Laparoscopic hysteropexy: 1- to 4-year follow-up of women postoperatively

INTRODUCTION AND HYPOTHESIS

Uterine conserving re-suspension surgery has become more popular in recent years. Such surgery may allow preservation of fertility in younger women, but may also have the added benefit of augmenting weak connective tissue and possibly providing stronger apical support than the conventional hysterectomy. Our goal was to evaluate the 1- to 4-year outcome of laparoscopic hysteropexy for the surgical management of uterine prolapse.

METHODS

This study was a prospective observational study of 182 consecutive women who underwent laparoscopic hysteropexy, with or without additional vaginal repair, from the beginning of 2007 until the end of 2010. Women were invited to attend a dedicated clinic for interview and their prolapse was assessed using the Patient Global Impression of Improvement (PGI-I), the International Consultation on Incontinence Questionnaire for Vaginal Symptoms (ICIQ-VS) and the pelvic organ prolapse quantification (POP-Q) scale. Wilcoxon signed-rank test was used to compare pre-operative with postoperative data. Complications and women's satisfaction were also noted.

RESULTS

One hundred and forty women agreed to participate; the mean interval from operation was 2.1 years (range 1-4.4). Eighty-nine percent of women felt that their prolapse is "very much" or "much" better using PGI-I subjective outcome measure. There was significant improvement for all parameters of ICIQ-VS and POP-Q scoring post-surgery (p < 0.001). Six women (4 %) had further apical prolapse; of these, 3 underwent further prolapse surgery. None of the participants had any mesh exposure. Ninety two percent of participants would recommend the operation.

CONCLUSIONS

Laparoscopic hysteropexy is a safe and effective treatment. The 1- to 4-year outcome suggests high patient satisfaction and low rates of apical prolapse recurrence. Longer term follow-up and randomized controlled studies are required.

Low rate of active treatment of patients with hilar cholangiocarcinoma

INTRODUCTION

The results of surgical resection and palliative chemotherapy use in hilar cholangiocarcinoma (HC) have been well publicised but the proportion of patients able to undergo these treatments and the comparative outcomes in a population of patients with HC are less well known.

METHODS

Patients with HC were identified by review of all patients undergoing percutaneous cholangiography over a nine-year period (2002-2010) in a tertiary facility. The treatment undertaken and outcomes were recorded.

RESULTS

Overall, 68 patients were identified (37 female) with a median age of 70 years. Forty-five (66%) were treated solely by insertion of a metal stent (median survival 4.73 months) and nine (13%) also received palliative chemotherapy (median survival 13.7 months). Persisting jaundice after stent insertion was noted in 18 of 35 patients (51%) tested within one month of death. Fourteen patients (21%) underwent surgical resection (median survival 20.2 months).

CONCLUSIONS

Patients undergoing surgical resection had significantly longer survival than those receiving only a palliative stent but not compared with those also receiving palliative chemotherapy, with short-term follow-up. Only a third of patients, however, receive active treatment (surgery or chemotherapy) and improvements in long-term biliary palliation are needed.

Salmonella and Escherichia coli O157:H7 prevalence in cattle and on carcasses in a vertically integrated feedlot and harvest plant in Mexico

To determine the prevalence of Salmonella and Escherichia coli O157:H7 in cattle feedlots and the impact of subsequent contamination on carcasses in a Mexican Federal Inspection Type Standards harvest facility, 250 animals were tagged and sampled in each step of the slaughter process. Samples were taken from hides and fecal grabs, and composite samples were taken from three anatomical carcass sites (hindshank, foreshank, and inside round) during the slaughter process, at preevisceration (PE), prior to entering the hot box (PHB), and after 24 h of dry chilling (DC). Additionally, 250 fecal samples were collected from the feedlot (FL), holding pens (HP), and intestinal feces (IF), and water samples were taken from the HP area. E. coli O157:H7 and Salmonella detection were carried out with the BAX System, immunomagnetic separation, and conventional methods. Overall Salmonella prevalence was 52.5%. The highest prevalence (92.4%) was found on hides, followed by feces from the HP (91.0%), FL (55.56%), PE (49.0%), IF (46.8%), and PHB (24.8%), for all sampling periods combined. The lowest prevalence of 6.0% was found after DC. The overall prevalence of E. coli O157:H7 was as follows: 11.7% for hides, 5.2% for IF, 2.7% for FL, 2.0% for HP, 0.8% for PE, 0.4% for PHB, and 0.4% for the cooler. High prevalence of Salmonella in IF and on hides present a significant risk factor for contamination by Salmonella at the different processing steps. These results serve as a warning as to the risks of contamination in meats for these pathogens and the importance of following good manufacturing practices during beef production processes.

