Equal remission rates and reduced length of hospital stay with twice-daily repetitive transcranial magnetic stimulation (rTMS) for major depression - A large naturalistic retrospective cohort association study

OBJECTIVES

Repetitive transcranial magnetic stimulation (rTMS) is a level 1a evidence-based treatment for major depression, but high cost of care and limited effectiveness in naturalistic cohorts have been lingering criticisms. This naturalistic, retrospective cohort analysis compares the effect of once and twice daily treatment protocols of rTMS using quality assurance data collected at an Australian private psychiatric hospital.

METHODS

A total of 210 inpatients self-selected into two groups receiving up to 30 sessions of either daily (n = 101) or twice daily (n = 109) 10 Hz rTMS to the left dorsolateral prefrontal cortex (DLPFC). The a priori primary outcome measure was remission rate as measured by pre and post treatment HAMD-17 scores. Length of hospital stay was a secondary post hoc outcome adopted due to the importance to cost of acute psychiatric care.

RESULTS

Remission rates were similar across groups, with 44.9% and 45.4% for twice daily and daily rTMS groups respectively, although these may be confounded by patient expectations, other treatments and medication changes given the naturalistic setting. The length of hospital stay was 10.11 days and 18.44 days for twice daily and daily rTMS respectively - the twice daily rTMS length of hospital stay was 45.1% shorter 95% CI [38.7% - 51.56%]. Dropout rates were high; Twenty-seven (24.77%) twice daily participants dropped out before 20 sessions were completed, and 35 (34.65%) of daily participants.

CONCLUSIONS

Twice daily 10 Hz left sided rTMS remission outcomes were similar to traditional once daily rTMS but required a shorter length of hospital stay. This finding has substantial cost of care implications. If these findings are independently replicated, twice daily rTMS may become the standard of care for inpatient rTMS.

South African Thoracic Society position statement on the management of non-cystic fibrosis bronchiectasis in adults: 2023

Background

Bronchiectasis is a chronic lung disorder that affects the lives of many South Africans. Post-tuberculosis (TB) bronchiectasis is an important complication of previous pulmonary TB and a common cause of bronchiectasis in South Africa (SA). No previous statements on the management of bronchiectasis in SA have been published.

Objectives

To provide a position statement that will act as a template for the management of adult patients with bronchiectasis in SA.

Methods

The South African Thoracic Society appointed an editorial committee to compile a position statement on the management of adult non-cystic fibrosis (CF) bronchiectasis in SA.

Results

A position statement addressing the management of non-CF bronchiectasis in adults in SA was compiled. This position statement covers the epidemiology, aetiology, diagnosis, investigations and various aspects of management of adult patients with non-CF bronchiectasis in SA.

Conclusion

Bronchiectasis has largely been a neglected lung condition, but new research has improved the outlook for patients. Collaboration between interprofessional team members in patient management is important. In SA, more research into the epidemiology of bronchiectasis, especially post-TB bronchiectasis and HIV-associated bronchiectasis, is required.

Abstract

The South African Thoracic Society mandated a multidisciplinary team of healthcare providers to compile a position statement on the management of non-cystic fibrosis bronchiectasis in South Africa (SA). International guidelines on the management of bronchiectasis were reviewed and used as a basis from which the current position statement was compiled. This is the first position statement on the management of adult non-cystic fibrosis bronchiectasis in SA. A description of the epidemiology and aetiology of bronchiectasis is provided, as well as guidance on its diagnosis and management. The position statement provides guidance on the management of bronchiectasis to healthcare providers, policymakers and regulatory authorities.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Splints and immobilisation approaches used for second to fifth metacarpal fractures: a systematic review

BACKGROUND: The second to fifth metacarpal fractures are immobilised with splints, plaster of Paris (POP) or buddy strapping for a period of time. However, no recent evidence-based splinting and immobilisation programme exists for the management thereof, leaving a gap in the literature to inform clinical practice. This review aimed to review, appraise and collate the literature on splints and immobilisation approaches used for second to fifth metacarpal fractures after surgical and conservative management in adults aged 20 to 59 years. METHODS: The review included experimental study designs, quasi-experimental studies, cohort studies and case-control studies from January 2008 to September 2018. Two reviewers independently screened, selected, appraised and extracted data from the included studies. Preferred reporting items for systematic reviews and meta-analysis (PRISMA) guided the reporting. Joanna Briggs Institute (jBl) critical appraisal tools were used to assess the risk of bias for each included study. RESULTS: Database searches generated 1 005 articles with ten additional articles found on Google Scholar. Ten articles were included: two randomised controlled trials (RCTs), one quasi-RCT, four prospective studies, one retrospective record review, one retrospective study and one comparative study with descriptive reporting of the results. CONCLUSION: High level 1b evidence suggests that no reduction, a soft wrap and buddy strapping for three weeks with early active finger and wrist mobilisation are effective for individuals who sustained boxer's fractures with < 70° angulation. To guide clinical practice, high-level research is needed to determine the immobilisation of second to fifth metacarpal fracture types. Level of evidence: Level 2

Supporting individuals with intellectual and developmental disability during the first 100 days of the COVID-19 outbreak in the USA

BACKGROUND

It is unknown how the novel Coronavirus SARS-CoV-2, the cause of the current acute respiratory illness COVID-19 pandemic that has infected millions of people, affects people with intellectual and developmental disability (IDD). The aim of this study is to describe how individuals with IDD have been affected in the first 100 days of the COVID-19 pandemic.

