Psychometric analysis of the modified COVID-19 Yorkshire Rehabilitation Scale (C19-YRSm) in a prospective multicentre study

BACKGROUND

Long COVID (LC) is a novel multisystem clinical syndrome affecting millions of individuals worldwide. The modified COVID-19 Yorkshire Rehabilitation Scale (C19-YRSm) is a condition-specific patient-reported outcome measure designed for assessment and monitoring of people with LC.

OBJECTIVES

To evaluate the psychometric properties of the C19-YRSm in a prospective sample of people with LC.

METHODS

1314 patients attending 10 UK specialist LC clinics completed C19-YRSm and EuroQol 5D-5L (EQ-5D-5L) longitudinally. Scale characteristics were derived for C19-YRSm subscales (Symptom Severity (SS), Functional Disability (FD) and Overall Health (OH)) and internal consistency (Cronbach's alpha). Convergent validity was assessed using the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue Scale. Known groups validity was assessed for the Other Symptoms subscale as tertiles, as well as by hospitalisation and intensive care admission. Responsiveness and test-retest reliability was evaluated for C19-YRSm subscales and EQ-5D-5L. The minimal important difference (MID) and minimal clinically important difference (MCID) were estimated. Confirmatory factor analysis was applied to determine the instrument's two-factor structure.

RESULTS

C19-YRSm demonstrated good scale characteristic properties. Item-total correlations were between 0.37 and 0.65 (for SS and FD), with good internal reliability (Cronbach's alphas>0.8). Item correlations between subscales ranged between 0.46 and 0.72. Convergent validity with FACIT was good (-0.46 to -0.62). The three subscales discriminated between different levels of symptom burden (p<0.001) and between patients admitted to hospital and intensive care. There was moderate responsiveness for the three subscales ranging from 0.22 (OH) to 0.50 (SS) which was greater than for the EQ-5D-5L. Test-retest reliability was good for both SS 0.86 and FD 0.78. MID was 2 for SS, 2 for FD and 1 for OH; MCID was 4 for both the SS and FD. The factor analysis supported the two-factor SS and FD structure.

CONCLUSIONS

The C19-YRSm is a condition-specific, reliable, valid and responsive patient-reported outcome measure for LC.

Long COVID Clinical Severity Types Based on Symptoms and Functional Disability: A Longitudinal Evaluation

Background: Long COVID (LC) is a multisystem clinical syndrome with functional disability and compromised overall health. Information on LC clinical severity types is emerging in cross-sectional studies. This study explored the pattern and consistency of long COVID (LC) clinical severity types over time in a prospective sample. Methods: Participants with LC completed the condition-specific outcome measure C19-YRSm (Yorkshire Rehabilitation Scale modified version) at two assessment time points. A cluster analysis for clinical severity types was undertaken at both time points using the k-means partition method. Results: The study included cross-sectional data for 759 patients with a mean age of 46.8 years (SD = 12.7), 69.4% females, and a duration of symptoms of 360 days (IQR 217 to 703 days). The cluster analysis at first assessment revealed three distinct clinical severity type clusters: mild (n = 96), moderate (n = 422), and severe (n = 241). Longitudinal data on 356 patients revealed that the pattern of three clinical severity types remained consistent over time between the two assessments, with 51% of patients switching clinical severity types between the assessments. Conclusions: This study is the first of its kind to demonstrate that the pattern of three clinical severity types is consistent over time, with patients also switching between severity types, indicating the fluctuating nature of LC.

Threat of shock increases distractor susceptibility during the short-term maintenance of visual information

BACKGROUND

Work on anxiety related attention control deficits suggests that elevated arousal impacts the ability to filter out distractors. To test this, we designed a task to look at distractor suppression during periods of threat. We administered trials of a visual short-term memory (VSTM) task, during periods of unpredictable threat, and hypothesized that threat would impair performance during trials where subjects were required to filter out large numbers of distractors.

METHOD

Experiment 1 involved fifteen healthy participants who completed one study visit. They performed four runs of a VSTM task comprising 32 trials each. Participants were presented with an arrow indicating left or right, followed by an array of squares. They were instructed to remember the target side and disregard the distractors on the off-target side. A subsequent target square was shown, and participants indicated whether it matched one of the previously presented target squares. The trial conditions included 50% matches and 50% mismatches, with an equal distribution of left and right targets. The number of target and distractor squares varied systematically, with high (4 squares) and low (2 squares) target and distractor conditions. Trials alternated between periods of safety and threat, with startle responses recorded using electromyography (EMG) following white noise presentations.Experiment 2 involved twenty-seven healthy participants who completed the same VSTM task inside an MRI scanner during a single study visit. The procedure mirrored that of Experiment 1, except for the absence of white noise presentations.

RESULTS

For Experiment 1, subjects showed significantly larger startle responses during threat compared to safe period, supporting the validity of the threat manipulation. However, results suggested that the white noise probes interfered with performance. For Experiment 2, we found that both accuracy was affected by threat, such that distractor load negatively impacted accuracy only in the threat condition.

CONCLUSION

Overall, these findings suggest that threat affects distractor susceptibility during the short-term maintenance of visual information. The presence of threat makes it more difficult to filter out distracting information. We believe that this is related to hyperarousal of parietal cortex, which has been observed during unpredictable threat.

