Trauma-related shame predicts daily non-medical prescription opioid use among individuals with PTSD symptoms

Non-medical prescription opioid use (NMPOU) is the use of opioids without a prescription or in a way different from how they were prescribed and is the fourth most common type of drug use in the United States. Separate research has shown that trauma-related shame is linked to posttraumatic stress disorder (PTSD) and, respectively, opioid use. However, no study to date has empirically examined the association between trauma-related shame and NMPOU among individuals with PTSD symptoms. Forty adults with clinical or subclinical PTSD who reported engaging in NMPOU at least one day in the prior month before the study completed 28 days of daily surveys. Trauma-related shame was measured at baseline. NMPOU and underlying motives to engage in NMPOU were assessed once daily via a smartphone app. Twenty-four participants (60 %) reported NMPOU over the 28-day period. After controlling for PTSD symptoms and covariates, mixed models showed that higher trauma-related shame significantly predicted higher risk of daily NMPOU (B = 0.06, SE = 0.03, t = 2.14, p=.03). After controlling for false discovery rates, trauma-related shame also significantly predicted NMPOU due to the following motives (p's < 0.031): to manage depression/sadness, to manage anxiety, to manage other stress/worry, and to get high. Among individuals with PTSD, higher baseline trauma-related shame prospectively and positively predicted greater NMPOU over a four-week daily monitoring period. Findings suggest a need to attend to trauma-related shame and its impact on subsequent motivations to engage in NMPOU. Future research should examine how treatments may effectively target trauma-related shame to reduce NMPOU and more severe PTSD symptoms.

Assessment of Comorbid Obsessive-Compulsive Disorder and Posttraumatic Stress Disorder

Obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) are commonly comorbid and share prominent features (e.g., intrusions, safety behaviors, and avoidance). Excellent self-report and clinician-administered assessments exist for OCD and PTSD individually, but few assess both disorders, and even fewer provide instruction on differential diagnosis or detection of comorbid OCD and PTSD. To address this gap in the literature, the current paper aims to (1) highlight diagnostic and functional similarities and differences between OCD and PTSD to inform differential diagnosis, (2) outline assessment recommendations for individuals with suspected comorbid OCD and PTSD, OCD with a significant trauma history or posttraumatic symptoms, or PTSD with significant obsessive-compulsive symptoms, and (3) explore future directions to evaluate and improve methods for assessing co-occurring OCD and PTSD.

The role of posttraumatic guilt and anger in integrated treatment for PTSD and co-occurring substance use disorders among primarily male veterans

OBJECTIVE

PTSD and substance use disorders (SUD) frequently co-occur among veterans. Integrated exposure-based treatments, such as Concurrent Treatment of PTSD and SUD Using Prolonged Exposure (COPE), are efficacious in reducing PTSD and SUD symptoms and posttraumatic emotions. This study examines whether guilt and anger (a) decreased in a randomized clinical trial comparing COPE with Relapse Prevention (RP) therapy for SUD and (b) mediated PTSD and SUD symptom reductions or vice versa.

METHOD

Veterans (90.1% men) diagnosed with PTSD and SUD were randomized to 12 sessions of COPE (n = 54) or RP (n = 27). Guilt and anger were assessed at 10 time points during treatment. Multilevel linear models assessed changes in guilt and anger across treatments and lagged multilevel mediation analyses assessed within-subject change in guilt and anger predicting PTSD and percent days of substance use, and vice versa.

RESULTS

Guilt (B = -.12, SE = .02, p < .001) and anger (B = -.13, SE = .02, p < .001) improved in both treatments, however guilt was significantly lower in Sessions 7 through 11 among veterans receiving COPE. Improvement in guilt mediated PTSD symptom improvement in both treatment groups (B = -.08, SE = .04, 95% CI [-.16, -.01]), and PTSD symptom improvement mediated anger reduction in COPE (B = -.03, SE = .01, 95% CI [-.06, -.01]). The substance use models were insignificant.

CONCLUSIONS

Among veterans, integrated, trauma-focused treatments may be associated with greater guilt (directly) and anger (indirectly) reductions due to processing trauma. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Fear of sin and fear of God: Scrupulosity predicts women's daily experiences of mental contamination following sexual trauma

Mental contamination refers to feelings of dirtiness in response to thoughts, images, or memories. Mental contamination is frequently reported after sexual trauma and is associated with symptoms of posttraumatic stress disorder (PTSD). Differences in individuals' views about morality and purity may influence the severity of mental contamination, though this has been studied primarily outside of samples assessed for trauma and/or PTSD. The present study addressed this gap by investigating scrupulosity as a prospective predictor of daily sexual trauma-related mental contamination and PTSD symptoms. Participants included 40 adult women with a history of sexual trauma and current sexual trauma-related mental contamination who completed baseline diagnostic interviews and questionnaires followed by two assessments every day for 2 weeks. The results indicate that scrupulosity was positively correlated with PTSD symptom severity and sexual trauma-related mental contamination at baseline. Scrupulosity was also a prospective predictor of increased daily sexual trauma-related mental contamination, B = 0.19, SE = 0.07, p = .010, but not daily PTSD symptoms, B = -0.10, SE = .08, p = .198. The findings indicate that scrupulosity may be an important factor in understanding recovery from sexual assault.

Advancing the Measurement of Trauma-Related Shame Among Women With Histories of Interpersonal Trauma

Shame is a predominant emotion for many interpersonal trauma (IPT) survivors and is associated with more severe posttraumatic stress disorder (PTSD) symptoms. Measurement challenges have led to difficulties in understanding the impact of trauma-related shame. The Trauma-Related Shame Inventory (TRSI) was developed to address this limitation, yet additional psychometric support is needed. The present study evaluated and provided psychometric support for the TRSI among women with IPT histories, although recommendations for improvement are discussed. The impact of trauma-related shame, relative to trait shame and trauma-related guilt, on PTSD symptoms was also studied, with results suggesting that trauma-related shame had the strongest association.

