Looking after patients, not looking for patients

How transfers from ward to ward can affect continuity of care.

Self-hypnosis for intrapartum pain management in pregnant nulliparous women: a randomised controlled trial of clinical effectiveness

Objective

(Primary) To establish the effect of antenatal group self-hypnosis for nulliparous women on intra-partum epidural use.

Design

Multi-method randomised control trial (RCT).

Setting

Three NHS Trusts.

Population

Nulliparous women not planning elective caesarean, without medication for hypertension and without psychological illness.

Methods

Randomisation at 28–32 weeks’ gestation to usual care, or to usual care plus brief self-hypnosis training (two × 90-minute groups at around 32 and 35 weeks’ gestation; daily audio self-hypnosis CD). Follow up at 2 and 6 weeks postnatal.

Main outcome measures

Primary: epidural analgesia. Secondary: associated clinical and psychological outcomes; cost analysis.

Results

Six hundred and eighty women were randomised. There was no statistically significant difference in epidural use: 27.9% (intervention), 30.3% (control), odds ratio (OR) 0.89 [95% confidence interval (CI): 0.64–1.24], or in 27 of 29 pre-specified secondary clinical and psychological outcomes. Women in the intervention group had lower actual than anticipated levels of fear and anxiety between baseline and 2 weeks post natal (anxiety: mean difference −0.72, 95% CI −1.16 to −0.28, P = 0.001); fear (mean difference −0.62, 95% CI −1.08 to −0.16, P = 0.009) [Correction added on 7 July 2015, after first online publication: ‘Mean difference’ replaced ‘Odds ratio (OR)’ in the preceding sentence.]. Postnatal response rates were 67% overall at 2 weeks. The additional cost in the intervention arm per woman was £4.83 (CI −£257.93 to £267.59).

Conclusions

Allocation to two-third-trimester group self-hypnosis training sessions did not significantly reduce intra-partum epidural analgesia use or a range of other clinical and psychological variables. The impact of women's anxiety and fear about childbirth needs further investigation.

Tweetable abstract

Going to 2 prenatal self-hypnosis groups didn't reduce labour epidural use but did reduce birth fear & anxiety postnatally at < £5 per woman.

Production of functional human insulin-like growth factor binding proteins (IGFBPs) using recombinant expression in HEK293 cells

Insulin-like growth factor binding proteins (IGFBPs) display many functions in humans including regulation of the insulin-like growth factor (IGF) signaling pathway. The various roles of human IGFBPs make them attractive protein candidates in drug discovery. Structural and functional knowledge on human proteins with therapeutic relevance is needed to design and process the next generation of protein therapeutics. In order to conduct structural and functional investigations large quantities of recombinant proteins are needed. However, finding a suitable recombinant production system for proteins such as full-length human IGFBPs, still remains a challenge. Here we present a mammalian HEK293 expression method suitable for over-expression of secretory full-length human IGFBP-1 to -7. Protein purification of full-length human IGFBP-1, -2, -3 and -5 was conducted using a two-step chromatography procedure and the final protein yields were between 1 and 12mg protein per liter culture media. The recombinant IGFBPs contained PTMs and exhibited high-affinity interactions with their natural ligands IGF-1 and IGF-2.

Glenoid Rim Anatomy: Risk for Glenoid Vault Perforation During Labral Repair

Background:

Injuries to the glenoid labrum frequently require repair with anchors. Placing anchor devices arthroscopically can be challenging, and anchor malpositioning can complicate surgical outcomes.

Purpose:

To determine the safe insertion range and optimal insertion angle of glenoid labral anchors at various positions on the glenoid rim and to establish surgical guidelines that minimize risk of anchor perforation.

Study Design:

Descriptive laboratory study.

Methods:

Three-dimensional computed tomography scans of 30 normal cadaveric specimens were obtained. A virtual model of a generic labral anchor was inserted into the rim of the glenoid at the clockface positions represented by 12:00, 1:30, 3:00, 4:30, 6:00, 7:30, 9:00, and 10:30. At each position, the safe insertion range was the maximal range measured, and the optimal insertion angle was identified as the angle between the bisector of the safe insertion range and the glenoid face.

