Hirschsprung's disease in the UK and Ireland: incidence and anomalies

OBJECTIVES

To describe clinical characteristics and preoperative management of a national cohort of infants with Hirschsprung's disease (HD).

DESIGN

Population-based cohort study of all live-born infants with HD born in the UK and Ireland from October 2010 to September 2012.

SETTING

All 28 paediatric surgical centres in the UK and Ireland.

PARTICIPANTS

305 infants presenting before 6 months of age with histologically proven HD.

MAIN OUTCOME MEASURES

Incidence, clinical characteristics including gestational age, birth weight, gender, associated anomalies; age and clinical features at presentation; and use of rectal washouts or stoma.

RESULTS

The incidence of HD in the UK and Ireland was 1.8 per 10 000 live births (95% CI 1.5 to 1.9). Male to female ratio was 3.3:1. An associated anomaly was identified in 23% (69), with 15% (47) having a recognisable syndrome. The proportion of infants who presented and were diagnosed in the neonatal period was 91.5% (279) and 83.9% (256), respectively. 23.9% (73) and 44.2% (135) passed meconium within 24 and 48 hours of birth. 81% (246) first presented to a hospital without tertiary paediatric surgical services, necessitating interhospital transfer. Initial colonic decompression was by rectal washouts in 86.2% (263) and by defunctioning stoma in 12.8% (39). Subsequently, 27.4% (72) of infants failed management with rectal washouts and required a delayed stoma, resulting in 36.4% (111) of infants having a stoma.

CONCLUSIONS

In this population-based cohort, presentation outside the neonatal period was rare. Nearly half of the infants with HD passed meconium within 48 hours of birth and over one third were managed with a stoma.

Is H2S a suitable process indicator for odour abatement performance of sewer odours?

Odour abatement units are typically designed and maintained on H(2)S concentrations, but operational failures are reported in terms of overall odour removal, suggesting a wide range of malodorous compounds emitted from sewers that may not be efficiently removed by existing odour abatement processes. Towards providing greater insight into this issue, several activated carbon filters and biofilters treating odorous emissions from sewer systems in Sydney (Australia) were monitored by collecting and analysing gas samples before and after treatment. The monitoring studies were conducted by both olfactometric measurements and gas-chromatography-based chemical analysis. Single H(2)S assessment often failed to indicate the odour abatement performance for treatment systems in the abatement units studied, particularly when the incoming H(2)S concentrations were in the sub-ppm range (i.e. below H(2)S odour threshold). Chemical analysis indicated that some non-H(2)S odorous compounds were not removed efficiently during odour treatment. Additionally, when odour eliminations were correlated with the removal of individual compounds (Pearson's correlations) it was observed that the correlation (with a coefficient of 0.79) was best when the overall removal of all the measured odorous compounds that exceeded their odour threshold values was used for the analysis. These findings may help to further advance the design and operation of odour abatement processes to address the treatment of sewer odour emissions.

Reduced sulfur compounds in the atmosphere of sewer networks in Australia: geographic (and seasonal) variations

The management of odorous emissions from sewer networks has become an important issue for sewer system operators resulting in the need to better understand the composition of reduced sulfur compounds (RSCs). Gaseous RSCs including hydrogen sulfide (H2S), methanethiol (MeSH), dimethyl sulfide (DMS), carbon disulfide (CS2), dimethyl disulfide (DMDS) and dimethyl trisulfide (DMTS) were measured in the atmosphere of selected sewer networks in two major Australian cities (Sydney and Melbourne) during 2011-2012. The RSC concentrations in the sewer air were detected in a highly variable range. H2S and MeSH were found at the highest concentrations, followed by DMS (39.2-94.0 μg/m(3)), CS2 (18.3-19.6 μg/m(3)), DMDS (7.8-49.6 μg/m(3)) and DMTS (10.4-35.3 μg/m(3)). Temporal trends in the occurrence of targeted RSCs were observed and the highest sulfur concentration occurred either in summer or spring, which are typically regarded as the warmer seasons. Statistical significant difference in the magnitude of targeted RSCs was found between samples collected in Sydney and Melbourne.

