Epidemiological surveillance study of female genital mutilation in the UK

OBJECTIVES

Describe cases of female genital mutilation (FGM) presenting to consultant paediatricians and sexual assault referral centres (SARCs), including demographics, medical symptoms, examination findings and outcome.

DESIGN

The well-established epidemiological surveillance study performed through the British Paediatric Surveillance Unit included FGM on the monthly returns.

SETTING

All consultant paediatricians and relevant SARC leads across the UK and Ireland.

PATIENTS

Under 16 years old with FGM.

INTERVENTIONS

Data on cases from November 2015 to November 2017 and 12 months later meeting the case definition of FGM.

MAIN OUTCOME MEASURES

Returns included 146 cases, 103 (71%) had confirmed FGM and 43 (29%) did not meet the case definition. There were none from Northern Ireland.

RESULTS

The mean reported age was 3 years. Using the WHO classification of FGM, 58% (n=60) had either type 1 or type 2, 8% (n=8) had type 3 and 21% (n=22) had type 4. 13% (n=13) of the cases were not classified and none had piercings or labiaplasty. The majority, 70% had FGM performed in Africa with others from Europe, Middle East and South-East Asia. There were few physical and mental health symptoms. Only one case resulted in a successful prosecution.

CONCLUSIONS

There were low numbers of children presenting with FGM and in the 2 years there was only one prosecution. The findings may be consistent with attitude changes in FGM practising communities and those at risk should be protected and supported by culturally competent national policies.

Nutritional rickets under 16 years: UK surveillance results

OBJECTIVE

The UK national incidence of nutritional rickets is unknown. We aimed to describe the incidence, presentation and clinical management of children under 16 years with nutritional rickets in the UK presenting to secondary care.

METHODS

Prospective data were collected monthly between March 2015 and March 2017 from 3500 consultant paediatricians using British Paediatric Surveillance Unit methodology. Clinicians completed online clinical questionnaires for cases fitting the surveillance case definition.

RESULTS

125 cases met the case definition, an annual incidence of 0.48 (95% CI 0.37 to 0.62) per 100 000 children under 16 years. 116 children were under 5 years (annual incidence of 1.39 (95% CI 1.05 to 1.81) per 100 000. Boys (70%) were significantly more affected than girls (30%) (OR 2.17, 95% CI 1.25 to 3.78). The majority were of Black (43%) or South Asian (38%) ethnicity. 77.6% of children were not taking vitamin D supplements despite being eligible. Complications included delayed gross motor development (26.4%), fractures (9.6%), hypocalcaemic seizures (8%) and dilated cardiomyopathy (3%). Two children died (1.6%). In eight cases, rickets was confirmed radiologically and biochemically [raised serum alkaline phosphatase (ALP) and parathyroid hormone (PTH) levels ] but were excluded from the incidence analysis for not meeting the case definition of 25-hydroxyvitamin D of <25 nmol/L.

CONCLUSION

The incidence of nutritional rickets in the UK is lower than expected. Serious complications and unexpected deaths, particularly in Black and South Asian children under 5 years, occurred. Both vitamin D deficiency and dietary calcium deficiency are role players in pathogenesis. Uptake of vitamin D supplementation remains low.

P2431Stay on the safe side: in-silico assessment of ablation protocols to prevent steam pops during radiofrequency ablation

Background

Steam pops (SP) are among the most serious complications of radiofrequency ablation (RFA) due to its potential to cause myocardial tear or tamponade. SP occur when the tissue overheats, causing its water content to transform into steam and explode. Ablation parameters are critical in order to obtain an optimal lesion size while avoiding the occurrence of SP. However, the interaction between ablation settings and the physical parameters that predispose to SP occurrence during irrigated RFA are not fully understood.

Purpose

To characterize regularly used ablation protocols by means of a computational model, in order to achieve optimal lesion size while avoiding SP occurrence.