Periaqueductal gray matter and medial prefrontal cortex reflect negative prediction errors during differential conditioning

Computational models of associative learning posit that negative prediction errors arising from the omission of aversive outcomes weaken aversive Pavlovian associations during differential conditioning and extinction. It is possible that negative prediction errors may underlie exaggerated conditioned responses to the CS- during differential conditioning and to the CS+ during extinction in patients with clinical anxiety disorders. Although previous research has demonstrated that manipulations of the periaqueductal gray matter (PAG) interfere with extinction learning in animals, the role of the PAG in processing negative prediction errors within the human brain is presently unclear. We set out to investigate how PAG BOLD responses and connectivity are impacted by negative prediction errors using ultra-high field (7T) functional MRI and hierarchical Bayesian analysis. During differential conditioning, negative prediction errors were associated with larger BOLD responses within the lateral and dorsolateral PAG and increased connectivity between the dorsolateral PAG and medial areas of Brodmann area 9. The relationship between negative prediction errors and BOLD responses during extinction was not significant. Collectively, these results shed light on the association between activity within the PAG and medial prefrontal cortex and the omission of aversive outcomes during Pavlovian learning.

Third international challenge to model the medium- to long-range transport of radioxenon to four Comprehensive Nuclear-Test-Ban Treaty monitoring stations

In 2015 and 2016, atmospheric transport modeling challenges were conducted in the context of the Comprehensive Nuclear-Test-Ban Treaty (CTBT) verification, however, with a more limited scope with respect to emission inventories, simulation period and number of relevant samples (i.e., those above the Minimum Detectable Concentration (MDC)) involved. Therefore, a more comprehensive atmospheric transport modeling challenge was organized in 2019. Stack release data of Xe-133 were provided by the Institut National des Radioéléments/IRE (Belgium) and the Canadian Nuclear Laboratories/CNL (Canada) and accounted for in the simulations over a three (mandatory) or six (optional) months period. Best estimate emissions of additional facilities (radiopharmaceutical production and nuclear research facilities, commercial reactors or relevant research reactors) of the Northern Hemisphere were included as well. Model results were compared with observed atmospheric activity concentrations at four International Monitoring System (IMS) stations located in Europe and North America with overall considerable influence of IRE and/or CNL emissions for evaluation of the participants' runs. Participants were prompted to work with controlled and harmonized model set-ups to make runs more comparable, but also to increase diversity. It was found that using the stack emissions of IRE and CNL with daily resolution does not lead to better results than disaggregating annual emissions of these two facilities taken from the literature if an overall score for all stations covering all valid observed samples is considered. A moderate benefit of roughly 10% is visible in statistical scores for samples influenced by IRE and/or CNL to at least 50% and there can be considerable benefit for individual samples. Effects of transport errors, not properly characterized remaining emitters and long IMS sampling times (12-24 h) undoubtedly are in contrast to and reduce the benefit of high-quality IRE and CNL stack data. Complementary best estimates for remaining emitters push the scores up by 18% compared to just considering IRE and CNL emissions alone. Despite the efforts undertaken the full multi-model ensemble built is highly redundant. An ensemble based on a few arbitrary runs is sufficient to model the Xe-133 background at the stations investigated. The effective ensemble size is below five. An optimized ensemble at each station has on average slightly higher skill compared to the full ensemble. However, the improvement (maximum of 20% and minimum of 3% in RMSE) in skill is likely being too small for being exploited for an independent period.

Home-based Extended Rehabilitation for Older people (HERO): study protocol for an individually randomised controlled multi-centre trial to determine the clinical and cost-effectiveness of a home-based exercise intervention for older people with frailty as extended rehabilitation following acute illness or injury, including embedded process evaluation

Background

The majority of older people (> 65 years) in hospital have frailty and are at increased risk of readmission or death following discharge home. In the UK, following acute hospitalisation, around one third of older people with frailty are referred on for rehabilitation, termed ‘intermediate care’ services. Although this rehabilitation can reduce early readmission to hospital (< 30 days), recipients often do not feel ready to leave the service on discharge, suggesting possible incomplete recovery. Limited evidence suggests extended rehabilitation is of benefit in several conditions and there is preliminary evidence that progressive physical exercise can improve mobility and function for older people with frailty, and slow progression to disability. Our aim is to evaluate the effectiveness of the Home-based Older People’s Exercise (HOPE) programme as extended rehabilitation for older people with frailty discharged home from hospital or intermediate care services after acute illness or injury.

Methods

A multi-centre individually randomised controlled trial, to evaluate the clinical and cost-effectiveness of the HOPE programme. This individualised, graded and progressive 24-week exercise programme is delivered by NHS physiotherapy teams to people aged 65 and older with frailty, identified using the Clinical Frailty Scale, following discharge from acute hospitalisation and linked intermediate care rehabilitation pathways. The primary outcome is physical health-related quality of life, measured using the physical component summary score of the modified Short Form 36- item health questionnaire (SF36) at 12 months. Secondary outcomes include self-reported physical and mental health, functional independence, death, hospitalisations, care home admissions. Plans include health economic analyses and an embedded process evaluation.

Discussion

This trial seeks to determine if extended rehabilitation, via the HOPE programme, can improve physical health-related quality of life for older people with frailty following acute hospitalisation. Results will improve awareness of the rehabilitation needs of older people with frailty, and provide evidence on the clinical and cost-effectiveness of the targeted exercise intervention. There is potential for considerable benefit for health and social care services through widespread implementation of trial findings if clinical and cost-effectiveness is demonstrated.

Trial registration

ISRCTN 13927531. Registered on April 19, 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05778-5.