Concurrent and proximal associations among PTSD symptoms, prescription opioid use, and co-use of other substances: Results from a daily monitoring study

OBJECTIVE

Posttraumatic stress disorder (PTSD) and nonmedical prescription opioid use (NMPOU) are linked. Much of the research documenting this association uses cross-sectional or longitudinal designs that describe patterns of use over extended intervals. The present study used a daily monitoring design to examine how daily fluctuations in PTSD symptoms predicted patterns of prescription opioid use (both medical and nonmedical) and co-use of other substances. This approach has distinct advantages for understanding proximal temporal relations between PTSD symptom variation and substance use patterns.

METHOD

Forty adults with clinical or subclinical PTSD and past-month NMPOU completed daily measures of PTSD symptoms, physical pain, prescription opioid use, and other substance use for 28 days using a smartphone application.

RESULTS

Same day co-use of prescription opioids and at least one other substance was common. Higher-than-typical PTSD symptoms on a given day (within-person) was associated with an increased likelihood of reporting NMPOU (overall and with co-use of one or more additional substances) on the same day. This association was specific to PTSD alterations in arousal and reactivity symptoms (Criteria E). Neither total PTSD symptoms nor individual PTSD symptom clusters prospectively predicted next-day prescription opioid use (overall or with co-use). Use of prescription opioids also did not predict next-day PTSD symptom severity.

CONCLUSION

This is the first study to demonstrate positive associations between day-to-day fluctuations in PTSD symptoms and NMPOU. Results from the current study also highlight the importance of examining polysubstance use patterns among individuals with PTSD who use prescription opioids. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Obsessive-Compulsive Symptoms and Daily Experiences of Posttraumatic Stress and Mental Contamination Following Sexual Trauma

Although cross-sectional research highlights similarities between symptoms of obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) among individuals exposed to sexual trauma, little is known about how these disorders relate over time. The goal of the present study was to examine whether 1) OCD symptoms prospectively predicted daily symptoms of PTSD, and 2) OCD and PTSD symptoms prospectively predicted daily experiences of sexual trauma-related mental contamination (i.e., dirtiness in the absence of a physical pollutant). Forty-one women with a sexual trauma history completed baseline measures of OCD and PTSD, as well as twice-daily assessments of PTSD symptoms and mental contamination over a two-week period. Total OCD symptoms and the unacceptable thoughts dimension significantly predicted daily PTSD symptoms after accounting for other OCD dimensions. Only total OCD symptoms significantly predicted daily mental contamination when examined together with total PTSD symptoms. No individual PTSD or OCD clusters/dimensions significantly predicted daily mental contamination when examined simultaneously. Findings from this study highlight the nuanced associations among OCD symptoms, PTSD symptoms, and experiences of mental contamination. Future research is needed to further understand the development of PTSD, OCD, and mental contamination over time to inform targets for intervention.

Using Statistical Shape and Appearance Modelling to characterise the 3D shape and material properties of human lumbar vertebrae: A proof of concept study

Patient variation affects the outcomes of a range of spinal interventions, from disc replacement to vertebral fixation and vertebroplasty. Statistical Shape and Appearance Modelling (SSAM) can be used to describe anatomical variation and pathological differences within the population. To better understand how bone density and shape variation affect load transfer with respect to surgical treatments, Finite Element (FE) models can be generated from a SSAM. The aim for this study is to understand whether geometric and density variation as well as multiple vertebral levels can be incorporated into a single SSAM and whether this can be used to investigate the relationships between, and effects of, the various modes of variation. FE models of 14 human lumbar vertebrae that had been μCT imaged and validated through experimental testing were used as input specimens for a SSAM. The validity of the SSAM was evaluated by using principal component analysis to identify the primary modes of geometric and bone density variation and comparing to those in the input set. FE models were generated from the SSAM to examine the response to loading. The mean error between the input set and generated models for volume, mean density and FE compressive stiffness were 10%, 3% and 10% respectively. Principal Component (PC) 1 captured the majority of the bone density variation. The remaining PCs described specific geometric variation. The FE models generated from the SSAM showed the variations in vertebral stiffness as a result of complex relationships between bone density and shape. The SSAM created has limited data for its input set, however, it acts as a proof of concept for the novel combination of material and shape variation into a single shape model. This approach and the tools developed can be applied to wider patient groups and treatment scenarios to improve patient stratification and to optimise treatments.

Affective Lability Moderates the Associations between Negative and Positive Urgency and Posttraumatic Stress

Urgency and affective lability are two vulnerabilities that have been linked to posttraumatic stress disorder (PTSD). Urgency refers to rash action when experiencing intense positive or negative affect, whereas affective lability is the tendency to shift rapidly between emotion states. Although individuals high in urgency and affective lability may be more likely to engage in behaviors often exhibited by individuals with PTSD (e.g., substance use, risky behaviors), the extent to which urgency and affective lability interact to impact PTSD symptoms has yet to be examined. The current study hypothesized that the association between urgency (negative and positive) and PTSD symptoms would be stronger among those reporting elevated affective lability. Participants included 232 trauma-exposed college students who completed a series of questionnaires. Among individuals low in affective lability, both positive and negative urgency were positively associated with PTSD symptoms. Contrary to hypotheses, among those high in affective lability, positive and negative urgency were not associated with PTSD symptoms. Models with dimensions of affective lability were also examined. Findings suggest that the association between urgency and PTSD symptoms may only emerge among individuals who do not already possess the vulnerability associated with higher affective lability.

Emotion production of facial expressions: A comparison of deaf and hearing children

The production of facial expressions is an important skill that allows children to share and adapt emotions during social interactions. While deaf children are reported to show delays in their social and emotion understanding, the way in which they produce facial expressions of emotions has been relatively unexplored. The present study investigated the production of facial expressions of emotions by young congenitally deaf children. Six facial expressions of emotions produced by 5 congenitally deaf children and 5 hearing children (control group) were filmed across three tasks: 1) voluntarily posed expression of emotion 2) responding to social stories 3) intentionally mimicking expressions of emotion. The recorded videos were analysed using a software based of the Facial Action Coding System (FACS), and then judged by adult raters using two different scales: according to the emotion elicited (i.e. accuracy) and the intensity of the emotion produced. The results of both measurement scales showed that all children (deaf and hearing) were able to produce socially recognisable prototypical configuration of facial expressions. However, the deaf children were rated by adults as expressing their emotions with greater intensity compared to the hearing children. The results suggest deaf children may show more exaggerated facial expressions of emotion, possibly to avoid any ambiguity in communication.