Uptake and effectiveness of a community pharmacy intervention programme to improve asthma management

WHAT IS KNOWN AND OBJECTIVE

Pharmacists frequently see patients with asthma in the community who have suboptimal management. This study aimed to compare the uptake and effectiveness of pharmacist-initiated mailed and face-to-face interventions for patients whose asthma may not be well managed.

METHODS

Seventy-one community pharmacies in South Australia, Tasmania and Victoria (Australia) installed a software application that data-mined dispensing records, generating a list of patients who had received six or more asthma reliever inhalers in the preceding 12 months. The pharmacists were randomized, by pharmacy, to perform either a mailed or face-to-face intervention, whereby these patients received educational material and a referral to their general practitioner (GP) for an asthma management review. Matching patients from each pharmacy were also randomly assigned to a control group for 'usual care'.

RESULTS AND DISCUSSION

A total of 1483 patients were identified and grouped as follows: 510 (34·4%) mailed intervention, 480 (32·4%) face-to-face intervention and 493 (33·2%) controls. Significantly fewer face-to-face interventions were offered than mailed interventions (66·6% vs. 89·4%, respectively; χ(2) = 64·2, P < 0·0001). There were significant improvements in the preventer-to-reliever ratio after the intervention period (P < 0·0001) in each group. In a per-protocol analysis, the magnitude of improvement in the face-to-face intervention group was greater than in the mailed intervention group. The reverse was true in an intention-to-treat analysis. The improvement in the P : R ratios was mainly due to significant decreases in reliever usage.

WHAT IS NEW AND CONCLUSION

Community pharmacy dispensing records can effectively identify patients with suboptimal asthma management, who can then be referred to their GP for review. Time constraints in busy pharmacies may limit the uptake and effectiveness of face-to-face interventions in the 'real world' setting, making mailed interventions an attractive option.

A snapshot of genetic lineages of Mycobacterium tuberculosis in Ireland over a two-year period, 2010 and 2011

Mycobacterial interspersed repetitive-unit-variable-number tandem repeat typing alone was used to investigate the genetic lineages among 361 Mycobacterium tuberculosis strains circulating in Ireland over a two-year period, 2010 and 2011. The majority of isolates, 63% (229/361), belonged to lineage 4 (Euro-American), while lineages 1 (Indo-Oceanic), 2 (East-Asian) and 3 (East-African–Indian) represented 12% of isolates each (42/361, 45/361, and 45/361, respectively). Sub-lineages Beijing (lineage 2), East-African–Indian (lineage 1) and Delhi/central-Asian (lineage 3) predominated among foreign-born cases, while a higher proportion of Euro-American lineages were identified among cases born in Ireland. Eighteen molecular clusters involving 63 tuberculosis (TB) cases were identified across four sub-lineages of lineage 4. While the mean cluster size was 3.5 TB cases, the largest cluster (involving 12 Irish-born cases) was identified in the Latin American–Mediterranean sub-lineage. Clustering of isolates was higher among Irish-born TB cases (47 of 63 clustered cases), whereas only one cluster (3/63) involved solely foreign-born individuals. Four multidrug-resistant cases identified during this period represented lineages 2 and 4. This study provides the first insight into the structure of the M. tuberculosis population in Ireland.