Inter-rater reliability of care home staff's proxy judgements with residents' assessments of their own health-related quality of life: an analysis of the PATCH trial EQ-5D data

OBJECTIVES

to compare care staff proxies with care home residents' self-assessment of their health-related quality of life (HRQoL).

METHODS

we assessed the degree of inter-rater reliability between residents and care staff proxies for the EQ-5D-5L index, domains and EQ Visual Analogue Scale at baseline, 3 months and 6 months, collected as part of the PATCH trial. We calculated kappa scores. Interpreted as <0 no agreement, 0-0.2 slight, 0.21-0.60 fair to moderate and >0.6 substantial to almost perfect agreement. Qualitative interviews with care staff and researchers explored the challenges of completing these questions.

RESULTS

over 50% of the HRQoL data from residents was missing at baseline compared with a 100% completion rate by care staff proxies. A fair-to-moderate level of agreement was found for the EQ-5D-5L index. A higher level of agreement was achieved for the EQ-5D-5L domains of mobility and pain. Resident 'non-completers' were more likely to: be older, have stayed a longer duration in the care home, have lower Barthel Index and Physical Activity and Mobility in Residential Care (PAM-RC) scores, a greater number of co-morbidities and have joined the trial through consultee agreement. Interviews with staff and researchers indicated that it was easier to rate residents' mobility levels than other domains, but in general it was difficult to obtain data from residents or to make an accurate proxy judgement for those with dementia.

CONCLUSIONS

whilst assessing HRQoL by care staff proxy completion provides a more complete dataset, uncertainty remains as to how representative these values are for different groups of residents within care homes.

Recruitment and Consent in an observational study

OBJECTIVE

The study sought to explore the consent rate and associated potential bias across a cohort in a large longitudinal population based study.

RESEARCH DESIGN

Data were taken from a study designed to examine the effects of the reintroduction of community water fluoridation on children's oral health over a five-year period. Children were recruited from a fluoridated and non-fluoridated area in Cumbria, referred to as Group 1 and Group 2.

RESULTS

Data were available for 3138 individuals. The consent rate was 12.91 percentage points lower in Group 2 than Group 1 (95% CI -16.27 to -9.56, p⟨0.001). The population in Group 2 was more deprived (higher Index of Multiple Deprivation (IMD)) than Group 1 before consent was taken. Consent was not associated with deprivation in either group.

CONCLUSION

The cohort appeared to be unaffected by IMD-related non-consent. However there was a difference in consent rate between the two groups. With the population in Group 1 being more deprived than Group 2, it will be important to incorporate these differences into the analysis at the end of this longitudinal study.

A posture and mobility training package for care home staff: results of a cluster randomised controlled feasibility trial (the PATCH trial)

BACKGROUND

provision of care for care home residents with complex needs is challenging. Physiotherapy and activity interventions can improve well-being but are often time-limited and resource intensive. A sustainable approach is to enhance the confidence and skills of staff who provide care. This trial assessed the feasibility of undertaking a definitive evaluation of a posture and mobility training programme for care staff.

DESIGN AND SETTING

a cluster randomised controlled feasibility trial with embedded process evaluation. Ten care homes in Yorkshire, United Kingdom, were randomised (1:1) to the skilful care training package (SCTP) or usual care (UC).

PARTICIPANTS

residents who were not independently mobile.

INTERVENTION

SCTP-delivered by physiotherapists to care staff.

OBJECTIVES AND MEASUREMENTS

key objectives informed progression to a definitive trial. Recruitment, retention and intervention uptake were monitored. Data, collected by a blinded researcher, included pain, posture, mobility, hospitalisations and falls. This informed data collection feasibility and participant safety.

RESULTS

a total of 348 residents were screened; 146 were registered (71 UC, 75 SCTP). Forty two were lost by 6 months, largely due to deaths. While data collection from proxy informants was good (>95% expected data), attrition meant that data completion rates did not meet target. Data collection from residents was poor due to high levels of dementia. Intervention uptake was variable-staff attendance at all sessions ranged from 12.5 to 65.8%. There were no safety concerns.

CONCLUSION

care home and resident recruitment are feasible, but refinement of data collection approaches and intervention delivery are needed for this trial and care home research more widely.

CRISPR-based gene editing enables FOXP3 gene repair in IPEX patient cells

The prototypical genetic autoimmune disease is immune dysregulation polyendocrinopathy enteropathy X-linked (IPEX) syndrome, a severe pediatric disease with limited treatment options. IPEX syndrome is caused by mutations in the forkhead box protein 3 (FOXP3) gene, which plays a critical role in immune regulation. As a monogenic disease, IPEX is an ideal candidate for a therapeutic approach in which autologous hematopoietic stem and progenitor (HSPC) cells or T cells are gene edited ex vivo and reinfused. Here, we describe a CRISPR-based gene correction permitting regulated expression of FOXP3 protein. We demonstrate that gene editing preserves HSPC differentiation potential, and that edited regulatory and effector T cells maintain their in vitro phenotype and function. Additionally, we show that this strategy is suitable for IPEX patient cells with diverse mutations. These results demonstrate the feasibility of gene correction, which will be instrumental for the development of therapeutic approaches for other genetic autoimmune diseases.