METHODS

Shortly after the first COVID-19 case was reported in the USA, our organisation, which provides continuous support for over 11 000 individuals with IDD, assembled an outbreak committee composed of senior leaders from across the health care organisation. The committee led the development and deployment of a comprehensive COVID-19 prevention and suppression strategy, utilising current evidence-based practice, while surveilling the global and local situation daily. We implemented enhanced infection control procedures across 2400 homes, which were communicated to our employees using multi-faceted channels including an electronic resource library, mobile and web applications, paper postings in locations, live webinars and direct mail. Using custom-built software applications enabling us to track patient, client and employee cases and exposures, we leveraged current public health recommendations to identify cases and to suppress transmission, which included the use of personal protective equipment. A COVID-19 case was defined as a positive nucleic acid test for SARS-CoV-2 RNA.

RESULTS

In the 100-day period between 20 January 2020 and 30 April 2020, we provided continuous support for 11 540 individuals with IDD. Sixty-four per cent of the individuals were in residential, community settings, and 36% were in intermediate care facilities. The average age of the cohort was 46 ± 12 years, and 60% were male. One hundred twenty-two individuals with IDD were placed in quarantine for exhibiting symptoms and signs of acute infection such as fever or cough. Sixty-six individuals tested positive for SARS-CoV-2, and their average age was 50. The positive individuals were located in 30 different homes (1.3% of total) across 14 states. Fifteen homes have had single cases, and 15 have had more than one case. Fifteen COVID-19-positive individuals were hospitalised. As of 30 April, seven of the individuals hospitalised have been discharged back to home and are recovering. Five remain hospitalised, with three improving and two remaining in intensive care and on mechanical ventilation. There have been three deaths. We found that among COVID-19-positive individuals with IDD, a higher number of chronic medical conditions and male sex were characteristics associated with a greater likelihood of hospitalisation.

CONCLUSIONS

In the first 100 days of the COVID-19 outbreak in the USA, we observed that people with IDD living in congregate care settings can benefit from a coordinated approach to infection control, case identification and cohorting, as evidenced by the low relative case rate reported. Male individuals with higher numbers of chronic medical conditions were more likely to be hospitalised, while most younger, less chronically ill individuals recovered spontaneously at home.

Evaluation of VIDAS® Salmonella (SLM) Immunoassay Method with Rappaport-Vassiliadis (RV) Medium for Detection of Salmonella in Foods: Collaborative Study

A collaborative study was conducted to compare the VIDAS Salmonella (SLM) with Rappaport-Vassiliadis (RV) method for detection of Salmonella in foods to the current standard method presented in the U.S. Food and Drug Administration's Bacteriological Analytical Manual (BAM) and the culture method presented in AOAC's Official Methods of Analysis. The VIDAS SLM with RV method uses tetrathionate broth in combination with RV medium in place of selenite cystine broth for selective enrichment, thereby eliminating the hazardous waste issue for laboratories. Twenty five laboratories participated in the evaluation, each testing one or more of 8 test products: nonfat dry milk, dried egg, soy flour, lactic casein, milk chocolate, raw ground pork, raw ground turkey, and raw peeled shrimp. Results of the study showed no significant differences in the numbers of confirmed positive samples with the VIDAS SLM with RV procedure and the BAM/AOAC culture procedure. The VIDAS SLM with RV method was effective for rapid detection of Salmonella in foods. It is recommended that AOAC INTERNATIONAL modify the VIDAS Salmonella SLM procedure to include the RV method.

3M™ Petrifilm™ Staph Express Count Plate Method for the Enumeration of Staphylococcus aureus in Selected Types of Meat, Seafood, and Poultry: Collaborative Study

The 3M™ Petrifilm™ Staph Express Count plate method was compared with AOAC Official Method 975.55 for the enumeration of Staphylococcus aureus in selected foods. Four foods—cooked, diced chicken; cured ham; smoked salmon; and pepperoni—were analyzed for S. aureus by 12 collaborating laboratories. For each food tested, the collaborators received 8 blind test samples consisting of a control sample, a low inoculation level, a medium inoculation level, and a medium inoculation level with background flora, each in duplicate. The mean log10 counts for the methods were comparable for all 4 foods. The repeatability and reproducibility variances of the 24 h Petrifilm Staph Express Count plate method were similar to those of the 72 h standard method.

