Cell-type specific distribution and activation of type I IFN pathway molecules at the placental maternal-fetal interface in response to COVID-19 infection

BACKGROUND AND OBJECTIVE

COVID-19 infection in pregnancy significantly increases risks of adverse pregnancy outcomes. However, little is known how the innate immunity at the placental maternal-fetal interface responds to COVID-19 infection. Type I IFN cytokines are recognized as a key component of the innate immune response against viral infection. In this study, we specifically evaluated expression of IFN antiviral signaling molecules in placentas from women infected with COVID-19 during pregnancy.

METHODS

Expression of IFN activation signaling pathway molecules, including cyclic GMP-AMP synthase (cGAS), stimulator of interferon genes (STING), interferon regulatory factor 3 (IRF3), Toll-like receptor 7 (TLR7), mitochondrial antiviral-signaling protein (MAVS), and IFNβ were determined in formalin-fixed paraffin embedded (FFPE) placental tissue sections (villous and fetal membrane) by immunostaining. A total of 20 placentas were examined, 12 from COVID-19 patients and 8 from non-COVID-19 controls. Patient demographics, clinical data, and placental pathology report were acquired via EPIC medical record review.

RESULTS

Except BMI and placental weight, there was no statistical difference between COVID and non-COVID groups in maternal age, gestational age at delivery, gravity/parity, delivery mode, and newborn gender and weight. In COVID-exposed group, the main pathological characteristics in the placental disc are maternal and fetal vascular malperfusion and chronic inflammation. Compared to non-COVID controls, expression of IFN activation pathway molecules were all upregulated with distinct cell-type specific distribution in COVID-exposed placentas: STING in villous and decidual stromal cells; IRF3 in cytotrophoblasts (CTs) and extra-villous trophoblasts (EVTs); and TLR7 and MAVS in syncytiotrophoblasts (STs), CTs, and EVTs. Upregulation of STING, MAVS and TLR7 was also seen in fetal endothelial cells.

CONCLUSIONS

STING, IRF3, TLR7, and MAVS are key viral sensing molecules that regulate type I IFN production. Type I IFNs are potent antiviral cytokines to impair and eradicate viral replication in infected cells. The finding of cell-type specific distribution and activation of these innate antiviral molecules at the placental maternal-fetal interface provide plausible evidence that type I IFN pathway molecules may play critical roles against SARS-CoV-2 infection in the placenta. Our findings also suggest that placental maternal-fetal interface has a well-defined antiviral defense system to protect the developing fetus from SARS-CoV-2 infection.

Delayed Infection of Porous Polyethylene Implants After Oncologic Maxillectomy and Reconstruction: 2 Case Reports and Review of Literature

Medpor porous polyethylene implants are commonly used for facial skeletal reconstruction due to reported biocompatibility, fibrovascularization, and durability. While uncommon, late implant infections are an important consideration. We report delayed infections in 2 patients after unilateral total oncologic maxillectomy and reconstruction using Medpor implants for an ossifying fibroma and squamous cell carcinoma, respectively. In the first patient, annual interval computed tomography (CT) scans showed no recurrence of tumor or inflammatory changes. The second was lost to follow-up after adjuvant chemoradiation 1 year after resection. Patients both presented with swelling, drainage, and erythema around the implant at a mean of 4.5 years following maxillectomy. Both failed several attempts at conservative treatment. Cultures of implants removed at a mean of 2.5 months after infection grew α-hemolytic Streptococcus in the first and multiple organisms in the second, showing that the potential for delayed infection should be considered years after reconstruction.

Clinical Utility of Weekly Laboratory Testing in the Outpatient Management of Preeclampsia and Gestational Hypertension

Objective  To investigate the utility of obtaining weekly laboratory testing in patients managed as an outpatient for gestational hypertension and preeclampsia without severe features. Study Design  A multisite retrospective cohort study was performed evaluating preterm women diagnosed with gestational hypertension/preeclampsia managed in an outpatient setting between gestational ages of 23 ^0/7 and 36 ^6/7 . Patients were divided into two groups: weekly laboratory evaluation (laboratories group) and a no laboratories group. The primary study outcome was composite maternal morbidity including more than one of the following: development of severe features, HELLP syndrome, eclampsia, placental abruption, maternal intensive care unit admission, or maternal death. Results  A total of 204 patients were included in this study, laboratories group ( n  = 120) and no laboratories group ( n  = 84). The laboratories group was older (28.8 vs. 26.6 years, p  = 0.02), had a higher rate of chronic hypertension (44 [36.7%] vs. 17 [20.2%], p  = 0.01), and more often experienced the primary composite outcome (53 [44.2%] vs. 24 [28.5%], p  = 0.02). No patients in our cohort were delivered for abnormal laboratory values. Conclusion  This study found that weekly laboratory testing may have minimal clinical utility in the outpatient management protocol in monitoring patients with mild gestational hypertension or preeclampsia. Delivery was guided by other clinical factors.

Effects of Clove Oil as a Euthanasia Agent on Blood Collection Efficiency and Serum Cortisol Levels in Danio rerio

Zebrafish are an important laboratory animal model for biomedical research and are increasingly being used for behavioral neuroscience. Tricaine methanesulfonate (MS222) is the standard agent used for euthanasia of zebrafish. However, recent studies of zebrafish behavior suggest that MS222 may be aversive, and clove oil might be a possible alternative. In this study, we compared the effects of MS222 or clove oil as a euthanasia agent in zebrafish on the volume of blood collected and on serum levels of cortisol. Greater amounts of serum could be collected and lower serum levels of cortisol were present in fish euthanized with clove oil compared with equipotent dose of MS222. Euthanasia with clove oil did not blunt the expected elevation of serum cortisol levels elicited by an acute premortem stress. According to our findings, clove oil is a fast-acting agent that minimizes the cortisol response to euthanasia in zebrafish and allows the collection of large volumes of blood postmortem. These results represent a significant refinement in euthanasia methods for zebrafish.

