Evaluation of the NHS England 'Op COURAGE' High Intensity Service for military veterans with significant mental health problems

INTRODUCTION

In November 2020, The NHS for England launched a pilot High Intensity Service (HIS) programme for treating military veterans complex mental health problems. Seven regional grants were awarded to manage the HIS, including NHS Solent, in South East England. This paper details an evaluation of the HIS, which was conducted from February 2021 to August 2022.

METHODS

This mixed-methods study gained quantitative data from a specifically designed questionnaire that included a number of validated psychometric questionnaires. These were completed by either HIS staff or beneficiaries at entry and exit from the HIS, and qualitative data were gained from semi-structured interviews with the HIS staff.

RESULTS

Data were sourced from 45 pre-questionnaires, 25 post programme questionnaires and 11 interviews. This evaluation identified reductions in situational stressors, symptoms and reported illnesses for veterans in crisis. There were reductions in depression, anxiety and post-traumatic stress disorder following programme exit. Staff reported that there was no notable changes in stress levels which appeared to remain high at programme exit. Staff interviews highlighted the importance of simultaneously understanding the social and psychological needs of veterans in mental health crisis. The benefits of integrating veteran staff members into military veteran health services were identified, demonstrating improvements in education around military culture in civilian services.

CONCLUSIONS

The importance of collaboration between clinical and veteran staff members in veteran health services was noted, demonstrating the positive impact social care provision has on veteran's overall health and well-being. Veteran engagement with the service was advocated as a result of veterans accessing the service feeling understood. This first independent evaluation of the HIS provides a positive reflection, and adds to the limited empirical evidence exploring veteran engagement in health services.

Prevalence and risk factors of suicide and suicidal ideation in veterans who served in the British Armed Forces: a systematic review

INTRODUCTION

Research into the factors resulting in suicide in the military veteran population has yet to reach a consensus. Available research is concentrated on a small number of countries, and there is a lack of consistency with contradictory conclusions. The USA has produced a significant amount of research in a country where suicide is identified as a national health crisis, but in the UK, there is little research regarding veterans from the British Armed Forces.

METHODS

This systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Corresponding literature searches were conducted in PsychINFO, MEDLINE and CINAHL. Articles that discussed suicide, suicidal ideation, prevalence or risk factors among British Armed Forces veterans were eligible for review. A total of 10 articles met the inclusion criteria and were analysed.

RESULTS

Veterans' suicide rates were found to be comparable to those of the general UK population. The method of suicide used was most commonly found to be hanging and strangulation. Firearms was recorded in 2% of suicide cases. Demographic risk factors were often contradictory with some research stating that there was risk in older veterans and some in younger. However, female veterans were found to be at higher risk than female civilians. Those who had deployed on combat operations were at lower risk of suicide, with research finding that veterans who took longer to seek help for mental health (MH) difficulties reported more suicidal ideation.

CONCLUSIONS

Peer-reviewed research publications have revealed that UK veteran suicide prevalence is broadly comparable to the general population while highlighting differences across international armed forces. Veteran demographics, service history, transition and MH have all been identified as potential risk factors of suicide and suicidal ideation. Research has also indicated that female veterans are at higher risk than that of their civilian counterparts due to veterans being predominantly male; this could skew results and requires investigation. Current research is limited and further exploration of suicide prevalence and risk factors in the UK veteran population is required.

Phenotyping Superagers Using Resting-State fMRI

BACKGROUND AND PURPOSE

Superagers are defined as older adults with episodic memory performance similar or superior to that in middle-aged adults. This study aimed to investigate the key differences in discriminative networks and their main nodes between superagers and cognitively average elderly controls. In addition, we sought to explore differences in sensitivity in detecting these functional activities across the networks at 3T and 7T MR imaging fields.

MATERIALS AND METHODS

Fifty-five subjects 80 years of age or older were screened using a detailed neuropsychological protocol, and 31 participants, comprising 14 superagers and 17 cognitively average elderly controls, were included for analysis. Participants underwent resting-state-fMRI at 3T and 7T MR imaging. A prediction classification algorithm using a penalized regression model on the measurements of the network was used to calculate the probabilities of a healthy older adult being a superager. Additionally, ORs quantified the influence of each node across preselected networks.

RESULTS

The key networks that differentiated superagers and elderly controls were the default mode, salience, and language networks. The most discriminative nodes (ORs > 1) in superagers encompassed areas in the precuneus posterior cingulate cortex, prefrontal cortex, temporoparietal junction, temporal pole, extrastriate superior cortex, and insula. The prediction classification model for being a superager showed better performance using the 7T compared with 3T resting-state-fMRI data set.

CONCLUSIONS

Our findings suggest that the functional connectivity in the default mode, salience, and language networks can provide potential imaging biomarkers for predicting superagers. The 7T field holds promise for the most appropriate study setting to accurately detect the functional connectivity patterns in superagers.

Cambridge hybrid closed-loop algorithm in children and adolescents with type 1 diabetes: a multicentre 6-month randomised controlled trial

BACKGROUND

Closed-loop insulin delivery systems have the potential to address suboptimal glucose control in children and adolescents with type 1 diabetes. We compared safety and efficacy of the Cambridge hybrid closed-loop algorithm with usual care over 6 months in this population.