102 Process Evaluation Exploring the Delivery and Uptake of Posture and Mobility Training for Staff in Care Homes

Introduction

Provision of care for care home residents with complex needs is challenging. Physiotherapists can play a major role in enhancing the confidence, skills and abilities of care home staff. The Skilful Care Training Package (SCTP) aims to provide staff with an understanding of good posture and training in skilled facilitation of movement. This process evaluation explored barriers and facilitators to delivery and uptake of the SCTP within the context of a feasibility cluster randomised controlled trial (cRCT) in 10 care homes.

Methods

A mixed methods process evaluation, incorporating non-participant observations and interviews, conducted in the five care homes receiving the SCTP intervention. Interviews were audio recorded and transcribed verbatim; resident conversations were captured via a Dictaphone and/or field-notes. Data analysis used the Framework approach.

Results

Fourteen staff training sessions were observed. Interviews with 22 staff and four trainers, and 13 conversations with residents were completed. Five factors influenced delivery and uptake of the SCTP:Organisational factors: strategies to publicise and facilitate access to training improved attendance; a convenient training location and trainer flexibility encouraged attendance and staff engagement.Intervention delivery: a practical participatory element to the training was highly valued; adapting the training to meet the needs of the homes was well-received.Engagement and interaction: relating training to workplace and residents’ experiences engaged staff; high levels of engagement and positive interaction within the training sessions were reported; challenges relating to staff hierarchy affected training delivery in some homes.Intervention content: posture and mobility elements were seen as important; however, some repetition with prior training was highlighted.Training impact: there were indications that staff adopted SCTP techniques. Staff reported an increase in their wellbeing and confidence in movement facilitation; cascade training was reported in some homes.

Conclusions

Training was well-received, and feedback on its impact was largely positive. Practical elements were viewed favourably over classroom-based learning. Intervention content should be revised to optimise focus and avoid overlap with other training.

101 A Posture and Mobility Training Package for Care Home Staff: Results of A Cluster Randomised Controlled Feasibility Trial

Introduction

Provision of care for care home residents with complex needs is challenging. Physiotherapy and activity interventions can improve physical well-being but are often time-limited and resource intensive. A sustainable approach is to enhance the confidence, skills and abilities of care home staff. This trial assessed the feasibility of undertaking a definitive evaluation of the Skilful Care Training Package (SCTP) - a posture and mobility training programme developed by physiotherapists for care home staff.

Methods

A parallel-group, cluster randomised controlled feasibility trial was undertaken in ten care homes in Yorkshire. Five were randomised to receive SCTP, five to usual care. SCTP was delivered by specialist physiotherapists, with the intention of training all direct care staff. Following consent, data were collected from and about residents with restricted mobility (those fulfilling the eligibility criteria) at baseline, three and six months post-randomisation by blinded researchers. Outcome measurement included resident mobility, posture, pain and quality of life. The feasibility of recruitment, retention, data collection and intervention delivery was assessed.

Results

All residents (348) at participating homes were screened for eligibility. 250 were eligible and 146 took part. Follow-up was balanced between arms, with an overall loss-to-follow-up rate of 28.8% at six months. Where residents were available for six-month follow-up, proxy data provision was excellent (97.1% - 100% of expected data). Difficulty collecting data directly from residents was experienced (43.3% of expected data) due to high levels of cognitive impairment. Staff attendance at training met or was close to pre-specified criteria for acceptability in three homes, with 63.0%, 63.6% and 65.8% direct care staff attending all sessions, and &gt;85% attending at least one session across all three homes. However attendance fell short of acceptability in two homes, with only 21.4% and 12.5% staff attending all sessions.

Conclusions

It is feasible to recruit and follow-up residents in a randomised trial comparing SCTP and usual care. Proxy data collection is a successful method, but collection of data from residents is difficult. Intervention delivery success was variable, illustrating heterogeneity between care homes. Future research will be informed by learning from those homes with greater intervention compliance. Work should be undertaken to investigate how best to collect meaningful data from residents.

Imaging hepatic angiomyolipomas: key features and avoiding errors

Hepatic angiomyolipomas (HAMLs) are rare mesenchymal neoplasms, which have highly variable imaging appearances, often leading to misdiagnosis. They belong to the family of perivascular epithelioid cell neoplasms (PEComas). HAMLs have a wide spectrum of imaging appearances due to variable amounts of smooth muscle cells, adipose tissue, and blood vessels in their makeup. Although typically sporadic, they are also associated with tuberous sclerosis. Sporadic lesions tend to be solitary whilst patients with tuberous sclerosis often have multiple HAMLs invariably accompanied by renal AMLs. Having been originally considered benign hamartomas, increasing reports of complications, including malignant behaviour, has also resulted in uncertainty in regard to their optimal management. Typically described imaging characteristics are of a hypervascular fat-containing lesion with prominent intratumoural vessels and an early draining vein; however HAMLs commonly demonstrate a paucity of fat or wash-out on contrast-enhanced imaging, and not all HAML lesions are hypervascular. HAMLs can therefore easily be misdiagnosed as other hepatic lesions, in particular hepatocellular carcinoma. This review describes the imaging characteristics of HAMLs, illustrating the wide variety of potential appearances across ultrasound, contrast-enhanced ultrasound, computed tomography, and magnetic resonance imaging, and highlights the challenges and potential errors that can be made. This review will aid radiologists in avoiding potentially major pitfalls when faced with this rare but important liver pathology.