Abstract 2880: Modulating disease susceptibility in a model of human colon cancer by microbiome rederivation

To understand the impact of differences in complex microbiota on colon cancer susceptibility, we utilized the Pirc (Polyposis In Rat Colon) model of familial human colon cancer to correlate the longitudinal changes of the gut microbiota with early adenoma development. Recent human epidemiologic studies have shown associations of gut microbiota differences in patients with colorectal cancer vs. controls.

To test if differences in the gut microbiota modulate susceptibility, we used the F344/NTac-ApcPirc/+ rat model and altered the microbiome through embryo rederivation using three distinct strains of surrogate dams: F344/NHsd, LEW/SsNHsd, and Crl:SD, all harboring different commensal microbiota. Fecal samples from the pups and dams were collected at various time points. Extracted DNA was sequenced using the Illumina MiSeq platform for the 16S rRNA gene V4 hypervariable region. Adenoma development was monitored periodically via colonoscopy and terminal tumor counts and histology were performed at 180 days. We found the complex microbiota of the surrogates to be distinct from one another and that the pups resembled their respective dams. At the terminal time-point, rats harboring the LEW microbiota had significantly reduced colonic tumor burden (number and size) compared to both F344 (p<0.001) and SD (p<0.05). Colonic tumors were also absent in 2 of the 15 rederived pups with the LEW microbiota reducing the Pirc phenotype penetrance from 100% to 87%.

At weaning, we found the LEW microbiota to be unique with a high percentage of Prevotella copri. Pups with the LEW microbiota also differed significantly from the other pups by an additional 8 operational taxonomic units (OTUs). At 6 months of age, the relative abundance of P. copri, and 5 additional OTUs correlated with decreased tumor burden in these pups (Spearman’s, p≤0.05). Conversely, higher prevalence of family Peptococcaceae and Akkermansia muciniphila were positively correlated (p<0.05) with increased tumor number. Histological analysis of colons from the LEW and SD offspring showed significant goblet cell hyperplasia (p<0.002) in the distal colon of the LEW pups. No aberrant crypt foci (ACF) or microadenomas were found in the two LEW pups that did not harbor colonic adenomas, indicating a possible inhibition of initiation. Immunohistochemical staining for Ki67 showed that the proliferation index of both the normal epithelium and tumors in the SD group was trending significantly higher compared to the LEW rats.

Our results indicate that microbial alteration through rederivation affects colon cancer susceptibility. The prevalence or lack of specific OTUs at weaning can potentially serve as predictors of tumor burden at later stages. More importantly, the study points towards differences in the microbiota of the offspring acting as modulators of disease phenotype affecting initiation or progression of colon cancer.

Citation Format: James Amos-Landgraf, Susheel Busi, Aaron Ericsson, Marina McCoy, Taybor Parker, Rebecca Schehr, Miriam Hankins, Craig Franklin, Elizabeth Bryda. Modulating disease susceptibility in a model of human colon cancer by microbiome rederivation. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2880. doi:10.1158/1538-7445.AM2015-2880

Maintaining stable symptom control in inflammatory bowel disease: a retrospective analysis of adherence, medication switches and the risk of relapse

BACKGROUND

Maintenance therapy with 5-aminosalicylic acid (5-ASA) is a key strategy for preventing relapse in many patients with inflammatory bowel disease (IBD). Factors which disrupt 5-ASA delivery, such as non-adherence and 5-ASA switches, may destabilise symptom control.

AIM

To investigate the impact of non-adherence and medication switches on stable symptom control in UK patients with IBD.

METHODS

A retrospective cohort study was conducted using a UK dispensing database. Adherence was analysed in randomised matched samples for each of the six leading oral mesalazine formulations, measured by medication possession ratio (MPR); MPR ≥80% was classified as adherent. Relationships among adherence, switch and relapse were analysed over 18 months in patients receiving continuous mesalazine therapy throughout a 6-month baseline period (primary subgroup analysis). Relapses of active ulcerative colitis were identified using a doubling of MPR as a proxy.

RESULTS

Only 39% of patients in the matched samples (n = 1200) were classed as adherent. No significant differences in adherence were observed among mesalazine formulations. In the primary subgroup analysis (n = 568), non-adherent patients had a significantly greater risk of relapse than adherent patients (RR = 1.44, 95% CI = 1.08-1.94; P = 0.014). Among adherent patients (n = 276), those who switched had a 3.5-fold greater risk of relapse than those who did not switch (95% CI = 1.16-10.62; P = 0.008).

CONCLUSIONS

Both non-adherence and mesalazine switches in adherent patients were associated with significant increases in the risk of relapse, suggesting that disruption of mesalazine maintenance therapy may destabilise symptom control. These findings provide evidence to advocate caution when considering mesalazine switches for stable patients.

Oral vs intravenous paracetamol for lower third molar extractions under general anaesthesia: is oral administration inferior?