Increased sensitivity to traumatic axonal injury on postconcussion diffusion tensor imaging scans in National Football League players by using premorbid baseline scans

OBJECTIVE

Statistical challenges exist when using diffusion tensor imaging (DTI) to assess traumatic axonal injury (TAI) in individual concussed athletes. The authors examined active professional American football players over a 6-year time period to study potential TAI after concussion and assess optimal methods to analyze DTI at the individual level.

METHODS

Active American professional football players recruited prospectively were assessed with DTI, conventional MRI, and standard clinical workup. Subjects underwent an optional preseason baseline scan and were asked to undergo a scan within 5 days of concussion during gameplay. DTI from 25 age- and sex-matched controls were obtained. Both semiautomated region-of-interest analysis and fully automated tract-based spatial statistics (TBSS) were used to examine DTI at individual and group levels. Statistical differences were assessed comparing individual DTI data to baseline imaging versus a normative database. Group-level comparisons were also performed to determine if longer exposure to professional-level play or prior concussion cause white matter microstructural integrity changes.

RESULTS

Forty-nine active professional football players were recruited into the study. Of the 49 players, 7 were assessed at baseline during the preseason and after acute concussion. An additional 18 players were assessed after acute concussion only. An additional 24 players had only preseason baseline assessments. The results suggest DTI is more sensitive to suspected TAI than conventional MRI, given that 4 players demonstrated decreased fractional anisotropy (FA) in multiple tracts despite normal conventional MRI. Furthermore, the data suggest individual assessment of DTI data using baseline premorbid imaging is more sensitive than typical methods of comparing data to a normative control group. Among all subjects with baseline data, 1 reduced FA tract (± 2.5 standard deviations) was found using the typical normative database reference versus 10 statistically significant (p < 0.05) reduced FA tracts when referencing internal control baseline data. All group-level comparisons were statistically insignificant (p > 0.05).

CONCLUSIONS

Baseline premorbid DTI data for individual DTI analysis provides increased statistical sensitivity. Specificity using baseline imaging also increases because numerous potential etiologies for reduced FA may exist prior to a concussion. These data suggest that there is a high potential for false-positive and false-negative assessment of DTI data using typical methods of comparing an individual to normative groups given the variability of FA values in the normal population.

Engaging Athletic Trainers in Concussion Detection: Overview of the National Football League ATC Spotter Program, 2011-2017

OBJECTIVE

To assist sideline medical staff and to augment detection of concussion in National Football League (NFL) players during preseason and regular season games via the use of certified athletic trainer (ATC) spotters.

BACKGROUND

Detecting concussive injuries in contact-sport athletes can be a challenging task for health care providers on the sideline. Over the past 8 years, professional sport leagues have begun to use additional sets of eyes (medical spotters along with video review) to help identify athletes with possible concussive injuries.

DESCRIPTION

The NFL first began a program using spotters in 2011, and the ATC Spotter Program has undergone systematic enhancements each year. This article describes the evolution of the ATC Spotter Program, the requirements and training of its participants, and the program data available to date. Directions for future improvement and research are addressed.

CLINICAL ADVANTAGES

The use of ATC spotters stationed in the broadcast booth has enhanced the real-time detection of concussed players in the NFL.

National Football League Head, Neck and Spine Committee’s Concussion Diagnosis and Management Protocol: 2017-18 season

One of the National Football League’s (NFL) Head, Neck and Spine Committee’s principal goals is to create a ‘best practice’ protocol for concussion diagnosis and management for its players. The science related to concussion diagnosis and management continues to evolve, thus the protocol has evolved contemporaneously. The Fifth International Conference on Concussion in Sport was held in Berlin in 2016, and guidelines for sports concussion diagnosis and management were revised and refined. The NFL Head, Neck and Spine Committee has synthesised the most recent empirical evidence for sports concussion diagnosis and management including the Berlin consensus statement and tailored it to the game played in the NFL. One of the goals of the Committee is to provide a standardised, reliable, efficient and evidence-based protocol for concussion diagnosis and management that can be applied in this professional sport during practice and game day. In this article, the end-of-season version of the 2017–18 NFL Concussion Diagnosis and Management Protocol is described along with its clinical rationale. Immediate actions for concussion programme enhancement and research are reviewed. It is the Committee’s expectation that the protocol will undergo refinement and revision over time as the science and clinical practice related to concussion in sports crystallise

Older adults' outdoor walking and the built environment: does income matter?

Background

Our aim was to examine the association between Street Smart Walk Score® and self-reported outdoor walking among older Canadians, and to determine whether socioeconomic status modifies this association.