Methods

The in-silico evaluation is performed using our previously developed computational irrigated RFA model. Our model takes into account the blood-saline interaction as well as the mechanical deformation of the tissue due to the contact with the catheter tip. We test the effects of applied power and contact force on two catheter tip designs (spherical and cylindrical) and two substrates, simulated human atrium and ventricle, during 30 sec applications. A fixed blood flow and catheter-tip saline irrigation (0.5m/s and 17mL/min, respectively) are considered. We simulate human tissue by using the biophysical, mechanical and physiological properties found in the literature. SP occurrence is predicted when the temperature within the tissue reaches 100°C.

Results

Based on the interaction of power and contact force, four risk maps are constructed encompassing the two catheter-tip designs and the two simulated tissues. The maps allow the identification of those ablation protocols (contact force and delivered power) that can potentially result on SP. They correspond to that area of critical temperature values where the temperature within the tissue reach the established criteria for SP occurrence. We also present the lesion size dimensions of ablation protocols that avoid the formation of steam pops.

Conclusion

Our results indicate that the applied power has a strong impact in the formation of SP for a cylindrical catheter, while a combination of contact force and power is important to avoid risks in the case of the spherical catheter tip. The tissue characteristics do not affect significantly the SP occurrence, in agreement with experimental literature. However, the resulting lesion size appears to be larger in the simulated human atrium in comparison to the simulated human ventricle.

Acknowledgement/Funding

BERC 2018-2021, SEV-2017-0718

The Role of Radiotherapy in the Treatment of Stage III Non-Small Cell Lung Cancer: A Survey of Clinical Practices in Lombardy, Italy, by the Airo-Lombardia Cooperative Group

Aims and background

The role of radiotherapy in the treatment of stage III non-small cell lung cancer is controversial. The aim of this survey was to investigate the use of this modality in current clinical practice in Lombardy, a highly industrialized region of northern Italy.

Methods

A questionnaire was sent to all 13 radiotherapy centers in Lombardy, covering statistical, clinical, technical and strategical aspects, and the responses were analyzed.

Results

A wide range of attitudes was observed among participating radiation oncologists; the percentage of cases treated with curative intent varied largely between centers (4-100%), as did the proportion of patients given to radiation only rather than combined modality treatment (5-100% vs 0-90%).

Conclusions

An urgent need exists for better cooperation between all clinicians involved in lung cancer treatment, pursuing the goals of a more uniform clinical practice and a more aggressive clinical research attitude.

Primary Lymphoma of the Central Nervous System

Primary lymphoma of the central nervous system (CNS) represents a pathology that is no longer considered rare, also in the light of its high correlation with the human immunodeficiency virus (HIV) syndrome reported recently. Often the correct diagnosis of the disease is difficult to reach, owing to the wide spectrum of non-lymphoma pathologies from which it should be differentiated and the invasiveness of some diagnostic techniques. The biologic aggressiveness of the neoplasm often makes a combined radio-chemotherapeutic approach necessary. In contrast, surgical resection does not seem to provide any significant benefit. The clinical experience reported here, together with a review of the most recent literature, lead the authors to suggest the opportunity of treating primary lymphoma of the CNS with the most active and modern chemotherapeutic protocols in association with traditional treatments to obtain an improvement in overall survival.

Cisplatin and Radiotherapy in the Treatment of Unresectable Lung Cancer

The goal of this pilot study was to verify the efficacy of the association of cisplatin plus radiotherapy in the treatment of lung cancer. Thirty-seven consecutive patients entered the study. They were treated with radiotherapy (four weekly doses of 2.5 Gy for a total of 50 Gy) and cisplatin once weekly (12 mg/m2). Partial remission was obtained in 15 patients, and 1 patient had a complete remission. Three patients previously inoperable underwent surgical treatment. The actuarial survival curve of the 29 evaluable patients showed a mean survival of 8.5 months. The mean survival of the latter is not evaluable because half of the patients are still alive after 12 to 30 months. No hematologic or renal toxicity was observed with the above schedule.

Preliminay study for the Italian validation of the screen for cognitive impairment in psychiatry (SCIP)

Introduction

The screen for cognitive impairment in psychiatry (SCIP) is a brief, accessible scale designed for detecting cognitive deficits in psychiatric disorders.