BACKGROUND

Paracetamol formulations provide effective analgesia after surgery [Duggan ST, Scott LJ. Intravenous paracetamol (acetominophen). Drugs 2009; 69: 101-13; Toms L, McQuay HJ, Derry S, Moore RA. Single dose oral paracetamol (acetaminophen) for postoperative pain in adults. Cochrane Database Syst Rev 2008: CD004602]. I.V. paracetamol is superior to oral for pain rescue (Jarde O, Boccard E. Parenteral versus oral route increases paracetamol efficacy. Clin Drug Invest 1997; 14: 474-81). By randomized, double-blinded trial, we aimed to determine whether preoperative oral paracetamol provides inferior postoperative analgesia to preoperative i.v. paracetamol.

METHODS

One hundred and thirty participants received either oral paracetamol and i.v. placebo (Group OP), or oral placebo and i.v. paracetamol (Perfalgan™) (Group IP). Oral preparations were given at least 45 min before surgery; i.v. preparations after induction of anaesthesia. Pain was assessed by a 100 mm visual analogue scale (VAS) 1 h from the end of surgery. Rescue analgesia was given on request.

RESULTS

A total of 128 patients completed the study. There were no significant differences in baseline characteristics or intraoperative variables between the groups. The study was designed to reveal whether OP is inferior to IP, with an inferiority margin of 20%. The number of patients reporting satisfactory analgesia at 1 h with VAS ≤ 30 mm were 15 (OP) and 17 (IP), respectively. The secondary outcome measure of the mean (standard deviation) VAS (mm) for the whole of each group was 52 (22) for OP and 47 (22) for IP. Analysis of confidence intervals indicates that oral paracetamol is not inferior to i.v. paracetamol. The median survival (90% CI) to rescue analgesia request was 54.3 (51.2-57.4) min in Group OP and 57.3 (55.4-59.2) min in Group IP; there was no significant difference in this measure.

CONCLUSIONS

In this study of lower third molar extraction, oral paracetamol is not inferior to i.v. for postoperative analgesia. ISRCTN Registration http://www.controlled-trials.com/ISRCTN77607163.

Measuring asthma-specific quality of life: structured review

Measuring quality of life (QoL) has become an increasingly important dimension of assessing patient well-being and drug efficacy. As there are now several asthma QoL questionnaires to choose from, it is important to appreciate their strengths and weaknesses. To assist in this choice, we have reviewed the existing questionnaires in a structured way. Information relating to the conceptual and measurement model, reliability, validity, interpretability, burden, administration format and translations was extracted from the published literature. The instruments differ in almost all criteria considered, and therefore it cannot be assumed that they measure the same thing. We recommend the selection of questionnaires that are designed only for asthma and that do not assess symptoms as part of QoL. Only two of the questionnaires reviewed fulfill these requirements: the Sydney Asthma QoL Questionnaire (AQLQ-S) and the Living with Asthma Questionnaire (LWAQ). However, for multinational studies, it may be convenient or practical to use questionnaires that have been linguistically validated in many languages (AQLQ-J, SGRQ). It remains unclear which of these questionnaires best reflects patient perceptions of QoL. Our review did not involve patients, so for the time being choosing from existing questionnaires requires a compromise based on the rigor of the development process and the target patient group.

Conducting oral examinations for cancer in general practice: what are the barriers?

BACKGROUND

The incidence of oral (mouth) cancer in the UK is continuing to rise. Individuals who are at greatest risk rarely visit a dentist but do consult general medical practitioners (GMPs). Therefore, GMPs could have an important role in the early detection of oral cancer. Research has shown that GMPs do not opportunistically screen high-risk individuals; however, the barriers to screening are poorly understood.

OBJECTIVES

To understand the reasons why GMPs may not screen for oral cancer.

METHODS

A questionnaire was developed, using the Theory of Planned Behaviour (TPB), to measure GMPs attitudes to and screening for oral cancer. The questionnaire was designed using all the key theoretical constructs of the TPB and incorporating the themes identified in a qualitative elicitation study. The questionnaire was posted to 499 GPs in Surrey Primary Care trust.

RESULTS

Two hundred and twenty-eight completed questionnaires were returned (46%). Two TPB constructs [subjective norm (e.g. peer pressure) and perceived external control factors (e.g. adequate equipment, time constraints)] were identified as significant predictors of 'intention' to perform oral screening. Intention and perceived internal control factors (e.g. self-efficacy) were predictive of actually performing oral screening with patients.

CONCLUSIONS

The results of the study suggest that there is considerable potential for improving intention to perform oral cancer screening in general practice. Theory-based interventions could include further training to enhance confidence, expertise, knowledge and ease of examination, the provision of adequate equipment in the surgery and increasing the motivation to comply with significant others by introducing guidelines on opportunistic screening.

Interventions to increase self-efficacy in the context of addiction behaviours: a systematic literature review

This article describes the effectiveness of interventions aimed at increasing self-efficacy and consequently, changing addiction behaviours. Electronic databases were searched and bibliographies of retrieved references scanned. Ten studies targeting tobacco smoking, alcohol and illicit drug use met the inclusion criteria. The interventions ranged from computer-generated tailored letters to intensive group-based interventions. Seven of the 10 studies reported positive effects of interventions upon self-efficacy. The two that assessed behaviour change reported a significant effect but as neither performed mediation analyses, behaviour change could not reliably be attributed to self-efficacy change. In conclusion, self-efficacy can be increased using a range of methods. There is, however, little evidence to determine whether such increases change behaviour.