METHODS

In a multicentre, multinational, parallel randomised controlled trial, participants aged 6-18 years using insulin pump therapy were recruited at seven UK and five US paediatric diabetes centres. Key inclusion criteria were diagnosis of type 1 diabetes for at least 12 months, insulin pump therapy for at least 3 months, and screening HbA1c levels between 53 and 86 mmol/mol (7·0-10·0%). Using block randomisation and central randomisation software, we randomly assigned participants to either closed-loop insulin delivery (closed-loop group) or to usual care with insulin pump therapy (control group) for 6 months. Randomisation was stratified at each centre by local baseline HbA1c. The Cambridge closed-loop algorithm running on a smartphone was used with either (1) a modified Medtronic 640G pump, Medtronic Guardian 3 sensor, and Medtronic prototype phone enclosure (FlorenceM configuration), or (2) a Sooil Dana RS pump and Dexcom G6 sensor (CamAPS FX configuration). The primary endpoint was change in HbA1c at 6 months combining data from both configurations. The primary analysis was done in all randomised patients (intention to treat). Trial registration ClinicalTrials.gov, NCT02925299.

FINDINGS

Of 147 people initially screened, 133 participants (mean age 13·0 years [SD 2·8]; 57% female, 43% male) were randomly assigned to either the closed-loop group (n=65) or the control group (n=68). Mean baseline HbA1c was 8·2% (SD 0·7) in the closed-loop group and 8·3% (0·7) in the control group. At 6 months, HbA1c was lower in the closed-loop group than in the control group (between-group difference -3·5 mmol/mol (95% CI -6·5 to -0·5 [-0·32 percentage points, -0·59 to -0·04]; p=0·023). Closed-loop usage was low with FlorenceM due to failing phone enclosures (median 40% [IQR 26-53]), but consistently high with CamAPS FX (93% [88-96]), impacting efficacy. A total of 155 adverse events occurred after randomisation (67 in the closed-loop group, 88 in the control group), including seven severe hypoglycaemia events (four in the closed-loop group, three in the control group), two diabetic ketoacidosis events (both in the closed-loop group), and two non-treatment-related serious adverse events. There were 23 reportable hyperglycaemia events (11 in the closed-loop group, 12 in the control group), which did not meet criteria for diabetic ketoacidosis.

INTERPRETATION

The Cambridge hybrid closed-loop algorithm had an acceptable safety profile, and improved glycaemic control in children and adolescents with type 1 diabetes. To ensure optimal efficacy of the closed-loop system, usage needs to be consistently high, as demonstrated with CamAPS FX.

FUNDING

National Institute of Diabetes and Digestive and Kidney Diseases.

Moving forward in microplastic research: A Norwegian perspective

Given the increasing attention on the occurrence of microplastics in the environment, and the potential environmental threats they pose, there is a need for researchers to move quickly from basic understanding to applied science that supports decision makers in finding feasible mitigation measures and solutions. At the same time, they must provide sufficient, accurate and clear information to the media, public and other relevant groups (e.g., NGOs). Key requirements include systematic and coordinated research efforts to enable evidence-based decision making and to develop efficient policy measures on all scales (national, regional and global). To achieve this, collaboration between key actors is essential and should include researchers from multiple disciplines, policymakers, authorities, civil and industry organizations, and the public. This further requires clear and informative communication processes, and open and continuous dialogues between all actors. Cross-discipline dialogues between researchers should focus on scientific quality and harmonization, defining and accurately communicating the state of knowledge, and prioritization of topics that are critical for both research and policy, with the common goal to establish and update action plans for holistic benefit. In Norway, cross-sectoral collaboration has been fundamental in supporting the national strategy to address plastic pollution. Researchers, stakeholders and the environmental authorities have come together to exchange knowledge, identify knowledge gaps, and set targeted and feasible measures to tackle one of the most challenging aspects of plastic pollution: microplastic. In this article, we present a Norwegian perspective on the state of knowledge on microplastic research efforts. Norway's involvement in international efforts to combat plastic pollution aims at serving as an example of how key actors can collaborate synergistically to share knowledge, address shortcomings, and outline ways forward to address environmental challenges.

Temporal trends of persistent organic pollutants in Arctic marine and freshwater biota

More than 1000 time-series of persistent organic pollutants (POPs) in Arctic biota from marine and freshwater ecosystems some extending back to the beginning of 1980s were analyzed using a robust statistical method. The Arctic area encompassed extended from Alaska, USA in the west to northern Scandinavian in the east, with data gaps for Arctic Russia and Arctic Finland. The aim was to investigate whether temporal trends for different animal groups and matrices were consistent across a larger geographical area. In general, legacy POPs showed decreasing concentrations over the last two to three decades, which were most pronounced for α-HCH and least pronounced for HCB and β-HCH. Few time-series of legacy POPs showed increasing trends and only at sites suspected to be influenced by local source. The brominated flame retardant congener BDE-47 showed a typical trend of increasing concentration up to approximately the mid-2000s followed by a decreasing concentration. A similar trend was found for perfluorooctane sulfonic acid (PFOS). These trends are likely related to the relatively recent introduction of national and international controls of hexa- and hepta-BDE congeners and the voluntary phase-out of PFOS production in the USA in 2000. Hexabromocyclododecane (HBCDD) was the only compound in this study showing a consistent increasing trend. Only 12% of the long-term time-series were able to detect a 5% annual change with a statistical power of 80% at α < 0.05. The remaining 88% of time-series need additional years of data collection before fulfilling these statistical requirements. In the case of the organochlorine long-term time-series, 45% of these would require >20 years monitoring before this requirement would be fulfilled.

Protein Contamination of the Laryngeal Mask Airway and its Relationship to Re-use

The Laryngeal Mask Airway is a reusable device for maintaining the patency of a patient's airway during general anaesthesia. The device can be reused after it has been cleaned and sterilized. Protein contamination of medical instruments is a concern and has been found to occur despite standard sterilization techniques. The reason for the concern relates to the possibility of the transmission of prions and the risk of developing a neurodegenerative disorder such as Creutzveldt-Jacob disease. The purpose of this study was to quantify the amount of protein contamination that occurs, and to relate this to the number of times the Laryngeal Mask Airway has been used. Fifty previously used Classic Laryngeal Masks were collected after routine sterilization and packaging. The devices were immersed in protein detecting stain and then visual inspection performed to assess the degree and distribution of the staining. The researcher was blinded to the number of times the Laryngeal Mask Airway had been used. Linear regression analysis of the degrees of staining of the airway revealed that protein contamination occurs after the first use of the device and this increases with each subsequent use. This finding highlights the concern that the currently used cleaning and sterilization methods do not prevent the accumulation of proteinaceous material on Laryngeal Mask Airways. Consideration should be given to the search for more efficient cleaning and sterilization techniques or the use of disposable devices.