Results:

Progressing in the clockwise direction, beginning at the 12:00 position, the safe insertion ranges (mean ± SD ) were 55.9° ± 10.6°, 63.6° ± 17.6°, 47.7° ± 9.1°, 46.1° ± 8°, 73.9° ± 9.7°, 40.9° ± 6.5°, 40.4° ± 7.4°, and 39.9° ± 7.1°, respectively. The optimal insertion angles were 47.9° ± 7.6°, 53.1° ± 10.9°, 35.0° ± 4.4°, 42.4° ± 4.9°, 60.9° ± 8.4°, 36.6° ± 5.9°, 31.2° ± 4.9°, 34.8° ± 4.6°, respectively.

Conclusion:

Optimal insertion angles and safe insertion ranges varied significantly with respect to the position on the glenoid face. The safe insertion range and optimal insertion angle were found to be wider at the anterior glenoid as compared with the posterior glenoid. A posterolateral insertion angle was safer than an anterior insertion angle at the 10:30 position.

Clinical Relevance:

Proper arthroscopic technique resulting in anchor insertion at the correct angle, depth, and location will prevent anchor-related glenohumeral complications such as glenoid perforation, cartilage damage, persistent pain, decreased range of motion, and failure of the reconstruction.

Diagnosis and management of primary ciliary dyskinesia

Primary ciliary dyskinesia (PCD) is an inherited autosomal-recessive disorder of motile cilia characterised by chronic lung disease, rhinosinusitis, hearing impairment and subfertility. Nasal symptoms and respiratory distress usually start soon after birth, and by adulthood bronchiectasis is invariable. Organ laterality defects, usually situs inversus, occur in ∼50% of cases. The estimated prevalence of PCD is up to ∼1 per 10,000 births, but it is more common in populations where consanguinity is common. This review examines who to refer for diagnostic testing. It describes the limitations surrounding diagnosis using currently available techniques and considers whether recent advances to genotype patients with PCD will lead to genetic testing and screening to aid diagnosis in the near future. It discusses the challenges of monitoring and treating respiratory and ENT disease in children with PCD.

First Report of Anthracnose on Peach Fruit Caused by Colletotrichum truncatum in South Carolina

