Evaluation of environmental features that support breastfeeding: A photovoice study

The United Kingdom (UK) has some of the lowest breastfeeding rates in the world, and Stoke-on-Trent has some of the lowest breastfeeding rates and highest infant mortality rates in the UK. Vicarious experience of formula feeding, formula feeding culture, and a lack of physical environments to support breastfeeding are known barriers to uptake and maintenance. Improving physical environments and increasing the visibility of breastfeeding in public would help to challenge these barriers. This research employs a participatory approach to understand the facilitators and barriers to breastfeeding in public. Nine breastfeeding peer supporters were recruited as co-researcher for a photovoice study. Co-researchers collated images of features in environments which they felt either supported or acted as a barrier to public breastfeeding. An analysis workshop was held to review the data collected and produce collaboratively agreed findings. Various environmental features were highlighted as facilitators to breastfeeding including family rooms, welcoming signage, supportive staff members, and displays of information about breastfeeding. In addition, poorly designed family rooms, lack of inclusivity within breastfeeding spaces, breastfeeding spaces within toilets and a lack of information were barriers to public breastfeeding. This research illustrates that while some environments are well designed to support breastfeeding many others are not. Environments often lack basic provision and/or make token gestures towards breastfeeding support, such as welcome signage, without providing the infrastructure needed to support breastfeeding. More education about breastfeeding friendly spaces and resources for putting this information into practice are needed for environment owners, managers, and policy makers.

Frailty as an indicator of postoperative complications following surgical excision of non-melanoma skin cancer on the head and neck

INTRODUCTION

Non-melanoma skin cancer (NMSC) predominantly affects those aged over 90 years, with 85% of lesions arising on the head and neck, where surgical excision remains the treatment of choice. Frailty is a measure of physiologic age and can be used as a predictor of adverse treatment outcomes. The aim of this study was to determine if the Rockwood Frailty Index is predictive of complications following excision of NMSC.

METHODS

Data were collected prospectively for patients who underwent an excision of a suspected NMSC from the head or neck across a two-month period. Details of the patient, lesion and procedure were recorded alongside ASA grade and Rockwood's Frailty score. Postoperative complications were recorded four weeks later.

RESULTS

There was a total of 125 patients: 74 (60%) male, 51 (40%) female; mean age was 78 (±9.8) years. Of the excised sites, 61% were closed primarily, 26% with a full thickness skin graft (FTSG), 13% with a local flap. Frailty ranged from 1 to 7 (median = 4). ASA ranged from 1 to 4 (median = 3). A total of 21 (17%) patients reported postoperative complications. Within this group, the median frailty and ASA grades were 5 and 3. Both frailty and ASA were positively significantly associated with age (p ≤ 0.001). There was no significant difference between the frailty or ASA grades of patients that experienced complications and those who did not. Patients who had a FTSG were significantly more likely to experience complications (p ≤ 0.05).

CONCLUSIONS

Frailty is not predictive of postoperative complications following excision of NMSC on the head and neck. Postoperative complications are significantly more associated with FTSG.

An Online experiment during the 2020 US-Iran crisis shows that exposure to common enemies can increase political polarization

A longstanding theory indicates that the threat of a common enemy can mitigate conflict between members of rival groups. We tested this hypothesis in a pre-registered experiment where 1670 Republicans and Democrats in the United States were asked to complete an online social learning task with a bot that was labeled as a member of the opposing party. Prior to this task, we exposed respondents to primes about (a) a common enemy (involving Iran and Russia); (b) a patriotic event; or (c) a neutral, apolitical prime. Though we observed no significant differences in the behavior of Democrats as a result of priming, we found that Republicans-and particularly those with very strong conservative views-were significantly less likely to learn from Democrats when primed about a common enemy. Because our study was in the field during the 2020 Iran Crisis, we were able to further evaluate this finding via a natural experiment-Republicans who participated in our study after the crisis were even less influenced by the beliefs of Democrats than those Republicans who participated before this event. These findings indicate common enemies may not reduce inter-group conflict in highly polarized societies, and contribute to a growing number of studies that find evidence of asymmetric political polarization in the United States. We conclude by discussing the implications of these findings for research in social psychology, political conflict, and the rapidly expanding field of computational social science.