Avoidance Coping Partially Accounts for the Relationship Between Trauma-Related Shame and PTSD Symptoms Following Interpersonal Trauma

Research has demonstrated that individuals experiencing trauma-related shame exhibit greater posttraumatic stress disorder (PTSD) symptoms. However, little research has investigated additional factors relevant to the shame-PTSD relationship. The current study examined the role of avoidance and approach coping in accounting for the trauma-related shame-PTSD association among 60 women who had experienced interpersonal trauma. Indirect effects tests revealed that avoidance coping partially accounted for the association between shame and interviewer-assessed PTSD symptoms, β = .21, SE = 0.08, 95% confidence interval (CI) = [0.03, 0.36]. These findings offer a novel contribution to the growing literature examining negative outcomes following interpersonal trauma.

Distress Tolerance Interacts with Peritraumatic Emotions to Predict Posttraumatic Stress Symptoms Following Sexual Victimization

The intensity of peritraumatic emotions occurring at the time of, and in the hours or days immediately following, a traumatic event prospectively predicts posttraumatic stress symptom severity. However, less is known about how the perception of one's ability to tolerate distressing emotions affects the relation between peritraumatic emotions and posttraumatic stress symptoms. Therefore, the current study investigated how perceived distress tolerance affects the association between peritraumatic emotional intensity and symptoms of posttraumatic stress. Participants included 72 adult women with a history of sexual victimization. Ratings of peritraumatic emotions (e.g., fear, anger, sadness, guilt, and shame), perceived distress tolerance, and posttraumatic stress symptoms were examined. All analyses controlled for general negative affect. Significant interactions emerged for overall peritraumatic emotional intensity, and specifically for peritraumatic anger, sadness, and shame. The associations between these peritraumatic emotions and posttraumatic stress symptoms were stronger for individuals with lower perceived ability to tolerate distress. Our results suggest that peritraumatic emotional experiences may be particularly relevant to understanding the development and maintenance of posttraumatic stress symptoms among individuals who have difficulty tolerating intense negative emotional states. Future research should examine whether perceived distress tolerance might serve as a potential target for posttraumatic stress prevention efforts.

0665 Bilateral Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea

Introduction

Hypoglossal Nerve Stimulation (HGNS) decreases obstructive sleep apnea (OSA) severity by contracting the tongue and decreasing upper airway collapsibility. This study assessed the safety and effectiveness of a new implantable device that delivers bilateral HGNS: the Genio™ system.

Methods

The BLAST OSA study (BiLAteral Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea), was a prospective, open-label, non-randomized, single arm treatment study conducted at eight centres in three countries (Australia, France, UK). Primary outcomes were the incidence of device-related Serious Adverse Events (SAEs) and change in the Apnea-Hypopnea Index (AHI). The secondary outcome was change in the 4% Oxygen Desaturation Index (ODI). Additional outcomes included measures of sleepiness, quality of life, snoring, and device use. Participants were eligible if: 21-75 years old; BMI ≤ 32 kg/m2; obstructive AHI 20-60 events/hr and combined central and mixed AHI &lt; 10 events/hr; no positional OSA; no Complete Concentric Collapse of the soft palate during Drug Induced Sleep Endoscopy; and failed to tolerate or accept Positive Airway Pressure treatments.

Results

27 participants were implanted (63% male, aged 55.9±12.0 years, BMI 27.4±3.0 kg/m2). 22 completed the protocol. At 6 months, AHI decreased from 23.7±12.2 to 12.9±10.1 events/hr [p&lt;0.001]; and ODI decreased from 19.1±11.2 to 9.8±6.9 events/hr [p&lt;0.001]. Daytime sleepiness (ESS, p=0.011) and sleep-related quality of life (FOSQ-10, p=0.016) both significantly improved. 91% of participants reported using their device &gt;5 days per week, and 77% used it &gt;5 hours per night. The number of bed partners reporting disruptive snoring decreased from 96% to 35%. No device-related SAE occurred.

Conclusion

In a targeted population of individuals with moderate-to-severe OSA, the Genio system reduced OSA severity and sleepiness, improved quality of life, and was associated with high adherence and an acceptable safety profile.

Support

This study trial was funded by Nyxoah S.A. This trial was registered with ClinicalTrials.gov, number NCT03048604.

Shame Proneness, Negative Cognitions, and Posttraumatic Stress Among Women with a History Sexual Trauma

While fear and anger have been extensively studied as emotions involved in posttraumatic stress disorder, shame is an important emotion to examine in those who have experienced a traumatic event, as it is often associated with treatment avoidance and treatment resistance. Compared to guilt, which is associated with having participated in something that violates social/cultural norms or expectations, shame is associated with a negative perception of the self. The current paper sought to examine the role of shame proneness and guilt proneness, as it relates to posttraumatic cognitions and posttraumatic stress symptoms (PTSS) among women reporting a history of sexual trauma. Seventy-two community-recruited women with a history of sexual trauma completed self-report measures of shame and guilt proneness and negative posttraumatic cognitions as well as a semi-structured interview assessing PTSS. There was an indirect effect of shame proneness on PTSS, through its positive association with negative cognitions about the self but not others or the world. Guilt proneness was not significantly related to PTSS or negative posttraumatic cognitions. The current paper outlines the importance of these findings and future directions for continuing to better understand the relations between shame and posttraumatic stress disorder symptoms and treatment.

A Prospective Examination of Child Avoidance Coping and Parental Coping Assistance After Pediatric Injury: A Mixed-Methods Approach

OBJECTIVE

Millions of children experience injuries annually, and avoidance coping increases risk of negative emotional and physical outcomes after injury. Little is known about how children select avoidance coping strategies. Parents may help their children cope with an injury by encouraging or discouraging the use of specific strategies, such as avoidance coping. The present study examined parental influence of child use of avoidance coping post-injury.