Data warehousing methods and processing infrastructure for brain recovery research

In order to accelerate translational neuroscience with the goal of improving clinical care it has become important to support rapid accumulation and analysis of large, heterogeneous neuroimaging samples and their metadata from both normal control and patient groups. We propose a multi-centre, multinational approach to accelerate the data mining of large samples and facilitate data-led clinical translation of neuroimaging results in stroke. Such data-driven approaches are likely to have an early impact on clinically relevant brain recovery while we simultaneously pursue the much more challenging model-based approaches that depend on a deep understanding of the complex neural circuitry and physiological processes that support brain function and recovery. We present a brief overview of three (potentially converging) approaches to neuroimaging data warehousing and processing that aim to support these diverse methods for facilitating prediction of cognitive and behavioral recovery after stroke, or other types of brain injury or disease.

Toxicity associated with combination oxaliplatin plus fluoropyrimidine with or without cetuximab in the MRC COIN trial experience

We present the preliminary toxicity data from the MRC COIN trial, a phase III randomised controlled trial of first-line therapy in advanced colorectal cancer, with particular reference to the addition of cetuximab to an oxaliplatin-fluoropyrimidine combination. A total of 804 patients were randomised between March 2005 and July 2006 from 78 centres throughout the United Kingdom. Patients were allocated to oxaliplatin plus fluoropyrimidine chemotherapy with or without the addition of weekly cetuximab. The choice of fluoropyrimidine (either 5-fluorouracil (5FU) or capecitabine) was decided by the treating physician and patient before randomisation. Toxicity data were collected from all patients. Two hundred and three patients received 5FU plus oxaliplatin (OxMdG, 25%), 333 oxaliplatin+capecitabine (Xelox, 41%), 102 received OxMdG+cetuximab (OxMdG+C, 13%) and 166 Xelox+cetuximab (21%). Percent grade 3/4 toxicities included diarrhoea 6, 15, 13 and 25%, nausea/vomiting 3, 7, 7 and 14% for OxMdG, Xelox, OxMdG+C and Xelox+C, respectively. Sixty-day all-cause mortality was 6, 5, 5 and 7%. Statistically significant differences were evident for patients receiving Xelox+cetuximab vs Xelox alone: diarrhoea relative risk (RR) 1.69 (1.17, 2.43, P=0.005) and nausea/vomiting RR 2.01 (1.16, 3.47, P=0.012). The excess toxicity observed in the oxaliplatin-, capecitabine-, cetuximab-treated patients led the trial management group to conclude that a capecitabine dose adjustment was required to maintain safety levels when using this regimen.

Calcium and zinc ion release from polyalkenoate cements formed from zinc oxide/apatite mixtures

Calcium and zinc ion release from hydroxyapatite-zinc oxide-poly(acrylic acid) (HAZnO-PAA) composite cements into deionised water was investigated as a function of HA content, PAA concentration, PAA molecular weight and maturation time. At any given maturation time, zinc ion release was constant until the HA content was at the maximum loading (60 wt%) resulting in the cement matrix breaking up, allowing exacerbated ion release. The calcium ion release increased with increased HA content in the composite until the maximum loading where the release drops off. Up to this point, the release of both ionic species was proportional to square root time for the initial 24 hour period, indicating that the release is diffusion controlled. In agreement with related data from conventional Glass Polyalkenoate Cements (GPCs), it is the concentration of the PAA, not the molecular weight, that influences ion release from these materials. However, unlike GPCs, the release of the active ions results in a pH rise in the deionised water, more conventionally seen with Bioglass and related bioactive glasses. It is this pH rise, caused by the ion exchange of Zn(2+) and Ca(2+) for H(+) from the water, leaving an excess of OH(-), that should result in a favourable bioactive response both in vitro and in-vivo.

Nutrition in the community - an exploratory study of oral nutritional supplements in a health board area in Ireland

BACKGROUND

A review of the General Medical (Payments) Scheme data in the Midland Health Board (MHB) Ireland identified a spend of just over euro 0.5 million on enteral nutritional supplements (oral and tube feeds) in an 11-month period in 1998 [General Medical Services (Payments) Board, 1998, MHB Clinical Nutritional Products: January-December 1998, Dublin]. In 2000, a figure of euro5 million was reported as the annual spend (oral and tube feeds) [General Medical Services (Payments) Board, 2000, MHB Clinical Nutritional Products: January-December 2000, Dublin]. Research has shown that a high proportion of Oral Nutritional Supplements (ONS) are inappropriately prescribed by primary care practitioners (Gall et al., 2001). The role of General Practitioners (GPs) and Public Health Nurses (PHNs) in prescribing ONS to patients aged 65 years and older was examined, as they are directly involved in the delivery of primary health care.