Objectives

The objective of this study is to test the SCIP's validity as a cognitive test by comparison with standard neuropsychological scale using the Pearson's correlation.

Aims Test the convergent and discriminant validity of the SCIP within the Italian SCIP validation project.

Methods

Patients between 18 and 65 years who are in a stable phase of the disease, diagnosed with schizophrenia, schizoaffective disorder or bipolar I disorder were enrolled in this study, from the community mental health department of Ferrara.

Results

The tests were administered to 110 patients (mean age: 45 ± 11,4) and to 86 controls (mean age: 35 ± 12,6) of both sex. SCIP presents high correlation with the R-BANS total score (P < 0.01) and the subscales (verbal learning test-immediate, working memory, verbal fluency test, verbal learning test-delayed, processing speed test, P < 0.01). There are significant differences (P < 0.01) in all SCIP dimensions between patient and control group (Table 1).

Conclusions

Our analysis confirm the results of the English, French and Spanish version of the SCIP regarding convergent and discriminant validity. The SCIP represents a valid, simple and brief screening tool for the cognitive evaluation of patients with schizophrenia-spectrum disorders.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Polarization of cells and soft objects driven by mechanical interactions: consequences for migration and chemotaxis

We study a generic model for the polarization and motility of self-propelled soft objects, biological cells, or biomimetic systems, interacting with a viscous substrate. The active forces generated by the cell on the substrate are modeled by means of oscillating force multipoles at the cell-substrate interface. Symmetry breaking and cell polarization for a range of cell sizes naturally "emerge" from long range mechanical interactions between oscillating units, mediated both by the intracellular medium and the substrate. However, the harnessing of cell polarization for motility requires substrate-mediated interactions. Motility can be optimized by adapting the oscillation frequency to the relaxation time of the system or when the substrate and cell viscosities match. Cellular noise can destroy mechanical coordination between force-generating elements within the cell, resulting in sudden changes of polarization. The persistence of the cell's motion is found to depend on the cell size and the substrate viscosity. Within such a model, chemotactic guidance of cell motion is obtained by directionally modulating the persistence of motion, rather than by modulating the instantaneous cell velocity, in a way that resembles the run and tumble chemotaxis of bacteria.

Treatment of facial erythema in patients with rosacea with topical brimonidine tartrate: correlation of patient satisfaction with standard clinical endpoints of improvement of facial erythema

BACKGROUND

Once-daily brimonidine tartrate (BT) 0.5% gel was shown to provide significantly greater efficacy vs. vehicle for the treatment of facial erythema in patients with rosacea.

OBJECTIVES

To demonstrate that patient satisfaction with overall appearance is correlated with reduction in facial erythema, as measured by clinician and patient assessments.

METHODS

Data from two identical phase III, multicentre, randomized, controlled trials of moderate facial erythema of rosacea (study A: n = 260; study B: n = 293) with topical BT 0.5% compared to vehicle gel once-daily for 4 weeks were analysed. Correlations of Patient's Assessment of Appearance (PAA) with Clinician's Erythema Assessment (CEA) and Patient's Self-Assessment (PSA) of erythema were evaluated by calculation of gamma statistics.

RESULTS

PAA correlated with CEA post-application on Days 1, 15 and 29 for the intent-to-treat population and provided a median gamma value of 0.57 (min = 0.28, max = 0.61). PAA and PSA was also highly correlated post-application on Days 1, 15 and 29; with a median gamma value of 0.87 (min = 0.66, max = 0.89). Subjects who achieved a clinically meaningful improvement in both CEA and PSA scales were more likely to report satisfaction with the overall appearance of their skin (P < 0.001).

CONCLUSIONS

Both one- and two-grade improvements in facial erythema assessed by subjects (PSA) and clinicians (CEA) correlate well with PAA, a patient-centered representation of meaningful change.