In July 2013, two diseased peach fruit (Prunus persica (L.) Stokes) of the cv. Sweet Dream were collected from a commercial orchard in Ridge Springs, South Carolina. Affected peaches were at or near maturity and symptoms resembled anthracnose disease caused by Colletotrichum spp. with circular sunken tan to brown lesions that were firm in touch, and had wrinkled concentric rings. The center of the lesion was covered with black acervuli containing setae. To isolate the causal agent, the two symptomatic fruit were surface-sterilized in 10% bleach for 2 min and rinsed with sterile distilled water. Lesions were cut in half, and necrotic tissue from the inside of the fruit was placed on acidified potato dextrose agar (APDA). Flat colonies covered with olive-gray to iron-gray acervuli developed on APDA incubated at 22°C with a 12-h cycle of fluorescent light and darkness. Morphology of acervuli, setae (avg. 90 to 160 μm), conidiophores (up to 90 um long), and conidia (avg. 22 × 3.8 μm) of single spore isolates were consistent with descriptions of Colletotrichum truncatum (Schwein.) Andrus & W.D. Moore (3), a causal agent of anthracnose disease. Genomic DNA was extracted from isolate Ct_RR13_1 using the MasterPure Yeast DNA Purification Kit (Epicentre, Madison, WI). The ribosomal ITS1-5.8S-ITS2 region and a partial sequence of the actin gene were amplified with primer pair ITS1 and ITS4 (4), and primer pair ACT-512F and ACT-783A (2), respectively. A multilocus sequence identification in Q-bank Fungi revealed a 100% similarity with C. truncatum (1). The C. truncatum sequences from the peach isolate were submitted to GenBank (accessions KF906258 and KF906259). Pathogenicity of isolate Ct_RR13_1 was confirmed by inoculating five mature but still firm peach fruits with a conidial suspension of C. truncatum. Peaches were washed with soap and water, surface-disinfected for 2 min with 10% bleach, rinsed with sterile distilled water, and air dried. Dried fruit were stabbed at three equidistant points, each about 2 cm apart, to a depth of 9.5 mm using a sterile 26G3/8 beveled needle (Becton Dickinson & Co., Rutherford, NJ). For inoculation, a 30-μl droplet of conidia suspension prepared in distilled, sterile water (1 to 2 × 10⁴ spores/ml) was placed on each wound; control fruit received sterile water without conidia. Fruit were incubated at 22°C for 2 days at 100% humidity and another 12 days at 70% humidity. Inoculated fruit developed anthracnose symptoms with sporulating areas as described above and the fungus was re-isolated. All control fruit remained healthy. C. truncatum has a wide host range, including legumes and solanaceous plants of the tropics, and is especially common in the Fabaceae family. Its occurrence in a commercial peach orchard is worrisome because control measures may need to be developed that are different from those developed for endemic species, i.e. C. acutatum and C. gloeoporioides, due to differences in disease cycle or fungicide sensitivity. To our knowledge, this is the first report of C. truncatum causing anthracnose on a member of the genus Prunus. References: (1) P. Bonants et al. EPPO Bull. 43:211, 2013. (2) I. Carbone et al. Mycologia 91:553, 1999. (3) U. Damm et al. Fungal Divers. 39:45, 2009. (4) T. J. White et al. Pages 315-322 in: PCR Protocols: A Guide to Methods and Application. Academic Press, NY, 1993.

The individual supported living (ISL) manual: a planning and review instrument for individual supported living arrangements for adults with intellectual and developmental disabilities

BACKGROUND

Following the closure of large residential facilities over the past several decades, emphasis on community living for adults with developmental disabilities has strengthened. However, the concept of community living is ambiguous. The term is often associated with congregation of people with disabilities in ordinary houses 'in' the community. Group homes, the most common contemporary formal expression of 'community living', may use ordinary houses and accommodate a small number of residents comparable to a large family. Individual supported living (ISL) arrangements around a single person with a disability using person-centred principles are occurring with increasing frequency. The ISL manual was developed over 4 years in two sequential research projects to produce a quality framework articulating ISL and operationalising the framework into a review and planning instrument for ISL arrangements.

METHOD

The ISL manual was developed in three stages and overseen by a reference group of key stakeholders purposively recruited as well-versed in ISL. The first stage operationalised the quality framework over two half-day workshops with a group of key informants. Participants identified indicators and sources of evidence for each attribute of the quality framework. The quality framework, indicators, and sources of evidence were compiled into an initial evaluation instrument of nine themes consisting of 27 attributes. This was piloted in two rounds to enhance the utility of the instrument and develop the final manual which contained eight themes and 21 attributes. A comprehensive literature search was carried out to identify relevant empirical ISL studies.

RESULTS

The literature search identified four empirical studies that incorporated ISL over the preceding 3 years. A previous literature search from the first research project that produced the quality framework spanned 27 years and identified five empirical studies. We concluded that the empirical base for developing evidence for the nature and outcomes of ISL arrangements was sparse. The ISL manual and scoring booklet developed in the current research project includes six illustrative case studies of ISL, instructions for potential users to review living arrangements or set up a new arrangement, and the review framework consisting of descriptions of themes and attributes, indicators, and sources of evidence.

CONCLUSIONS

The dearth of empirical studies of ISL arrangements for people with developmental disabilities, despite increased policy emphasis on individualised options, underscores the importance of planning and review tools to promote quality outcomes. The ISL manual can assist adults with developmental disabilities, families, carers, and service providers to plan and review ISL arrangements. Further research will enhance the properties of this instrument and establish the relationship between quality of ISL arrangements and outcomes such as quality of life, and participation and inclusion.

