Systematic review of fever, febrile convulsions and serious adverse events following administration of inactivated trivalent influenza vaccines in children

In 2010, increased febrile convulsions (FC) occurred after administration of inactivated trivalent influenza vaccine (TIV) in Australia. We systematically reviewed the rates of fever, FC and serious adverse events (SAEs) after TIV, focussing on published and unpublished clinical trial data from 2005 to 2012, and performed meta-analysis of fever rates. From 4,372 records in electronic databases, 18 randomised controlled trials (RCTs), 14 non-randomised clinical trials, six observational studies and 12 registered trials (five RCTs and seven non-randomised) were identified. In published RCTs, fever ≥ 38 °C rates after first dose of non-adjuvanted TIV were 6.7% and 6.9% for children aged 6–35 months and ≥ 3 years, respectively. Analysis of RCTs by vaccine manufacturer showed pooled fever estimates up to 5.1% with Sanofi or GlaxoSmithKline vaccines; bioCSL vaccines were used in two non-randomised clinical trials and one unpublished RCT and were associated with fever in 22.5–37.1% for children aged 6–35 months. In RCTs, FCs occurred at a rate of 1.1 per 1,000 vaccinated children. While most TIVs induced acceptably low fever rates, bioCSL influenza vaccines were associated with much higher rates of fever in young children. Future standardised study methodology and access to individual level data would be illuminating.

Predictors of functional outcome in individuals at high clinical risk for psychosis at six years follow-up

BACKGROUND

The long-term functional status of subjects at ultra high risk for psychosis (HR) is relatively under investigated. This study explores baseline predictors of long-term functional outcome in HR subjects who did not convert to psychosis during a 6 years follow-up period.

METHODS

A total of 154 HR were followed up for an average of 6 years. The primary outcome variable was global assessment of functioning at the last follow-up visit as assessed with the Global Assessment of Functioning tool. A multinomial logistic regression was performed to identify potential predictors of functional outcome.

RESULTS

Baseline and follow-up data on functioning was available for 92 HR. Twenty-four (43%) individuals who did not convert to psychosis reported poor functioning at follow-up. Baseline scores in the GAF (Exp(b) = 0.857; 95% CIs: 0.75/0.97), employment status (Exp(b) = 0.029; 95% CIs: 0.00/0.268), and CAARMS total scores (Exp(b) = 1.976; 95% CIs: 1.00/1.14) predicted functional outcome in HR subjects at 6 years.

CONCLUSIONS

Despite the preventive treatments received, many individuals who did not convert to full-blown psychosis in the longer term do not functionally remit. These individuals are lower functioning, unemployed and have higher symptom loading at the time of their presentation to the prodromal clinic. Our study suggests the need for innovative treatments targeting long term functional status beyond the prevention of psychosis onset in the HR population.

Treatment patterns in advanced melanoma: findings from a survey of European oncologists

With the emergence of new therapies, established patterns of treating advanced melanoma are changing. The aim of this study was to understand how advanced melanoma is treated in clinical practice in Europe following the introduction of ipilimumab and vemurafenib. An online survey was conducted between August and November 2012 with 150 oncologists and dermatologists, from France, Germany, Italy, Spain and the U.K.; respondents reported treating the majority of patients with one or two lines of therapy. For BRAF mutant melanoma, the most frequently used first-line treatments were vemurafenib and dacarbazine. For BRAF wild-type melanoma, the most frequently used first-line treatment was dacarbazine. There was no single preferred agent for the second-line treatment of BRAF mutant or BRAF wild-type disease. Most sequencing from first- to second-line was from conventional dacarbazine to newer agents such as ipilimumab and vemurafenib. The treatment of advanced melanoma is rapidly evolving due to the introduction of new agents. This study presents an early insight into access to the new agents, ipilimumab and vemurafenib, and clinical practice in several European countries.