A snapshot of genetic lineages of Mycobacterium tuberculosis in Ireland over a two-year period, 2010 and 2011

Binary file ES_Abstracts_Final_ECDC.txt matches

Association between genetic variants in adhesion molecules and outcomes after hematopoietic cell transplants

Allogeneic hematopoietic cell transplant (HCT) is associated with a high morbidity and mortality. Adhesion molecules play an important role in endothelial activation and initiation of inflammatory response. We hypothesized that single nucleotide polymorphisms (SNPs) in the endothelial molecules may contribute to heterogeneity in HCT outcomes. We evaluated the association of 4 SNPs in ICAM1 (rs5498), PECAM1 (rs668 and rs1131012) and SELL (rs2229569) genes with acute and chronic graft-versus-host disease (GvHD) and those experiencing transplant-related mortality (TRM) within 1 year among 425 allogeneic HCT recipient-donor pairs. Using a Fine and Gray proportional hazards model to evaluate the association between genetic variants and clinical outcomes, after adjustment for recipient age, race, diagnosis, disease status, gender mismatch, cytomegalovirus serostatus, gender, donor type, conditioning regimen and year of transplant, only rs5498 in the ICAM1 gene among both recipients and donors was associated with a decreased risk of TRM (P ≤ 0.02). None of the SNPs were associated with acute or chronic GvHD risk. These findings suggest that genetic variants in the vascular adhesion molecules may be used to identify patients at high risk for TRM.

Circulating tumor cells in immunohistochemical subtypes of metastatic breast cancer: lack of prediction in HER2-positive disease treated with targeted therapy

BACKGROUND

Circulating tumor cells (CTCs) are associated with inferior prognosis in metastatic breast cancer (MBC). We hypothesized that the relationship between CTCs and disease subtype would provide a better understanding of the clinical and biologic behavior of MBC.

PATIENTS AND METHODS

We retrospectively analyzed 517 MBC patients treated at a single institution. Subtypes of primary tumors were analyzed by immunohistochemical (IHC) or fluorescent in situ hybridization analyses and CTCs were enumerated by CellSearch(®) at starting a new therapy. Overall survival (OS) and progression-free survival durations for each IHC subtype were determined.

RESULTS

At a median follow-up of 24.6 months, 276 of 517 (53%) patients had died. The median OS for patients with <5 and ≥ 5 CTCs were 32.4 and 18.3 months, respectively (P < 0.001). Except in HER2+ patients, the prognostic value of CTCs was independent of disease subtype and disease site.

CONCLUSIONS

In this large retrospective study, CTCs were strongly predictive of survival in all MBC subtypes except HER2+ patients who had been treated with targeted therapy. Our results clearly demonstrate the value of enumerating CTCs in MBC and strongly suggest an interesting biological implication in the HER2+ subset of patients that need to be further explored.

Value of subtraction MRI in assessing treatment response following image-guided loco-regional therapies for hepatocellular carcinoma

AIM

To compare contrast-enhanced subtraction magnetic resonance imaging (MRI) with contrast-enhanced standard MRI in assessing treatment response following loco-regional therapies for hepatocellular carcinoma (HCC).

METHOD AND MATERIALS

Institutional review board approval was obtained and informed consent was waived for this retrospective study. All patients were analysed from our institution's liver tumour database that had loco-regional HCC therapy and the following: (1) a contrast-enhanced MRI ≤6 weeks post-treatment, (2) an unenhanced T1-weighted high-signal treatment zone (TZ) ≥1 cm, (3) follow-up contrast-enhanced MRI performed ≥6 months post-treatment. Randomized standard and subtraction TZ datasets were independently assessed by three blinded radiology readers for either complete treatment necrosis or residual disease. The standard of reference (SOR) comprised a consensus read by two radiologists with knowledge of the follow-up MRI and all available clinical data. Statistical analyses were performed using receiver operating characteristics (ROC), t-test, and kappa statistic.

RESULTS

Twenty-six patients (19 male and seven female patients; mean age 60 years, standard deviation 10.9 years, range 46-88 years) had a total of 45 corresponding HCCs and TZs. For ROC, the area under the curve (AUC) was 0.93 (subtraction protocol) versus 0.90 (standard protocol; p = 0.49). For the t-test, the mean reader confidence level was 4.4, 3.6, and 4.4 (subtraction protocol) versus 3, 3, and 3.7 (standard protocol; p ≤ 0.011). The kappa statistic for reader-to-SOR agreement was 0.83, 0.63, and 0.71 (subtraction protocol) versus 0.51, 0.36, and 0.64 (standard protocol).

CONCLUSION

Subtraction MRI significantly improves the reader confidence level in the assessment of treatment response following loco-regional therapies for HCC.

Infections in postmenopausal women with osteoporosis treated with denosumab or placebo: coincidence or causal association?