Ten-year follow up of hydroxychloroquine treatment for ABCA3 deficiency

We present a child with interstitial lung disease (ILD) who was diagnosed with desquamative interstitial pneumonitis following CT thorax and open lung biopsy aged 2 years. Subsequently, surfactant protein gene analysis revealed mutations in the ABCA3 gene. This case of ABCA3 deficient ILD describes a stable clinical course over 10 years and highlights the potential benefit of hydroxychloroquine for this condition.

First Report of Fusarium Wilt of Strawberry Caused by Fusarium oxysporum in South Carolina

During October 2011, wilted and dead strawberry (Fragaria × ananassa cv. Albion) plants from two commercial fields in South Carolina were sent to the Clemson University Plant Problem Clinic in Pendleton, SC. Symptoms consisted of wilting and chlorosis of foliage, scorch and dieback of older leaves, and stunting of plants. Internal vascular and cortical tissues of plant crowns showed a distinct reddish brown discoloration. To isolate the causal agent, necrotic crown tissue selected from two symptomatic plants from one location and four symptomatic plants from the other were placed on acidified potato dextrose agar (APDA) and on quarter strength acidified PDA (QPDA). Colonies with light purple mycelia and beige or orange reverse colony colors developed on APDA after 5 days of incubation at 25°C. Colonies on QPDA were light purple. Morphology, growth, and development of macroconidia and microconida were consistent with descriptions of Fusarium oxysporum Schlechtend emend. Snyder & Hansen (3). Genomic DNA from 3 isolates (11-1246A, 11-1247A, and 11-1247B) was extracted and purified according to Chi et al. (1). The internal transcribed spacer region comprising ITS1, ITS2, and 5.8S rRNA was amplified by primers ITS1 and ITS4 (4). The sequence comparison revealed a 100% match with F. oxysporum sequences in GenBank. To confirm the pathogenicity of the fungus, roots of 15 strawberry plants (cv. Albion) were cut and then five plants were soaked for 10 min in either 500 ml of conidial suspension (10⁴ conidia/ml) of one of the two isolates or in sterile distilled water. All were then potted in 15-cm pots with artificial peat-based soil mix and maintained at 25°C in the greenhouse. After 6 weeks, all plants inoculated with isolates 1247A and B were stunted and developed wilt symptoms similar to those observed in the field, while the control plants remained healthy. Support roots on all affected plants were soft and flaccid and new feeder roots had brown lesions. Crowns of three plants inoculated with isolate 1247A and four plants inoculated with 1247B showed vascular discoloration. To reisolate, crowns were plated as above and roots were surface sterilized in 10% bleach for 1 min and rinsed in sterile distilled water prior to plating on QPDA. F. oxysporum was isolated at frequencies of 70 and 100% from crowns and 100% from roots of all inoculated plants. To our knowledge, this is the first report of the occurrence of Fusarium wilt caused by F. oxysporum on strawberry plants in South Carolina. The presence of Fusarium wilt in South Carolina should alert growers, county agents, and specialists to properly identify Fusarium wilt symptoms, which may be confused with Anthracnose or Phytophthora crown rot of strawberry. The disease has been reported previously in other countries including the United States (2). References: (1) M. H. Chi et al. Plant Pathol. J. 25:108, 2009. (2) S. T. Koike et al. Plant Dis. 93:1077, 2009. (3) W. C. Snyder and H. N. Hansen. Am. J. Bot. 27:64, 1940. (4) T. J. White et al. Page 315 in: PCR Protocols: A Guide to Methods and Application. Academic Press, NY, 1993.

SU-E-T-262: Treatment Room Activation after 15 MV Single Fraction Radiation Treatments Delivered Using Varian's TrueBeam and Trilogy Linear Accelerators

PURPOSE

To measure radiation levels in treatment room due to activation after 15MV single fraction radiation treatment (SFRT) delivered to a solid water phantom.