METHODS

Children ages 8-13 (65% male; 50% White) hospitalized for pediatric injury and their parents (N = 96 child-parent dyads) participated in an interview and discussion task about coping at baseline, and then completed coping/coping assistance measures at three time points: T1 (within 2 weeks post-injury), T2 (6-weeks post-injury), and T3 (12-weeks post-injury).

RESULTS

When presented with an ambiguous situation in the observational interview and discussion task, the number of avoidance coping solutions offered by children independently as well as during a discussion with their parent predicted the child's ultimate avoidance versus non-avoidance coping choice. The number of avoidance coping solutions offered by parents did not predict children's final choice to use avoidance coping. Longitudinal data suggest that parent encouragement of avoidance coping predicted child avoidance coping within the first 6-weeks post-trauma.

CONCLUSIONS

Our study suggests that child avoidance coping is multifaceted and may result from both parent encouragement as well as independent decisions by children. Future research may explore additional factors that influence child avoidance coping, outside of parental suggestion, in response to trauma exposure.

Facets of Emotion Regulation and Posttraumatic Stress: An Indirect Effect via Peritraumatic Dissociation

Research suggests important associations between emotion regulation difficulties and posttraumatic stress disorder (PTSD) symptomology, with prospective studies indicating that emotion regulation difficulties may lead to increased PTSD symptoms. Peritraumatic dissociation is considered an important and consistent predictor of PTSD symptoms. The present study examines whether peritraumatic dissociation accounts for associations between facets of emotion regulation difficulties and PTSD symptoms. Adult women with a history of sexual victimization participated in an interview to assess past-month PTSD symptoms and self-report questionnaires to assess peritraumatic dissociation and emotion regulation difficulties. Results showed a partial indirect effect of three facets of emotion regulation difficulties (i.e., nonacceptance of negative emotional responses, limited access to emotion regulation strategies perceived as effective in the context of distress, and impulse control difficulties when experiencing negative emotions) on PTSD symptoms through peritraumatic dissociation. Reverse indirect effects models were also explored. The present study offers preliminary evidence that peritraumatic dissociation by traumatized individuals may signal the presence of specific emotion regulation deficits, which may indicate increased risk of heightened PTSD severity.

Protection against maternal infection-associated fetal growth restriction: proof-of-concept with a microbial-derived immunomodulator

Infection-associated inflammatory stress during pregnancy is the most common cause of fetal growth restriction and/or miscarriage. Treatment strategies for protection of at-risk mothers are limited to a narrow range of vaccines, which do not cover the bulk of the common pathogens most frequently encountered. Using mouse models, we demonstrate that oral treatment during pregnancy with a microbial-derived immunomodulator (OM85), currently used clinically for attenuation of infection-associated airway inflammatory symptoms in infants-adults, markedly reduces risk for fetal loss/growth restriction resulting from maternal challenge with bacterial lipopolysaccharide or influenza. Focusing on LPS exposure, we demonstrate that the key molecular indices of maternal inflammatory stress, notably high levels of RANTES, MIP-1α, CCL2, KC, and G-CSF (granulocyte colony-stimulating factor) in gestational tissues/serum, are abrogated by OM85 pretreatment. Systems-level analyses conducted in parallel using RNASeq revealed that OM85 pretreatment selectively tunes LPS-induced activation in maternal gestational tissues for attenuated expression of TNF, IL1, and IFNG-driven proinflammatory networks, without constraining Type1-IFN-associated networks central to first-line antimicrobial defense. This study suggests that broad-spectrum protection-of-pregnancy against infection-associated inflammatory stress, without compromising capacity for efficient pathogen eradication, represents an achievable therapeutic goal.

Daily Goals and Psychological Well-Being in Midlife and Older Women: Physical Pain Interacts with Goal Conflict

Physical pain is more prevalent with older age and female gender, and pain can interfere with goal pursuit and its psychological benefit. In particular, insofar as pain is associated with fatigue, it may limit resources for goal pursuit and increase goal resource conflict: the competition between goals for time and energy. Therefore, the pursuit of goals with high value and low resource conflict should provide the most psychological benefit, particularly for women who experience physical pain. Women in middle and older age (N = 200) completed up to 7 daily diaries (n = 1,380), in which they reported and rated their daily goals and assessed their daily pain, distress, fatigue, and cognitive function. Raters also assessed goal conflict. Multilevel models tested the within- and between-person relationships of goal value and goal conflict with daily distress, fatigue, and cognitive function, as well as moderation by pain. Higher goal value was associated with less distress and fatigue and better cognitive function within and between women. Depending on whether or not a woman had physical pain, goal conflict had different relationships with fatigue and cognitive function: for women with no pain, there was a modest positive relationship between goal conflict and both cognitive difficulties and subjective fatigue; for women with pain, there was a negative relationship between goal conflict and both cognitive difficulties and subjective fatigue. Results suggest women without pain may be taxed by their goal conflict, whereas women with pain may regulate their goal conflict in response to their available resources.

Affective lability predicts decreased habituation in posttraumatic stress symptom responding during a single laboratory session of imaginal exposure

Affective lability, or the instability of emotional states, is associated with heightened levels of trauma-related emotional responding and posttraumatic stress disorder (PTSD) symptoms. However, the impact of affective lability, specifically on habituation to idiographic trauma cues, has yet to be examined among trauma-exposed individuals. The current study examined differential response trajectories to trauma-related imaginal exposure as a function of affective lability. Specifically, 72 women with a history of sexual victimization participated in a laboratory-based study involving a single session of repeated imaginal exposures to idiographic traumatic event cues. As hypothesized, participants higher in affective lability reported less reduction in trauma-cue elicited posttraumatic stress symptoms across exposure trials. Given these results, it will be important to continue to extend these laboratory findings to better understand how elevated affective lability is related to response to trauma-focused exposure therapy among individuals with PTSD or other trauma-related psychopathology (e.g., borderline personality disorder).