Methods

We linked objective walkability data with cross-sectional survey data from the Canadian Community Health Survey Healthy-Aging 2008–2009 Cycle for a sample of 1309 British Columbians aged ≥ 65 years. We examined associations between Street Smart Walk Score and meeting physical activity guidelines (≥150 min of moderate to vigorous activity/week) through self-reported outdoor walking using multivariable logistic regression, and tested for significant interactions with household income.

Results

A ten point higher Street Smart Walk Score was associated with a 17 % higher odds of meeting physical activity guidelines through walking outside (95 % CI: 1.07,1.27). In addition, older adults living in neighbourhoods categorised as Walker’s Paradise were over three times more likely to meet guidelines than those living in Car-dependent/Very car dependent neighbourhoods. We found no evidence that household income moderated the effect of Walk Score on walking outside.

Conclusions

Neighbourhood design may be one avenue whereby physical activity levels of older people can be enhanced through outdoor walking, with benefit across socioeconomic strata.

Tidal Heating of Earth-like Exoplanets around M Stars: Thermal, Magnetic, and Orbital Evolutions

The internal thermal and magnetic evolution of rocky exoplanets is critical to their habitability. We focus on the thermal-orbital evolution of Earth-mass planets around low-mass M stars whose radiative habitable zone overlaps with the "tidal zone," where tidal dissipation is expected to be a significant heat source in the interior. We develop a thermal-orbital evolution model calibrated to Earth that couples tidal dissipation, with a temperature-dependent Maxwell rheology, to orbital circularization and migration. We illustrate thermal-orbital steady states where surface heat flow is balanced by tidal dissipation and cooling can be stalled for billions of years until circularization occurs. Orbital energy dissipated as tidal heat in the interior drives both inward migration and circularization, with a circularization time that is inversely proportional to the dissipation rate. We identify a peak in the internal dissipation rate as the mantle passes through a viscoelastic state at mantle temperatures near 1800 K. Planets orbiting a 0.1 solar-mass star within 0.07 AU circularize before 10 Gyr, independent of initial eccentricity. Once circular, these planets cool monotonically and maintain dynamos similar to that of Earth. Planets forced into eccentric orbits can experience a super-cooling of the core and rapid core solidification, inhibiting dynamo action for planets in the habitable zone. We find that tidal heating is insignificant in the habitable zone around 0.45 (or larger) solar-mass stars because tidal dissipation is a stronger function of orbital distance than stellar mass, and the habitable zone is farther from larger stars. Suppression of the planetary magnetic field exposes the atmosphere to stellar wind erosion and the surface to harmful radiation. In addition to weak magnetic fields, massive melt eruption rates and prolonged magma oceans may render eccentric planets in the habitable zone of low-mass stars inhospitable for life.

Extreme water loss and abiotic O2 buildup on planets throughout the habitable zones of M dwarfs

We show that terrestrial planets in the habitable zones of M dwarfs older than ∼1 Gyr could have been in runaway greenhouses for several hundred million years following their formation due to the star's extended pre-main sequence phase, provided they form with abundant surface water. Such prolonged runaway greenhouses can lead to planetary evolution divergent from that of Earth. During this early runaway phase, photolysis of water vapor and hydrogen/oxygen escape to space can lead to the loss of several Earth oceans of water from planets throughout the habitable zone, regardless of whether the escape is energy-limited or diffusion-limited. We find that the amount of water lost scales with the planet mass, since the diffusion-limited hydrogen escape flux is proportional to the planet surface gravity. In addition to undergoing potential desiccation, planets with inefficient oxygen sinks at the surface may build up hundreds to thousands of bar of abiotically produced O2, resulting in potential false positives for life. The amount of O2 that builds up also scales with the planet mass; we find that O2 builds up at a constant rate that is controlled by diffusion: ∼5 bar/Myr on Earth-mass planets and up to ∼25 bar/Myr on super-Earths. As a result, some recently discovered super-Earths in the habitable zone such as GJ 667Cc could have built up as many as 2000 bar of O2 due to the loss of up to 10 Earth oceans of water. The fate of a given planet strongly depends on the extreme ultraviolet flux, the duration of the runaway regime, the initial water content, and the rate at which oxygen is absorbed by the surface. In general, we find that the initial phase of high luminosity may compromise the habitability of many terrestrial planets orbiting low-mass stars.

Habitable evaporated cores: transforming mini-Neptunes into super-Earths in the habitable zones of M dwarfs

We show that photoevaporation of small gaseous exoplanets ("mini-Neptunes") in the habitable zones of M dwarfs can remove several Earth masses of hydrogen and helium from these planets and transform them into potentially habitable worlds. We couple X-ray/extreme ultraviolet (XUV)-driven escape, thermal evolution, tidal evolution, and orbital migration to explore the types of systems that may harbor such "habitable evaporated cores" (HECs). We find that HECs are most likely to form from planets with ∼1 M⊕ solid cores with up to about 50% H/He by mass, though whether or not a given mini-Neptune forms a HEC is highly dependent on the early XUV evolution of the host star. As terrestrial planet formation around M dwarfs by accumulation of local material is likely to form planets that are small and dry, evaporation of small migrating mini-Neptunes could be one of the dominant formation mechanisms for volatile-rich Earths around these stars.