Correlation of SARS-CoV2 Viral Growth on Cultures, Ct Values, SARS-CoV-2 Variant and Vaccination Status in Asymptomatic, Pre-Symptomatic and Post-Infection Asymptomatic COVID Patients

Introduction/Objective

COVID-19 large scale immunizations have helped control the infectious spread, but breakthrough infections are still observed and some of these patients remain asymptomatic. In this study, we compared the viral growth characteristics with vaccination status in asymptomatic patients.

Methods/Case Report

We searched our institutional laboratory database for asymptomatic patients infected with delta variant (November-December 2021, n=65) and omicron variant (December 2021, n=68), that were further classified as “truly asymptomatic”, “pre-symptomatic” and “post-infection asymptomatic” based on detailed chart reviews. The patients’ left-over nasopharyngeal swab samples’ cycle threshold values and the recovery of infectious virus in cell culture were compared.

Results (if a Case Study enter NA)

In the delta cohort, out of 65 asymptomatic patients, 36 were truly asymptomatic, 26 presymptomatic and 3 post infection asymptomatic patients. In the omicron cohort, out of 68 asymptomatic patients, 45 were truly asymptomatic and 23 were presymptomatic patients. The vaccination rate was 59% in truly asymptomatic (delta cohort=56%, omicron cohort=62%), 55% in presymptomatic (delta cohort=50%, omicron cohort=61%) and 67% in post-infection patients (delta cohort only). There was no significant difference in the Ct values of truly asymptomatic (mean Ct=21.08), presymptomatic (mean Ct=20.30) and post-infection asymptomatic patients (mean Ct=20.84) in the combined cohort (p=0.78) and in the delta (p=0.95) or omicron (p=0.45) subcohorts. The Ct values were not correlated with the vaccination status of the patients (vaccinated patients mean Ct=20.56, non-vaccinated patients mean Ct=20.16, p=0.68). Samples with positive viral growth on cultures had significantly lower Ct values (mean Ct= 17.16), compared to samples with negative viral culture results (mean Ct= 24.61) (p<0.0001). The viral growth on culture was not associated with the symptom status, SARS-CoV-2 variant type (delta vs omicron) and vaccination status of the patients in the delta and omicron subcohorts.

Conclusion

Our findings show that there is no significant correlation between vaccination status and viral loads and culture results in asymptomatic patients.

A method for campus-wide SARS-CoV-2 surveillance at a large public university

The systematic screening of asymptomatic and pre-symptomatic individuals is a powerful tool for controlling community transmission of infectious disease on college campuses. Faced with a paucity of testing in the beginning of the COVID-19 pandemic, many universities developed molecular diagnostic laboratories focused on SARS-CoV-2 diagnostic testing on campus and in their broader communities. We established the UC Santa Cruz Molecular Diagnostic Lab in early April 2020 and began testing clinical samples just five weeks later. Using a clinically-validated laboratory developed test (LDT) that avoided supply chain constraints, an automated sample pooling and processing workflow, and a custom laboratory information management system (LIMS), we expanded testing from a handful of clinical samples per day to thousands per day with the testing capacity to screen our entire campus population twice per week. In this report we describe the technical, logistical, and regulatory processes that enabled our pop-up lab to scale testing and reporting capacity to thousands of tests per day.

Football-related maxillofacial injuries

Maxillofacial injuries sustained playing sports are becoming increasingly common, and in the UK where football is the most popular team sport, associated maxillofacial injuries are a regular occurrence. This study retrospectively examined data on patients who were referred with facial injuries sustained playing football between 2007 and 2019 (n = 265). Demographics, mechanism of injury, diagnosis, and treatment received were analysed. The mean (SD) age was 25 (11.0) years (range 3-85) and there was a strong male predominance (n = 256, 97% male). Facial fractures were diagnosed in 143 (54%) patients. The most common injury was a midface fracture and the most common mechanism of injury was a clash of heads. Patients with a facial fracture were significantly more likely to have sustained a concurrent head injury (p = 0.006). Those who were elbowed or punched were significantly more likely to have a facial fracture than a soft tissue or dentoalveolar injury (p ≤ 0.05). Players who clashed heads were significantly more likely to have a midface fracture (p ≤ 0.001). In conclusion, football-related maxillofacial injuries predominantly affect young adult males following a clash of heads. An elbow or punch to the face carries a significant risk of facial fracture and concurrent head injury. Therefore, to reduce the percentage of maxillofacial injuries seen in this sport, observed intentional contact between players, using an elbow or fist to the face in particular, must continue to carry the highest sanction.