Serious adverse events of infections that occurred in subjects receiving denosumab or placebo in the Fracture Reduction Evaluation of Denosumab in Osteoporosis every 6 Months (FREEDOM) study were examined in detail. Serious adverse events of infections in denosumab subjects had heterogeneous etiology, with no clear clinical pattern to suggest a relationship to time or duration of exposure to denosumab.

INTRODUCTION

Denosumab reduces the risk for new vertebral, hip, and nonvertebral fractures compared with placebo. In the pivotal phase 3 fracture trial (FREEDOM), the overall safety profile and incidence of adverse events including adverse events of infections were similar between groups. Serious adverse events of erysipelas and cellulitis were more frequent in denosumab-treated subjects. In this report, we further evaluate the details of infectious events in FREEDOM to better understand if RANKL inhibition with denosumab influences infection risk.

METHODS

FREEDOM was an international multicenter, randomized, double-blind, placebo-controlled study in postmenopausal women with osteoporosis randomly assigned to receive placebo (n = 3,906) or denosumab 60 mg every 6 months (n = 3,902). The incidence of adverse events and serious adverse events categorized within the Medical Dictionary for Regulatory Activities system organ class, "Infections and Infestations," was compared between the placebo and denosumab groups by body systems and preferred terms. The temporal relationship between occurrence of serious adverse events of infections of interest and administration of denosumab was explored.

RESULTS

Serious adverse events of infections involving the gastrointestinal system, renal and urinary system, ear, and endocarditis were numerically higher in the denosumab group compared with placebo, but the number of events was small. No relationship was observed between serious adverse events of infections and timing of administration or duration of exposure to denosumab.

CONCLUSIONS

Serious adverse events of infections that occurred with denosumab treatment had heterogeneous etiology, with no clear clinical pattern to suggest a relationship to time or duration of exposure to denosumab.

Potential barriers to veterinary student access to counselling and other support systems: perceptions of staff and students at a UK veterinary school

Considerable evidence suggests that veterinary surgeons' mental health is often poorer than comparable populations and that the incidence of suicide is higher among veterinary surgeons than the general public. Veterinary students also appear to suffer from high levels of anxiety and stress, and may possess inadequate coping strategies when faced with adversity. Veterinary students may find it difficult to access central university support systems due to their heavy workload and geographical isolation on some veterinary campuses. A previous study of University of Edinburgh fourth-year veterinary students found that support services located several miles from the main veterinary campus was a barrier to students accessing counselling services. Consequently, a pilot project was initiated, which provided a counselling service at the University of Edinburgh's rural Easter Bush veterinary campus one afternoon a week during 2010. As part of the evaluation of this service, web-based questionnaires were delivered via e-mail to all veterinary staff and students towards the end of the 12-month pilot period to evaluate perceptions of barriers to student counselling and to investigate student-valued support services. Questionnaire responses were received from 35 per cent of veterinary students and 52 per cent of staff. Stigmatisation of being unable to cope was a potent inhibitor of seeking support within the veterinary environment, but counselling was perceived as valuable by the majority of staff and students. Provision of an on-site counselling service was considered important for increasing ease of access; however, students viewed friends and family as their most important support mechanism. Workload was cited as the main cause of veterinary student stress. The majority of staff and student respondents perceived veterinary students as having an increased need for counselling support compared with other students.

P5-01-17: HER2 Amplification in Primary Tumor: A Potential Marker for Presence of Circulating Tumor Cells in Inflammatory Breast Cancer Patients?