Improving rehabilitation after critical illness through outpatient physiotherapy classes and essential amino acid supplement: A randomized controlled trial

PURPOSE

Patients recovering from critical illness may be left with significant muscle mass loss. This study aimed to evaluate whether a 6-week program of enhanced physiotherapy and structured exercise (PEPSE) and an essential amino acid supplement drink (glutamine and essential amino acid mixture [GEAA]) improves physical and psychological recovery.

MATERIALS AND METHODS

Intensive care patients aged 45 years or older, with a combined intensive care unit stay/pre-intensive care unit stay of 5 days or more were recruited to a randomized controlled trial examining the effect of PEPSE and GEAA on recovery. The 2 factors were tested in a 2 × 2 factorial design: (1) GEAA drink twice daily for 3 months and (2) 6-week PEPSE in first 3 months. Primary efficacy outcome was an improvement in the 6-minute walking test at 3 months.

RESULTS

A total of 93 patients were randomized to the study. Patients receiving the PEPSE and GEA had the biggest gains in distance walked in 6-minute walking test (P < .0001). There were also significant reductions in rates of anxiety in study groups control supplement/PEPSE (P = .047) and GEAA supplement/PEPSE (P = .036) and for GEAA supplement/PEPSE in depression (P = .0009).

CONCLUSION

Enhanced rehabilitation combined with GEAA supplement may enhance physical recovery and reduce anxiety and depression.

Pragmatic randomized controlled trial of a structured allergy intervention for adults with asthma and rhinitis in general practice

BACKGROUND

It is widely believed that in patients with allergic rhinitis and asthma, avoidance of specific triggers can help improve symptom control and reduce need for medication. Whilst most patients with asthma or rhinitis are sensitized to airborne allergens, primary care diagnostic and management decisions are often made without either obtaining a detailed history of the patient's allergic triggers or performing skin prick tests. Thus, management decisions are empirical and allergen avoidance advice is either not given or, if given, not tailored to the patient's sensitivities.

METHOD

To ascertain whether allergy assessment and tailored advice in general practice for patients with asthma and rhinitis enhance well-being, we conducted a pragmatic, open, randomized controlled trial of allergy intervention (structured allergy history and skin prick testing and appropriate advice on allergy avoidance) versus usual care in adult patients with a working diagnosis of asthma and/or rhino-conjunctivitis. Outcomes were assessed after 12 months by an observer who was blinded to allocation. The main outcome measures were asthma and rhinitis symptoms, disease-specific health-related quality of life, generic quality of life and lung function.

RESULTS

There were no significant differences in baseline demographics or disease characteristics between patients assigned to immediate or delayed skin prick testing. No significant differences were observed between groups for any measures of symptoms, quality of life or lung function at 12 months (all P > 0.05).

CONCLUSION

Amongst adults with known asthma and/or rhinitis in primary care, taking a structured allergy history with skin prick tests and giving tailored advice on allergy avoidance made no difference to their symptoms, quality of life or lung function as measured twelve months later.

Quantification of low levels of methionine oxidation in erythropoietin drug substance

A pharmacopoeial monograph under development for recombinant human erythropoietin (rhEPO) drug substance is likely to contain a specification limit for the proportion of the methionine-oxidised variant. Methionine oxidation has no effect on the folded structure and global thermodynamic stability of rhEPO but can decrease biological activity [1]. We describe here the development of a reference standard, a calibrated mixture of the native and oxidised tryptic peptides which contain methionine-54, and an optimised peptide mapping procedure to support this assay. The approach may be developed for analysis of drug product or generalised for other assays in which product-related impurities are quantified by peptide mapping.