Benefits of the epilepsy specialist nurses (ESN) role, standardized practices and education around the world

Epilepsy, often considered as a stigmatizing disease, affects 65 million people worldwide and is frequently associated with comorbidities that increase both direct and indirect costs. The degree of impact on quality of life and the cost of care differs depending on the social and health care organizations in place, political, medico-economic and/or socio-cultural contexts. Across the globe, healthcare is provided by nurses in primary care, urgent or emergency care, and within specialized domains of practice. In Epilepsy the global care could be enhanced by developing standardized nursing education in close collaboration with other caregivers. The impact of epilepsy nursing care has been documented in some developed countries, but the diversity of nursing practices and professional education of nurses raise difficulties in generalizing these findings. Specialized education in epilepsy will improve access, treatment and ultimately the quality of life of patients.

PATCH: posture and mobility training for care staff versus usual care in care homes: study protocol for a randomised controlled trial

BACKGROUND

Residents of care homes have high levels of disability and poor mobility, but the promotion of health and wellbeing within care homes is poorly realised. Residents spend the majority of their time sedentary which leads to increased dependency and, coupled with poor postural management, can have many adverse outcomes including pressure sores, pain and reduced social interaction. The intervention being tested in this project (the Skilful Care Training Package) aims to increase the awareness and skills of care staff in relation to poor posture in the older, less mobile adult and highlight the benefits of activity, and how to skilfully assist activity, in this group to enable mobility and reduce falls risk. Feasibility work will be undertaken to inform the design of a definitive cluster randomised controlled trial.

METHODS

This is a cluster randomised controlled feasibility trial, aiming to recruit at least 12-15 residents at each of 10 care homes across Yorkshire. Care homes will be randomly allocated on a 1:1 basis to receive either the Skilful Care Training Package alongside usual care or to continue to provide usual care alone. Assessments will be undertaken by blinded researchers with participating residents at baseline (before care home randomisation) and at three and six months post randomisation. Data relating to changes in physical activity, mobility, posture, mood and quality of life will be collected. Data at the level of the home will also be collected and will include staff experience of care and changes in the numbers and types of adverse events residents experience (for example, hospital admissions, falls). Details of NHS service usage will be collected to inform the economic analysis. An embedded process evaluation will explore intervention delivery and its acceptability to staff and residents.

DISCUSSION

Participant uptake, engagement and retention are key feasibility outcomes. Exploration of barriers and facilitators to intervention delivery will inform intervention optimisation. Study results will inform progression to a definitive trial and add to the body of evidence for good practice in care home research.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN50080330 . Registered on 27 March 2017.

Sugar before bed: a simple dietary risk factor for caries experience

Clinical care pathways have placed renewed emphasis on caries risk assessment and the ability to predict and prevent further disease. With diet considered a key factor in the development of caries, the level of caries risk posed by dietary habits, such as the frequency of intake and timing of free sugars is questioned.

OBJECTIVE

To identify reliable and simple dietary risk factors for caries experience.

RESEARCH DESIGN

A cross-sectional observational study of a convenience sample with data gained from clinical examinations, questionnaire and a 24 hour dietary-recall interview.

PARTICIPANTS

128 subjects aged 11-12 from comprehensive schools in Greater Manchester and Newcastle upon-Tyne, UK.

OUTCOME MEASURES

free sugars consumed between meals, before bed and total % of total free sugars consumed were assessed from dietary assessments led by a dietitian. D4-6MFT was generated with a caries threshold of ICDAS stage 4 from clinical examinations.

RESULTS

Analysis revealed no significant differences in caries experience when looking specifically at caries into dentine, referred to as the cavity group (split at D4-6MFT), between high and low deprivation, consumption of free sugars between meals and free sugars (%). The consumption of free sugars within the hour before bed revealed a statistically significant difference between the cavity/no cavity groups (p=0.002). Logistic regression analysis on the cavity/no cavity groups revealed an odds ratio of 2.4 (95%CI 1.3,4.4) for free sugars consumption before bedtime.

CONCLUSIONS

The study suggests that the consumption of free sugars before bedtime may be an important risk factor for adolescent caries into dentine experience.

Prevalence and severity of dental fluorosis in four English cities

Objective

To assess the prevalence and severity of dental fluorosis in four city-based populations using a robust photographic method with TF index reporting; and to record the aesthetic satisfaction scores of children in all four cities.

Basic research design

Cross sectional epidemiological survey (surveillance).

Participants

1,904 children aged 11-14 years, in four English cities.

Interventions

Two cities were served by community water fluoridation schemes supplying water at 1mg/l F. The other two cities did not have water fluoridation schemes and had low levels of fluoride naturally present.

Main outcome measures

The prevalence and severity of dental fluorosis. Scoring was undertaken using high quality digital images by a single calibrated examiner.

Results

Data suggest that the prevalence of fluorosis at levels greater than TF2 are broadly similar to previous studies (F 10%, NF 2%), with an apparent increase in the total number of TF1 cases across both fluoridated (41%) and non-fluoridated cities (32%) with a commensurate decrease in TF0 (F 39%, NF 63%). Data suggest that the proportion of children expressing dissatisfaction with the appearance of their teeth is the same in fluoridated and non-fluoridated communities although the reasons for this may differ.

Conclusions

The levels of fluorosis that might be considered of aesthetic concern are low and stable while the increase in TF1 may be due to an increase in self- and professionally-applied fluoride products or the increased sensitivity afforded by the digital imaging system. It is not however a public health problem or concern. Further monitoring appears justified.

The impact of CBCT imaging when placing dental implants in the anterior edentulous mandible: a before-after study

OBJECTIVES

To evaluate the impact of CBCT imaging when placing dental implants in the anterior edentulous mandible, using a "before-after" study design.