Background: Inflammatory breast cancer (IBC) is a rare but aggressive form of invasive breast cancer accounting for 3–6% of all cases and have higher rates of distant recurrence. Circulating tumor cells (CTCs) are known to predict outcome in metastatic breast cancer (BC) patients, but little is known about their prognostic significance in non-metastatic BC. We hypothesized that CTCs can be identified in patients with IBCs and may correlate with primary tumor characteristics. Methods: All patients had blood samples collected at the time of primary surgery. CTCs (per 7.5 ml blood) were detected using the Cell Search™ system (Veridex) and were defined as nucleated cells lacking CD45 but expressing cytokeratins (CK) 8, 18, or 19. The presence of ≥ 1 epithelial cells meeting morphologic criteria for malignancy was considered a positive result. Statistical analyses employed Chi square and Fisher's exact tests using STATA IC 11. Results: We prospectively evaluated 41 IBC patients enrolled in an IRB approved protocol undergoing surgery for stage I-III breast cancer. Median follow-up was 30 months. Mean age was 52 years. Thirty five patients (94%) had positive lymph nodes (LNs) at presentation, 30 (75%) had high-grade tumors and 20 (53%) had lymphovascular invasion. Eleven patients (28%) were ER positive, 11 (27%) were PR positive and 18 (44%) were HER2 positive. IBCs were more likely to be high grade (P&lt;0.0001), ER negative (P&lt;0.0001), PR negative (P&lt;0.0001), HER2 positive (P&lt;0.0001), High Ki-67 (P= 0.005) and had a BMI of more than 25kg/m2 (P=0.04). Eleven (27%) patients were CTC positive. CTCs were more likely be found in HER2 positive (8/18; 44%) vs. HER2 negative primary tumors (3/20; 15%) [OR= 4.53; 95% C.I. = 1.02−19.52; P= 0.04]. We found no statistically significant correlations between primary tumor characteristics (ER, PR, LNs, high grade) and presence of CTCs. Conclusions: About a quarter of IBC patients had CTCs at the time of primary surgery. In these patients HER2 overexpression predicted the presence of CTCs. Studies with longer follow-ups is needed to determine if CTCs predicted survival.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-01-17.

Fish response to the temporal hierarchy of the natural flow regime in the Daly River, northern Australia

In this study, relationships between flow variation across multiple temporal scales and the distribution and abundance of three fish species, western rainbowfish Melanotaenia australis, sooty grunter Hephaestus fuliginosus and barramundi Lates calcarifer were examined at eight sampling reaches in the Daly River, Northern Territory, Australia. Discharge was highly seasonal during the study period of 2006-2010 with a distinct wet-dry discharge pattern. Significant catchment-wide correlations were identified between species abundance and hydrologic variables across several scales describing the magnitude and variability of flow. A Bayesian hierarchical model which accounted for >80% of variation in abundances for all species and age classes (i.e. juvenile and adult), identified the extent to which the influence of short-term flow variation was dependent upon the historical flow regime. There were distinct ontogenetic differences in these relationships for H. fuliginosus, with variability of recent flows having a negative effect on juveniles which was stronger at locations with higher historical mean daily flow. Lates calcarifer also displayed ontogenetic differences in relationships to flow variation with adults showing a positive association with increase in recent flows and juveniles showing a negative one. The effect of increased magnitude of wet-season flows on M. australis was negative in locations with lower historical mean daily flow but positive in locations with higher historical mean daily flow. The results highlighted how interactions between multiple scales of flow variability influence the abundance of fish species according to their life-history requirements.

Use of patient navigation to improve diagnostic and treatment delays among patients with abnormal mammography results from a mobile unit

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Background: Screening mammography is frequently the initial step to breast cancer diagnosis. Upon detection of an abnormality on a mammogram, the patient must undergo follow-up procedures for diagnosis and treatment. The objective of this study was to examine the diagnostic and treatment delays after detection of an abnormality on a mammogram performed at a mobile unit.

Methods: During one-year beginning in February 2010, the mobile mammography unit of the University of Arkansas for Medical Sciences (UAMS) performed 1,547 mammograms in women who resided in counties that lacked a stationary mammography unit. Most of these counties are in rural areas with high poverty rates. The women were predominantly non-Hispanic white (62%) or African-American (36%) and 41% lacked health insurance. A patient navigator was available to assist patients through scheduling follow-up appointments, when needed. Diagnostic delay was defined as time from abnormal mammogram to biopsy that exceeded 60 days. Treatment delay was defined as time from abnormal mammogram to treatment initiation that exceeded 90 days.

Results: A total of 14 cancer cases were detected among the 1,547 women screened. The median age of these patients was 56 years of age and ranged from 46-79 years. The median time from screening mammography to biopsy was 31.5 days and ranged from 9-92 days, and diagnostic delay occurred in 2 (14%) patients. The median time from screening mammography to treatment was 78 days and ranged from 37-199 days, and treatment delay occurred in 5 (36%) patients. Three of these patients were managed outside the UAMS health care system, one patient required bilateral mastectomies and one patient refused the initial treatment recommendation.