Skin resistance to oxidative stress induced by resveratrol: from Nrf2 activation to GSH biosynthesis

Skin is particularly exposed to oxidative stress, either from environmental insults such as sunlight or pollution or as a consequence of specific impairments in antioxidant status resulting from pathologies or aging. Traditionally, antioxidant products are exogenously provided to neutralize pro-oxidant species. However, another approach based on stimulation of endogenous antioxidant defense pathways is more original. Resveratrol (RSV) was reported to display such a behavior in various tissues, but data about the mechanisms of action in skin are scarce. We show here that, in primary culture of normal human keratinocytes (NHKs) or in full-thickness reconstructed human skin, RSV activated the Nrf2 pathway at nontoxic doses, from 20 µM up to 100µM. Among the Nrf2 downstream genes, glutamylcysteinyl ligase and glutathione peroxidase-2 were induced at the mRNA and protein levels. In parallel, a significant increase in glutathione content, assessed by LC/MS analysis, was observed in both models. Nrf2 gene silencing experiments performed in NHKs confirmed that Nrf2 was involved in RSV-induced modulation of cellular antioxidant status, in part by increasing cellular glutathione content. Finally, improvement of endogenous defenses induced in RSV-pretreated reconstructed skin ensured protection against the toxic oxidative effects of cumene hydroperoxide (CHP). In fact after RSV pretreatment, in response to CHP stress, glutathione content did not decrease as in unprotected samples. Cellular alterations at the dermal-epidermal junction were clearly prevented. Together, these complementary experiments demonstrated the beneficial effects of RSV on skin, beyond its direct antioxidant properties, by upregulation of a cutaneous endogenous antioxidant pathway.

Cannabis use and transition to psychosis in people at ultra-high risk

BACKGROUND

Cannabis use is associated with an increased risk of developing a psychotic disorder but the temporal relationship between cannabis use and onset of illness is unclear. The objective of this study was to assess prospectively the influence of cannabis use on transition to psychosis in people at ultra-high risk (UHR) for the disorder.

METHOD

Lifetime and continued cannabis use was assessed in a consecutively ascertained sample of 182 people (104 male, 78 female) at UHR for psychosis. Individuals were then followed clinically for 2 years to determine their clinical outcomes.

RESULTS

Lifetime cannabis use was reported by 134 individuals (73.6%). However, most of these individuals had stopped using cannabis before clinical presentation (n=98, 73.1%), usually because of adverse effects. Among lifetime users, frequent use, early-onset use and continued use after presentation were all associated with an increase in transition to psychosis. Transition to psychosis was highest among those who started using cannabis before the age of 15 years and went on to use frequently (frequent early-onset use: 25%; infrequent or late-onset use: 5%; χ(2)1=10.971, p=0.001). However, within the whole sample, cannabis users were no more likely to develop psychosis than those who had never used cannabis (cannabis use: 12.7%; no use: 18.8%; χ(2)1=1.061, p=0.303).

CONCLUSIONS

In people at UHR for psychosis, lifetime cannabis use was common but not related to outcome. Among cannabis users, frequent use, early-onset use and continued use after clinical presentation were associated with transition to psychosis.

Nephronophthisis and retinal degeneration in tmem218-/- mice: a novel mouse model for Senior-Løken syndrome?

Mice deficient in TMEM218 (Tmem218(-/-) ) were generated as part of an effort to identify and validate pharmaceutically tractable targets for drug development through large-scale phenotypic screening of knockout mice. Routine diagnostics, expression analysis, histopathology, and electroretinogram analyses completed on Tmem218(-/-) mice identified a previously unknown role for TMEM218 in the development and function of the kidney and eye. The major observed phenotypes in Tmem218(-/-) mice were progressive cystic kidney disease and retinal degeneration. The renal lesions were characterized by diffuse renal cyst development with tubulointerstitial nephropathy and disruption of tubular basement membranes in essentially normal-sized kidneys. The retinal lesions were characterized by slow-onset loss of photoreceptors, which resulted in reduced electroretinogram responses. These renal and retinal lesions are most similar to those associated with nephronophthisis (NPHP) and retinitis pigmentosa in humans. At least 10% of NPHP cases present with extrarenal conditions, which most often include retinal degeneration. Senior-Løken syndrome is characterized by the concurrent development of autosomal recessive NPHP and retinitis pigmentosa. Since mutations in the known NPHP genes collectively account for only about 30% of NPHP cases, it is possible that TMEM218 could be involved in the development of similar ciliopathies in humans. In reviewing all other reported mouse models of NPHP, we suggest that Tmem218(-/-) mice could provide a useful model for elucidating the pathogenesis of cilia-associated disease in both the kidney and the retina, as well as in developing and testing novel therapeutic strategies for Senior-Løken syndrome.