Benefits of introduction of Oncotype DX® testing

INTRODUCTION

Decisions regarding adjuvant chemotherapy in women with oestrogen receptor positive, human epidermal growth factor receptor 2 negative, node negative, early invasive breast cancer are unclear. The Recurrence Score® (RS) from Oncotype DX® (ODX) testing guides decisions based on individual cancer genomics. The aim of this study was to evaluate the impact of introducing ODX results on adjuvant treatment decisions and its potential economic benefits.

METHODS

Patients offered the test were identified from the ODX requesting system. Information on reasons behind chemotherapy treatment decisions were collected from clinical letters and the pathology system. The Nottingham prognostic index (NPI) scores were calculated for each individual patient.

RESULTS

A total of 101 patients were identified as having undergone ODX testing over 21 months. The median age was 57 years (range: 41-72 years), the median NPI was 3.70 (range: 3.40-5.26) and the median RS was 17 (range: 0-59). NPI did not predict the risk category. All of the patients in the high risk group, 35.1% in the intermediate risk group and 5.4% in the low risk group received chemotherapy. The majority of low risk patients who received chemotherapy made a decision prior to the ODX result.

CONCLUSIONS

In our unit, RS aided our decision making regarding adjuvant chemotherapy. Patients with a higher RS were more likely to receive chemotherapy. If NPI had been used alone, more women would have been offered chemotherapy. Good communication with patients prior to testing is important to ensure it is cost effective.

IMPACT: A Generic Tool for Modelling and Simulating Public Health Policy

Background: Populations are under-served by local health policies and management of resources. This partly reflects a lack of realistically complex models to enable appraisal of a wide range of potential options. Rising computing power coupled with advances in machine learning and healthcare information now enables such models to be constructed and executed. However, such models are not generally accessible to public health practitioners who often lack the requisite technical knowledge or skills.

Objectives: To design and develop a system for creating, executing and analysing the results of simulated public health and health-care policy interventions, in ways that are accessible and usable by modellers and policy-makers.

Methods: The system requirements were captured and analysed in parallel with the statistical method development for the simulation engine. From the resulting software requirement specification the system architecture was designed, implemented and tested. A model for Coronary Heart Disease (CHD) was created and validated against empirical data.

Results: The system was successfully used to create and validate the CHD model. The initial validation results show concordance between the simulation results and the empirical data.

Conclusions: We have demonstrated the ability to connect health policy-modellers and policy-makers in a unified system, thereby making population health models easier to share, maintain, reuse and deploy.

Additive Models Reveal Sources of Metals and Organic Pollutants in Norwegian Marine Sediments

We characterized spatial patterns of surface sediment concentrations of seven polychlorinated biphenyls (PCBs), seven polycyclic aromatic hydrocarbons (PAHs), three chlorinated pesticides, and five metals in Norwegian waters and Skagerrak. In total, we analyzed 5036 concentrations of 22 chemical substances that were measured between 1986 and 2014 at 333 sampling sites by means of generalized additive models (GAMs). We found that GAMs with organic carbon content of the sediment and latitude and longitude as co-variates explained as ca. 75% of the variability of the contaminant sediment concentrations. For metals, a predominantly hotspot-driven spatial pattern was found, i.e., we identified historical pollution hotspots (e.g., Sørfjord in western Norway) for mercury, zinc, cadmium, and lead. Highest concentrations of PAHs and PCBs were found close to densely populated and industrialized regions, i.e., in the North Sea and in the Kattegat and Skagerrak. The spatial pattern of the PCBs suggests the secondary and diffuse atmospheric nature of their sources. Atmospheric inputs are the main sources of pollution for most organic chemicals considered, but north of the Arctic circle, we found that concentrations of PAHs increased from south to north most likely related to a combination of coal-eroding bedrock and the biological pump. The knowledge acquired in the present research is essential for developing effective remediation strategies that are consistent with international conventions on pollution control.

Identification of Berenil Target Sites in Plasmid pBR322

Berenil, a minor groove DNA binding molecule, has been extensively used in veterinary medicine. Modeling studies have suggested that berenil binds to A/T rich regions on the DNA and the product of this interaction causes the formation of crosslinks between opposite DNA strands. These crosslinks could potentially inhibit fundamental biological processes including transcription and DNA replication. We had previously used the pBR322 genome as a model system to investigate the role of A/T sequences on berenil activity. We reported that the insertion of poly(dA)poly(dT) sequences into the pBR322 genome causes replication inhibition of the recombinant plasmids when cultures were exposed to berenil. However, we noticed that even in the absence of these sequences the parental plasmid replication was also inhibited, albeit less than the recombinants. This observation led us to the present study were we attempted to identify the location of natural berenil target sites in the pBR322 genome. Through a combination of deletion analysis, recombinant DNA and a replication assay we uncovered a 378 bp DNA fragment that has all the hallmarks of a berenil target site. A recombinant plasmid lacking this region is more refractive to the drug than the parental plasmid, and another variant containing and extra copy of this region increases the susceptibility of the plasmid towards berenil. The 378 bp region is about 60% A/T rich and contains about 21 potential berenil binding sites.