Attending an STI Foundation course increases chlamydia testing in primary care, but not HIV testing

Summary:

The Sexually Transmitted Infection Foundation course (STIF) is a recommended training course for UK general practitioners (GPs) and others delivering sexual health services in the community. We assessed the impact of attending the course on testing for HIV and chlamydia. Thirty-one GPs attending Brighton STIF courses were identified and the laboratory database was searched to identify all chlamydia and HIV tests they requested in the three months prior to attending, the first three months after attending and the subsequent three months. Three hundred and eight chlamydia tests were performed precourse, 390 postcourse and 342 in the following three months. This represented a significant increase from baseline to postcourse (P = 0.007), which was lost by three to six months (P = 0.25). The proportion of positives did not change. A total of 98, 111 and 131 HIV tests were performed in the three time periods of which; none were positive. Barriers other than training may need to be overcome to increase HIV testing in primary care.

Self-sampling for oropharyngeal and rectal specimens to screen for sexually transmitted infections: acceptability among men who have sex with men

OBJECTIVES

To explore the feasibility and acceptability of self-sampling for oropharyngeal and rectal specimens to screen for sexually transmitted infections (STIs) among men who have sex with men (MSM). Participant's willingness to self-sample at home was also explored.

METHODS

Participants of a study to evaluate the sensitivity and specificity of self versus nurse taken oropharyngeal and rectal specimens were surveyed to assess the feasibility and acceptability of self-sampling using specimen collection methods (gargle, OraSure mouth pad to collect oropharyngeal specimens and APTIMA unisex swabs to collect rectal and pharyngeal specimens). Acceptability was measured using a five-point Likert-type response scale (for example, 1 = strongly disagree; 5 = strongly agree). Open-ended questions explored participants' experiences of self-sampling.

RESULTS

Of 334 eligible MSM, 301 (90%) participated in the study. Altogether, 301 participants self-sampled using gargle and rectal and pharyngeal swabs and 288 using mouth pad. Complete questionnaire data from 274 participants showed that feasibility and acceptability of self-sampling using gargle and mouth pad was higher (92%) than pharyngeal swabs (76%). Rectal swabs were acceptable to 82% participants. Despite some discomfort and difficulty in using swabs, 76% were willing to use all four methods for self-sampling in the future. Home sampling was acceptable (84%) as it was perceived to be less intrusive and more convenient than a clinic visit and likely to reduce genitourinary medicine (GUM) waiting time.

CONCLUSIONS

Self-sampling for rectal and oropharyngeal specimens is feasible and acceptable to MSM. Self-sampling can be offered as an alternative to clinic-based testing and has the potential to improve choice, access and uptake of screening for STIs.

Long-term results of a hydroxyapatite-coated femoral component in total hip replacement: a 15- to 21-year follow-up study

Between 1986 and 1991 we implanted 331 consecutive Furlong hydroxyapatite-coated femoral components of a total hip replacement in 291 patients. A cemented acetabular prosthesis was used in 217 hips and a hydroxyapatite-coated component in 114. We describe the long-term clinical and radiological survival of the femoral component at a mean follow-up of 17.5 years (15 to 21). Only two patients (0.68%) were lost to follow-up. With revision of the femoral component for any reason as the endpoint, the survival at a mean of 17 years was 97.4% (95% confidence interval 94.1 to 99.5), and with revision for aseptic loosening as the endpoint it was 100%. The survival at a maximum of 21 years with revision of the femoral component for any reason as the endpoint was 97.4% (95% confidence interval 81.0 or 99.5). These results compare favourably with the best long-term results of cemented or uncemented femoral components used in total hip replacement.

The impact of genetic testing for Crohn's disease, risk magnitude and graphical format on motivation to stop smoking: an experimental analogue study

Genetic tests may motivate risk-reducing behaviour more than other types of tests because they generate higher risk magnitudes and because their results have high personal relevance. To date, trial designs have not allowed the disentangling of the effects of these two factors. This analogue study examines the independent impacts of risk magnitude and provenance, and of risk display type, on motivation to quit smoking. A total of 180 smokers were randomly allocated to one of the 18 Crohn's disease risk vignettes in a 3 (risk provenance: family history. genetic test mutation positive. genetic test mutation negative) x 3 (risk magnitude: 3%, 6%, 50%) x 2 (display: grouped or dispersed icons) design. The 50% group had significantly higher intentions to quit than the 3% group. A significant risk provenance x magnitude interaction showed that participants in 50% or 6% groups were equally motivated, regardless of risk provenance, while participants in the 3% group had higher intentions associated with a mutation negative result than with a result based on family history alone. Grouped icon displays were more motivating than the dispersed icons. Using genetic tests to estimate risks of common complex conditions may not motivate behaviour change beyond the impact of the numerical risk estimates derived from such tests.

Assessing patients' beliefs about cardiac rehabilitation as a basis for predicting attendance after acute myocardial infarction

BACKGROUND

Some sociodemographic and psychological variables such as patients' belief about illness are associated with attendance at cardiac rehabilitation. Exploration of patients' beliefs about treatment regarding cardiac rehabilitation has been limited to qualitative studies; their role in relation to attendance at cardiac rehabilitation after acute myocardial infarction (AMI) remains speculative.

OBJECTIVES

To develop a valid and reliable measure of patients' beliefs regarding cardiac rehabilitation and to ascertain the relationship between such beliefs and attendance.

DESIGN

A prospective questionnaire-based study.

SETTING

Coronary care unit of a London teaching hospital.