1456 Back-To-Back Surgeries: A Clinic Case Report Regarding Multiple Complex Spinal Surgeries for Treatment of Multiple Osteochondroma With Histological Conversion to Chondrosarcoma

Background

Multiple Hereditary Osteochondromas [MHO], previously known as multiple hereditary exostoses, is a rare disorder of bone growth, whereby osseous transformation of the cartilage caps within the diaphyses of long bones or flat bones within the skeleton occurs. A significant complication of MHO is the conversion of any present osteochondroma into a malignant chondrosarcoma. Chondrosarcomas are mesenchymal, non-meningothelial tumours and most commonly present with insidious pain, associated neurological deficit by means of impingement of underlying nerves.

Case presentation

We present a clinical case of a 29-year-old female medical student with a background history of multiple hereditary osteochondromas. A previously competitive cross-fitter, she developed the conversion of MHO into a malignant chondrosarcoma. Presenting to outpatient clinic in late 2017, this lady had a 2-year history of lower back pain and an associated palpable lump. An MRI of the thoracolumbar spine demonstrated a large mass arising from the posterior elements of T11 to L2. A biopsy at the time was found to be of benign pathology, most likely in keeping with this patient’s diagnosis of MHO. The patient returned for review in early 2018, where a repeat MRI showed extension of the previously described lesion into the spinal canal at the level of L1 vertebra. This was concerning that this previously identified osteochondroma lesion could be undergoing malignant transformation. The patient went on to have a series of complex spinal surgeries which we will discuss below.

Merkel cell carcinoma of the head and neck in the south-east of England

Merkel cell carcinoma (MCC) is a rare and highly aggressive neuroendocrine malignancy of the skin. Its incidence is increasing with half of cases involving the head and neck. To the best of our knowledge, few large studies have been published in the UK, and to date this is the largest reported series of head and neck MCC. We retrospectively reviewed the outcomes of patients with MCC in three hospitals in the south-east of England over a 12-year period (2008-2019). Diagnosis was based on histological data following biopsy. Overall survival and disease-specific survival were calculated using Kaplan-Meier and log-rank tests. Fifty-eight patients met the inclusion criteria (24 stage I, 22 stage II, 9 stage III, and 3 unclassified). Median disease-free survival was 36 months (95% CI 0 to 77.2) and median overall survival 50 months (95% CI 29.9 to 70). Overall five-year survival was 34.4% (95% CI 17% to 52%) with two-year survival at 62% (95% CI 48% to 76%). Five-year disease-free survival was 26.7% (95% CI 17 to 52%) with two-year disease-free survival at 54% (95% CI 40% to 68%). To date, this is the largest UK based study reporting overall and disease-free survival associated with MCC of the head and neck. Half the patients presented late, and surgery was the mainstay of treatment, augmented by adjuvant radiotherapy. There is a need to better stratify patients at risk of developing metastatic disease, with the use of sentinel lymph node biopsy and positron-emission tomography-computed tomography (PET-CT), as immunotherapy and targeted agents are now available to treat advanced disease.

Subjective functional outcomes in oropharyngeal cancer treated with induction chemotherapy using the MD Anderson Symptom Inventory (MDASI)

OBJECTIVES

Evaluate the use of induction chemotherapy (IC) in oropharyngeal cancer (OPC) and its impact on subjective functional outcomes using a validated MD Anderson Symptom Inventory-Head and Neck (MDASI-HN) survey tool.

METHODS

A single institution retrospective review of OPC patients who received IC, including reasons given for using IC, regimens employed, responses, and patient-reported outcomes (PRO). The latter included pain, distress, dysphagia, xerostomia, and feeding tube placement and dependency. PRO's were assessed using the validated MD Anderson Symptom Inventory-Head and Neck (MDASI-HN) conducted at baseline, during treatment, and at six-month follow up.