Conclusions: Responsive health systems require vehicles to strengthen the continuum of breast care. With the use of a patient navigator, the proportion of patients with breast cancer who experienced diagnostic delays is comparable to that of other studies, but the proportion with treatment delays is higher than in other reports. Patient navigation provides a promising model to decrease diagnostic delays and improve access for the medically underserved.

Assessment of veterinary practitioners in the British Isles' approaches towards the management of canine osteoarthritis

The aim of this questionnaire-based retrospective study was to ascertain veterinary practitioners in the British Isles' approaches to osteoarthritis in dogs. The Mann-Whitney U test, Kruskal-Wallis test and multiple ordinal logistic regression were used to compare demographic data with treatment options. Questionnaires were returned by 228 practitioners (a response rate of 22.8 per cent). The majority of responses were from males (70 per cent). Eighty-six per cent (188 of 220) of the respondents had graduated from veterinary schools in the UK and Ireland. Veterinarians who had graduated less recently used exercise modulation less frequently (P<0.004, odds ratio [OR]=1.06) and ranked exercise modulation as less important (P=0.008, OR=1.04). Veterinarians who had graduated outside the UK or Ireland were less likely (P=0.033, OR=0.46) to use exercise modulation than those who had graduated in the UK or Ireland. Veterinarians who had graduated more recently were less likely (P=0.008, OR=0.95) to use medications. Female veterinary surgeons were less likely to rank medications as important (P<0.0001, OR=0.29) and less likely to rank corticosteroids as important (P=0.046, OR=0.42) than male veterinary surgeons. Practitioners who had graduated outside the UK or Ireland were less likely (P=0.01, OR=0.30) to rank corticosteroids as important. There was a significant mild negative correlation between the frequency of use of structure-modifying osteoarthritis drugs (SMOADs) and practitioners' opinions on rank importance (-0.32, P<0.0001). Medications such as SMOADs and nutraceuticals were ranked as not important but were used frequently. Overall, age, sex, the university of graduation and the number of canine consultations per day had an impact on the practitioners' treatment protocols.

Occupational stress and the outcome of basic military training

BACKGROUND

Military training has a high dropout rate but the role of occupational stress is not known.

AIMS

To examine the relationship between occupational stress and outcome of training.

METHODS

A study of occupational stress in 476 army recruits (as measured in Week 4 of 23 weeks of basic military training) using previously identified risk factors for lack of success in training and outcome of training.

RESULTS

Using stepwise logistic regression, occupational stress levels as measured at Week 4 were significant predictors of outcome in training. Psychological scale scores predicted 85% of those who were asked to leave. Other factors previously thought to be predictive of outcome of training were not predictive in this cohort of recruits.

CONCLUSIONS

Levels of occupational stress measured 4 weeks into training predicted outcome of training.

Biomagnification of cadmium selenide quantum dots in a simple experimental microbial food chain

Previous studies have shown that engineered nanomaterials can be transferred from prey to predator, but the ecological impacts of this are mostly unknown. In particular, it is not known if these materials can be biomagnified-a process in which higher concentrations of materials accumulate in organisms higher up in the food chain. Here, we show that bare CdSe quantum dots that have accumulated in Pseudomonas aeruginosa bacteria can be transferred to and biomagnified in the Tetrahymena thermophila protozoa that prey on the bacteria. Cadmium concentrations in the protozoa predator were approximately five times higher than their bacterial prey. Quantum-dot-treated bacteria were differentially toxic to the protozoa, in that they inhibited their own digestion in the protozoan food vacuoles. Because the protozoa did not lyse, largely intact quantum dots remain available to higher trophic levels. The observed biomagnification from bacterial prey is significant because bacteria are at the base of environmental food webs. Our findings illustrate the potential for biomagnification as an ecological impact of nanomaterials.