Apneic Seizures in Infants: Role of Continuous EEG Monitoring

Respiratory compromise is not uncommon in epileptic seizures. However, pure apneic seizures are rare. In this study, we report 10 children who presented with pure apneic seizures. All the children were admitted because of apneic events. Seizures were also considered in the differential diagnosis. Six patients had nonspecific findings consisting of multifocal interictal epileptiform activity with no event correlation. Continuous 24–72 hours electroencephalogram (EEG) was performed in all patients to rule out apneic seizures. Ictal EEG showed high correlation with the apneic episodes, confirming the diagnosis of apneic seizures. Our study suggests that continuous EEG monitoring is essential in the diagnosis and treatment of apneic seizures.

Development and testing of a prototype tool for integrated assessment of chemical status in marine environments

We report the development and application of a prototype tool for integrated assessment of chemical status in aquatic environments based on substance- and matrix-specific environmental assessment criteria (thresholds). The Chemical Status Assessment Tool (CHASE) integrates data on hazardous substances in water, sediments and biota as well as bio-effect indicators and is based on a substance- or bio-effect-specific calculation of a 'contamination ratio' being the ratio between an observed concentration and a threshold value. Values <1.0 indicate areas potentially 'unaffected', while values >1.0 indicate areas potentially 'affected'. These ratios are combined within matrices, i.e. for water, sediment and biota and for biological effects. The overall assessment used a 'one out, all out principle' with regard to each matrix. The CHASE tool was tested in the Baltic Sea and the North Sea in 376 assessment units. In the former, the chemical status was >1.0 in practically all areas indicating that all areas assessed were potentially affected. The North Sea included areas classified as unaffected or affected. The CHASE tool can in combination with temporal trend assessments of individual substances be advantageous for use in remedial action plans and, in particular, for the science-based evaluation of the status and for determining which specific substances are responsible for a status as potentially affected.

Quantifying the Burden of Hospital-Acquired Bloodstream Infection in Children in England by Estimating Excess Length of Hospital Stay and Mortality Using a Multistate Analysis of Linked, Routinely Collected Data

BACKGROUND

Hospital-acquired bloodstream infection (HA-BSI) is associated with substantial morbidity, mortality, and healthcare costs in all patient populations. Young children have been shown to have a high rate of healthcare-associated infections compared with the adult population. We aimed to quantify the excess mortality and length of stay in pediatric patients from HA-BSI.

METHODS

We analyzed data collected retrospectively from a probabilistically linked national database of pediatric (aged 1 month-18 years) in-patients with a microbiologically confirmed HA-BSI in England between January and March 2009. A time-dependent Cox regression model was fit to determine the presence of any effect. Furthermore, a multistate model, adjusted for the time to onset of HA-BSI, was used to compare outcomes in patients with HA-BSI to those without HA-BSI. We further adjusted for patients' characteristics as recorded in hospital admission data.

RESULTS

The dataset comprised 333 605 patients, with 214 cases of HA-BSI. After adjustment for time to HA-BSI and comorbidities, the hazard for discharge (dead or alive) from hospital for patients with HA-BSI was 0.9 times (95% confidence interval [CI], .8-1.1) that of noninfected patients. Excess length of stay associated with all-cause HA-BSI was 1.6 days (95% CI, .2-3.0), although this duration varied by pathogen. Patients with HA-BSI had a 3.6 (95% CI, 1.3-10.4) times higher hazard for in-hospital death than noninfected patients.

CONCLUSIONS

Hospital-acquired bloodstream infection increased the length of stay and mortality of pediatric inpatients. The results of this study provide an evidence base to judge the health and economic impact of programs to prevent and control HA-BSI in children.

Serum antibody responses to pneumococcal colonization in the first 2 years of life: results from an SE Asian longitudinal cohort study

Assessment of antibody responses to pneumococcal colonization in early childhood may aid our understanding of protection and inform vaccine antigen selection. Serum samples were collected from mother-infant pairs during a longitudinal pneumococcal colonization study in Burmese refugees. Maternal and cord sera were collected at birth and infants were bled monthly (1–24 months of age). Nasopharyngeal swabs were taken monthly to detect colonization. Serum IgG titres to 27 pneumococcal protein antigens were measured in 2624 sera and IgG to dominant serotypes (6B, 14, 19F, 19A and 23F) were quantified in 864 infant sera. Antibodies to all protein antigens were detectable in maternal sera. Titres to four proteins (LytB, PcpA, PhtD and PhtE) were significantly higher in mothers colonized by pneumococci at delivery. Maternally-derived antibodies to PiuA and Spr0096 were associated with delayed pneumococcal acquisition in infants in univariate, but not multivariate models. Controlling for infant age and previous homologous serotype exposure, nasopharyngeal acquisition of serotypes 19A, 23F, 14 or 19F was associated significantly with a ≥2-fold antibody response to the homologous capsule (OR 12.84, 7.52, 6.52, 5.33; p <0.05). Acquisition of pneumococcal serotypes in the nasopharynx of infants was not significantly associated with a ≥2-fold rise in antibodies to any of the protein antigens studied. In conclusion, nasopharyngeal colonization in young children resulted in demonstrable serum IgG responses to pneumococcal capsules and surface/virulence proteins. However, the relationship between serum IgG and the prevention of, or response to, pneumococcal nasopharyngeal colonization remains complex. Mechanisms other than serum IgG are likely to have a role but are currently poorly understood.

Malignant uveal schwannoma with peripheral nerve extension in a 12-week-old color-dilute Labrador Retriever

The formalin-fixed, amber-colored right globe from a 12-week-old female silver Labrador Retriever dog was submitted to the Comparative Ocular Pathology Laboratory of Wisconsin for light microscopic evaluation. The clinical history described a collapsed anterior chamber and multifocal nodular lesions in the peripheral iris. Histologically, immunohistochemically, and ultrastructurally, the uveal mass was consistent with a malignant schwannoma; there was extension along peripheral nerves within the sclera. The signalment and behavior of the neoplasm distinguish it from the uveal schwannoma of blue-eyed dogs and bear some resemblance to the ocular lesions in human neurofibromatosis. The dilute color mutation may contribute to the cause. Six weeks later, the dog did not develop any additional masses.