Deep-water anoxygenic photosythesis in a ferruginous chemocline

Ferruginous Lake Matano, Indonesia hosts one of the deepest anoxygenic photosynthetic communities on Earth. This community is dominated by low-light adapted, BChl e-synthesizing green sulfur bacteria (GSB), which comprise ~25% of the microbial community immediately below the oxic-anoxic boundary (OAB; 115-120 m in 2010). The size of this community is dependent on the mixing regime within the lake and the depth of the OAB-at ~117 m, the GSB live near their low-light limit. Slow growth and C-fixation rates suggest that the Lake Matano GSB can be supported by sulfide even though it only accumulates to scarcely detectable (low μm to nm) concentrations. A model laboratory strain (Chlorobaculum tepidum) is indeed able to access HS- for oxidation at nm concentrations. Furthermore, the GSB in Lake Matano possess a full complement of S-oxidizing genes. Together, this physiological and genetic information suggests that deep-water GSB can be supported by a S-cycle, even under ferruginous conditions. The constraints we place on the metabolic capacity and physiology of GSB have important geobiological implications. Biomarkers diagnostic of GSB would be a good proxy for anoxic conditions but could not discriminate between euxinic and ferruginous states, and though GSB biomarkers could indicate a substantial GSB community, such a community may exist with very little metabolic activity. The light requirements of GSB indicate that at light levels comparable to those in the OAB of Lake Matano or the Black Sea, GSB would have contributed little to global ocean primary production, nutrient cycling, and banded iron formation (BIF) deposition in the Precambrian. Before the proliferation of oxygenic photosynthesis, shallower OABs and lower light absorption in the ocean's surface waters would have permitted greater light availability to GSB, potentially leading to a greater role for GSB in global biogeochemical cycles.

Tumour cell retention of rucaparib, sustained PARP inhibition and efficacy of weekly as well as daily schedules

Background:

Poly(ADP-ribose) polymerase-1 (PARP) inhibitors (PARPi) exploit tumour-specific defects in homologous recombination DNA repair and continuous dosing is most efficacious. Early clinical trial data with rucaparib suggested that it caused sustained PARP inhibition. Here we investigate the mechanism of this durable inhibition and potential exploitation.

Methods:

Uptake and retention of rucaparib and persistence of PARP inhibition were determined by radiochemical and immunological assays in human cancer cell lines. The pharmacokinetics and pharmacodynamics of rucaparib were determined in tumour-bearing mice and the efficacy of different schedules of rucaparib was determined in mice bearing homologous recombination DNA repair-defective tumours.

Results:

Rucaparib accumulation is carrier mediated (Km=8.4±1.2 μM, Vmax=469±22 pmol per 10⁶ cells per 10 min), reaching steady-state levels >10 times higher than the extracellular concentration within 30 min. Rucaparib is retained in cells and inhibits PARP ⩾50% for ⩾72 h days after a 30-min pulse of 400 nM. In Capan-1 tumour-bearing mice rucaparib accumulated and was retained in the tumours, and PARP was inhibited for 7 days following a single dose of 10 mg kg⁻¹ i.p or 150 mg kg⁻¹ p.o. by 70% and 90%, respectively. Weekly dosing of 150 mg kg⁻¹ p.o once a week was as effective as 10 mg kg⁻¹ i.p daily for five days every week for 6 weeks in delaying Capan-1 tumour growth.