METHODS

We performed radiation surveys of two LINAC treatment rooms immediately after 15 MV SFRT. We delivered a sequence of two 15 MV single fraction IMRT treatments to a phantom at the end of a typical treatment day. The first treatment delivered was 6201MU (about 12 Gy) and the second one, 15 minutes later was 12711 MU (24 Gy). Both were delivered to the pelvic region of a solid water anthropomorphic phantom. In a second technique, a 15 MV VMAT SFRT (4326 MU) was delivered using the Varian TrueBeam LINAC. Radiation measurements were recorded repetitively at four locations using a thin windowed Geiger Muller detector, a sodium iodide photon spectrometer and a pressurized ionization chamber. The four locations surveyed were: the top of the collimator head, the collimator window surface, the isocenter, and the inferior end of the patient support assembly.

RESULTS

Radiation levels at the isocenter at the end of the treatment day and before the two IMRT SFRTs varied from 0.06 to 0.1 mR/h. Within 2-3 minutes after finishing the second IMRT SFRT the radiation levels were approximately 10 and 1.4 mR/h at isocenter for the TrueBeam and Trilogy rooms respectively and around 0.6 mR/h for the TrueBeam VMAT SFRT. Closing the MLC and the jaws significantly reduces the radiation level at isocenter. The average half life of the mixture of radionuclides produced is about 10 minutes.

CONCLUSIONS

High dose single fraction IMRT treatments with 15 MV photons produce elevated treatment room activation as compared to conventional IMRT. In addition, activation levels varied between the TrueBeam and Trilogy for similar SFRT schemes. There is no funding support, disclosures, or conflict of interest.

Identification of the Drosophila and Tribolium receptors for the recently discovered insect RYamide neuropeptides

One year ago, we discovered a new family of insect RYamide neuropeptides, which has the C-terminal consensus sequence FFXXXRYamide, and which is widely occurring in most insects, including the fruitfly Drosophila melanogaster and the red flour beetle Tribolium castaneum (F. Hauser et al., J. Proteome Res. 9 (2010) 5296-5310). Here, we identify a Drosophila G-protein-coupled receptor (GPCR) coded for by gene CG5811 and its Tribolium GPCR ortholog as insect RYamide receptors. The Drosophila RYamide receptor is equally well activated (EC(50), 1×10(-9)M) by the two Drosophila RYamide neuropeptides: RYamide-1 (PVFFVASRYamide) and RYamide-2 (NEHFFLGSRYamide), both contained in a preprohormone coded for by gene CG40733. The Tribolium receptor shows a somewhat higher affinity to Tribolium RYamide-2 (ADAFFLGPRYamide; EC(50), 5×10(-9)M) than to Tribolium RYamide-1 (VQNLATFKTMMRYamide; EC(50), 7×10(-8)M), which might be due to the fact that the last peptide does not completely follow the RYamide consensus sequence rule. There are other neuropeptides in insects that have similar C-terminal sequences (RWamide or RFamide), such as the FMRFamides, sulfakinins, myosuppressins, neuropeptides F, and the various short neuropeptides F. Amazingly, these neuropeptides show no cross-reactivity to the Tribolium RYamide receptor, while the Drosophila RYamide receptor is only very slightly activated by high concentrations (>10(-6)M) of neuropeptide F and short neuropeptide F-1, showing that the two RYamide receptors are quite specific for activation by insect RYamides, and that the sequence FFXXXRYamide is needed for effective insect RYamide receptor activation. Phylogenetic tree analyses and other amino acid sequence comparisons show that the insect RYamide receptors are not closely related to any other known insect or invertebrate/vertebrate receptors, including mammalian neuropeptide Y and insect neuropeptide F and short neuropeptide F receptors. Gene expression data published in Flybase (www.flybase.org) show that the Drosophila CG5811 gene is significantly expressed in the hindgut of adult flies, suggesting a role of insect RYamides in digestion or water reabsorption.