Serum antibody responses to pneumococcal colonization in the first 2 years of life: results from an SE Asian longitudinal cohort study

Assessment of antibody responses to pneumococcal colonization in early childhood may aid our understanding of protection and inform vaccine antigen selection. Serum samples were collected from mother-infant pairs during a longitudinal pneumococcal colonization study in Burmese refugees. Maternal and cord sera were collected at birth and infants were bled monthly (1–24 months of age). Nasopharyngeal swabs were taken monthly to detect colonization. Serum IgG titres to 27 pneumococcal protein antigens were measured in 2624 sera and IgG to dominant serotypes (6B, 14, 19F, 19A and 23F) were quantified in 864 infant sera. Antibodies to all protein antigens were detect ablein maternal sera. Titres to four proteins (LytB, PcpA, PhtD and PhtE) were significantly higher in mothers colonized by pneumococci at delivery. Maternally-derived antibodies to PiuA and Spr0096 were associated with delayed pneumococcal acquisition in infants in univariate,but not multivariate models. Controlling for infant age and previous homologous serotype exposure, nasopharyngeal acquisition of serotypes 19A, 23F, 14 or 19F was associated significantly with a ≥2-fold antibody response to the homologous capsule (OR 12.84, 7.52,6.52, 5.33; p <0.05). Acquisition of pneumococcal serotypes in the nasopharynx of infants was not significantly associated with a ≥2-fold rise in antibodies to any of the protein antigens studied. In conclusion, nasopharyngeal colonization in young children resulted in demonstrable serum IgG responses to pneumococcal capsules and surface/virulence proteins. However, the relationship between serum IgG and the prevention of, or response to, pneumococcal nasopharyngeal colonization remains complex. Mechanisms other than serum IgG are likely to have a role but are currently poorly understood.

Severe acute mountain sickness, brain natriuretic peptide and NT-proBNP in humans

AIM

To examine the response of brain natriuretic peptide (BNP) and NT-proBNP to high altitude (HA) both at rest and following exercise.

METHODS

We measured NT-proBNP and BNP and Lake Louise (LL) acute mountain sickness (AMS) scores in 20 subjects at rest in Kathmandu (Kat; 1300 m), following exercise and at rest at 4270 and 5150 m.

RESULTS

BNP and NT-proBNP (pg ml(-1) , mean ± SEM) rose significantly from Kat (9.2 ± 2 and 36.9 ± 6.6, respectively) to arrival at 4270 m after exercise (16.6 ± 4 and 152 ± 56.1, P=0.008 and P<0.001, respectively) and remained elevated the next morning at rest (28.9 ± 9 and 207.4 ± 65.1, P = 0.004 and P<0.001 respectively). At 5150, immediately following ascent/descent to 5643 m, BNP and NT-proBNP were 32.3 ± 8.8 and 301.1 ± 96.3 (P=0.003 and P<0.001 vs. Kat, respectively) and at rest the following morning were 33.3 ± 9.7 and 258.9 ± 89.5 (P=0.008 and P=0.001 vs. Kat respectively). NT-proBNP and BNP correlated strongly at 5150 m (ρ 0.905, P<0.001 and ρ 0.914, P<0.001 for resting and post-exercise samples respectively). At 5150 m, BNP levels were significantly higher among the four subjects with severe (LL score>6) AMS (58.4 ± 18.7) compared with those without (BNP 22.7 ± 8.6, P=0.048). There were significant correlations between change in body water from baseline to 5150 m with both BNP and NT-proBNP (ρ 0.77, P=0.001, ρ 0.745, P=0.002 respectively).

CONCLUSION

In conclusion, these data suggest that BNP and NT-proBNP increase with ascent to HA both after exercise and at rest. We also report the novel finding that BNP is significantly greater in those with severe AMS at 5150 m.

Characterization of polymorphic states in energetic samples of 1,3,5-trinitro-1,3,5-triazine (RDX) fabricated using drop-on-demand inkjet technology

The United States Army and the first responder community are evaluating optical detection systems for the trace detection of hazardous energetic materials. Fielded detection systems must be evaluated with the appropriate material concentrations to accurately identify the residue in theater. Trace levels of energetic materials have been observed in mutable polymorphic phases and, therefore, the systems being evaluated must be able to detect and accurately identify variant sample phases observed in spectral data. In this work, we report on the novel application of drop-on-demand technology for the fabrication of standardized trace 1,3,5-trinitro-1,3,5-triazine (RDX) samples. The drop-on-demand sample fabrication technique is compared both visually and spectrally to the more commonly used drop-and-dry technique. As the drop-on-demand technique allows for the fabrication of trace level hazard materials, concerted efforts focused on characterization of the polymorphic phase changes observed with low concentrations of RDX commonly used in drop-on-demand processing. This information is important when evaluating optical detection technologies using samples prepared with a drop-on-demand inkjet system, as the technology may be "trained" to detect the common bulk α phase of the explosive based on its spectral features but fall short in positively detecting a trace quantity of RDX (β-phase). We report the polymorphic shifts observed between α- and β-phases of this energetic material and discuss the conditions leading to the favoring of one phase over the other.

A national survey of acute hospitals in England on their current practice in the use of femoral nerve blocks when splinting femoral fractures

INTRODUCTION

Missed compartment syndrome can have devastating long-term impact on a patient's function. Femoral fracture has been reported in 52-58% of acute thigh compartment syndromes in the existing literature. Time to diagnosis of compartment syndrome is cited as a key determinant of outcome. Use of femoral nerve blocks in splinting of femoral fractures may mask signs of early compartment syndrome. We present the attitudes of emergency department and orthopaedic staff in NHS trusts in England with regard to this issue.