Conclusions:

Rucaparib accumulates and is retained in tumour cells and inhibits PARP for long periods such that weekly schedules have equivalent anticancer activity to daily dosing in a pre-clinical model, suggesting that clinical evaluation of alternative schedules of rucaparib should be considered.

Paramedic rapid sequence intubation in patients with non-traumatic coma

INTRODUCTION

Pre-hospital intubation by paramedics is widely used in comatose patients prior to transportation to hospital, but the optimal technique for intubation is uncertain. One approach is paramedic rapid sequence intubation (RSI), which may improve outcomes in adult patients with traumatic brain injury. However, many patients present to emergency medical services with coma of non-traumatic cause and the role of paramedic RSI in these patients remains uncertain.

METHODS

The electronic Victorian Ambulance Clinical Information System was searched for the term 'suxamethonium' between 2008 and 2011. We reviewed the patient care records and included patients with suspected non-traumatic coma who were treated and transported by road-based paramedics. Demographics, intubation conditions, vital signs (before and after drug administration) and complications were recorded. Younger patients (<60 years) were compared with older patients.

RESULTS

There were 1152 paramedic RSI attempts of which 551 were for non-traumatic coma. The success rate for intubation was 97.5%. There was a significant drop in blood pressure in younger patients (<60 years) with the mean systolic blood pressure decreasing by 16 mm Hg (95% CI 11 to 21). In older patients, the systolic blood pressure also decreased significantly by 20 mm Hg (95% CI 17 to 24). Four patients suffered brief cardiac arrest during pre-hospital care, all of whom were successfully resuscitated and transported to hospital.

CONCLUSIONS

Paramedic RSI in patients with non-traumatic coma has a high procedural success rate. Further studies are required to determine whether this procedure improves outcomes.

Early reproductive losses are a major factor contributing to the poor reproductive performance of Merino ewe lambs mated at 8–10 months of age

The reproductive performance of Merino ewe lambs is lower than that achieved by mature ewes and is highly variable. It is likely that embryo loss represents a major source of reproductive wastage in Merino ewe lambs, but to our knowledge no studies have attempted to determine when the major reproductive losses occur or identify predisposing factors that are likely to lead to high rates of pregnancy failures in ewe lambs. After characterising where reproductive losses occurred in Merino ewe lambs mated at 8–10 months of age, we tested the hypothesis that pregnancy failure in ewe lambs is influenced by nutrition and liveweight change around conception and the genetic potential for growth of the ewe lamb. Two-hundred and twenty-four Merino ewe lambs born from 10 sires with Australian Sheep Breeding Values were teased for 14 days using vasectomised rams, and then fed two different diets for 68 days during mating. All ewe lambs were weighed and the appearance of crayon marks on their rump was recorded most days. Blood samples for progesterone assay were collected on Days 5, 12 and 17 after the first record of a crayon mark. Ultrasonography using a trans-rectal probe was used to measure the number of corpora lutea present, as a proxy for ovulation rate, 9 days after the first record of a crayon mark during the mating period. A further trans-rectal ultrasonography was undertaken 30 days after marking from the entire ram to determine pregnancy status and count the number of embryos. Over the entire mating period 54% of ewe lambs were pregnant with 66 fetuses per 100 ewes mated. The average ovulation rate was 150% however up to 84% of this potential was lost by weaning and the major contributor to this apparent deficit was the loss that occurred during the first 17 days after mating. Pregnancy failure was not significantly related to nutrition or liveweight change during mating however, there were significant differences in pregnancy failure between different sire groups. Pregnancy failure was significantly less for ewe lambs from sires with higher breeding values for weight and fat at post-weaning age (8–10 months). Only 60% of ewe lambs had achieved puberty when rams were introduced and only 83% by 35 days after mating. In addition, almost half of the ewe lambs that were mated for the first time during the first 35 days after rams were introduced, but failed to get pregnant, then seemed to skip a cycle or did not cycle again before the end of the 68-day mating period. Liveweight at introduction of entire rams was positively related to fertility, ovulation rate and reproductive rate. This study confirms that selection of sires with higher breeding values for post-weaning weight and fat will increase the fertility and reproductive rate of Merino ewe lambs mated at 8–10 months. This response is due in part to enhancing the onset of puberty and increasing the proportion of ewe lambs cycling at the start of mating and reducing pregnancy failure.