Comparative pharmacokinetics and bioavailability of brimonidine following ocular and dermal administration of brimonidine tartrate ophthalmic solution and gel in patients with moderate-to-severe facial erythema associated with rosacea

BACKGROUND

Persistent facial erythema is the most common primary pathological feature of rosacea, the only treatment for which is brimonidine tartrate (BT) gel.

OBJECTIVES

To assess the relative bioavailability of topical BT gel in comparison with the ophthalmic BT solution.

METHODS

A pharmacokinetic study was conducted to compare intraindividual systemic exposures after dermal application of BT gel (0·07%, 0·18% and 0·5%) under maximal use conditions in patients with moderate-to-severe facial erythema associated with rosacea, and administration of BT ophthalmic solution 0·2%.

RESULTS

Patients who received BT ophthalmic solution 0·2% three times a day for 1 day had a mean Cmax of 54 ± 28 pg mL(-1) and a mean 0-24-h area under the curve (AUC0-24 h ) of 568 ± 277 pg h mL(-1) . Topical application of BT gel for 29 days resulted in quantifiable systemic exposure in 22%, 48%, 71% and 79% of patients who received BT gel 0·07% twice daily, 0·18% once daily, 0·18% twice daily and 0·5% once daily, respectively. The mean Cmax values for the BT gels ranged between 13 and 25 pg mL(-1) , and mean AUC0-24 h values ranged between 42 and 290 pg h mL(-1) . Systemic exposure increased with applied dose, with no drug accumulation for the duration of treatment. The systemic exposure observed with the highest dose of BT gel (0·5% once daily) was significantly lower than the systemic levels observed for the ophthalmic solution. 0·2% apply for all the concentrations.

CONCLUSIONS

The systemic safety profile of BT gel may be considered better than that of the ophthalmic solution.

Synchronization and liquid crystalline order in soft active fluids

We introduce a phenomenological theory for a new class of soft active fluids with the ability to synchronize. Our theoretical framework describes the macroscopic behavior of a collection of interacting anisotropic elements with cyclic internal dynamics and a periodic phase variable. This system can (i) spontaneously undergo a transition to a state with macroscopic orientational order, with the elements aligned, a liquid crystal, (ii) attain another broken symmetry state characterized by synchronization of their phase variables, or (iii) a combination of both types of order. We derive the equations describing a spatially homogeneous system and also study the hydrodynamic fluctuations of the soft modes in some of the ordered states. We find that synchronization can promote or inhibit the transition to a state with orientational order, and vice versa. We provide an explicit microscopic realization: a suspension of microswimmers driven by cyclic strokes.

Translations and rotations at low Reynolds number: a study of simple model swimmers with finite amplitude strokes

We present a simple dynamical model of self-propeller at low Reynolds number in which self-propulsion is achieved via rotary elements (rotors). In this model by changing the sense of rotation of the rotors, the self-propeller can switch between a "linear swimming" phase where it swims in a straight line and a "tumbling" phase in which it can change direction in a controllable way via a global rotation of its body. We study the dynamics of this propeller in detail. To do this we provide an analytic framework within which the non-perturbative aspects of the internal dynamics can be treated allowing us to study the swimming process for arbitrary values of the swimmer deformations. Using it, we compute the averages (over a deformation cycle) of a number of characteristic properties of the swimmer such as its self-propulsion velocity, the dissipated power, its efficiency and the fluid flow patterns it generates. We compare these results to the corresponding average quantities for another class of model swimmers, where self-propulsion is achieved via periodic translations. Finally, we provide an explanation of why non-perturbative results can be obtained for these models using the geometrical language of gauge theory.

Once-daily topical brimonidine tartrate gel 0·5% is a novel treatment for moderate to severe facial erythema of rosacea: results of two multicentre, randomized and vehicle-controlled studies

BACKGROUND

Erythema of rosacea is thought to result from abnormal cutaneous vasomotor activity. Brimonidine tartrate (BT) is a highly selective α(2) -adrenergic receptor agonist with vasoconstrictive activity.