RESULTS

One hundred and twenty-five patients were evaluable. They were more likely to have large primary and/or bulky or low neck nodal disease as a reason for IC. A taxane-containing regimen was most common. Primary tumor response was seen in 83.2% and the nodal response in 81.6%. Pain and xerostomia improved with IC, dysphagia was not adversely affected with IC. These symptoms all increased with consolidation chemoradiotherapy (CRT) but returned to baseline by 6 months post treatment. Feeding tube placement did not increase with IC but did with CRT, most patients were no longer feeding tube dependent at 6 months.

CONCLUSION

This retrospective review of subjective functional outcomes, especially swallowing and feeding tube dependency, using the MDASI survey tool in 125 oropharyngeal cancer patients with large primary tumors and/or bulky adenopathy treated predominantly with platinum-taxane based induction chemotherapy showed that such outcomes were not adversely impacted. While not standard, such approach may be beneficial in such patients.

LEVEL OF EVIDENCE

2.

Pyridylphosphinate metal complexes: synthesis, structural characterisation and biological activity

For the first time, a series of 25 pseudo-octahedral pyridylphosphinate metal complexes (Ru, Os, Rh, Ir) has been synthesised and assessed in biological systems. Each metal complex incorporates a pyridylphosphinate ligand, a monodentate halide and a capping η(6)-bound aromatic ligand. Solid- and solution-state analyses of two complexes reveal a structural preference for one of a possible two diastereomers. The metal chlorides hydrolyse rapidly in D2O to form a 1 : 1 equilibrium ratio between the aqua and chloride adducts. The pKa of the aqua adduct depends upon the pyridyl substituent and the metal but has little dependence upon the phosphinate R' group. Toxicity was measured in vitro against non-small cell lung carcinoma H460 cells, with the most potent complexes reporting IC50 values around 50 μM. Binding studies with selected amino acids and nucleobases provide a rationale for the variation in toxicity observed within the series. Finally, an investigation into the ability of the chelating amino acid l-His to displace the phosphinate O-metal bond shows the potential for phosphinate complexes to act as prodrugs that can be activated in the intracellular environment.

Screening for primary aldosteronism using the newly developed IDS-iSYS® automated assay system

BACKGROUND

The recommended approach to screening for primary aldosteronism (PA) in at-risk populations is to determine the ratio of aldosterone concentration (serum (SAC)/plasma (PAC)) to renin measured in plasma as activity (PRA) or concentration (DRC). However, lack of assay standardisation mandates the need for method-specific decision thresholds and clinical validation in the local population.

AIM

The study objective was to establish method-specific aldosterone: renin ratio (ARR) cut-offs for PA in men and women using the IDS-iSYS® assay system (IDS plc).

METHODS

A prospective cohort study design was used. PAC and DRC were measured immunochemically in ethylenediamine-tetraacetic acid (EDTA) plasma on the IDS-iSYS® instrument.

RESULTS

A total of 437 subjects (218 men, 219 women) were recruited including: healthy normotensive volunteers (n=266) and women taking the oral contraceptive pill (OCP; n=15); patients with essential hypertension (EH; n=128); confirmed PA (n=16); adrenal cortical carcinoma (ACC; n=3); Addison's disease (AD; n=4) and phaeochromocytoma/paraganglioma (PPGL; n=5). In this population, an ARR cut-off at >37.4 pmol/mIU provided 100% diagnostic sensitivity, 96% specificity and positive likelihood ratio for PA of 23:1. When the ARR decision threshold was stratified according to gender, a cut-off of >26.1 pmol/mIU in men and >113.6 pmol/mIU in women resulted in diagnostic sensitivity and specificity of 100%.

CONCLUSION

This study demonstrates that decision thresholds for PA should not only be method-specific but also gender-specific. However, given the small number of PA patients (n=16), particularly women (n=4), further validation through a prospective study with a larger PA cohort is required before the thresholds presented here could be recommended for routine clinical use.