Corticosteroid and Anesthetic Injections for Muscle Strains and Ligament Sprains in the NFL

BACKGROUND

Administering local anesthetic or corticosteroid injections in professional athletes to allow return to play is common but has traditionally been viewed as suspect and taboo. The skepticism surrounding therapeutic injections stems predominantly from anecdotal experience as opposed to scientific data.

QUESTIONS/PURPOSES

The purpose of this paper is to evaluate the current use of corticosteroid injections for muscle strains and ligaments sprains in the National Football League to document player's ability to return to play and possible adverse effects.

PATIENTS AND METHODS

Athletes from a single National Football League team who received at least one corticosteroid or anesthetic injection for either a muscle strain or ligament sprain during three consecutive seasons were retrospectively reviewed. Thirty-seven injections were given over the three seasons. Injections were either performed blindly or by using ultrasound guidance.

RESULTS

Twice as many defensive players were injected than offensive players. The average number of days of conservative treatment before injection was 6.5 days. All players returned to play after injection. There were no complications from any of the injections. Seventeen (55%) players did not miss a single game, and nine (30%) did not miss a single day. Quadriceps strains were associated with the most missed games (four) and the most missed days (36.5). Proximal hamstring strains were second with an average of three missed games and 28 missed days.

CONCLUSION

Corticosteroid injections are a safe and effective therapeutic intervention for treating muscle strains and ligament sprains in order to enable athletes to return to competition earlier.

Effects of extreme obliquity variations on the habitability of exoplanets

We explore the impact of obliquity variations on planetary habitability in hypothetical systems with high mutual inclination. We show that large-amplitude, high-frequency obliquity oscillations on Earth-like exoplanets can suppress the ice-albedo feedback, increasing the outer edge of the habitable zone. We restricted our exploration to hypothetical systems consisting of a solar-mass star, an Earth-mass planet at 1 AU, and 1 or 2 larger planets. We verified that these systems are stable for 10(8) years with N-body simulations and calculated the obliquity variations induced by the orbital evolution of the Earth-mass planet and a torque from the host star. We ran a simplified energy balance model on the terrestrial planet to assess surface temperature and ice coverage on the planet's surface, and we calculated differences in the outer edge of the habitable zone for planets with rapid obliquity variations. For each hypothetical system, we calculated the outer edge of habitability for two conditions: (1) the full evolution of the planetary spin and orbit and (2) the eccentricity and obliquity fixed at their average values. We recovered previous results that higher values of fixed obliquity and eccentricity expand the habitable zone, but we also found that obliquity oscillations further expand habitable orbits in all cases. Terrestrial planets near the outer edge of the habitable zone may be more likely to support life in systems that induce rapid obliquity oscillations as opposed to fixed-spin planets. Such planets may be the easiest to directly characterize with space-borne telescopes.

Development and validation of a risk model for identification of non-neutropenic, critically ill adult patients at high risk of invasive Candida infection: the Fungal Infection Risk Evaluation (FIRE) Study

BACKGROUND

There is increasing evidence that invasive fungal disease (IFD) is more likely to occur in non-neutropenic patients in critical care units. A number of randomised controlled trials (RCTs) have evaluated antifungal prophylaxis in non-neutropenic, critically ill patients, demonstrating a reduction in the risk of proven IFD and suggesting a reduction in mortality. It is necessary to establish a method to identify and target antifungal prophylaxis at those patients at highest risk of IFD, who stand to benefit most from any antifungal prophylaxis strategy.

OBJECTIVES

To develop and validate risk models to identify non-neutropenic, critically ill adult patients at high risk of invasive Candida infection, who would benefit from antifungal prophylaxis, and to assess the cost-effectiveness of targeting antifungal prophylaxis to high-risk patients based on these models.

DESIGN

Systematic review, prospective data collection, statistical modelling, economic decision modelling and value of information analysis.

SETTING

Ninety-six UK adult general critical care units.

PARTICIPANTS

Consecutive admissions to participating critical care units.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Invasive fungal disease, defined as a blood culture or sample from a normally sterile site showing yeast/mould cells in a microbiological or histopathological report. For statistical and economic modelling, the primary outcome was invasive Candida infection, defined as IFD-positive for Candida species.

RESULTS

Systematic review: Thirteen articles exploring risk factors, risk models or clinical decision rules for IFD in critically ill adult patients were identified. Risk factors reported to be significantly associated with IFD were included in the final data set for the prospective data collection.