OBJECTIVE

To determine the optimal concentration and dose regimen of topical BT gel for the treatment of erythema of rosacea and to evaluate its efficacy and safety.

METHODS

In study A, 122 subjects were randomized to receive a single application of BT 0·07%, 0·18%, 0·5% or vehicle. In study B (4-week treatment and 4-week follow-up), 269 subjects were randomized to receive BT 0·5% once daily, BT 0·18% once daily, vehicle once daily, BT 0·18% twice daily or vehicle twice daily. Evaluations included Clinician's Erythema Assessment (CEA), Patient's Self-Assessment (PSA), Chroma Meter measurements and adverse events.

RESULTS

In study A, a single application of topical BT gel reduced facial erythema in a dose-dependent fashion. A significant difference between BT 0·5% and vehicle in Chroma Meter redness value was observed from 30min to 12h after application. In study B, BT 0·5% once daily had a statistically superior success profile (defined as a two-grade improvement on both CEA and PSA over 12h) compared with vehicle once daily on days 1, 15 and 29 (all P<0·001). No tachyphylaxis, rebound of erythema or aggravation of other disease signs (telangiectasia, inflammatory lesions) was observed. All regimens were safe and well tolerated with similarly low incidence of adverse events.

CONCLUSIONS

Once-daily BT gel 0·5% is well tolerated and provides significantly greater efficacy than vehicle gel for the treatment of moderate to severe erythema of rosacea.

Hydrodynamic synchronization of nonlinear oscillators at low Reynolds number

We introduce a generic model of a weakly nonlinear self-sustained oscillator as a simplified tool to study synchronization in a fluid at low Reynolds number. By averaging over the fast degrees of freedom, we examine the effect of hydrodynamic interactions on the slow dynamics of two oscillators and show that they can lead to synchronization. Furthermore, we find that synchronization is strongly enhanced when the oscillators are nonisochronous, which on the limit cycle means the oscillations have an amplitude-dependent frequency. Nonisochronity is determined by a nonlinear coupling α being nonzero. We find that its (α) sign determines if they synchronize in phase or antiphase. We then study an infinite array of oscillators in the long-wavelength limit, in the presence of noise. For α>0, hydrodynamic interactions can lead to a homogeneous synchronized state. Numerical simulations for a finite number of oscillators confirm this and, when α<0, show the propagation of waves, reminiscent of metachronal coordination.

Updating clinical recommendations for breast, colorectal and lung cancer treatments: an opportunity to improve methodology and clinical relevance

BACKGROUND

clinical guidelines can improve quality of care summarising available knowledge and proposing recommendations for health care decisions. Being up to date is one of their quality requisites. Little experience is available on when and how guidelines should be updated. We report on the update process of evidence-based clinical recommendations on anticancer drugs.

METHODS

three multidisciplinary panels, supported by methodology experts, updated the recommendations. The methodologists were in charge of the qualitative and quantitative synthesis of the evidence. The panels were responsible for the final decision about risk/benefit profile of the drugs and strength of the recommendations. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used.

RESULTS

six recommendations out of 15 were completely updated in 8 months time. In four cases, the strength of the recommendation changed; in two of them, we moved from a weak to a strong positive one. Despite the increased certainty about the positive risk/benefit profile, this was translated in a change in the strength of the recommendation only in one case out of three. Three recommendations were refined making them more clinically specific.

CONCLUSIONS

accumulation of evidence is an opportunity for guideline panels to refine methodological rigour, clinical relevance and to foster consensus on recommendations. This requires time and resource investments.

Minimal two-sphere model of the generation of fluid flow at low Reynolds numbers

Locomotion and generation of flow at low Reynolds number are subject to severe limitations due to the irrelevance of inertia: the "scallop theorem" requires that the system have at least two degrees of freedom, which move in non-reciprocal fashion, i.e. breaking time-reversal symmetry. We show here that a minimal model consisting of just two spheres driven by harmonic potentials is capable of generating flow. In this pump system the two degrees of freedom are the mean and relative positions of the two spheres. We have performed and compared analytical predictions, numerical simulation and experiments, showing that a time-reversible drive is sufficient to induce flow.