Abstract P1-15-02: Long term follow-up of the neo-adjuvant pilot trial evaluating activity of letrozole in combination with bevacizumab in post-menopausal women with newly diagnosed estrogen and/or progesterone receptor positive primary breast cancer

Introduction: Vascular endothelial growth factor overexpression has been associated with resistance to anti-estrogen therapy (Cancer Res 2008; 68: 6232); our preclinical data showed that anti-VEGF therapy reverse resistance to estrogen therapy. We postulated that anti-VEGF therapy would enhance anti-estrogen therapy and thus designed a pilot study to assess the feasibility and efficacy of neoadjuvant letrozole and bevacizumab in post-menopausal women with stage II/III, ER/PR positive breast cancer.

Patients and Methods: Eligible patients were treated with a neo-adjuvant regimen of letrozole, 2.5 mg/day (PO) and bevacizumab 15 mg/kg every 3 weeks (IV) for a total of 24 weeks prior to surgical treatment of their breast cancer. Patients were followed for toxicity at three week intervals and for tumor assessment at 6 week intervals. Research tumor biopsies were taken before and 6 weeks after initiation of therapy. The primary endpoint was pathological complete remission (pCR). Patients with inflammatory breast cancer were excluded.

Results: Twenty six patients were enrolled and 25 were treated (one patient had a TIA the day before initiation of therapy). The regimen was well tolerated with 2 patients taken off-study due to uncontrolled hypertension. Objective clinical response occurred in 68% of the patients (17/25), 16% with CR and 52% with partial response (PR). Sixteen percent of the patients (4/25) had clinical stable disease (SD) and 2 patients progressed (PD) while on therapy. Three patients had pCR and 1 patient had microscopic residual tumor cells in the LNs but not in the breast (pCR 16%). Thirty two percent of the patients attained stage 0 or 1 status. None of the pCR patients received adjuvant chemotherapy and none have relapsed after a median follow-up of 6.1 years (range, 5.8+ to 7.5+). Eight of the 13 patients with PR did not receive chemotherapy and only one relapsed with a median follow-up of 6.2 years (range, 3.7 to 7.7+). At a median follow-up of 6.4 years, 88% of the patients have not relapsed and 12% relapsed (1 PD [basal-like], 1 PR [Luminal B], 1 SD [HER2] relapsed at 1.7, 4, and 6.8 years respectively). Of the 17 patients with CR and PR, only 1 has relapsed (6%). Next Generation Sequencing Analysis and evaluation of markers of proliferation/apoptosis are underway.

Conclusion: Combination neoadjuvant therapy with letrozole and bevacizumab was well tolerated and resulted in an impressive pCR of 16%. At a median of 6.4 years, the relapse free survival is 88% for all comers and 94% for responding patients (Luminal A and B). Full correlation of clinical and genomic/biomarker analysis will be presented at the time of the meeting. This encouraging data has led The Breast Cancer Translational Research Consortium to complete a randomized phase II trial (TBCRC002) of letrozole ± bevacizumab in this patient population.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-15-02.

Terlipressin therapy for moderate-to-severe hyponatraemia in patients with liver failure

BACKGROUND

Hyponatraemia in liver failure is associated with increased morbidity and mortality. Improving serum sodium in liver failure has been observed in patients receiving terlipressin.

METHODS

We assessed the response of hyponatraemia in patients with liver failure to terlipressin using comparative retrospective analysis.