DATA COLLECTION

Data were collected on 60,778 admissions between July 2009 and March 2011. Overall, 383 patients (0.6%) were admitted with or developed IFD. The majority of IFD patients (94%) were positive for Candida species. The most common site of infection was blood (55%). The incidence of IFD identified in unit was 4.7 cases per 1000 admissions, and for unit-acquired IFD was 3.2 cases per 1000 admissions. Statistical modelling: Risk models were developed at admission to the critical care unit, 24 hours and the end of calendar day 3. The risk model at admission had fair discrimination (c-index 0.705). Discrimination improved at 24 hours (c-index 0.823) and this was maintained at the end of calendar day 3 (c-index 0.835). There was a drop in model performance in the validation sample. Economic decision model: Irrespective of risk threshold, incremental quality-adjusted life-years of prophylaxis strategies compared with current practice were positive but small compared with the incremental costs. Incremental net benefits of each prophylaxis strategy compared with current practice were all negative. Cost-effectiveness acceptability curves showed that current practice was the strategy most likely to be cost-effective. Across all parameters in the decision model, results indicated that the value of further research for the whole population of interest might be high relative to the research costs.

CONCLUSIONS

The results of the Fungal Infection Risk Evaluation (FIRE) Study, derived from a highly representative sample of adult general critical care units across the UK, indicated a low incidence of IFD among non-neutropenic, critically ill adult patients. IFD was associated with substantially higher mortality, more intensive organ support and longer length of stay. Risk modelling produced simple risk models that provided acceptable discrimination for identifying patients at 'high risk' of invasive Candida infection. Results of the economic model suggested that the current most cost-effective treatment strategy for prophylactic use of systemic antifungal agents among non-neutropenic, critically ill adult patients admitted to NHS adult general critical care units is a strategy of no risk assessment and no antifungal prophylaxis.

FUNDING

Funding for this study was provided by the Health Technology Assessment programme of the National Institute for Health Research.

Randomized clinical trial of selective versus routine preoperative duplex ultrasound imaging before arteriovenous fistula surgery

Background

Anatomical suitability for arteriovenous fistula (AVF) formation was formerly determined by clinical examination alone. There are potential benefits from imaging to assess anatomical suitability. Existing studies examined the role of routine preoperative ultrasonography versus clinical examination alone. The role of a selective duplex ultrasound imaging policy is unknown. This study aimed to compare a policy of selective versus routine ultrasound assessment before AVF formation.

Methods

All patients referred for fistula formation were assessed for inclusion. Suitable patients were randomized to either routine or selective preoperative ultrasound imaging; selective imaging was performed only when clinical criteria were not met. The primary outcome measures were site of AVF formation and 30-day primary failure rate, and secondary outcome measures included the rate of complications.

Results

A total of 106 patients were assessed, and 94 were randomized: 47 to selective and 47 to routine duplex ultrasonography. The groups were well matched for age, co-morbidities and medications. The primary failure rate (29 per cent overall) was not significantly different between the selective and routine imaging groups: 36 per cent (14 of 39) and 21 per cent (8 of 38) respectively (P = 0·144). There were no significant differences in the sites of AVF formation or complication rates.

Conclusion

Routine preoperative ultrasound vessel imaging did not significantly reduce early failure rates, influence the site of AVF formation or reduce complications. If clinical evaluation detects anatomy suitable for AVF formation, duplex imaging may not be needed. Registration number: NCT01004627 (http://www.clinicaltrials.gov).

Does neighbourhood walkability moderate the effects of mass media communication strategies to promote regular physical activity?

BACKGROUND

Mass media campaigns are widely used in Australia and elsewhere to promote physical activity among adults. Neighbourhood walkability is consistently shown to be associated with walking and total activity. Campaigns may have different effects on individuals living in high and low walkable neighbourhoods.

PURPOSE

The purpose of this study is to compare pre- and post-campaign cognitive and behavioural impacts of the Heart Foundation's Find Thirty every day® campaign, in respondents living in high and lower walkable neighbourhoods.

METHODS

Pre- and post-campaign cross-sectional survey data were linked with objectively measured neighbourhood walkability. Cognitive and behavioural impacts were assessed using logistic regression stratified by walkability.

RESULTS

Cognitive impacts were significantly higher post-campaign and consistently higher in respondents in high compared with lower walkable neighbourhoods. Post campaign sufficient activity was significantly higher and transport walking significantly lower, but only in residents of lower walkable areas.

CONCLUSIONS

Cognitive impacts of mass media physical activity campaigns may be enhanced by living in a more walkable neighbourhood.

Would you Find Thirty online? Website use in a Western Australian physical activity campaign

ISSUE ADDRESSED

Mass media campaigns have used a range of traditional media (television, radio and print) to communicate health messages. In the past decade the Internet has added to these traditional methods with Web 2.0, smart phone technology and interactive media. 'Find Thirty every day(®)', a Western Australia population-wide mass media campaign delivered over 2 years, used a combination of traditional mass media, a website, online resources and banner advertising. The aim of the present study is to describe the use of the Find Thirty every day(®) website during the campaign media activities of May 2008-June 2010.