METHODS AND MATERIALS

Survey of all 171 acute hospitals in the United Kingdom accepting trauma admissions. On-call middle grade doctors in emergency and orthopaedic department completed a telephone survey into departmental protocol and their experience of femoral nerve blocks for lower limb fractures.

RESULTS

Middle grades from all 171 trusts completed the survey (100% response rate). 54 emergency departments (30.8%) had a protocol for the use of femoral nerve blocks. Middle grades in the ED reported using a nerve block routinely in 95 hospitals (54%) with 63 using a long-acting and 32 a short-acting agent. Of those that did not 70% (n=53) felt they were unnecessary, 21% (n=16) were not confident in the technique and 9% (n=7) had worries over compartment syndrome. 68% would be worried about compartment syndrome in high-energy injuries. Orthopaedic departmental protocols for nerve block use were reported in 16 trusts (9%). 45 orthopaedic middle grades (26%) indicated that they would use them routinely with 17 using long-acting and 28 using short-acting agents. 59.5% (n=75) of orthopaedic middle grades felt nerve blocks were unnecessary, whilst 22% (n=28) had worries about compartment syndrome and 18% (n=23) were not confident with the technique. 77% orthopaedic middle grades would be more worried about compartment syndrome in high energy injuries.

CONCLUSION

Femoral nerve block is an under-utilised, effective mode of analgesia following femoral fractures. There is a low risk of associated compartment syndrome, but clinicians should be especially vigilant in high-energy injuries. We recommend that all acute trusts receiving trauma should have a protocol for the use of femoral nerve blocks agreed by the emergency and orthopaedic departments.

Temporal trends of Hg in Arctic biota, an update

A statistically robust method was applied to 83 time-series of mercury in Arctic biota from marine, freshwater and terrestrial ecosystems with the purpose of generating a 'meta-analysis' of temporal trend data collected over the past two to three decades, mostly under the auspices of the Arctic Monitoring and Assessment Program (AMAP). Sampling locations ranged from Alaska in the west to northern Scandinavia in the east. Information from recently published temporal trend studies was tabulated to supplement the results of the statistical analyses. No generally consistent trend was evident across tissues and species from the circumpolar Arctic during the last 30years or so. However, there was a clear west-to-east gradient in the occurrence of recent increasing Hg trends, with larger numbers and a higher proportion of biotic datasets in the Canadian and Greenland region of the Arctic showing significant increases than in the North Atlantic Arctic. Most of the increasing datasets were for marine species, especially marine mammals. A total of 16 (19%) out of the 83 time-series could be classified as "adequate", where adequate is defined as the number of actual monitoring years in a time-series being equal to or greater than the number of years of sampling required to detect a 5% annual change in Hg concentrations, with a significance level of P<0.05 and 80% statistical power. At the time of the previous AMAP Assessment, only 10% of the Hg time-series were deemed adequate. If an additional 5years of data were to be added to the current set of time-series, it is predicted that 53% of time-series would become adequate.

Two-stage revision for prosthetic joint infection: predictors of outcome and the role of reimplantation microbiology

Objectives

We describe rates of success for two-stage revision of prosthetic joint infection (PJI), including data on reimplantation microbiology.

Methods

We retrospectively collected data from all the cases of PJI that were managed with two-stage revision over a 4 year period. Patients were managed with an antibiotic-free period before reimplantation, in order to confirm, clinically and microbiologically, that infection was successfully treated.

Results

One hundred and fifty-two cases were identified. The overall success rate (i.e. retention of the prosthesis over 5.75 years of follow-up) was 83%, but was 89% for first revisions and 73% for re-revisions [hazard ratio = 2.9, 95% confidence interval (CI) 1.2–7.4, P = 0.023]. Reimplantation microbiology was frequently positive (14%), but did not predict outcome (hazard ratio = 1.3, 95% CI 0.4–3.7, P = 0.6). Furthermore, most unplanned debridements following the first stage were carried out before antibiotics were stopped (25 versus 2 debridements).

Conclusions

We did not identify evidence supporting the use of an antibiotic-free period before reimplantation and routine reimplantation microbiology. Re-revision was associated with a significantly worse outcome.

A randomized controlled trial evaluating a topical treatment for chemotherapy-induced neuropathy: NCCTG trial N06CA

9531

Background: Chemotherapy induced peripheral neuropathy (CIPN) is a prevalent dose limiting toxicity for several important cancer treatment agents. CIPN can impair function and cause distress. There are no proven pharmacologic treatments for established CIPN currently. This double blind randomized placebo controlled trial evaluated a compounded topical gel for this problem. The novelty of this treatment is that it might incorporate several agents with different mechanisms of action to provide relief locally without negative systemic effects. Methods: Patients with CIPN (rated ≥4 out of 10) for at least one month, related to previous and/or concurrent exposure to neurotoxic agents, were randomized to baclofen 10 mg, amitriptyline HCL 40 mg and ketamine 20 mg in a pluronic lecithin organogel (BAK-PLO) vs placebo (PLO) to determine its effect on numbness, tingling, pain, and motor function. Exclusion criteria included other causes and/or current treatment for peripheral neuropathy. The primary endpoint was the baseline adjusted sensory subscale of the EORTC QLQ-CIPN20, at 4 weeks. Results: Between February and May 2008, 208 patients were enrolled onto this trial. Four week data are shown in the table below, higher numbers being better. The percentage of patients that had improvements of at least 10, on a 100 point scale, in the motor subscale was statistically significantly higher in the BAK-PLO arm, p=.04. There were no unwanted toxicities associated with the BAK-PLO that were significantly different from placebo and no evidence of CNS or systemic toxicity. Conclusions: Topical treatment with BAK-PLO appears to moderately improve symptoms of CIPN. This topical gel was well tolerated without systemic side effects.