Spontaneously arising concurrent ileocaecal adenocarcinoma and renal pelvis transitional cell carcinoma in a rhesus macaque (Macaca mulatta)

A 25-year-old, female rhesus macaque (Macaca mulatta) presented with a history of weight loss despite a normal appetite and supportive care. The animal was humanely destroyed due to poor prognosis. Post-mortem examination revealed a focally extensive, firm, white annular constriction at the ileocaecal junction and an incidental finding of a pale white nodule approximately 0.8 cm in diameter in the left renal pelvis. Based on the microscopical findings, ileocaecal adenocarcinoma and renal pelvis transitional cell carcinoma (TCC) were diagnosed. The use of cytokeratin (CK)-7 and -20 and uroplakin III as potential renal TCC markers was evaluated. The neoplastic cells were labelled intensely with antibodies to uroplakin III, but not to CK-7 or -20. Spontaneous intestinal adenocarcinoma has been documented in the rhesus macaque, but concurrent renal pelvis TCC is highly unusual.

Dielectric Relaxation of La-Doped Zirconia Caused by Annealing Ambient

La-doped zirconia films, deposited by ALD at 300°C, were found to be amorphous with dielectric constants (k-values) up to 19. A tetragonal or cubic phase was induced by post-deposition annealing (PDA) at 900°C in both nitrogen and air. Higher k-values (~32) were measured following PDA in air, but not after PDA in nitrogen. However, a significant dielectric relaxation was observed in the air-annealed film, and this is attributed to the formation of nano-crystallites. The relaxation behavior was modeled using the Curie-von Schweidler (CS) and Havriliak-Negami (HN) relationships. The k-value of the as-deposited films clearly shows a mixed CS and HN dependence on frequency. The CS dependence vanished after annealing in air, while the HN dependence disappeared after annealing in nitrogen.

Metal organic chemical vapour deposition of vertically aligned ZnO nanowires using oxygen donor adducts

Vertically aligned zinc oxide (ZnO) nanowires (NWs) have been grown by liquid injection Metal Organic Chemical Vapour Deposition, using oxygen donor adducts of Me2Zn. The growth and characterisation of the nanowires grown using [Me2Zn(L)] where L = monodentate ethers, tetrahydrofuran (C4H8O) (1), tetrahydropyran (C5H10O) (2), furan (C4H4O) (3) and the bidentate ethers, 1,2-dimethoxyethane (C4H12O2,) (4) 1,4-dioxane (C4H8O2) (5) and 1,4-thioxane (C4H8SO) (6) is discussed. Single crystal X-ray structures of (4), (5), (6) have been established and are included here. The ZnO NWs were deposited in the absence of a seed catalyst on Si(111) and F-doped SnO2/glass substrates over the temperature range 350-600 degrees C. X-ray diffraction (XRD) data shows that the nanowires grown from all adduct precursors were deposited in the wurtzitic phase.

Digital metastases of giant cell rich malignant fibrous histiocytoma

Background. Metastatic spread of soft tissue sarcomas to the digits is extremely rare and metastasis of MFH to the fingers and toes has not been documented.Purpose. We present two case reports of metastatic spread from a giant cell rich malignant fibrous histiocytoma to the digits and discuss their management.

Content variability of active drug substance in compounded oral 3,4-diaminopyridine products

WHAT IS KNOWN AND OBJECTIVE

3,4-diaminopyridine (3,4-DAP; amifampridine) is used for symptomatic treatment of Lambert-Eaton myasthenic syndrome. Until recently, it was only available as a compounded product, which raises safety concerns because of possible high variability in active drug substance content. The objective of this study was to evaluate the variability in dosage form weight, active content variability and impurity of compounded oral 3,4-DAP drug products.

METHODS

Ten samples each of 9 oral 3,4-DAP compounded products were weighed, extracted with water and the 3,4-DAP content determined by ultra high-performance liquid chromatography.

RESULTS AND DISCUSSION

Variability in dosage form weight ranged from 0·81% relative standard deviation (RSD) to 4·82% RSD. In the 90 samples tested, 3,4-DAP content ranged from 22·2% to 125·2% of declared label content. All 10 samples of one compounded product had active drug substance content well below the declared label content (35·0%, 51·7% RSD). No compounded product achieved the Good Manufacturing Practice (GMP) standard of 95-105% range limit of declared label content; one achieved 90-110%, and four others achieved 80-120% of declared content for all 10 samples. There was no evidence of a significant presence of degradation products or related substances in any compounded product.

WHAT IS NEW AND CONCLUSION

Compounded 3,4-DAP products are subject to considerable variability in active drug substance content. This variability seems to be principally because of heterogeneous formulated material rather than variation in dosage form weight.

The optical properties of vertically aligned ZnO nanowires deposited using a dimethylzinc adduct

The optical properties of zinc oxide nanowires are critically influenced by the growth process. Herein, we describe a metal-organic chemical vapour deposition (MOCVD) process for the growth of ZnO nanowires with improved optical properties. A tetrahydrofuran adduct is used to control the reactivity of dimethylzinc to enable this. Vertically aligned zinc oxide nanowires have been grown on Si(111) substrates by liquid injection MOCVD, using a solution of [Me(2)Zn(tetrahydrofuran)] in the presence of oxygen. The ZnO morphology becomes nanowire-like in a narrow temperature range centred about 500 degrees C. Above and below this temperature range, the ZnO is deposited in the form of polycrystalline films. The ZnO nanowires grow from a polycrystalline nucleation layer, with the (0002) c-axis parallel to the Si[111] substrate orientation. High-resolution electron microscopy reveals a highly crystalline nanowire microstructure. Resonance enhanced ultraviolet Raman spectroscopy shows that the ratio of first- and second-order longitudinal optic modes is commensurate with electron-phonon coupling effects observed previously in ZnO nanostructures. Photoluminescence exhibits intense near band-edge emission with a full width at half-maximum of 110 meV at room temperature and shows negligible defect-related visible emission.