PATIENTS

130 patients with AMI; 104 (83%) men; mean age 58.4 (standard deviation (SD) 10.7) years.

INTERVENTIONS

Patients completed a 26-item questionnaire consisting of statements pertaining to beliefs about cardiac rehabilitation.

MAIN OUTCOME MEASURES

Cardiac rehabilitation attendance; beliefs of patients about cardiac rehabilitation.

RESULTS

Four subscales pertaining to patients' beliefs about cardiac rehabilitation were produced, accounting for 65.3% of the attendance variance: perceived necessity of cardiac rehabilitation (alpha = 0.71), concerns about exercise (alpha = 0.79), practical barriers (alpha = 0.70) and perceived personal suitability (alpha = 0.74). Patients who attended were more likely to believe that cardiac rehabilitation was necessary and to understand its role compared with non-attenders (17.7 (SD 2.7) v 16.9 (SD 3.0), p = 0.029). Patients who thought cardiac rehabilitation was suitable for a younger, more active person were less likely to attend (5.6 (SD 1.9) v 4.6 (SD 1.7), p = 0.007). Patients who expressed concerns about exercise or who reported practical barriers to attendance were less likely to attend, although these did not reach statistical significance.

CONCLUSION

Beliefs about cardiac rehabilitation can be quantified and differ between attenders and non-attenders of cardiac rehabilitation.

Effect of age on treatment and survival among patients with non-small cell lung cancer

18504

Background: Lung cancer is a disease of the elderly. Yet older patients are underrepresented in clinical trials resulting in scanty efficacy data. We sought to assess the relationship between age, treatment and overall survival in a cohort of patients with non-small cell lung cancer (NSCLC). Methods: We conducted a retrospective cohort study of patients with consecutively diagnosed NSCLC between 1999 and 2003 at the Boston Veterans Administration Medical Center (BVAMC). All patients with a biopsy proven NSCLC were included. Patients diagnosed at autopsy were excluded. Data sources included the BVAMC tumor registry and medical records. Deaths were ascertained from the Social Security Administration and VA databases. All patients were right censored at death from any cause or at 12/31/2004, whichever came first. Our primary endpoints were 1) receipt of surgery; 2) receipt of chemotherapy; and 3) three-year overall survival. Our independent variable was age, operationalized as 70 years and older versus less than 70 years. We used logistic regression analysis to assess the relationship between age and treatment and Kaplan-Meier curves and Cox proportional hazards modeling to determine the effect of age on survival. Results: We studied 410 patients. 211 (51%) of the cohort were ≥70 years and 199 (49%) were <70 years. Among those with localized disease (stages I and II) there was no significant difference in the odds of receiving surgery between the two age categories, (OR = 1.54, 95% CI, 0.72, 3.28). Among those with non-localized disease (stages III and IV) those who were ≥ 70 years were less likely to receive chemotherapy (OR = 0.46, 95% CI, 0.27, 0.79). There were 308 deaths from all causes: 167 in the ≥ 70 year group and 141 in the <70 year group. The three-year overall survival was 20.4% (95% CI, 14.5%, 26.3%) and 32.7% (95% CI, 25.3%, 39.5%) for the ≥70 and <70 year groups, respectively. The adjusted hazard ratio was 0.72 (95% CI, 0.57, 0.92), P = 0.03 by the log rank test in favor of those less than 70 years. Other significant predictors of overall survival included stage at diagnosis and treatment. Comorbidity was not a significant predictor of overall survival. Conclusion: The poorer survival outcome among older NSCLC patients at the BVAMC may be improved by more aggressive treatment with chemotherapy.

No significant financial relationships to disclose.

Simplifying the assessment of the recovery from surgical injury to the lingual nerve

OBJECTIVE

To determine the sensitivity of conventional sensory assessment in monitoring lingual nerve recovery subsequent to third molar surgery and to evaluate if the assessment methods can be predictive of injury outcome.

METHOD

A prospective case series of 94 patients presenting with lingual nerve injuries evaluated using objective mechanosensory and subjective methods during the recovery period of up to 12 months.

RESULTS

The conventional tests were often unable to diagnose the presence of injury due to variability and they were not predictive of outcome. As a result of this study, we are able to identify patients more likely to have permanent rather than temporary lingual nerve injury at four to eight weeks post injury, using patient reported subjective function. The subjective function test also minimises the requirements for specialist training or equipment providing an ideal method for general dental practice.

CONCLUSIONS

The development of these simple subjective tests may enable us to identify which patients are at risk of permanent lingual nerve injuries in the early post injury phase, thus allowing expeditious therapy when indicated.

The psychological impact of human papillomavirus testing in women with borderline or mildly dyskaryotic cervical smear test results: 6-month follow-up

State anxiety (S-STAI-6), distress (GHQ-12), concern and quality of life (EuroQoL-EQ-5D) 6 months after human papillomavirus (HPV) testing in women with borderline or mildly dyskaryotic smear test results were assessed based on a prospective questionnaire study, with 6-month follow-up after the smear test result. Two centres participated in an English pilot study of HPV testing. Participants included two groups of women receiving abnormal smear test results: (tested for HPV and found to be (a) HPV positive (n=369) or (b) HPV negative (n=252)) and two groups not tested for HPV (those receiving (c) abnormal smear test results (n=102) or (d) normal smear test results (n=288)). There were no differences in anxiety, distress or health-related quality of life between the four study groups at 6 months. Levels of concern about the smear test result remained elevated in all groups receiving an abnormal smear test result, and were highest in the group untested for HPV. Predictors of concern across all groups receiving an abnormal smear test were perceived risk of developing cancer, being HPV positive or untested for HPV, sexual health worries and the smear being a woman's first smear test. The raised anxiety and distress observed in women immediately after being informed of an abnormal smear test result and that they are HPV positive was no longer evident at 6 months. Concern about the smear test result was however still raised in these women and those who tested negative for HPV, and particularly among those who did not undergo HPV testing.