Intravenous thrombolysis in the emergency department for the treatment of acute ischaemic stroke

BACKGROUND AND AIMS

Thrombolytic therapy with intravenous recombinant tissue plasminogen activator (rt-PA) improves outcome in patients with ischaemic stroke treated within 3 h of symptom onset, but its extended implementation is limited. A pilot study was designed to verify whether evaluation of patients with acute ischaemic stroke and their treatment with intravenous rt-PA in the emergency department (ED), followed by transportation to a semi-intensive stroke care unit, offers a safe and effective organisational solution to provide intravenous thrombolysis to acute stroke patients when a stroke unit (SU) is not available.

METHODS

After checking for inclusion and exclusion criteria, ED doctors contacted the stroke team with a single page, located family members and urgently obtained computed tomography scan and laboratory tests. A stroke team investigator clinically assessed the patient, obtained written informed consent and supervised intravenous rt-PA in the ED. After treatment, the patient was transferred to the SU for rehabilitation and treatment of complications, under supervision of the same stroke team investigator.

RESULTS

52 patients were treated with intravenous rt-PA within 3 h of symptom onset. 20 patients (38%) improved neurologically after 24 h, the number increased to 30 (58%) after one week. At 3 months 22 patients had a favourable outcome (43%). The 3-month mortality rate was 12%. Symptomatic cerebral haemorrhage was observed in two patients (4%).

CONCLUSIONS

Intravenous rt-PA administration in the ED is an effective organisational solution for acute ischaemic stroke when an SU is not established.

A randomized study comparing filgrastim versus lenograstim versus molgramostim plus chemotherapy for peripheral blood progenitor cell mobilization

We conducted a prospective randomized clinical trial to assess the mobilizing efficacy of filgrastim, lenograstim and molgramostim following a disease-specific chemotherapy regimen. Mobilization consisted of high-dose cyclophosphamide in 45 cases (44%), and cisplatin/ifosfamide/etoposide or vinblastine in 22 (21%), followed by randomization to either filgrastim or lenograstim or molgramostim at 5 microg/kg/day. One hundred and three patients were randomized, and 82 (79%) performed apheresis. Forty-four (43%) patients were chemonaive, whereas 59 (57%) were pretreated. A median number of one apheresis per patient (range, 1-3) was performed. The median number of CD34+ cells obtained after mobilization was 8.4 x 10(6)/kg in the filgrastim arm versus 5.8 x 10(6)/kg in the lenograstim arm versus 4.0 x 10(6)/kg in the molgramostim arm (P=0.1). A statistically significant difference was observed for the median number of days of growth factor administration in favor of lenograstim (12 days) versus filgrastim (13 days) and molgramostim (14 days) (P<0.0001) and for the subgroup of chemonaive patients (12 days) versus pretreated patients (14 days) (P<0.001). In conclusion, all three growth factors were efficacious in mobilizing peripheral blood progenitor cells with no statistically significant difference between CD34+ cell yield and the different regimens, and the time to apheresis is likely confounded by the different mobilization regimens.

Metal-contaminated soil remediation by means of paper mill sludges addition: chemical and ecotoxicological evaluation

Metal pollution of soils is a great environmental problem. The major risks due to metal pollution of soil consist of leaching to groundwater and potential toxicity to plants and/or animals. The objective of this study is to evaluate by means of chemical and ecotoxicological approach the effects of paper mill sludge addition on the mobile metal fraction of polluted metal soils. The study was carried out on acidic soil derived from mining activities and thus polluted with heavy metals, and on two paper mill sludges having different chemical features. The results obtained by leaching experiments showed that the addition of a paper mill sludge, consisting mainly of carbonates, silicates and organic matter, to a heavy-metal polluted soil produces a decrease of available metal forms. The carbonate content seems to play a key role in the chemical stabilisation of metals and consequently in a decrease of toxicity of soil. The leached solutions have a non-toxic effect. The mild remediation by addition of sludge has moreover a lasting effect.