Perceived feasibility of a community pharmacy-based asthma intervention: a qualitative follow-up study

WHAT IS KNOWN AND OBJECTIVE

Asthma is a National Health Priority Area in Australia; however, recent evidence suggests that its management remains suboptimal. Community pharmacists are in a unique position to help patients manage asthma, and a number of community pharmacy-based asthma interventions have demonstrated effectiveness with improved patient outcomes. This study aimed to explore the views of general practitioners (GPs), community pharmacists and patients towards a pharmacy-based intervention that saw patients with poorly managed asthma supplied with educational material and referred to their GP for an asthma management review.

METHODS

A qualitative follow-up study of participants who had been involved in the intervention was conducted. A sample of six GPs, 10 community pharmacists and 10 patients participated in semi-structured face-to-face interviews. Data were analysed using interpretive phenomenology.

RESULTS AND DISCUSSION

General practitioners accepted the intervention process if they had positive relationships with pharmacists. There was also some hesitance of GPs towards the intervention, related to a perceived encroachment on their area of responsibility and a perceived conflict of interest of pharmacists in providing health care. GPs indicated the need to be more involved with the intervention process, and expressed that patients were rarely forthcoming about problems with their asthma. Community pharmacists felt that patients can be apathetic about asthma and often fail to seek medical advice. The intervention was implemented very easily, with minimal disruptions to the pharmacists' workflow, and pharmacists suggested that it would be better if GPs were more involved with the intervention process. Patients' general satisfaction with pharmacy services was high, but their expectations were quite low. Although there was an appreciation by patients of community pharmacists' interest in their health, this did not necessarily translate into appointments with GPs for an asthma management review. The reason for this related primarily to patients' under-estimation of their asthma severity.

WHAT IS NEW AND CONCLUSION

A wider rollout of the asthma intervention, with an improved process for involving GPs, would be feasible and well accepted. Further research should determine the best approach in influencing patients' perceptions of asthma control and whether these perceptions are amenable to a more intensive educational intervention. This could result in more efficient asthma interventions, translating to improved patient outcomes.

The sustainability of a community pharmacy intervention to improve the quality use of asthma medication

WHAT IS KNOWN AND OBJECTIVE

A previously published asthma intervention used a software application to data mine pharmacy dispensing records and generate a list of patients with potentially suboptimal management of their asthma; in particular, a high rate of provision of reliever medication. These patients were sent educational material from their community pharmacists and advised to seek a review of their asthma management from their general practitioner. The intervention resulted in a 3-fold improvement in the ratio of dispensed preventer medication (inhaled corticosteroids) to reliever medication (short-acting beta-2 agonists). This follow-up study aimed to determine the long-term effects of the intervention programme on the preventer-to-reliever (P:R) ratio.

METHODS

The same data mining software was modified so that it could re-identify patients who were originally targeted for the intervention. Community pharmacists who participated in the previous intervention installed the modified version of the software. The dispensing data were then de-identified, encrypted and transferred via the Internet to a secure server. The follow-up dispensing data for all patients were compared with their pre- and post-intervention data collected originally.

RESULTS AND DISCUSSION

Of the 1551 patients who were included in the original study, 718 (46·3%) were eligible to be included in the follow-up study. The improved P:R ratio was sustained for at least 12 months following the intervention (P < 0·01). The sustained increase in the P:R ratio was attributed to significant decreases in the average daily usage of reliever medication (P < 0·0001).

WHAT IS NEW AND CONCLUSION

The follow-up study demonstrated a sustained improvement in the ratio of dispensed preventer medication to reliever medication for asthma. The intervention has the potential to show long-lasting and widespread improvements in asthma management, improved health outcomes for patients, and ultimately, a reduced burden on the health system.

HIV seroprevalence among hospital inpatients with neuropsychiatric and other central nervous system disorders

OBJECTIVE

To determine the seroprevalence of HIV among inpatients with neuropsychiatric and other central nervous system (CNS) disorders at the University Hospital of the West Indies (UHWI).

METHODS

Sera and data of hospital inpatients with disorders of the CNS were prospectively investigated and reviewed at the Virology Laboratory, UHWI, over the period January 1 to December 31, 2007. The study population included inpatients with a principal diagnosis of a neuropsychiatric or other CNS disorder and for whom a serological analysis for HIV had been requested. The CNS disorders were categorized as follows: neuropsychiatric disorder (eg schizophrenia), CNS infection (eg viral, bacterial), motor and psychogenic dysfunction not included in other categories (eg seizures), gross structural brain lesion (eg tumours) and other HIV prevalence rates were calculated and compared according to age, gender and diagnostic category.