[Table: see text]

No significant financial relationships to disclose.

Relationships between physiology, tissue contaminants, and biomarker responses in Atlantic cod (Gadus morhua L.)

It is generally assumed that there should be some relationship between tissue residues of contaminants and related biomarker responses in the same individual, with a possible additional modulation through physiological processes. The main basis for such assumptions originated from experimental studies, but it has been less easy to detect and quantify any such relationships in field-collected material. The aim of the current study was to clarify whether the responses of selected biomarkers (cytochrome P-4501A [CYP1A], delta-aminolevulinic acid dehydratase [ALA-D], metallothionein [MT]) could be correlated with physiological parameters and/or contaminant levels. Atlantic cod (Gadus morhua L.) were sampled over a decade at a number of locations along the Norwegian coast. The locations included both polluted and reference areas. In addition to contaminant-related responses (biomarkers), physiological characteristics were registered for each individual and the contaminant load determined. There were clear relationships between responses in all three biomarkers and tissue contaminants, but additional factors such as age or size and liver lipid or liver somatic index also contributed in multiple-regression models. The results indicated that responses in all three biomarkers reflected relevant, contaminant-related processes in the cod even though none of them provided a simple separation between polluted and pristine locations.

Healthcare issues of detainees in police custody in London, UK

Little is known about the general healthcare needs of detainees in police custody. The aims of this study were to: determine the level of general health issues, diseases and/or pathology for detainees in police custody, and to determine how well those general health issues, diseases and/or pathology are being managed. This was done by a detailed analysis of healthcare issues of a cohort of detainees and reviewing intended and prescribed medication needs with current medication availability. In August 2007, a prospective detailed, anonymised, structured questionnaire survey was undertaken of 201 detainees in police custody in London, UK. Of these 83.6% consented to participate in the study. 85.1% of subjects were male; mean age was 33.9 years; 70.8% had English as a first language; 13.7% were of no fixed abode; 70.2% were registered with a general practitioner (primary care physician); 25% were already in contact with other healthcare teams; 7.1% had previously been sectioned under the Mental Health Act 1983; 16.7% had previously intentionally self-injured; 33.9% were dependent on heroin, 33.9% on crack cocaine; 25% on alcohol, 16.6% on benzodiazepines and 63.1% on cigarettes. 56% of subjects had active medical conditions; of those with active medical conditions 74% were prescribed medication for those medical conditions; only 3/70 had their medication available. 28/70 were not taking medication regularly, and many were not taking it at all. Three subjects who had deep vein thromboses were not taking their prescribed anticoagulants and six subjects with severe mental health issues were not taking their anti-psychotic medication. Mental health issues and depression predominated, but there was a very large range of mixed diseases and pathology. Asthma, epilepsy, diabetes, deep vein thrombosis, pulmonary embolism, hepatitis, and hypertension were all represented. The study has achieved its aims and has also shown that--in part because of the chaotic lifestyle of many detainees--appropriate care was not being rendered, thereby, putting both detainee, and potentially others coming into contact with them, at risk.

Chick embryo lethal orphan virus can be polymer-coated and retargeted to infect mammalian cells

Non-human adenovirus vectors have attractive immunological properties for gene therapy but are frequently restricted by inefficient transduction of human target cells. Using chicken embryo lethal orphan (CELO) virus, we employed a nongenetic mechanism of polymer coating and retargeting with basic fibroblast growth factor (bFGF-pc-CELOluc), a strategy that permits efficient tropism modification of human adenovirus. bFGF-pc-CELOluc showed efficient uptake and transgene expression in chick embryo fibroblasts (CEF), and increased levels of binding and internalization in a variety of human cell lines. Transgene expression was also greater than unmodified CELOluc in PC-3 human prostate cells, although the specific activity (RLU per internalized viral genome) was decreased. In CEF, the specific activity of bFGF-pc-CELOluc was considerably higher than in the human prostate cell line PC-3. Retargeted virus was fully resistant to inhibition by human serum with known adenovirus-neutralizing activity in vitro, while in mice CELOluc was cleared less rapidly from the blood than Adluc following i.v. administration in the presence of adenovirus neutralizing serum. Polymer coating and retargeting with bFGF further reduced rates of clearance for both viruses, suggesting protection against both neutralizing and opsonizing factors. The data indicate that CELO virus may be retargeted to infect human cells via alternative, potentially disease-specific, receptors and resist the effects of pre-existing humoral immunity.

Radionuclides in fruit systems: a review of experimental studies

Existing information on processes and parameters analysed in experimental studies on fruits was reviewed at the inception of the activities of the IAEA BIOMASS Fruits Working Group. Additional information on experimental studies, collected during the activities of the Group and not included in the Review, is presented and discussed in this paper. Studies on deposition of (14)CO2, CO(35)S and (3)H2O in the gas phase to apple, raspberry, strawberry and blackcurrant have filled gaps in knowledge of uptake of gaseous pollutants in fruit plants, quantifying processes of deposition, translocation and carry-over between seasons. Measurements over a period of six years on vine plants contaminated via leaves and soil by dry deposition of 137Cs and 90Sr have improved knowledge of the processes of direct deposition to fruit, translocation and carry-over of radionuclides from year to year. Additional information is given on soil to fruit transfer of U, Th and Pb for apple and mandarin grown under intensive agricultural conditions.