A randomised controlled clinical trial to compare the incidence of injury to the inferior alveolar nerve as a result of coronectomy and removal of mandibular third molars

We randomised 128 patients who required operations on mandibular third molars and who had radiological evidence of proximity of the third molar to the canal of the inferior alveolar nerve to one of two operations: extraction [n=102], and coronectomy [n=94]. Some roots were dislodged during intended coronectomy and were therefore removed, resulting in two subgroups (successful coronectomy n=58, and failed coronectomy n=36). The mean (S.D.) follow up was 25 (13) months. Nineteen nerves were damaged (19%) after extraction, none after successful coronectomy, and three (8%) after failed coronectomy (p=0.01). The incidence of dry socket infection was similar in the three groups (10/102, 10%, 7/58, 12%, and 4/36, 11%, respectively). No root required removal or reoperation. To our knowledge this is the first clinical trial of the efficacy of coronectomy in preserving the inferior alveolar nerve. The length of follow up was about 2 years, which for the assessment of delayed eruption of the root fragments is not sufficient as this process may continue for up to 10 years. However, it seems that coronectomy reduces the incidence of injury to the inferior alveolar nerve without increasing the risk of dry socket or infection.

Improving uptake of HIV testing in patients with a confirmed STI

Up to 70% of GU clinic attendees with a sexually transmitted infection (STI) and undiagnosed HIV, remain HIV undiagnosed after their visit. STIs have been shown to facilitate HIV transmission. Therefore, patients with an STI should test for HIV. Our objective was to compare the uptake of HIV testing in GU clinic attendees with an STI (study group) with those receiving a negative GU screen (control group). This re-audit was performed after introduction of the following clinic changes: nurse-performed asymptomatic GU screening; 'opt-out' HIV testing policy; discontinuing routine pre-HIV test counselling; access to HIV results by post. The uptake of HIV testing overall, and in the study and control groups respectively was 53% (n = 573), 41% (n = 285) and 65%, showing significant improvement compared to the first audit in 1999 (18%, 14% and 33% respectively) (P < 0.01). The clinic interventions increased HIV testing rates which were in keeping with National Sexual Health strategy targets.

Quantitative thermosensory testing of the lingual and inferior alveolar nerves in health and after iatrogenic injury

Quantitative testing of the sensory thermal thresholds testing was applied at sites innervated by the third division of the trigeminal nerve in 20 patients with no reported sensory impairment and in 20 subjects with iatrogenic nerve injuries after third molar surgery. In the control group sensitivity to cooling was significantly greater than the sensitivity to warming at all sites. The labial mucosa innervated by the inferior alveolar nerve was significantly more sensitive to thermal changes than either the mental region or the lingual mucosa. At sites supplied by nerves that had been injured, there were raised thresholds to both warming and cooling compared with the control group, and with uninjured contralateral sites. The results indicate that this test can identify iatrogenic lingual and inferior alveolar nerve injury with reference to a control group but because of spatial variation selection of control sites for comparison should be done cautiously.

Comparison of POSSUM with P-POSSUM for prediction of mortality in infrarenal abdominal aortic aneurysm repair

The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is a simple and valid scoring system in predicting mortality and morbidity rates. The Portsmouth predictor equation (P-POSSUM) has been shown to be a more accurate predictor of death than the POSSUM in vascular patients. The length of hospital stay (LOS) equation has been suggested to be of value in predicting total length of stay. The aim of this study was to test the validity of the POSSUM, P-POSSUM, and LOS in predicting outcome of patients undergoing abdominal aortic aneurysm (AAA) repair. POSSUM scores in 118 patients who underwent AAA repair by a single consultant were recorded retrospectively. Observed rates of mortality, morbidity, and length of hospital stay were correlated with the rates predicted by POSSUM, P-POSSUM, and LOS equations in three groups: all cases, 93 elective repairs, and emergency AAA repairs. The POSSUM and the P-POSSUM performed similarly in terms of accuracy of prediction, with all predicted values being not significantly different from those observed. The POSSUM tended to overpredict mortality compared to the P-POSSUM. The POSSUM predicted morbidity well. The LOS equation failed to predict significantly observed total hospital stay. POSSUM and P-POSSUM outcome risk equations are thus valid in predicting mortality for all cases and emergency AAA repairs. The POSSUM morbidity equation predicts complications quantitatively.