RESULTS

Eighty-two patients were included. Sixty-one per cent were males and 39% females. The mean age in years (+/- SD) was 37.6 (+/- 16.3). There were significant differences in prevalence rates according to diagnostic category (p = 0.026). All of the patients with psychiatric disorders (n = 40) were HIV-negative and 25% (3 out of 12) of patients with CNS infection were HIV-positive. There were no statistically significant associations demonstrated between HIV and age or gender (p > 0.05).

CONCLUSION

Clinicians should have a high index of suspicion for HIV infection when faced with patients with CNS infection. Further research is needed to clearly identify the reasons for the comparatively low prevalence of HIV among the psychiatric patients included in this study.

The association of fatty acid deficiency symptoms (FADS) with actual essential fatty acid status in cheek cells

Seven clinical symptoms have been utilised in several studies as a means of potentially identifying children with a deficiency in essential polyunsaturated fatty acids (PUFAs). The purpose of this study was to investigate whether there was any correlation between parental reports of the frequency of these seven 'fatty acid deficiency symptoms' (FADS) with actual levels of fatty acids in buccal cell samples of 450 children aged 8-10 years old. Additionally, the relationship between FADS and cognitive test performance, ratings of attention and behaviour and other somatic complaints were explored. The severity of reported FADS was not related to the levels of omega-6 or omega-3 in buccal cell samples. There was a relationship between parental reports of child behaviour and reported FADS; with high FADS being related to higher ratings of behaviour problems. Using FADS as a marker of PUFA deficiency may not be appropriate especially when assessing typically developing children.

A double-blind, placebo-controlled study investigating the effects of omega-3 supplementation in children aged 8-10 years from a mainstream school population

Despite the increased interest in the effects of omega-3 supplementation on children's learning and behaviour, there are a lack of controlled studies of this kind that have utilised a typically developing population. This study investigated the effects of omega-3 supplementation in 450 children aged 8-10 years old from a mainstream school population, using a randomised, double-blind, placebo-controlled design. Participants were supplemented with either active supplements (containing docosahexaenoic acid, DHA and eicosapentaenoic acid, EPA) or a placebo for 16 weeks. Cheek cell fatty acid levels were recorded pre- and post-supplementation and a range of cognitive tests and parent and teacher questionnaires were used as outcome measures. After supplementation, changes in the relationship between omega-6 and omega-3 were significant in the active group. Despite the wide range of cognitive and behavioural outcome measures employed, only three significant differences between groups were found after 16 weeks, one of which was in favour of the placebo condition. Exploring the associations between changes in fatty acid levels and changes in test and questionnaire scores also produced equivocal results. These findings are discussed in relation to previous findings with clinical populations and future implications for research.

Childrens' learning and behaviour and the association with cheek cell polyunsaturated fatty acid levels

Increasing interest in the role of omega-3 fatty acids in relation to neurodevelopmental disorders (e.g. ADHD, dyslexia, autism) has occurred as a consequence of some international studies highlighting this link. In particular, some studies have shown that children with ADHD may have lower concentrations of polyunsaturated fatty acids (PUFAs), particularly omega-3, in their red blood cells and plasma, and that supplementation with omega-3 fatty acids may alleviate behavioural symptoms in this population. However, in order to compare levels it seems appropriate to establish fatty acid levels in a mainstream school aged population and if levels relate to learning and behaviour. To date no study has established this. For this study, cheek cell samples from 411 typically developing school children were collected and analysed for PUFA content, in order to establish the range in this population. In addition, measures of general classroom attention and behaviour were assessed in these children by teachers and parents. Cognitive performance tests were also administered in order to explore whether an association between behaviour and/or cognitive performance and PUFA levels exists. Relationships between PUFA levels and socio-economic status were also explored. Measures of reading, spelling and intelligence did not show any association with PUFA levels, but some associations were noted with the level of omega-3 fatty acids and teacher and parental reports of behaviour, with some evidence that higher omega-3 levels were associated with decreased levels of inattention, hyperactivity, emotional and conduct difficulties and increased levels of prosocial behaviour. These findings are discussed in relation to previous findings from omega-3 supplementation studies with children.