AIM

(i) Assess current trends, decision-making processes and monitoring procedures in the use of ONS for older patients in the community. (ii) Identify whether nutritional assessments and appropriate nutritional criteria are standard practice in determining selection of ONS.

METHODS

A study was conducted among 99 GPs and 120 PHNs in the MHB. All GPs were selected to participate and 50% (60) of PHNs were randomly selected. A telephone questionnaire was administered to each subject over a 2-week period.

RESULTS

Both GPs (78%) and PHNs (47%) reported that their prescription of/recommendations for ONS had increased in the last 4 years. None conducted a full nutritional assessment, but 25% of PHNs used a Nutrition Screening Tool when trying to ascertain whether a patient requires an ONS. Only 19.6% of GPs and 6.8% of PHNs surveyed were aware of the calorie content of a standard 200 mL ONS (sip-feed). In addition, a very significant proportion of both GPs and PHNs do not appear to give appropriate dietary advice to patients who may be at risk of malnutrition. Only 55% of GPs stated that they would specifically review a patient's ONS prescription. All GPs said that they would not conduct a full nutritional assessment at the review appointment.

CONCLUSION

The results of this study raise concerns as to the appropriateness of current ONS prescription and monitoring in the community. They also highlight the need for further intervention in the primary care setting in order to ensure that elderly malnourished patients are detected, treated and monitored in an appropriate and cost-effective manner.

Zinc ion release from novel hard tissue biomaterials

Zinc polyalkenoate cements (ZPCs) and glass polyalkenoate cements (GPCs) are used routinely in dentistry, but have potential for orthopaedic applications as they set at body temperature without shrinkage or significant heat evolution. However, the materials have drawbacks; ZPCs are biocompatible in implant studies, but a fibrous collagen capsular layer forms adjacent to the cement. GPCs are bioactive in the bone environment as a result of the release of calcium, phosphate and fluoride ions, as well as the formation of a silicious gel phase, but research has shown that aluminum ions released result in defective bone mineralisation and as a consequence the ability of these cements to chemically bond to bone is lost. Two approaches have been developed to overcome these problems. The ZPC route considers a ZnO : hydroxyapatite (HA) : poly(acrylic acid) (PAA) mixture, the HA incorporated to improve bioactivity. The GPC route employs a calcium zinc silicate glass; the zinc taking the role that aluminum plays in conventional GPCs. This study has shown that cements can be formulated by an acid base reaction between PAA and both calcium zinc silicate glasses (GPCs) and a mixture of hydroxyapatite and zinc oxide (ZPCs). The moduli of these cements are comparable to both bone and conventional acrylic cements, highlighting their potential for biomedical applications. Unfortunately, both materials have previously been shown to be toxic by cell culture methods, as a result of high zinc ion release, and so it is necessary to study ion release profiles of the cements in order to determine the magnitude of this release. Considering the ZPCs, the modulus of the cement has an inversely proportional relationship to the zinc ion release. From the data presented it is clear that increases in polymer concentration results in lower amounts of zinc ions being released, whilst molar mass of the PAA has no influence. Therefore it would appear that polymer concentration has a significant influence over ion release. Generally, the amount of Zn(2+) released decreases with increasing HA content and/or decreasing ZnO content. Considering the GPCs, the materials are all seen to release large amounts of the active ion, when compared to the commercial versions. The extent of this release increases with temperature and agitation. The release could be minimised by an increased P : L mixing ratio, and an increased PAA concentration, which would produce a more cross-linked cement matrix. Minimising the release of the active ion should improve the in vitro bioactivity of both materials. However, for a full understanding of the clinical benefits of such materials, an in vivo study would be required.