The placebo effect and its determinants in osteoarthritis: meta-analysis of randomised controlled trials

OBJECTIVE

To examine the placebo effect and its potential determinants in the treatment of osteoarthritis (OA) via a systematic literature search of Medline, EMBASE, Scientific Citation Index, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Cochrane Library.

METHODS

Randomised placebo controlled trials in OA were included. The placebo effect was defined as the overall change from baseline in the placebo group. It was estimated as the effect size (ES; the standard mean difference between baseline and endpoint) and this was compared with the ES obtained from untreated control. ES for pain was the primary outcome. Statistical pooling was undertaken as appropriate and 95% CIs were used for comparison. Quality of trials was assessed and potential determinants of placebo effect were examined using multiple regression analysis. The partial regression coefficient (beta) was used to present the adjusted size of the association.

RESULTS

We identified 198 trials with 193 placebo groups (16 364 patients) and 14 untreated control groups (1167 patients) that met our inclusion criteria. These included a range of therapies (non-pharmacological, pharmacological and surgical treatments). Placebo was effective at relieving pain (ES 0.51, 95% CI 0.46 to 0.55 for the placebo group and 0.03, 95% CI -0.13 to 0.18 for untreated control). Placebo was also effective at improving function and stiffness. The pain-relieving effect increased when the active treatment effect (beta=0.38, p<0.001), baseline pain (0.006, p=0.014) and sample size (0.001, p=0.004) increased, and when placebo was given through injections/needles (0.144, p=0.020).

CONCLUSION

Placebo is effective in the treatment of OA, especially for pain, stiffness and self-reported function. The size of this effect is influenced by the strength of the active treatment, the baseline disease severity, the route of delivery and the sample size of the study.

Development of specimen-specific finite element models of human vertebrae for the analysis of vertebroplasty

The aim of this study was to determine the accuracy of specimen-specific finite element models of untreated and cement-augmented vertebrae by direct comparison with experimental results. Eleven single cadaveric vertebrae were imaged using micro computed tomography (mCT) and tested to failure in axial compression in the laboratory. Four of the specimens were first augmented with PMMA cement to simulate a prophylactic vertebroplasty. Specimen-specific finite element models were then generated using semi-automated methods. An initial set of three untreated models was used to determine the optimum conversion factors from the image data to the bone material properties. Using these factors, the predicted stiffness and strength were determined for the remaining specimens (four untreated, four augmented). The model predictions were compared with the corresponding experimental data. Good agreement was found with the non-augmented specimens in terms of stiffness (root-mean-square (r.m.s.) error 12.9 per cent) and strength (r.m.s. error 14.4 per cent). With the augmented specimens, the models consistently overestimated both stiffness and strength (r.m.s. errors 65 and 68 per cent). The results indicate that this method has the potential to provide accurate predictions of vertebral behaviour prior to augmentation. However, modelling the augmented bone with bulk material properties is inadequate, and more detailed modelling of the cement region is required to capture the bone—cement interactions if the models are to be used to predict the behaviour following vertebroplasty.

Disparities in joint replacement utilization: a quality of care issue

Although total joint replacement is an effective treatment option for end-stage lower extremity osteoarthritis, racial disparities in joint replacement utilization have been well documented. These disparities may be due in part to patient-level factors such as willingness to consider joint replacement and worse expectations of joint replacement outcomes. In addition, African-Americans may have worse outcomes after total joint replacement and are more likely to have surgery performed by surgeons with lower volumes or in hospitals with lower volumes. All of these issues may be considered concerns with the quality of care delivered to African-Americans with osteoarthritis.

Elimination of transmissible spongiform encephalopathy infectivity and decontamination of surgical instruments by using radio-frequency gas-plasma treatment

It has now been established that transmissible spongiform encephalopathy (TSE) infectivity, which is highly resistant to conventional methods of deactivation, can be transmitted iatrogenically by contaminated stainless steel. It is important that new methods are evaluated for effective removal of protein residues from surgical instruments. Here, radio-frequency (RF) gas-plasma treatment was investigated as a method of removing both the protein debris and TSE infectivity. Stainless-steel spheres contaminated with the 263K strain of scrapie and a variety of used surgical instruments, which had been cleaned by a hospital sterile-services department, were examined both before and after treatment by RF gas plasma, using scanning electron microscopy and energy-dispersive X-ray spectroscopic analysis. Transmission of scrapie from the contaminated spheres was examined in hamsters by the peripheral route of infection. RF gas-plasma treatment effectively removed residual organic residues on reprocessed surgical instruments and gross contamination both from orthopaedic blades and from the experimentally contaminated spheres. In vivo testing showed that RF gas-plasma treatment of scrapie-infected spheres eliminated transmission of infectivity. The infectivity of the TSE agent adsorbed on metal spheres could be removed effectively by gas-plasma cleaning with argon/oxygen mixtures. This treatment can effectively remove 'stubborn' residual contamination on surgical instruments.

Cost effectiveness of a two-year home exercise program for the treatment of knee pain

OBJECTIVE

To assess the cost effectiveness of a 2-year home exercise program for the treatment of knee pain.

METHODS

A total of 759 adults aged > or = 45 years were randomized to receive exercise therapy, monthly telephone contact, exercise therapy and telephone contact, or no intervention. Efficacy was measured using self-reported knee pain at 2 years. Costs to both the National Health Service and to the patient were included.

RESULTS

Exercise therapy was associated with higher costs and better effectiveness. Direct costs for the interventions were pound 112 for the exercise program and pound 61 for the monthly telephone support. Participants allocated to receive exercise therapy were significantly more likely to incur higher medical costs than those in the no-exercise groups (mean difference pound 225; 95% confidence interval pound 218, pound 232; P < 0.001).

CONCLUSION

Exercise therapy is associated with improvements in knee pain, but the cost of delivering the exercise program is unlikely to be offset by any reduction in medical resource use.