METHODS

Cross-sectional self-reported survey data were collected from a random sample of adults using a computer-assisted telephone interview over the period February-March 2010. Objective online analytical measures of unique visits to the Find Thirty every day(®) website were collected between June 2008 and June 2010.

RESULTS

Monthly visitors to the Find Thirty every day(®) website increased from 3193 in 2009 to 4374 in 2010. During the last two media waves (October 2009 and February 2010), site visits were 5388 and 5272 per month, respectively.

CONCLUSION

The impact of the Find Thirty every day(®) website was a positive outcome, considering the minimal online presence. SO WHAT? Health communication campaign planners should maximise the potential synergy of traditional mass media and new social media in future campaigns. Accordingly, a multidisciplinary approach that includes communication researchers, experts in information systems and a creative team experienced in online environments will need to be the way forward.

Clinical and economic burden of invasive fungal diseases in Europe: focus on pre-emptive and empirical treatment of Aspergillus and Candida species

Invasive fungal diseases (IFDs) have been widely studied in recent years, largely because of the increasing population at risk. Aspergillus and Candida species remain the most common causes of IFDs, but other fungi are emerging. The early and accurate diagnosis of IFD is critical to outcome and the optimisation of treatment. Rapid diagnostic methods and new antifungal therapies have advanced disease management in recent years. Strategies for the prevention and treatment of IFDs include prophylaxis, and empirical and pre-emptive therapy. Here, we review the available primary literature on the clinical and economic burden of IFDs in Europe from 2000 to early 2011, with a focus on the value and outcomes of different approaches.

Ruptured AAA: suitability for endovascular repair is associated with lower mortality following open repair

OBJECTIVES

Perioperative mortality of open repair of ruptured abdominal aortic aneurysms (rAAA) remains unacceptably high: 30-day mortality ≈ 40 %. This study aimed to assess, quantify, and determine the consequences of anatomic suitability for endovascular repair of rAAA.

DESIGN

A retrospective analysis of the prospectively maintained database identified patients with rAAA.

METHODS

Preoperative CT scans were assessed for anatomic suitability for emergency EVAR and precluding factors recorded. Demographic information was collected and analysed for all patients.

RESULTS

A total of 141 patients underwent open surgical repair of rAAA. Forty-six patients had preoperative CT scans suitable for reconstruction. Morphological measurements indicated that 41 % would have been anatomically suitable for EVAR. Suitability was associated with lower mortality rates than unsuitability: 0, 11, and 20 % (24 h, 30 days, and 1 year respectively) versus 11, 33, and 59 % (statistically significant at 1 year; p = 0.02). The groups were comparable excepting diabetes incidence, which was higher in those suitable for EVAR (p = 0.003).

CONCLUSIONS

A minority of patients with ruptured AAA are anatomically suitable for EVAR. Anatomical suitability appears to identify patients at low risk from open surgery. Whether this is due to technically less demanding open surgery is unknown. This may be resolved by the IMPROVE trial results, which are eagerly awaited.

Operative and nonoperative treatment of cervical disc herniation in National Football League athletes

BACKGROUND

Limited evidence exists to guide clinical decision making regarding cervical disc herniations in professional athletes playing for the National Football League (NFL) in the United States.

PURPOSE

To describe the presentation and treatment outcomes of cervical disc herniations in NFL athletes with a focus on safety and return to sport.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The records of a single NFL team and its consulting physicians were reviewed from 2000 to 2011. Only athletes with magnetic resonance imaging (MRI)-proven disc herniation concordant with the reported symptoms were included.

RESULTS

A total of 16 athletes met inclusion criteria. Linemen, linebackers, and defensive backs were the most represented positions (13/16 athletes; 81%). The most common presentation was radiculopathy after a single traumatic event (9/16 athletes; 56%). Three players had transient paresis. Three players underwent one-level anterior cervical discectomy and fusion. These 3 players had failed nonoperative therapy and had evidence of spinal cord compression with signal change on MRI, but only 1 returned to sport. Three players received epidural steroid injections, which provided transient symptomatic relief. Five players were treated nonoperatively and did not return to sport. Two of these 5 athletes had cord compression with signal change and retired rather than undergo surgery. The other 3 were cleared but were released by the team. Eight players were treated nonoperatively and returned to sport. Three of these 8 athletes had evidence of disc material abutting the cord without cord signal change but had a normal examination finding and returned to sport after resolution of their symptoms and repeat MRI that demonstrated no cord compression. Five of the 8 players had evidence of root compression and were treated symptomatically. There were no subsequent traumatic spinal cord injuries at a minimum of 1-year follow-up.