The influence of hydroxyapatite: zinc oxide ratio on the setting behavior and mechanical properties of polyalkenoate cements

The influence of hydroxyapatite (HA) content on the setting behavior and mechanical properties of hydroxyapatite-zinc oxide-poly(acrylic acid) (HA-ZnO-PAA) composite cements were investigated as a function of HA content. The working time increased with HA content up to 45 wt % HA and then decreased whilst the setting time increased with increasing HA content. Mechanical properties were determined after storage in water at 37 degrees C for 1, 7 and 28 days. Young's moduli and compressive strength go through a maximum at approximately 30 and 45 wt % HA. Young's modulus increases with time, which is consistent with an ongoing crosslinking reaction.

The influence of poly(acrylic acid) molar mass on the properties of polyalkenoate cements formed from zinc oxide/apatite mixtures

The influence of poly(acrylic acid) molar mass was investigated on cements formed from zinc oxide-apatite mixtures at three aging times; one, seven and 28 days. Cements based on both hydroxyapatite and fluorapatite were investigated. The compressive strength, un-notched fracture strength and fracture toughness increased markedly with poly(acrylic acid) molar mass. The fracture toughness and un-notched fracture strength increased with aging time for the two highest molar mass cements, but decreased with time for the two lowest molar mass cements. The greater chain entanglement density present in the higher molar mass cements is thought to contribute significantly to the cement stability in addition to the crosslinking of the polyacrylate chains by calcium and zinc ions. Substitution of hydroxyapatite by fluorapatite had no significant influence on the mechanical properties of the cements at aging times longer than one day.

Proteinuria and mortality in diabetes: the WHO Multinational Study of Vascular Disease in Diabetes

The relation between proteinuria and mortality was investigated in 1188 patients with Type 1 diabetes and 3234 patients with Type 2 diabetes, aged 35-55 at baseline and followed up for a mean of 9.4 +/- 3.1 years in the WHO Multinational Study of Vascular Disease in Diabetes. Baseline prevalence of light or heavy proteinuria was the same (25%) in both types of diabetes after adjustment for differences in diabetes duration. Compared with patients with no proteinuria, all cause mortality ratios were 1.5 (95% confidence interval 1.1-2.0) and 2.9 (2.2-3.8) for Type 1 patients with light and heavy proteinuria, respectively, and 1.5 (1.2-1.8) and 2.8 (2.3-3.4) for Type 2 patients, after adjustment for age, duration of diabetes, blood pressure, cholesterol, and smoking. Proteinuria was associated with significantly increased mortality from renal failure, cardiovascular disease, and all other causes of death. In both types of diabetes, the association was strongest for renal deaths, and of similar magnitude for cardiovascular and all other causes of death. In conclusion, proteinuria is a common, important, and rather non-specific risk factor for increased morbidity and mortality in diabetes. The relation of proteinuria to mortality is similar for both types of diabetes. The benefits and risks of proteinuria reduction should be examined in large randomized trials with clinical endpoints.

New home-delivered training prospects for people with disabilities

The 'Home-Delivered Training Project' set out to test the viability of providing training in Information Technology to people with physical disabilities in their homes, using computers and modem links. The course included core modules on business applications software and optional modules on more specialist applications. The computer-based approach to instruction included computerized monitoring of student progress, the provision of on-line tutorial support as well as computerized test administration and marking. The 20 course participants, who lived in locations throughout Ireland, were unable to attend conventional training centres because of their limited mobility or other restrictions arising from their disabilities. They differed considerably in terms of disability type, educational qualifications and experience with computers. All but one of them completed the course successfully and were awarded certificates which are recognized in Ireland and the United Kingdom. Overall, they were very positive about the course, mainly because they could undertake it in their homes at a flexible pace to suit their learning patterns and the requirements of their disabilities. They recognized, however, that studying at home required a self-disciplined study routine which was not always easy to maintain. The fact that they were awarded an internationally recognized qualification on completion of the course was an important motivating factor, as it made the course relevant in terms of their employment aspirations.

A follow-up study of diabetic Oklahoma Indians. Mortality and causes of death

OBJECTIVE

To determine the mortality rates and causes of death for diabetic Oklahoma Indian adults by sex and age.

RESEARCH DESIGN AND METHODS

This was a cohort follow-up study with baseline examination between 1972-1980 and the mortality follow-up between 1986 and 1989. Mean follow-up time was 10 +/- 4 yr. A quasi-random sample of 1012 (379 men and 633 women) NIDDM American Indians in Oklahoma was performed. Mean age was 52 yr and duration was 7 yr at baseline. Mean degree of Indian blood was 92% (77% full blood). At follow-up, 548 (54%) were alive, 452 (45%) were decreased, and 12 (1%) could not be traced.

