prison. The high prevalence of sexual coercion reported by prisoners and its association with a range of factors indicates a need for a greater acknowledgement of the potential consequences of this within the criminal justice system. This could entail providing counselling and support services within the correctional setting.

Facing the future: the effects of the impending financial drought on NHS finances and how UK radiology services can contribute to expected efficiency savings

The recent turmoil within the banking sector has led to the development of the most significant recession since the "great depression" of the 1930s. Although the coalition government has promised to "guarantee that health spending increases in real terms in each year of Parliament", this may still not be enough to meet future needs over the coming years due to increasing demand and cost pressures. The expected mismatch between actual National Health Service (NHS) funding post-2011 and that required to satisfy increasing demand has been estimated by the Department of Health to require efficiency savings representing up to one-fifth of the overall NHS budget. This paper explains the reasons behind the anticipated slowdown in the growth of real NHS funding, and how, as a discipline, radiology can increase the efficiency of the services it provides in anticipation of future financial austerity within the NHS.

Knowledge of sexually transmissible infections: a comparison of prisoners and the general population

The World Health Organization (WHO) has identified a failure to provide education for vulnerable populations such as prisoners as a contributing factor to the epidemic of sexually transmissible infections (STIs). Despite this recognition, little is known about prisoners' level of knowledge of STIs compared with the general population. Using computer-assisted telephone interviews, we compared a representative sample of 2289 Australian prisoners, aged 18–59 years from New South Wales and Queensland prisons with a representative community sample of 3536 participants from these two states. Prisoners had significantly better knowledge than the general community of chlamydia-related questions, while knowledge of herpes (genital and oral) was slightly better in the community sample. Prisoners who were aged over 25 years, not married, female, self-identified as either homosexual or bisexual and reported a history of STIs tended to have better STI knowledge levels. Despite their more disadvantaged backgrounds, prisoners demonstrated relatively good health literacy in relation to STIs. Ongoing education about the transmission risks of STIs for prisoners and the general community is needed.

The value of postoperative/preadjuvant chemotherapy computed tomography in the management of patients with ovarian cancer

OBJECTIVE

The objectives of the study were to compare the operative assessment of residual disease with the postoperative computed tomography (CT) findings in patients with ovarian cancer who underwent primary surgical cytoreduction or interval debulking surgery to residual disease 1 cm or less and to assess the effect of potential prognostic factors on patient survival.

METHODS

Patients scheduled for surgery and with an available postoperative CT were eligible for the study. Images were retrospectively analyzed in consensus by 2 radiologists.A 5-point qualitative scoring system was used to evaluate the CT findings (1 = tumor definitely absent, 2 = tumor probably absent, 3 = tumor possibly present, 4 = tumor probably present, 5 = tumor definitely present).

RESULTS

Between September 2005 and December 2008, 206 consecutive patients were enrolled; 51 were eligible. In 30 cases (59%), the postoperative CT findings correlated with the surgeon's assessment of residual disease. For the univariate analyses, the only significant prognostic factors associated with overall survival were no residual disease versus residual disease of less than 1 cm as assessed by the surgeon (hazard ratio [HR], 3.06; 95%confidence interval [CI], 1.29--7.27; P = 0.011) and no residual disease versus residual disease greater than 1 cm on CT (HR, 2.57; 95% CI, 1.02--6.48; P = 0.045). The interaction of surgical residual disease and stage 3 was significant (HR, 3.40; 95% CI, 1.42--8.16;P = 0.006) in the multivariate Cox model.

CONCLUSIONS

There was only 59% correlation between the surgical assessment and post operative CT findings of residual disease in patients reported to have undergone optimal surgery. Stage and residual disease as assessed by the surgeon were significant prognostic factors for overall survival. The value for postoperative CT may lie in those cases with small-volume residual disease (visible but reported as G1 cm) at surgery.

Visceral abdominal obesity--is there an increased prevalence in men presenting with testicular teratoma?

BACKGROUND

There is evidence to suggest a link between the accumulation of visceral abdominal adipose tissue and an increased incidence of prostate, endometrial, breast, and colonic cancer.

PURPOSE

To investigate whether an increase in ratio of visceral to subcutaneous abdominal adipose tissue is demonstrated in patients with testicular teratoma.

MATERIAL AND METHODS

Following ethical approval, 22 male patients who had undergone staging computed tomography (CT) between 2004 and 2007 for testicular teratoma were identified from our database. Abdominal adipose tissue distribution for these 22 patients was compared with that of 22 control patients, standardized for age, sex, and body mass index. Visceral and subcutaneous adipose tissue volumes were calculated from a single axial CT slice at the level of the umbilicus. A two-sample t test for the difference in volume ratio between the two groups was used. A P value of < 0.05 was considered statistically significant.

RESULTS

There was a statistically significant difference in the mean ratio of visceral to subcutaneous volumes between the teratoma patients and controls (P=0.02). The ratio in teratoma patients was 1.56 times greater than seen in control patients.