METHODS

Eight dental practitioners, who regularly place dental implants in independent dental practice in the North West of England, were presented with realistic simulations of four edentulous cases. The practitioners were asked to assess case difficulty, select implants and then drill osteotomies in preparation for dental implants in the lower canine regions to support a complete overdenture. In the "before" part of the study, a panoramic and a trans-symphyseal view were available. In the "after" part of the study, a CBCT image was added. Perception of case difficulty, implant selection and the incidence of perforations or "near miss perforations" of the lingual cortical plate were recorded. Two cases were regarded as "regular" and two as "challenging".

RESULTS

In challenging cases, the availability of CBCT led practitioners to select narrower implants and to assess cases as more difficult. In the challenging cases only, there were fewer perforations of the lingual cortical plate after the availability of CBCT, but this difference was not statistically significant. There were no perforations in the regular cases either before or after the availability of CBCT.

CONCLUSIONS

Perception of case difficulty and implant selection are of importance only if they change the outcome for the patient. This study provided weak evidence that CBCT is helpful in avoiding perforations in challenging cases. The availability of CBCT had no impact in regular cases.

Conventional radiography and cross-sectional imaging when planning dental implants in the anterior edentulous mandible to support an overdenture: a systematic review

The objectives for this systematic review were to determine if the pre-operative availability of cross-sectional imaging, such as cone beam CT, has a diagnostic impact, therapeutic impact or impact on patients' outcome when placing two dental implants in the anterior mandible to support an overdenture. The Cochrane Oral Health Group's Trials Register (CENTRAL), MEDLINE® and Embase were searched up to, and including, February 2013. Studies were considered eligible for inclusion if they compared the impact of conventional and cross-sectional imaging when placing dental implants in sites including the anterior mandible. An adapted quality assessment tool was used for the assessment of the risk of bias in included studies. Pooled quantitative analysis was not possible and, therefore, synthesis was qualitative. Of 2374 potentially eligible papers, 5 studies were included. Little can be determined from a synthesis of these studies because of their small number, clinical diversity and high risks of bias. Notwithstanding, it may be tentatively inferred that cross-sectional imaging has a therapeutic impact in the more challenging cases. In terms of impact, this review has found no evidence to support any specific imaging modality when planning dental implant placement in any region of the mouth. Therefore, those who argue that cross-sectional imaging should be used for the assessment of all dental implant sites are unsupported by evidence.

A questionnaire study to investigate custom and practice of imaging methods for the anterior region of the mandible prior to dental implant placement

OBJECTIVES

To investigate the custom and practice of private dental implant practitioners in the north-west of England when planning imaging methods prior to implant placement in the symphyseal region of the edentulous mandible. To gain an understanding of decision-making when prescribing imaging methods.

METHODS

A web-based questionnaire presented two realistic clinical scenarios. Both were of edentulous patients for whom implant-retained lower complete dentures were planned. A mixed mode survey methodology was employed.

RESULTS

169 dentists were surveyed with an 80% response rate. The results showed no agreement on prescription of imaging methods. Those in the 0-10 years qualified group were significantly associated with the prescription of three-dimensional (3D) imaging. Implant practitioners who place more than 100 implants per year were significantly associated with the non-use of imaging guides and prescription of the same view for both cases. The sample as a whole, however, changed their prescription according to the case difficulty. Those who have a cone beam CT machine available were more likely to use 3D imaging regardless of the difficulty of the case.

CONCLUSIONS

Existing guidelines are open to interpretation and could be construed to support a range of imaging choices. Training in dental implantology may leave dentists to make their own judgements about selection criteria. The idiosyncratic nature of independent dental practice may be an important factor in the chaotic pattern of prescriptions. There is a need for widely disseminated, evidence-based selection criteria for imaging prior to dental implantology which are clear and specific.

Estimating the need for dental sedation: evaluating the threshold of the IOSN tool in an adult population

AIM

The aim of this study was, through a service evaluation, to assess the use of the IOSN tool in determining whether threshold values were appropriate for identification of IV sedation and general anaesthetic (GA) cases from a referral population.

METHODS

A total of 105 patients were taken from a dental minor oral surgery referral service within a north west primary care trust over the course of six months. The IOSN tool was completed to assess: treatment complexity, medical and behavioural factors and patient anxiety levels. Each patient was then followed through to treatment. The type of sedation modality they received was compared to their IOSN score previously calculated and these results evaluated.

RESULTS

The findings suggest that 94% of patients were treated within primary care by the MOS service, of which 58% received local anaesthetic (LA) alone and 42% were treated by LA with IV sedation. There was a general marked trend as the IOSN score increased so did the treatment modality from LA, through sedation to GA. Logistic regression using the components of the IOSN tool to predict sedation use indicated the IOSN predictors distinguished between those who required sedation and those who didn't (chi-square = 56.411, p <0.0001, df = 3) with treatment complexity (Exp B = 10.836, p <0.0001) and anxiety (Exp B = 4.319, p <0.0001) shown to be significant factors in determining sedation need.

CONCLUSIONS

The data collected have shown that there is a positive relationship between the IOSN score and the type of treatment modality the patient received, suggesting that the threshold values are correctly set. It is concluded that IOSN tool is a useful means of aiding the clinician in both assessing and referring patients for that sedation need.