RESULTS

Death certificates were obtained and coded (ICD-9) for 439 (97%) of the deceased. Mean annual mortality rates were 4.99% for men and 4.17% for women, with an increasing trend with age for both sexes. Compared with the general population of Oklahoma, the observed/expected ratios for number of deaths were 2.92 for men and 4.09 for women (P < 0.0001). The three leading causes of death were circulatory disease (38%), diabetes (24%), and malignant neoplasms (12%).

CONCLUSIONS

There is an excessively high mortality among diabetic Oklahoma Indians compared with the general population in the state and with diabetic patients in other populations.

Effects of secretin and caerulein on enzymes of cultured pancreatic acinar cells

We examined the effects of secretin (0 to 200 nM) and caerulein (0 to 100 nM) on rat pancreatic acinar cells cultured 0 to 48 h in serum-free medium. The effects of 100 nM secretin with 1 nM caerulein were also studied because secretin may potentiate the effects of caerulein. Cellular and media (secreted) lipase and amylase were analyzed as were cellular DNA and protein content. Cellular lipase and amylase activities significantly decreased (P less than 0.0001) over time in all treatment groups, whereas media amylase and lipase significantly increased (P less than 0.0001). Neither secretin nor caerulein affected cellular lipase or media amylase. However, secretin significantly increased (P less than 0.04) and caerulein tended to increase (P less than 0.08) media lipase in a dose-dependent manner. At 12 h, 10 nM secretin maximally increased media lipase (58%) suggesting that cultured acinar cells remain responsive to secretin in vitro. Caerulein, at all concentrations, significantly decreased (P less than 0.001) cellular amylase but exhibited a dose-dependent effect only at 24 h when 100 nM caerulein maximally decreased cellular amylase (34%). Secretin (100 nM) did not alter these effects of caerulein. These results support the proposed role of caerulein in the regulation of amylase but not a direct role of secretin in the regulation of lipase.

Telework as an employment option for people with disabilities

This feasibility study, based on intensive casework, examined the potential of home-based teleworking arrangements for people with severe physical disabilities. Eleven teleworking arrangements, each involving a unique combination of work, working conditions and worker characteristics, were set up in different parts of Ireland and monitored over periods ranging from 6 to 18 months. Eight were still operational at the end of the project and, with one exception, were set to continue as longer-term arrangements. Outcomes from this action-research project suggest that teleworking is a feasible form of employment for such persons--provided care is taken over selection of workers, identification of work that is suited to the telework format and management of telework units by employers. They also suggest that teleworking arrangements can be quite flexible, ranging from examples in which work is performed mainly from home to those which combine home-based activity with varying degrees of conventional office-based activity. It is concluded that telework will create new opportunities for people with severe disabilities, as well as enabling others who become disabled during employment to retain their jobs. However, it is important that workers are appropriately trained in the use of computers and advanced telecommunications and, in many cases, home-delivered training is required.

Localization by mutational analysis of transcription factor binding sequences in the U3 region of Rous sarcoma virus LTR

The transcription factor binding sequences in the U3 region of Rous Sarcoma virus LTR have been determined by gel retardation assays using mutant synthetic oligonucleotides. The results indicate that the factor, E2BP, specifically binds to sequences TGCAATAC and TGCAACAT, which are localized between nucleotides -222 to -215 and -203 to -196, respectively. This factor is present at elevated levels in avian QT6 cells compared to mouse 3T3 and rat 2 tk- cells. E2BP binds to a sequence that is similar or identical to the sequence recognized by rat liver C/EBP. However, the two proteins are different as judged by three criteria: (i) the E2BP complex migrates slightly faster than the E2-C/EBP complex; (ii) antibodies against C/EBP neither inhibit binding of E2BP nor form a supercomplex which migrates slower than the complex formed with the factor alone; and (iii) E2BP is heat labile whereas C/EBP is heat stable. Another factor, E3BP, which binds to a sequence from -169 to -158, in the U3 region is also detected mainly in QT6 cells but not in mouse or rat cells. These results suggest that different cell-specific factors interact with different cis-acting regulatory sequences in the U3 region of RSV LTR.