Preoperative chemoradiotherapy and total mesorectal excision surgery for locally advanced rectal cancer: correlation with rectal cancer regression grade

PURPOSE

Preoperative long-course chemoradiotherapy is recommended for rectal carcinoma when there is concern that surgery alone may not be curative. Downstaging of the tumor can be measured as rectal cancer regression grade (1-3) and may be of importance when estimating the prognosis. The aim of this study was to look at the long-term results of tumor regression in patients receiving long-course chemotherapy before surgical resection of rectal cancer.

METHODS

We reviewed those patients who received preoperative chemoradiotherapy followed by surgical resection for carcinoma of the mid rectum or distal rectum found to be stage T3/4 between January 1995 and November 1999. Patients received 45 to 50 Gy irradiation in 2-Gy fractions and an infusion of 5-fluorouracil. Surgical specimens were assessed for rectal cancer regression grade. Patients were followed up routinely with clinical examination, computed tomography, and colonoscopy.

RESULTS

Sixty-five patients with a mean age 65 (range, 32-83) years underwent chemoradiotherapy before surgical resection. Thirty patients (46 percent) were classified as rectal cancer regression Grade 1, with 9 patients (14 percent) having complete sterilization of the tumor. Fifty-three patients (82 percent) underwent a curative resection. Overall survival, with a median follow-up of 39 (range, 24-83) months, was 67 percent and was associated with tumor downstaging. The local recurrence rate was 5.8 percent in those patients who underwent a curative resection and was significantly lower with rectal cancer regression Grade 1 tumors (P = 0.03). Eight of nine patients (89 percent) whose tumor had been sterilized were alive and well with no recurrence of tumor at a median follow-up of 41 (range, 24-70) months.

CONCLUSIONS

Preoperative chemoradiotherapy resulted in significant regression of tumor. Overall survival was high and was associated with downstaging of tumor. The local recurrence rate was significantly lower with rectal cancer regression Grade 1 tumors and was not seen in patients with sterilized tumors.

Investigation of microstructural features in regenerating bone using micro computed tomography

We illustrate some of the uses of micro-computed tomography (micro-CT) to study tissue-engineered bone using a micro-CT facility for imaging and visualizing biomaterials in three dimensions (3-D). The micro-CT is capable of acquiring 3D X-ray CT images made up of 2000(3) voxels on specimens up to 5 cm in extent with resolutions down to 2 microm. This allows the 3-D structure of tissue-engineered materials to be imaged across orders of magnitude in resolution. This capability is used to examine an explanted, tissue-engineered bone material based on a polycaprolactone scaffold and autologous bone marrow cells. Imaging of the tissue-engineered bone at a scale of 1 cm and resolutions of 10 microm allows one to visualize the complex ingrowth of bone into the polymer scaffold. From a theoretical viewpoint the voxel data may also be used to calculate expected mechanical properties of the tissue-engineered implant. These observations illustrate the benefits of tomography over traditional techniques for the characterization of bone morphology and interconnectivity. As the method is nondestructive it can perform a complimentary role to current histomorphometric techniques.

Plasma cleaning of dental instruments

The theoretical risk of prion transmission via surgical instruments is of current public and professional concern. These concerns are further heightened by reports of the strong surface affinity of the prion protein, and that the removal of organic material by conventional sterilization is often inadequate. Recent reports of contamination on sterilized endodontic files are of particular relevance given the close contact that these instruments may make with peripheral nerve tissue. In this paper, we report the effective use of a commercial gas plasma etcher in the cleaning of endodontic files. A representative sample of cleaned, sterilized, files was screened, using scanning electron microscopy and energy-dispersive X-ray analysis, to determine the level of contamination before plasma cleaning. The files were then exposed for a short-term to a low-pressure oxygen-argon plasma, before being re-examined. In all cases, the amount of organic material (in particular that which may have comprised protein) was reduced to a level below the detection limit of the instrument. This work suggests that plasma cleaning offers a safe and effective method for decontamination of dental instruments, thus reducing the risk of iatrogenic transmission of disease during dental procedures. Furthermore, whilst this study focuses on dental files, the findings indicate that the method may be readily extended to the decontamination of general surgical instruments.

Home based exercise programme for knee pain and knee osteoarthritis: randomised controlled trial

OBJECTIVES

To determine whether a home based exercise programme can improve outcomes in patients with knee pain.

DESIGN

Pragmatic, factorial randomised controlled trial of two years' duration.

SETTING

Two general practices in Nottingham.

PARTICIPANTS

786 men and women aged >/=45 years with self reported knee pain.

INTERVENTIONS

Participants were randomised to four groups to receive exercise therapy, monthly telephone contact, exercise therapy plus telephone contact, or no intervention. Patients in the no intervention and combined exercise and telephone groups were randomised to receive or not receive a placebo health food tablet.

MAIN OUTCOME MEASURES

Primary outcome was self reported score for knee pain on the Western Ontario and McMaster universities (WOMAC) osteoarthritis index at two years. Secondary outcomes included knee specific physical function and stiffness (scored on WOMAC index), general physical function (scored on SF-36 questionnaire), psychological outlook (scored on hospital anxiety and depression scale), and isometric muscle strength.

RESULTS

600 (76.3%) participants completed the study. At 24 months, highly significant reductions in knee pain were apparent for the pooled exercise groups compared with the non-exercise groups (mean difference -0.82, 95% confidence interval -1.3 to -0.3). Similar improvements were observed at 6, 12, and 18 months. Regular telephone contact alone did not reduce pain. The reduction in pain was greater the closer patients adhered to the exercise plan.

CONCLUSIONS

A simple home based exercise programme can significantly reduce knee pain. The lack of improvement in patients who received only telephone contact suggests that improvements are not just due to psychosocial effects because of contact with the therapist.