Impact of OncoType DXTM Recurrence Score and Tumor Size on Making Chemotherapy Decisions in Breast Cancer Patients

Background: Oncotype DXTM is a 21 gene assay that calculates recurrence score(RS) and recurrence risk(RR) over 10 years. Despite the contention that this genomic assay is more accurate than tumor size(TS) and age in predicting outcome, these factors continue to have major impact in decision-making regarding chemotherapy(CT). We analyzed the impact of TS, RS, and age on the decision to give CT.Methods: An IRB-approved chart review of 105 lymph node(LN) negative patients with ER+ T1 and T2 tumors was performed, reviewing age, RS, TS, CT history, Her-2 status, and pathology. RS was low(0-17), intermediate(18-30), or high(&gt;30). TS was divided into T1a(0.1-0.5 cm), T1b(0.51–1.0 cm), T1c(1.1–2.0 cm), and T2(2.1-5.0 cm).Results: Mean patient age was 60.9 years(range 35-82 years). Average(AVG) RS was 20.9; AVG RR at 10 years, 13.6%. Mean TS was 1.5 cm(median 1.3 cm). Overall, 29 patients(27.6%) received CT; 76(72.4%) did not. AVG TS for CT patients was 1.8cm, AVG RS was 29.5, and AVG age was 56.4(range 35-75). Non-CT patients' AVG TS was 1.4cm; AVG RS, 17.7; AVG age, 62.6(range 44-86). 9 patients(8.5%) had T1a tumors with an AVG RS of 19.1, and no patient received CT. 25(23.8%) had T1b tumors with an AVG RS of 21.0, and 5(20.0%) received CT. 51(48.6%) had T1c tumors with an AVG RS of 20.4, and 15(29.4%) received CT. 20(19.0%) had T2 tumors with an AVG RS of 23.1; 9(45.0%) received CT. 41 patients(39.0%) had low RS: 4(9.8%) received CT; 37(90.2%) did not. AVG TS and RS were 1.6cm and 15.0 respectively for CT patients, and 1.5cm and 11.6 for no CT patients. 49 patients(46.7%) had intermediate RS: 13(26.5%) received CT; 36(73.5%) did not. AVG TS and RS were 1.9cm and 22.7 for CT patients; 1.3cm and 22.2 for no CT patients. 15 patients(14.3%) had high RS: 12(80.0%) received CT; 3(20.0%) did not. AVG TS and RS were 1.7cm and 44.7 for CT patients; 1.3cm and 39.3 for no CT patients. 10 patients were Her-2+, 5 with high, 4 with intermediate, and 1 with low RS. 7 had CT. 5 of the 15(33.3%) high RS patients were Her-2+. AVG RS for the Her-2+ patients was 36.2, and AVG TS was 1.9cm. AVG RS was 19.3 for the non-Her-2+ patients. 16 patients were &lt;50 years old. AVG TS was 1.5cm and AVG RS was 24.2. 8 received CT and 8 did not. 89 patients were ≥50. AVG TS was 1.5cm and AVG RS was 20.3. 21(23.6%) received CT and 68 did not. Discussion: AVG RS was 20.9 for all T stages. Overall, 27.6% of patients received CT. Of the 64 with RS&gt;18, only 25(39.1%) received CT; 4(9.8%) of low RS patients still received CT. Patients with larger tumors and younger age were more likely to receive CT. Neither RS, TS, nor age alone seemed to influence the final decision. Multiple factors are still considered by oncologists when making CT decisions, and conversely, patients may not accept CT despite high RS.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6039.

Approaches to end-of-life decision-making in the NICU: insights from Dostoevsky's The Grand Inquisitor

For many parents stopping life-sustaining medical treatment on their dying infant is psychologically impossible. Dostoevsky's insights into human behavior, particularly the fact that individuals do not want the anxiety and guilt associated with responsibility for making difficult decisions, might change the way physicians approach parents for permission to withdraw life-prolonging medical interventions on dying infants.

Percutaneous abscess drainage in the UK: A national survey and single centre study

AIM

To establish the current practice for management of radiologically placed percutaneous drains for abdominal sepsis in the UK and prospectively study the management of radiologically placed drains at our institution.

METHOD

A questionnaire on the management of radiologically placed drains was sent to all radiology departments on a Royal College of Radiologists database. We prospectively followed all drains placed by our radiology department for drainage of abdominal collections, over a 7-month period.

RESULTS

A total of 210 questionnaires were sent for the national survey, of these 117 were returned (55.7%). The majority of departments (70.5%) reported that after drain insertion the clinical team took over daily management. Just over 5% of departments either formally managed the drain or obtained final outcome data. From October 2003 to April 2004 we followed 63 consecutive drains placed in 45 patients, for abdominal sepsis. Thirty-nine drains (61.9%) were curative and 17 (26.9%) drains failed. Three drains (4.8%) were placed for palliation, and four drains (6.4%) were placed in order to temporise prior to surgery. Forty-three (68.3%) drains had a successful primary outcome: success after secondary percutaneous abscess drainage (PAD) improved to 46 (73.0%) drains. Two (3%) major complications occurred.

CONCLUSIONS

The current approach in the UK to management of radiologically placed drains differs significantly from that practised in the USA. The most common type of support offered by radiology departments in the UK is of informal advice and follow-up, with the clinical team managing the patient's drain. Observations in our hospital highlighted problems relating to drain management that may impact on the success of PAD. We suggest that more formal radiological support after PAD would improve communication and potentially improve outcomes.