The Transplant Effects Questionnaire (TxEQ): The development of a questionnaire for assessing the multidimensional outcome of organ transplantation - example of end stage renal disease (ESRD)

OBJECTIVES: To develop a questionnaire to assess the responses of transplant recipients to the receipt of an organ, including their self-care behaviour. DESIGN: Following a literature review, open-ended interviews and a focus group, a transplant questionnaire was developed. Two studies (Study 1: N = 231, Study 2: N = 105) were conducted to evaluate its psychometric properties. METHODS: A pool of 51 items was derived from themes identified in published studies and from interviews and a focus group discussion with renal transplant recipients. These were constructed into a questionnaire and were then administered to two renal transplant out-patients populations. Item responses of study sample 1 were subjected to principal components analysis (PCA) using varimax rotation to examine the structure of responses. In order to investigate the stability of the factor structure found in Study 1, item responses of the second sample were subjected to confirmatory factor analysis (CFA) using structural equation modelling. RESULTS: PCA indicated six factors that accounted for 64.2% of the variance. With extraneous items omitted, the final questionnaire derived from Study 1 has 24 items clustered around five conceptual coherent factors: worry about transplant (22.1%), guilt regarding donor (11.9%), disclosure (9.58%), medication adherence (8.73%), and responsibility (6.63%). CFA on the final 24-item version of the TxEQ revealed that the resulting model was a good fit for the Study 2 data (RMSEA = 0.08, pclose =.005). CONCLUSIONS: The TxEQ has potential application as a measure in the area of transplantation research. CFA demonstrated that the factor structure of the TxEQ is consistent across different renal transplant out-patients populations. Further research is currently in progress to assess other groups of transplant recipients and to examine its relationship to other measures.

The Satisfaction with Information about Medicines Scale (SIMS): a new measurement tool for audit and research

OBJECTIVE

To develop and examine the psychometric properties of the Satisfaction with Information about Medicines Scale (SIMS), a new 17-item tool designed to assess the extent to which patients feel they have received enough information about prescribed medicines.

METHODS

Patients from eight diagnostic categories were recruited at hospitals in London and Brighton and completed the SIMS questionnaire during hospital admission or attendance at outpatient clinic appointments. The SIMS was evaluated in terms of its ease of use, internal consistency, test-retest reliability, and criterion related validity using existing self-report measures of adherence and patient beliefs about medicines.

RESULTS

The SIMS was well accepted by patients in a variety of clinical settings and showed satisfactory internal consistency and test-retest reliability. As predicted, higher levels of satisfaction with medicines information were associated with higher levels of reported adherence, and lower levels of satisfaction were associated with stronger concerns about the potential adverse effects of medicines, providing evidence of criterion related validity.

CONCLUSION

The SIMS performed well on a number of psychometric indicators and shows promise as a tool for audit (measuring patients' satisfaction with information about their prescribed medicines), research (evaluating current or new forms of information provision), and clinical practice (identifying the information needs of individual patients and as an aid to planning medicine related consultations).

The Satisfaction with Information about Medicines Scale (SIMS): a new measurement tool for audit and research

OBJECTIVE

To develop and examine the psychometric properties of the Satisfaction with Information about Medicines Scale (SIMS), a new 17-item tool designed to assess the extent to which patients feel they have received enough information about prescribed medicines.

METHODS

Patients from eight diagnostic categories were recruited at hospitals in London and Brighton and completed the SIMS questionnaire during hospital admission or attendance at outpatient clinic appointments. The SIMS was evaluated in terms of its ease of use, internal consistency, test-retest reliability, and criterion related validity using existing self-report measures of adherence and patient beliefs about medicines.

RESULTS

The SIMS was well accepted by patients in a variety of clinical settings and showed satisfactory internal consistency and test-retest reliability. As predicted, higher levels of satisfaction with medicines information were associated with higher levels of reported adherence, and lower levels of satisfaction were associated with stronger concerns about the potential adverse effects of medicines, providing evidence of criterion related validity.

CONCLUSION

The SIMS performed well on a number of psychometric indicators and shows promise as a tool for audit (measuring patients' satisfaction with information about their prescribed medicines), research (evaluating current or new forms of information provision), and clinical practice (identifying the information needs of individual patients and as an aid to planning medicine related consultations).

Adherence to antiretroviral therapy: appropriate use of self-reporting in clinical practice

PURPOSE

This study investigated the factors that may affect adherence to antiretroviral therapy in people with HIV infection and compared the use of three self-report tools to determine client adherence.

METHOD

A descriptive, cross-sectional study of 260 HIV-infected clients attending nine HIV outpatient centers in England was conducted using researcher-administered instruments. Self-reports of adherence were assessed using the Morisky Medication Adherence Scale (MMAS), Reported Adherence to Medication Scale (RAM), and the Patient Adjustment to Medication Scale (PAM).

RESULTS

Univariate analysis of clients' self-reports indicated a number of associations with adherence. Significant associations with less adherent behavior identified by two or more self-report tools were the reported use of recreational drugs, p =.001; living alone, p =.041; feeling depressed, p =.02; being influenced by the media, p =.037; and lack of a close confidant, p =.037. Greater adherence was associated with clients reporting a positive mental attitude to HIV infection, p =.038. Principal component analysis (PCA) of each self-report tool identified two well-recognized constructs: intentional nonadherence and unintentional nonadherence. In addition, a third construct of following instructions was identified from PAM, a scale developed by the authors. Subsequent regression analysis failed to confirm the associations with adherence suggested by the univariate analysis.

CONCLUSION

This study suggests that the design and use of self-report tools to identify client's adherence to complex antiretroviral regimens may need to measure individual constructs of adherence to accurately assess adherence behavior.

Barriers to optimum management of heart failure by general practitioners

BACKGROUND

Published research offers clear pointers to the management of heart failure; however, the evidence for implementation into practice is sub-optimal.

AIM

To identify the salient barriers to adopting evidence-based management of heart failure in the community.

METHOD

Structured interviews were used to elicit the views of a stratified sample of 100 general practitioners (GPs) about the diagnosis and treatment of heart failure. Responses to three heart failure case scenarios provided an indication of the degree to which GPs' knowledge of heart failure and trial results might be applied to diagnosis and treatment intentions.