Young Adult Smokers' Neural Response to Graphic Cigarette Warning Labels

Introduction

The study examined young adult smokers' neural response to graphic warning labels (GWLs) on cigarette packs using functional magnetic resonance imaging (fMRI).

Methods

Nineteen young adult smokers (M age 22.9, 52.6% male, 68.4% non-white, M 4.3 cigarettes/day) completed pre-scan, self-report measures of demographics, cigarette smoking behavior, and nicotine dependence, and an fMRI scanning session. During the scanning session participants viewed cigarette pack images (total 64 stimuli, viewed 4 s each) that varied based on the warning label (graphic or visually occluded control) and pack branding (branded or plain packaging) in an event-related experimental design. Participants reported motivation to quit (MTQ) in response to each image using a push-button control. Whole-brain blood oxygenation level-dependent (BOLD) functional images were acquired during the task.

Results

GWLs produced significantly greater self-reported MTQ than control warnings (p < .001). Imaging data indicate stronger neural activation in response to GWLs than the control warnings at a cluster-corrected threshold p < .001 in medial prefrontal cortex, amygdala, medial temporal lobe, and occipital cortex. There were no significant differences in response to warnings on branded versus plain cigarette packages.

Conclusions

In this sample of young adult smokers, GWLs promoted neural activation in brain regions involved in cognitive and affective decision-making and memory formation and the effects of GWLs did not differ on branded or plain cigarette packaging. These findings complement other recent neuroimaging GWL studies conducted with older adult smokers and with adolescents by demonstrating similar patterns of neural activation in response to GWLs among young adult smokers.

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Novel data on the neurobiological effect of graphic cigarette warning labels (GWLs)

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GWLs produced activation indicating emotional and cognitive decision-making.

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Activation in response to GWLs also indicates memory formation.

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No differences in neural activity for GWLs on branded or plain cigarette packages

Increase in the pharmacological management of Type 2 diabetes with pay-for-performance in primary care in the UK

AIMS

To determine whether the financial incentives for tight glycaemic control, introduced in the UK as part of a pay-for-performance scheme in 2004, increased the rate at which people with newly diagnosed Type 2 diabetes were started on anti-diabetic medication.

METHODS

A secondary analysis of data from the General Practice Research Database for the years 1999-2008 was performed using an interrupted time series analysis of the treatment patterns for people newly diagnosed with Type 2 diabetes (n = 21 197).

RESULTS

Overall, the proportion of people with newly diagnosed diabetes managed without medication 12 months after diagnosis was 47% and after 24 months it was 40%. The annual rate of initiation of pharmacological treatment within 12 months of diagnosis was decreasing before the introduction of the pay-for-performance scheme by 1.2% per year (95% CI -2.0, -0.5%) and increased after the introduction of the scheme by 1.9% per year (95% CI 1.1, 2.7%). The equivalent figures for treatment within 24 months of diagnosis were -1.4% (95% CI -2.1, -0.8%) before the scheme was introduced and 1.6% (95% CI 0.8, 2.3%) after the scheme was introduced.

CONCLUSION

The present study suggests that the introduction of financial incentives in 2004 has effected a change in the management of people newly diagnosed with diabetes. We conclude that a greater proportion of people with newly diagnosed diabetes are being initiated on medication within 1 and 2 years of diagnosis as a result of the introduction of financial incentives for tight glycaemic control.

Small- and intermediate-conductance calcium-activated K+ channels provide different facets of endothelium-dependent hyperpolarization in rat mesenteric artery