CONCLUSION

Patients with testicular teratoma have a relatively greater proportion of abdominal visceral adipose tissue compared with controls. This is concordant with published literature for other malignancies.

A review of the biological and potential therapeutic actions ofHarpagophytum procumbens

Harpagophytum procumbens (Hp), commonly known as Devil's Claw is a perennial plant which thrives in arid conditions. For centuries, it has been used as a traditional treatment for a variety of illnesses, including fevers, skin complaints, arthritis and diseases of the digestive tract as well as an appetite stimulant. Since its introduction to Europe in the early twentieth century, it has become a popular antiinflammatory and analgesic preparation amongst herbalists for supportive or adjuvant treatment of degenerative joint diseases, tendonitis, headache, backache and menstrual pain. The validity of Hp as an effective antiinflammatory and analgesic preparation, particularly in the relief of arthritic symptoms, has been investigated in numerous animal, clinical and in vitro studies. Although some contradictory evidence exists, the majority of animal studies appear to indicate Hp as an effective antiinflammatory and analgesic preparation in the treatment of acute and subacute inflammation. Clinical trials support Hp as a beneficial treatment for the alleviation of pain and improvement of mobility in a variety of musculoskeletal conditions. Analysis of the in vitro and ex vivo studies that currently exist, indicate that Hp has significant effects on numerous proinflammatory markers. However, the exact mechanism(s) by which Hp may reduce inflammation remain to be elucidated.

Extreme cause-specific mortality in a cohort of adult prisoners—1988 to 2002: a data-linkage study

OBJECTIVES

Describe the standardized mortality ratio (SMR) and its trend in adults who have served time in prison.

DESIGN

A retrospective cohort study of 85,203 adults imprisoned in New South Wales (NSW), Australia, between 1 January 1988 and 31 December 2002.

METHODS

We obtained information on deaths by record linkage with the Australian National Death Index (NDI). Mortality rates were estimated using the person-time method. SMRs were calculated using sex, age, and calendar-specific death rates from the NSW population. Time trends in SMRs were assessed using the test for linear trends.

RESULTS

The median overall follow-up of the cohort was 7.7 years. We identified 5137 deaths (4714 men, 423 women) among the cohort of which the vast majority (4834, 94%) occurred following release from custody. All-cause SMR was 3.7 (95% CI: 3.6-3.8) in men and 7.8 (95% CI: 7.1-8.5) in women. SMRs were substantially raised for deaths due to mental and behavioural disorders (men: 13.2, 95% CI: 12.3-14.0; women: 62.8, 95% CI: 52.7-74.9) and drug-related deaths (men: 12.8, 95% CI: 12.2-13.5; women: 50.3, 95% CI: 43.7-57.8). The SMR for death by homicide was 10.2 (95% CI: 8.9-11.7) in men and 26.3 (95% CI: 17.8-39.0) in women. Aboriginal men were 4.8 times, and Aboriginal women 12.6 times, more likely to die than the general NSW population. Over the study period on average all-cause SMR decreased significantly in men (p = 0.003) and women (p = 0.05) largely due to the decline in SMRs for drug-related deaths and suicide.

CONCLUSION

In the largest study so far reported, mortality of male and female offenders was far greater than expected for all major causes, especially deaths caused by drug overdose. Despite some indication of a reduction in excess mortality in recent years, there remains an overwhelming need for enhanced responses to mental health and drug problems for people who have been in prison.

Selected fruits reduce azoxymethane (AOM)-induced aberrant crypt foci (ACF) in Fisher 344 male rats

Phytochemicals contribute to the vibrant colors of fruits and it is suggested that the darker the fruit the higher the antioxidative or anticarcinogenic properties. In this study we investigated the possible effects of blueberries (BLU), blackberries (BLK), plums (PLM), mangoes (MAN), pomegranate juice (POJ), watermelon juice (WMJ) and cranberry juice (CBJ) on azoxymethane (AOM)-induced aberrant crypt foci (ACF) in Fisher 344 male rats. Forty-eight male Fisher 344 rats were randomly assigned to eight groups (n=6). The groups were fed AIN-93G as a control (C) diet, the rats fed fruits received AIN-93G+5% fruits and the groups that were given fruits juices received 20% fruit juice instead of water. The rats received subcutaneous injections of AOM at 16 mg/kg body weight at seventh and eighth weeks of age. At 17th week of age, the rats were killed by CO(2) asphyxiation. Total ACF numbers (mean+/-SEM) in the rats fed CON, BLU, BLK, PLM, MNG, POJ, WMJ and CBJ were 171.67+/-5.6, 11.33+/-2.85, 24.0+/-0.58, 33.67+/-0.89, 28.67+/-1.33, 15.67+/-1.86, 24.33+/-3.92 and 39.0+/-15.31. Total glutathione-S-transferase (GST) activity (mICROmol/mg) in the liver of the rats fed fruits (except BLK) and fruit juices were significantly (p<0.05) higher in the rats fed fruits and fruit juices compared with the control. Our findings suggest that among the fruits and fruit juices, BLU and POJ contributed to significant (P<0.05) reductions in the formation of AOM-induced ACF.