RESULTS

Participants were generally well aware of clinical trials that showed that prognosis could be improved by treatment, but trial results appeared to have little influence on treatment intentions in the three case scenarios. The major barriers to optimum management were the difficulties of differential diagnosis and the perceived properties of angiotensin-converting enzyme inhibitors (ACE-I) relative to diuretics. In the case scenarios, less than 30% reported that they would undertake basic investigations, such as chest X-ray or haemoglobin, or prescribe ACE-I. Over 70% perceived diuretics to be a useful diagnostic tool. The most frequent reasons for not prescribing ACE-I were the perceived inconvenience and risks of adverse effects (41%) and the view that most patients can be managed successfully on diuretics alone (27%). Over two-thirds of the sample were dissatisfied with the quality of information accompanying heart failure patients discharged from hospital.

CONCLUSION

Facilitating evidence-based management of heart failure in the community requires further support for GPs in the form of additional training in the diagnosis of heart failure and the optimum use of both ACE-I and diuretics, and by improved communication between GPs and hospital doctors on a case-by-case basis.

Outbreak of sporotrichosis among tree nursery workers

In spring 1994, an outbreak of sporotrichosis occurred at a tree nursery in Florida; 9 (14%) of 65 workers involved in production of sphagnum moss topiaries developed lymphocutaneous sporotrichosis. A cohort study of all 65 employees was conducted to identify risk factors for sporotrichosis, and an environmental investigation was done. The risk of sporotrichosis increased significantly with the duration of working with sphagnum moss (P < .05), in particular with filling topiaries (P < .05), and with having less gardening experience (P < .05). Wearing gloves was protective (P < .005). Sporothrix schenckii was cultured from patients and sphagnum moss used in topiary production. Use of restriction fragment length polymorphism revealed an identical pattern for patient isolates that was different from the patterns of environmental isolates. Physicians should be aware of sporotrichosis in patients with ulcerative skin lesions who have a history of occupational or recreational exposure to sphagnum moss.

Use of pelvic ultrasound to monitor ovarian and uterine maturity in childhood onset anorexia nervosa

This study reports the use of pelvic ultrasound scanning in childhood onset anorexia nervosa. The aim was to determine the weight and weight for height ratio (wt/ht) that would correspond with ovarian and uterine maturity and therefore offer the optimal opportunity for the start or resumption of menstruation. On initial assessment, all children had mean weight, wt/ht, ovarian and uterine volumes significantly below expected. At follow up, half the children had started or resumed menstruation. When compared with those who had persisting amenorrhoea, the recovered children had a significantly higher mean weight (48.4 kg v 43.8 kg), mean wt/ht (96.5% v 87.5%), mean ovarian volume (6.2 ml v 4.9 ml), and mean uterine volume (14.6 ml v 10.8 ml). The study indicates that conventional target weight and wt/ht in anorexia nervosa may be too low to ensure ovarian and uterine maturity, and that pelvic ultrasound, which is well tolerated by this group of children, is a useful addition to their management.

Early abnormalities of retinal dopamine pathways in rats with hereditary retinal dystrophy

The dopaminergic pathway that affects rod-driven horizontal cells has been studied in the Royal College of Surgeons (RCS) rat during the period preceding photoreceptor degeneration (postnatal day 17-24). The experiments were performed by intracellular recording from single horizontal cells in vitro. Horizontal cells from the recessive control animals (postnatal day 17-24) were depolarized by dopamine (10 microM) and hyperpolarized by the D1 antagonist SCH 23,390 (10 microM). In contrast, cells from age-matched dystrophic retinas, though depolarized by dopamine, were unaffected by SCH 23390 (10-100 microM), suggesting a significant reduction in the level of endogenous dopamine release. Histologic examination for catecholaminergic neurons revealed no differences in either the cell number or anatomy between the retinas of the control and dystrophic animals. Furthermore, perfusion of the control retinas with melatonin (500 nM-1 microM) yielded response characteristic of the dystrophic type. In the period preceding degeneration, the RCS retina thus displays a discrete abnormality in dopaminergic pathways, such that there is a gross reduction in endogenous dopamine release below that required to activate D1 receptors. Since melatonin levels have been shown to be high in these retinas, we propose that abnormalities in the dopamine-melatonin systems give rise to an electrophysiologic deficit in the postphotoreceptoral retina of the RCS rat.

Spontaneous firing level distinguishes the effects of NMDA and non-NMDA receptor antagonists on the ganglion cells in the cat retina

Different responses of retinal ganglion cells to iontophoretically applied NMDA receptor antagonists and non-NMDA receptor antagonists were studied in anaesthetized cats. Cells with normal range of spontaneous firing and those with abnormally high spontaneous firing levels showed a different response to these drugs. Both visually driven and spontaneous firing of cells with 'normal' spontaneous firing level were blocked by non-NMDA receptor antagonists, but not by NMDA receptor antagonists which often raised spontaneous firing. In contrast, the responses of cells with abnormally high spontaneous firing level were blocked effectively by NMDA antagonists including MK-801, an NMDA channel blocker, as well as by non-NMDA receptor antagonists. The results suggest that under normal physiological conditions, NMDA receptors which are not involved in synaptic transmission may play a role in reducing the resting discharge level of the retinal ganglion cells. NMDA receptors, however, appear to open ion channels in response to glutamate input when ganglion cells become abnormally depolarized.