Activation of both small-conductance (SKCa) and intermediate-conductance (IKCa) Ca2+-activated K+ channels in endothelial cells leads to vascular smooth muscle hyperpolarization and relaxation in rat mesenteric arteries. The contribution that each endothelial K+ channel type makes to the smooth muscle hyperpolarization is unknown. In the presence of a nitric oxide (NO) synthase inhibitor, ACh evoked endothelium and concentration-dependent smooth muscle hyperpolarization, increasing the resting potential (approx. -53 mV) by around 20 mV at 3 microM. Similar hyperpolarization was evoked with cyclopiazonic acid (10 microM, an inhibitor of sarcoplasmic endoplasmic reticulum calcium ATPase (SERCA)) while 1-EBIO (300 microM, an IKCa activator) only increased the potential by a few millivolts. Hyperpolarization in response to either ACh or CPA was abolished with apamin (50 nM, an SKCa blocker) but was unaltered by 1-[(2-chlorophenyl) diphenylmethyl]-1H-pyrazole (1 microM TRAM-34, an IKCa blocker). During depolarization and contraction in response to phenylephrine (PE), ACh still increased the membrane potential to around -70 mV, but with apamin present the membrane potential only increased just beyond the original resting potential (circa -58 mV). TRAM-34 alone did not affect hyperpolarization to ACh but, in combination with apamin, ACh-evoked hyperpolarization was completely abolished. These data suggest that true endothelium-dependent hyperpolarization of smooth muscle cells in response to ACh is attributable to SKCa channels, whereas IKCa channels play an important role during the ACh-mediated repolarization phase only observed following depolarization.

A phase II/III study comparing intravenous ZD9331 with gemcitabine in patients with pancreatic cancer

ZD9331 is a novel antifolate inhibitor of thymidylate synthase (TS). This multicentre, randomised, phase II/III study compared the efficacy and safety of ZD9331 with gemcitabine in 55 patients with chemonai;ve, locally advanced or metastatic pancreatic cancer. Patients received intravenous (i.v.) ZD9331 (n=30), on days 1 and 8 of a 3-week cycle or i.v. gemcitabine (n=25), once a week for 7 weeks followed by a 1-week rest, then on days 1, 8 and 15 of a 4-week cycle. Objective tumour response and clinical benefit response (CBR) were similar for both groups. More ZD9331 patients were alive at the data cut-off point compared with gemcitabine patients (13 and 8%, respectively). Median survival (152 versus 109 days, respectively) and time to progression (70 versus 58 days, respectively) were longer in the ZD9331 group. Nausea and vomiting (grade 1/2) were the most common toxicities in both groups. These results suggest that, in pancreatic cancer, ZD9331 is equivalent to gemcitabine and may offer a promising alternative to current therapies.

Mortality and rebleeding following Transjugular Intrahepatic Portosystemic Stent Shunt for variceal haemorrhage

The present study investigates clinical factors associated with decreased survival following Transjugular Intrahepatic Portosystemic Stent Shunt (TIPSS). Sixty-seven patients underwent TIPSS for bleeding related to portal hypertension, 42 (63%) on an urgent basis. TIPSS was successfully placed in 65 (97%) patients with no fatal procedural complications. Thirty day mortality was 21%, there being several predictive factors: transfer from another institution, urgency of procedure, sepsis, encephalopathy, higher mean serum bilirubin and low serum albumin. However, using regression analysis, 30 day mortality was predicted independently only by severe liver disease (Child-Pugh C, P= 0.003) and older age (P= 0.003). When stratified by Child-Pugh class, cumulative survival rates at 1 year for class A, B and C were 100, 90 and 34%, respectively. Only three of 25 patient deaths were due to variceal rebleeding. Thirty (46%) patients had a total of 41 rebleeding episodes, with mean time to first rebleed of 4.8 months (range, 3 days-38 months). Cumulative rebleeding rate at 1 year was 25%. Log-rank analysis did not reveal a significant difference in overall survival between rebleeders and non-rebleeders (P= 0.125). When investigated, shunt abnormalities (stenosis, occlusion) were identified in all cases of rebleeding. Our findings confirm TIPSS can be safe and effective in the control of refractory variceal haemorrhage. However, prognosis remains poor for patients with advanced liver disease, particularly if older and in the emergency setting. Vigilant surveillance and high rate of intervention is necessary to maintain shunt patency. Consideration could be given to elective shunt surgery instead of TIPSS for patients with recurrent bleeding and good prognosis liver disease.

Postpartum avulsion of the terminal ileal wall in Crohn's disease

A case of acute perforation of the terminal ileum induced by avulsion of the bowel wall in a segment of acutely inflamed Crohn's disease is presented. This case is unusual in that the avulsion developed after delivery following the rapid retraction of the uterus which had been compressing a small localized perforation and abscess. A review of the literature has failed to demonstrate a similar case report.