Weight loss and long-term follow-up of severely obese individuals treated with an intense behavioral program

OBJECTIVE

To review weight loss and maintenance for severely obese individuals enrolled in intensive behavioral weight loss program using very-low or low-energy diets.

DESIGN

Chart review of consecutively treated patients between 1995 and 2002 seen at three weight loss centers.

SUBJECTS

One thousand five hundred and thirty one patients with severe obesity (>or=40 kg/m(2)) treated in three cities ('Study Group'). Of these, 1100 completed the 12-week core curriculum ('Completer Group'). Weight loss >or=100 lbs (>45 kg) was seen in 268 patients ('100-Pound Group').

MEASUREMENTS

Charts were reviewed for baseline characteristics, weekly weights, follow-up weights and side effects.

RESULTS

In the Study Group, average weight loss+/-s.e. for 998 women was 23.9+/-0.6 kg (18.5% of initial body weight (IBW)) and for 533 men was 36.0+/-1.0 kg (22.5%) over 30 weeks. For Completers, average weight loss for women was 30.8+/-0.6 kg (23.9%) and for men was 42.6+/-1.1 kg (26.7%) over 39 weeks. In the 100-Pound Group, average weight loss for women was 58.2+/-1.2 kg (41.5%) in 65 weeks and for men was 65.7+/-1.5 kg (37.5%) in 51 weeks. Side effects, assessed in 100 patients losing >45 kg, were mild to moderate in severity. Severe adverse events unrelated to the diet were noted in 5% of patients and during weight loss 1% had elective cholecystectomies. Follow-up weights were available for 86% of Completers at an average of 72 weeks with average maintenance of 23 kg or 59% of weight loss; follow-up weights were available for 94% of the 100-Pound Group at an average of 95 weeks with average maintenance of 41 kg or 65% of weight loss maintained.

CONCLUSIONS

Intensive behavioral treatment with meal replacements is a safe and effective weight-loss strategy for selected severely obese individuals.

Confirmation of CHD7 as a cause of CHARGE association identified by mapping a balanced chromosome translocation in affected monozygotic twins

BACKGROUND

CHARGE syndrome has an estimated prevalence of 1/10,000. Most cases are sporadic which led to hypotheses of a non-genetic aetiology. However, there was also evidence for a genetic cause with reports of multiplex families with presumed autosomal dominant, possible autosomal recessive inheritance and concordant twin pairs. We identified a monozygotic twin pair with CHARGE syndrome and a de novo balanced chromosome rearrangement t(8;13)(q11.2;q22).

METHODS

Fluorescence in situ hybridisation was performed with BAC and PAC probes to characterise the translocation breakpoints. The breakpoint on chromosome 8 was further refined using 10 kb probes we designed and produced using sequence data for clone RP11 33I11, the Primer3 website, and a long range PCR kit.

RESULTS

BAC and PAC probe hybridisation redefined the breakpoints to 8q12.2 and 13q31.1. Probe RP11 33I11 spanned the breakpoint on chromosome 8. Using our 10 kb probes we demonstrated that the chromodomain gene CHD7 was disrupted by the translocation between exons 3 and 8.

DISCUSSION

Identifying that the translocation breakpoint in our patients occurred between exons 3 and 8 of CHD7 suggests that disruption of this gene is the cause of CHARGE syndrome in the twins and independently confirms the role of CHD7 in CHARGE syndrome.

Validation of a test model of induced dysmenorrhea

BACKGROUND

The myometrial hyperactivity and reduced uterine blood flow of primary dysmenorrhea is to a large extent caused by increased vasopressin secretion. A new therapeutic approach for this condition is to develop antagonists of uterine vasopressin V1a receptors. We studied a test model of vasopressin-induced dysmenorrhea in healthy, sterilized women and compared responses against those in dysmenorrheic subjects.

METHODS

Eight women with primary dysmenorrhea and eight sterilized, healthy women participated in recordings of intrauterine pressure and experienced pain on days 1-2 of two menstruations. We tried to identify biochemical markers in plasma of uterine ischemia. Furthermore, the effects of repeated bolus injections of 10 pmol/kg b w of vasopressin or placebo on these parameters were assessed.

RESULTS

The vasopressin injections caused statistically significant increases in the area under the intrauterine pressure curve (AUC) in both healthy volunteers and patients with dysmenorrhea, the overall responses being greater in healthy volunteers. The experienced pain measured by visual analog scale in individual dysmenorrheic subjects tended to show higher maximal post-dose scores for the vasopressin injections than for placebo. Maximum visual analog scale scores and maximum AUCs in individual subjects tended to be related. Mean creatine kinase MB levels were higher in women with dysmenorrhea than in healthy subjects both before and after vasopressin administration, the converse being observed for C-reactive protein levels.

CONCLUSIONS

The present model appears to be useful for evaluating new drugs for the treatment of primary dysmenorrhea.