Modelling and experimental studies on the transfer of radionuclides to fruit

Although fruit is an important component of the diet, the extent to which it contributes to radiological exposure remains unclear, partially as a consequence of uncertainties in models and data used to assess transfer of radionuclides in the food chain. A Fruits Working Group operated as part of the IAEA BIOMASS (BIOsphere Modelling and ASSessment) programme from 1997 to 2000, with the aim of improving the robustness of the models that are used for radiological assessment. The Group completed a number of modelling and experimental activities including: (i) a review of experimental, field and modelling information on the transfer of radionuclides to fruit; (ii) discussion of recently completed or ongoing experimental studies; (iii) development of a database on the transfer of radionuclides to fruit; (iv) development of a conceptual model for fruit and (v) two model intercomparison studies and a model validation study. The Group achieved significant advances in understanding the processes involved in transfer of radionuclides to fruit. The work demonstrated that further experimental and modelling studies are required to ensure that the current generation of models can be applied to a wide range of scenarios.

Crystal structure of an aldehyde reductase Y50F mutant-NADP complex and its implications for substrate binding

Pig aldehyde reductase containing the active site mutation tyrosine(50) to phenylalanine has been crystallized in the presence of the cofactor NADP(H) to a resolution of 2.2 A. This structure clearly shows loss of the tyrosine hydroxyl group and no other significant perturbations compared with previously determined structures. The mutant binds cofactor (both oxidized and reduced) more tightly than the wild-type enzyme but shows a complete lack of binding of the aldehyde reductase inhibitor barbitone, as determined by fluorescence titrations. Numerous attempts at preparing a ternary complex with a range of small aldehyde substrates were unsuccessful. This result, in addition to the inability of the mutant protein to bind the inhibitor, provides strong evidence for the proposal that the tyrosine hydroxyl group is essential for substrate binding in addition to catalysis.

Molecular basis for immunoglobulin M specificity to epitopes in Cryptococcus neoformans polysaccharide that elicit protective and nonprotective antibodies

The protective efficacy of antibodies (Abs) to Cryptococcus neoformans glucuronoxylomannan (GXM) is dependent on Ab fine specificity. Two clonally related immunoglobulin M monoclonal Abs (MAbs) (12A1 and 13F1) differ in fine specificity and protective efficacy, presumably due to variable (V)-region sequence differences resulting from somatic mutations. MAb 12A1 is protective and produces annular immunofluorescence (IF) on serotype D C. neoformans, while MAb 13F1 is not protective and produces punctate IF. To determine the Ab molecular determinants responsible for the IF pattern, site-directed mutagenesis of the MAb 12A1 heavy-chain V region (V(H)) was followed by serological and functional studies of the various mutants. Changing two selected amino acids in the 12A1 V(H) binding cavity to the corresponding residues in the 13F1 V(H) altered the IF pattern from annular to punctate, reduced opsonic efficacy, and abolished recognition by an anti-idiotypic Ab. Analysis of the binding of the various mutants to peptide mimetics revealed that different amino acids were responsible for GXM binding and peptide specificity. The results suggest that V-region motifs associated with annular binding and opsonic activity may be predictive of Ab efficacy against C. neoformans. This has important implications for immunotherapy and vaccine design that are reinforced by the finding that GXM and peptide reactivities are determined by different amino acid residues.

Access to genitourinary medicine clinics in the United Kingdom

OBJECTIVES

To assess the variability in time taken for a patient to be seen in a genitourinary (GUM) clinic in the United Kingdom having contacted that clinic by telephone and compare this with GUM physicians' expectations.

METHODS

A postal questionnaire was sent to lead GUM physicians asking when they thought patients with two specific clinical scenarios would be seen in their clinics. Following this, healthcare personnel contacted individual units posing as patients with the same clinical scenarios and asked to be seen as soon as possible.

RESULTS

202/258 (78%) lead clinicians responded to the postal questionnaire. All clinics claimed to have procedures allowing patients with acute symptoms to be assessed urgently and estimated that such patients would be seen within 48 hours of the initial telephone contact. In 243 of 311 (78%) clinic contacts, the patient was invited to attend the clinic within 48 hours. For the remaining 68 contacts (22%) the patient could not be accommodated within 48 hours and, of these, 49 could not be seen for more than 1 week.

CONCLUSIONS

No clinician estimated that patients with acute severe symptoms would be seen more than 48 hours after the initial telephone contact, but in reality, for 22% of the patient contacts this was the case. This study may well underestimate the difficulties the general public may have in accessing GUM services. We hypothesise that this situation could be ameliorated by establishing process standards and addressing issues of resource allocation.

Signal peptidase and oligosaccharyltransferase interact in a sequential and dependent manner within the endoplasmic reticulum

We demonstrate that the signal peptides of prepro-alpha-factor and preinvertase must be cleaved before Asn-X-Ser/Thr acceptor tripeptides located near the signal peptides of these precursors can be efficiently glycosylated within the endoplasmic reticulum of the yeast Saccharomyces cerevisiae. The data support a model whereby the interaction of a signal peptide with the membrane prevents an acceptor tripeptide juxtaposed to the signal peptide from accessing the oligosaccharyltransferase active site until the signal peptide is cleaved.

Foods found in the wild around nuclear sites: an evaluation of radiological impact

Habit surveys were carried out around four licensed nuclear sites to identify people who collect foodstuffs from the wild (so-called 'free foods'). In total, around 800 collectors were readily identified, most of whom collected more than one free food. The data indicated that estimates of higher than average doses could reasonably be based on the three foodstuffs of most importance. Foods were selected for further study on the basis of either the number of collectors or the amount consumed. The radionuclides of interest were identified using published information on the discharges from each site. The resultant average and higher than average doses were estimated using the site-specific habit data. For all sites, doses from the consumption of free foods were low and of no radiological importance. Assessments based solely on data for cultivated foods would not therefore have underestimated radiological impact significantly. However, given the wide utilisation of free foods found in this study, for rigorous assessments it would be prudent to take account of the consumption of foods from the wild.