Pharmacology of INS37217 [P(1)-(uridine 5')-P(4)- (2'-deoxycytidine 5')tetraphosphate, tetrasodium salt], a next-generation P2Y(2) receptor agonist for the treatment of cystic fibrosis

INS37217 [P(1)-(uridine 5')-P(4)-(2'-deoxycytidine 5')tetraphosphate, tetrasodium salt] is a deoxycytidine-uridine dinucleotide with agonist activity at the P2Y(2) receptor. In primate lung tissues, the P2Y(2) receptor mRNA was located by in situ hybridization predominantly in epithelial cells and not in smooth muscle or stromal tissue. The pharmacologic profile of INS37217 parallels that of UTP, leading to increased chloride and water secretion, increased cilia beat frequency, and increased mucin release. The combined effect of these actions was confirmed in an animal model of tracheal mucus velocity that showed that a single administration of INS37217 significantly enhanced mucus transport for at least 8 h after dosing. This extended duration of action is consistent with the ability of INS37217 to resist metabolism by airway cells and sputum enzymes. The enhanced metabolic stability and resultant increased duration of improved mucociliary clearance may confer significant advantages to INS37217 over other P2Y(2) agonists in the treatment of diseases such as cystic fibrosis.

Quantification of histologic regression of rectal cancer after irradiation: a proposal for a modified staging system

PURPOSE

Long-course preoperative radiotherapy has been recommended for rectal carcinoma when there is concern about the ability to perform a curative resection, for example, in larger tethered tumors or those sited anteriorly or near the anal sphincter. "Downstaging" of the tumor may occur, and this is of importance when estimating the prognosis and selecting postoperative therapy for patients. We studied the effects of preoperative chemoradiotherapy on the pathology of rectal cancer, and we propose a simplified measurement of tumor regression, the Rectal Cancer Regression Grade.

METHODS

We have reviewed those patients who received preoperative chemoradiotherapy followed by surgical resection for carcinomas of the mid or distal third of the rectum found to be Stage T3/4 on transrectal ultrasound or CT between January 1995 and December 1998. Patients received 45 to 50 Gy irradiation and an infusion of 5-fluorouracil. The surgical specimens were examined by one pathologist, and the Rectal Cancer Regression Grade was quantified.

RESULTS

Forty-two patients, mean age 60 (range, 42-86) years, underwent chemoradiotherapy before surgery for rectal carcinoma. There were 28 anterior resections (67 percent; 9 with a colonic pouch), 12 abdominoperineal resections (27 percent), and 2 Hartmann's procedures (5 percent). Comparison of preoperative and pathologic staging revealed that the depth of invasion was downstaged in 17 patients (38 percent), and the status of involved lymph nodes was downstaged in 13 (50 percent) of 26 patients. Tumor regression was more than 50 percent (Rectal Cancer Regression Grades 1 and 2) in 36 patients (86 percent), with 7 patients (17 percent) having complete regression with absence of residual cancer cells.

CONCLUSION

Significant tumor regression was seen in 86 percent of cases after chemoradiotherapy, with 19 patients showing a "good" responsiveness. We propose a modified pathologic staging system for irradiated rectal cancer, the Rectal Cancer Regression Grade, which includes a measurement of tumor regression. The utility of the proposed Rectal Cancer Regression Grade must be tested against long-term outcomes before its value in predicting prognosis and survival can be determined.

A nurse-delivered advice intervention can reduce chronic non-steroidal anti-inflammatory drug use in general practice: a randomized controlled trial

OBJECTIVE

To find out whether a nurse-delivered educational package can reduce chronic oral non-steroidal anti-inflammatory drug (NSAID) usage in general practice.

METHOD

A prospective randomized controlled trial with assessment of economic cost/benefits was carried out in five general practices in Nottinghamshire with computerized prescribing systems, representing a mix of rural/urban and fundholding/non-fundholding practices. Patients suffering from non-malignant, non-inflammatory musculoskeletal pain received repeat prescriptions for oral NSAIDs. Two hundred and twenty-two patients were randomized to a control group (simple advice regarding NSAID use) or an intervention group (asked to withdraw their NSAIDs and employ appropriate alternative drug and non-drug therapies). All advice was supported by patient literature and delivered by a nurse practitioner trained in musculoskeletal assessment. The primary outcome measure was change in NSAID use 6 months after the intervention. Secondary outcome measures were changes in health and quality of life (SF-36 and EQ-5D questionnaires) and drug, health service and patient costs.

RESULTS

An extra 28% of patients in the intervention group either stopped taking oral NSAIDs or reduced dosage by > or =50% at 6 months compared with controls. There was no detrimental effect on health and well-being. Oral NSAID prescription costs were significantly lowered in the intervention group but not in the control group. A non-significant increase in total drug prescription costs occurred in both groups.

CONCLUSIONS

Nurse-based intervention can reduce chronic NSAID usage and costs in primary care and would be cost-effective if maintained in the long term. This intervention package would be readily applicable in primary care.

Primary extracranial meningioma of the mandible: A report of 2 cases and a review of the literature

Three cases of primary extracranial meningioma arising in the jaws have been reported in the English-language literature. The purpose of this report is to document 2 additional cases that arose in the mandible. Both cases occurred in women and appeared as radiolucent lesions. Microscopic examination revealed an unencapsulated tumor composed of uniform spindle-shaped cells arranged in whorls and interconnecting fascicles. Occasional nuclear pseudoinclusions and psammoma bodies were identified. The tumor cells demonstrated immunohistochemical reactivity for epithelial membrane antigen and vimentin. Both cases were treated by surgical excision. Based on previously published examples in the jaws, these neoplasms do not appear to be aggressive.

Cooperativity between KorB and TrbA repressors of broad-host-range plasmid RK2

The KorB and TrbA proteins of broad-host-range plasmid RK2 are key regulators of the plasmid genes required for conjugative transfer. trbBp is the primary promoter responsible for expression of mating pair formation genes. We show that despite the targets for KorB and TrbA at trbBp being about 165 bp apart, 189 bp upstream of the transcription start point and overlapping the -10 region, respectively, these two proteins show up to 10-fold cooperativity for the repression of trbBp. Deletion analysis of TrbA showed that the C-terminal domain (CTD), which has a high degree of sequence conservation with the CTD of KorA, is required for this cooperativity with KorB. Western blotting demonstrated that the apparently mutual enhancement of repression is not due simply to elevation of repressor level by the presence of the second protein, suggesting that the basis for cooperativity is interaction between KorB and TrbA bound at their respective operators.