RESULTS

Twenty-three patients received terlipressin for hyponatraemia after failed conservative management (median age 52 years (27-67), model for end-stage liver disease score 28 (16-38)). The median therapy was 7 days (1-27), with an average total dose of 25 mg (4-90) and a mean follow up of 51 days (5-1248). These patients were compared with 11 hyponatraemic patients managed conservatively during the same period with comparable age, baseline serum sodium and follow up. After 1 week of terlipressin therapy, serum sodium increased from a median of 120 (115-128) to 129 mmol/L (121-144) (P < 0.001), and at the end of terlipressin therapy, the serum sodium had increased significantly to 131 mmol/L (120-148) (P < 0.001). In comparison, in the conservatively managed group, the serum sodium did not increase significantly from the baseline of 123 (117-127) mmol/L. Adverse events occurred in 26% of patients receiving terlipressin, which predominantly pulmonary oedema. Importantly, more hyponatraemic patients treated with terlipressin (48%) were alive compared with the conservative group (18%), despite the latter having a significantly lower baseline median MELD score of 21 (16-30) (P = 0.008). Moreover, the transplant-free survival was higher in the terlipressin (30%) compared with the conservative group (0%).

CONCLUSIONS

Terlipressin is effective in treating hyponatraemia in liver failure. Importantly, terlipressin use results in better transplant-free survival but also more adverse events.

Intravesical botulinum type-A toxin (Dysport®) in the treatment of idiopathic detrusor overactivity in children

OBJECTIVE

Botulinum type-A toxin is increasingly used for refractory idiopathic detrusor overactivity (IDO) in children. We reviewed our experience and sought to ascertain the influence of dose and functional bladder capacity on outcome.

PATIENTS AND METHODS

Thirty patients, aged 6-16 years, with urodynamically proven IDO, had intravesical injections of 400-500 iu of Dysport(®). Outcome was assessed clinically at least 5 months after the injection.

RESULTS

Data were available for 27 patients. Urinary frequency was improved in 10; nocturia was improved in 7. Urgency resolved in 10 patients and urge incontinence in 12 (44%). Complications reported were UTI (7), urinary retention (1) and bladder pain (1). The dose of Dysport(®) used was not significantly higher (14 iu/kg v 13 iu/kg) in patients dry at follow up than in those who remained wet (p = 0.45). Functional bladder capacity was not significantly different in patients dry after treatment (p = 0.82).

CONCLUSION

This retrospective study demonstrates similar response to a single treatment with intravesical Botulinum type-A toxin to previous series. We did not demonstrate a correlation between dose or functional bladder capacity and resolution of incontinence. A multi-centre study is required to further investigate this promising treatment.

Mental and physical disability after sepsis

Sepsis remains a major cause of admissions to Intensive Care Units (ICU) and has a high mortality rates and significant morbidity in survivors. There are physical, cognitive and psychological sequelae from severe sepsis that have a negative effect on the patients' health related quality of life in the longer term and a social care and humanitarian impact. Although muscle mass loss during the septic period happens very quickly, recovery takes a considerable time and requires the patient to commit to exercising and eating well to rebuild. Where cognitive impairment has resulted from the septic illness the patients' ability to look after themselves may be affected and this has financial and family implications for future care. Patients may also develop psychological problems such as anxiety, depression or post traumatic stress disorder (PTSD), which can have a profound effect on their everyday functioning and the possibility of returning to work. As yet there are no published studies of rehabilitation with patients surviving severe sepsis, although there is one in progress at the moment. The use of techniques such as ICU diaries to help patients to understand their illness and deal with delusional memories they may have from their ICU stay has been shown to aid psychological recovery in general ICU patients, a percentage of whom will have suffered from sepsis. The use of a self-guided manualised 6 week rehabilitation program, the ICU Recovery Manual, has been shown to accelerate physical recovery in general ICU patients. Considerable amounts of money are spent treating patients with severe sepsis in ICU and not completing the job of returning them to as close as possible to their normal functioning does not make financial sense.