An extension program for ACCase inhibitor resistance in Manitoba : A case study

An extension program designed to encourage farmers to adopt herbicide rotation in favor of continuous use of acetyl-CoA carboxylase inhibitor herbicides was launched in 1991. The program has led to high levels of awareness of herbicide rotation in Manitoba (> 90%). Adoption of herbicide rotation is estimated at approximately 40%, but producers who have started to rotate herbicides are assumed to be doing so on a limited "trial" basis.The use of this group of products continues at high levels due to a combination of producer preference for these chemicals and of reluctance to use alternatives.

The role of the clinical nurse specialist in epilepsy

PURPOSE

To review and describe the key roles of the UK clinical nurse specialist in epilepsy (CNSE), and to identify the specialist nurses' contribution to care through an exploration of CNSE's perceptions of their roles.

METHOD

Using the Delphi technique [Applied Project Design and Analysis, 3rd ed., Churchill Livingstone, London, 2000, p. 243] a national survey of all known UK CNSEs was completed. One hundred and thirty questionnaires identifying nine key hypotheses central to the role of the CNSE were distributed and 76 valid questionnaires returned.

RESULTS

The response rate was 63% and was geographically representative of the UK population of CNSEs. CNSEs were employed in a range of hospital and community settings with differing patient groups. Seventy-two percent of respondents held higher academic nursing qualifications but only 36% had previous epilepsy or neurology experience. Thirty percent of respondents had been employed in the role of CNSE for more than 5 years and 84% were employed as a G or H grade nurse. Only 39% of CNSEs held nurse-led clinics and of those 32% were responsible for all decisions made during their clinic. Furthermore, 40% of CNSEs saw new patients who had not previously been reviewed by one of the medical team. The level of responsibility for drug management was mainly at a monitoring and advisory level but a small number of CNSEs held much greater responsibility. The responses to the nine hypotheses were compared using cross tabulations.

CONCLUSION

The findings of the study and the review of the CNSE in the UK revealed that the key roles of the CNSE were difficult to define. Yet, the respondents identified that there were common core features central to their contribution to care as specialist nurses.

The pitfalls of lung cancer screening

Lung cancer screening has received extensive attention for a number of years. As yet the goal of such a screening programme, a reduction in lung cancer mortality proven by a large randomised controlled trial, has not been achieved. Instead we are left with a number of unanswered questions and practical problems. In addition to the basic requirements for an effective screening programme, this review will identify the main pitfalls in lung cancer screening, with particular reference to multislice computed tomography. The specific difficulties relating to the identification of unimportant disease, the failure to identify important disease successfully, the consequences of investigating and treating identified disease and the financial costs will all be discussed.

Bispectral index-guided management of anaesthesia in permanent vegetative state

A patient in a permanent vegetative state required general anaesthesia for dental surgery. Because of the uncertainties involved in the appropriate monitoring and assessment of the conscious level of patients in a permanent vegetative state, it was decided to use the bispectral index to help guide the anaesthetic depth during surgery. We found that the bispectral index profile during anaesthesia and surgery was similar to that of a normal subject. The findings raise the possibility that patients in permanent vegetative states might sense noxious stimuli at a cortical level.

AP-1 activation and altered AP-1 composition in association with increased phosphorylation and expression of specific Jun and Fos family proteins induced by vinblastine in KB-3 cells

Vinblastine and other microtubule inhibitors are important antitumor agents that cause mitotic arrest, and induce apoptosis through poorly understood mechanisms, in a wide variety of cell lines. The activating protein 1 (AP-1) transcription factor is a major target of the c-Jun NH2-terminal kinase (JNK) signaling pathway, which is activated by microtubule inhibitors. Therefore, we examined the effect of vinblastine on AP-1 composition and activity in human KB-3 carcinoma cells. Vinblastine caused highly selective effects on AP-1 proteins in a concentration- and time-dependent manner. Specifically, c-Jun, expressed at a low level in control cells, was greatly increased and phosphorylated, Jun D was phosphorylated, Jun B underwent phosphorylation and subsequently became undetectable, and Fra 1 expression was also greatly increased. In contrast. Fra 2, c-Fos, and Fos B were relatively unchanged by vinblastine. Changes in AP-1 preceded caspase 3 activation and, therefore, occurred prior to the commitment phase of apoptosis. With the exception of c-Jun, which was not affected by paclitaxel, the same alterations in AP-1 proteins occurred after exposure to vincristine, paclitaxel, and colchicine, demonstrating that these are general responses to microtubule inhibition. Supershift assays demonstrated that in control cells, AP-1 binding activity was mediated by Jun D/Fra 2 heterodimers, whereas after vinblastine treatment, AP-1 complexes also containing c-Jun and Fra 1 were present, suggesting that induction of these latter proteins by vinblastine is functionally significant. Consistent with these observations, vinblastine stimulated AP-1-dependent luciferase reporter gene transcription. These findings suggest that alterations in AP-1 composition and activity may be key events in the early response of KB-3 cells to microtubule inhibitors.

Asymptomatic occlusion of the left main coronary artery by an aortic pseudoaneurysm

Extrinsic compression of the left main coronary artery is a rare cause of coronary ischemia. We describe a 35-year-old Asian woman with complete asymptomatic occlusion of the left main coronary artery by a large aortic pseudoaneurysm. She underwent repair of the pseudoaneurysm and coronary artery bypass grafting at the Mayo Clinic in Rochester, Minn. The differential diagnosis is discussed. Based on this patient's age and associated vascular lesions, we conclude that Takayasu arteritis was the most likely cause of her condition.