CONCLUSION

Data regarding the treatment of this unique population are limited but suggest that NFL athletes can safely return to sport after the treatment of cervical disc herniations. In the treatment algorithm for this study, cord compression with signal change in the cord on MRI was a consistent operative indication. Discs abutting the cord can be treated nonoperatively but do not allow for return to sport until symptoms have improved and repeat imaging demonstrates no cord compression. Isolated nerve root compression has a more favorable prognosis. It can be treated symptomatically and return to sport allowed when symptoms permit.

Pregnancy of a patient with multiple Acyl-CoA dehydrogenation deficiency (MADD)

We describe the pregnancy of a patient of French-Canadian descent with multiple Acyl-CoA dehydrogenation deficiency (MADD). The proband was found to harbor a previously reported homozygous missense mutation on EFTDH gene (p.Pro534Leu:c.1601C>T) confirming the biochemical diagnosis of MADD. This mutation was not found in 50 controls from the same ethnic background. The clinical and molecular information of all patients with ETFDH mutations reported in the literature up-to-date are summarized.

Lower Cervical Posterior Element Fractures in the National Football League: A Report of 2 Cases and a Review of the Literature

BACKGROUND AND IMPORTANCE:

Injuries in professional football players are common because of the nature of the collisions and the frequency of axial loading to the cervical spine. These injuries should be thoroughly evaluated because they can put the player at risk of future injury and even paralysis. The focus of this report is to present 2 cases of this injury and review the current body of literature.

CLINICAL PRESENTATION:

We present 2 cases of professional football players who experienced injuries to the lower posterior elements of their cervical spine simultaneously on a kickoff during a game. Both players described transient symptoms consistent with a “stinger,” which is commonly encountered. Workup revealed fractures of the lower cervical spine in both patients. One patient was able to be managed conservatively and returned to football the following season. The second patient had an unstable fracture that ultimately required operative intervention, and the patient retired from professional football.

CONCLUSION:

Cervical spine injuries in football players need to be adequately evaluated, and in many cases can be career threatening. We recommend that players with persistent pain after a transient neurapraxia undergo radiography and computed tomography of the cervical spine to evaluate for a fracture.

Injury profile of musicians in the Bloemfontein-based Free State symphony orchestra: a short report

Similar  to  professional  athletes,  musicians  are  required  to perform optimally.  Few  studies  have  been  conducted  to  clarify  the  nature of injuries associated with musicians. This study aimed to determine the types of injuries and their prevalence amongst the musicians of the Free State Symphony orchestra (FSSo), contributing factors, the musicians’ response to injury, and their perception of physiotherapy. Forty-five members of the FSSO participated in this descriptive study. Analysis of data included frequencies and percentages for categorical data and percentiles for continuous data. Thirty-eight (84.4%) participants reported injuries related to playing their instruments. Insufficient resting  periods  during playing  sessions  (70.3%),  continuing  to  play  while experiencing symptoms (63.2%) and performing the same movement repetitively (64.9%) were identified as the perceived risk factors in the development of symptoms.  Seventeen  (44.7%)  participants  indicated that they  did  nothing  to relieve their symptoms, while 34.2% sought physiotherapy treatment, 31.6% took medication to alleviate their symptoms and 31.6% reduced their playing hours. Majority of participants (75%) felt that their symptoms could be relieved by physiotherapy. Injuries amongst musicians result from a combination of factors such as posture, repetitive movements and fatigue. Possible physiotherapeutic intervention identified included educating musicians on the advantages of early management of injuries in extending their professional careers.

IRMER regulations: compliance rate of radiograph reporting by non-radiology clinicians

AIM

To assess compliance with regulation 7(8) of Ionizing Radiation Medical Exposure Regulations (IRMER) 2000 legislation amongst non-radiologists reporting radiographs in a large district general hospital.

MATERIALS AND METHODS

A prospective review of 100 consecutive radiography request cards from five different departments undertaking their specialty radiograph reporting were collected over 4 weeks. The requests were then traced to their respective case notes to assess documentation of radiographs. The five departments included chest, maxillo-facial, rheumatology, orthopaedics, and inpatients. Twenty-two case notes were gathered from chest clinics, 21 from maxillo-facial, 15 from rheumatology, 23 from orthopaedics fracture clinics, and 19 were taken from inpatients.

RESULTS

Only 53% of radiographs undertaken by non-radiologists had a documented report. The specialty most compliant with IRMER was orthopaedics 17/23 (74%) and the specialty least compliant was maxilla-facial 8/21 (38%). Of the documented radiographs, the consultant grade was the largest group of doctors [36% (19/53)] that undertook documentation, and for the undocumented radiographs, they were also the largest group of clinicians that did not document radiographs [77% (36/47)]. All radiographs that were documented in the notes also had documented interpretation of the radiograph.

CONCLUSION

Only 53% of plain radiographs were documented and reported by non-radiology clinicians even though IRMER legislation applies to all clinicians undertaking radiograph interpretation. All clinicians undertaking interpretation of radiographs should be made aware of this legislation and the responsibility to document their findings.