Quality Improvement Campaign Improved Utilization of Rapid Sequence MRI for Diagnosis of Pediatric Appendicitis

INTRODUCTION

Appendicitis is the most common indication for emergency general surgery in the pediatric population. Computed tomography (CT) or magnetic resonance imaging (MRI) may be used for diagnosis when ultrasound findings are equivocal. However, CT involves unnecessary radiation exposure if MRI is available. After introducing a rapid sequence MRI (rsMRI) appendicitis protocol at our institution, CT was still preferentially used. We therefore implemented a quality improvement (QI) campaign to reduce the rate of CTs and increase the rate of rsMRI. Here, we assess the effectiveness of the QI campaign while evaluating potential barriers to using rsMRI.

METHODS

We conducted a mixed methods study, first performing stakeholder interviews which informed the design of a QI campaign initiated in May 2021 and a midway feedback survey in December 2021. A retrospective cohort study was then performed of children evaluated for appendicitis at our institution between January 1, 2016, and April 30, 2022. CT and rsMRI rates were compared before and after QI campaign implementation.

RESULTS

There was a significant decrease in rate of CTs and increase in rate of rsMRIs performed following the initiation of the QI campaign (p < 0.0001). The rate of CT scans decreased by a factor of 0.4 while the rate of rsMRI increased by a factor of 9.5.

CONCLUSION

A successful QI campaign was initiated at our institution, resulting in decreased utilization of CT and increased use of rsMRI for the evaluation of suspected appendicitis. These results highlight the potential impact of QI projects.

LEVEL OF EVIDENCE

III.

The Impact of COVID-19 on Radiotherapy Services in Scotland, UK: A Population-based Study

AIMS

The effect of the COVID-19 pandemic on cancer radiotherapy services is largely unknown. The aim of the present study was to investigate the impact of the resultant contingency plans on radiotherapy cancer services in Scotland.

MATERIALS AND METHODS

Detailed data of radiotherapy activity at our centre were collected from 1 April 2019 to 31 March 2021. Differences in mean weekly radiotherapy courses, dose and fractionation patterns and treatment intent were compared with corresponding pre-pandemic months for all treatment sites. Qualitative data were collected for a subgroup of radical radiotherapy patients.

RESULTS

Total radiotherapy courses decreased from 6968 to 6240 (-10%) compared with the previous year, prior to the pandemic. Average weekly radiotherapy courses delivered were 134 (standard deviation ±13), decreasing by 10% to 120 (standard deviation 15) (Welch's t-test, P < 0.001). The greatest decrease in new start treatment courses was observed from May to August 2020 (-7.7%, -24.0%, -16.7% and -18.7%) compared with the corresponding months in 2019. A significant reduction was seen for female patients <70 years (-16%) compared with females >70 years (-8%) or their male counterparts (-7% and -6%, respectively). By diagnosis, the largest reductions between pre- and post-pandemic levels were for anal (-26%), breast (-18%) and prostate (-14%) cancer. Contrarily, a significant increase was found for bladder (28%) and oesophageal (11%) cancers.

CONCLUSIONS

Over the first 12 months of the COVID-19 pandemic, radiotherapy activity significantly decreased compared with the 12 months prior. Due to issued guidance, the use of hypofractionated regimens increased, contributing to the reduction in treatments for some tumour sites. An increase in other tumour sites can probably be attributed to the reduction or cancellation of surgical interventions. These results will inform our understanding of the indirect consequences of the pandemic on radiotherapy services.

POS0285 SUB-STANDARD CARE FOR PATIENTS WITH GOUT, DESPITE UPDATED GUIDELINES: A UK-WIDE, POPULATION-BASED COHORT STUDY

Background

Treat-to-target urate-lowering therapy (ULT) is highly effective at preventing flares and improving quality of life for patients with gout.1 However, in 2012, only 27% of patients with gout in UK primary care received prescriptions for ULT within 12 months of diagnosis.2 Since then, EULAR and BSR gout management guidelines have been updated, to recommend that all patients with gout should have ULT discussed and offered to them, with uptitration of dosing until target urate levels are achieved. We investigated whether gout management has improved in recent years.

Objectives

To assess temporal trends in the initiation of ULT and attainment of serum urate targets following new gout diagnoses in UK primary care from 2004 to 2020.

Methods

The Clinical Practice Research Datalink (CPRD) Gold database was used to assess the management of patients with index diagnostic codes for gout in UK primary care between January 2004 and October 2020. We analysed the proportion of patients with the following outcomes within 12 months of diagnosis: i) initiation of ULT (allopurinol, febuxostat, benzbromarone, probenecid or sulfinpyrazone); ii) serum urate ≤360 µmol/L; iii) serum urate ≤300 µmol/L; iv) treat-to-target urate monitoring (defined as two or more serum urate levels performed within 12 months of diagnosis and/or one or more urate ≤300 µmol/L). Interrupted time-series analyses (ITSA) were used to estimate the impact of updated EULAR and BSR gout management guidelines on these outcomes. Multivariate logistic regression was used to analyse predictors of ULT prescription and target attainment following new gout diagnoses.

Results

129,972 patients had index gout diagnoses between January 2004 and October 2020, of whom only 37,529 (28.9%) had ULT initiated within 12 months of diagnosis. ULT initiation improved modestly over the study period, from 26.8% for those diagnosed in 2004 to 36.6% in 2019, decreasing to 34.7% in 2020 (Figure 1). Of patients diagnosed in 2020 who had a serum urate performed within 12 months of diagnosis, 36.0% attained a urate ≤360 µmol/L, while 17.1% attained a urate ≤300 µmol/L. Of all participants, 18.9% received treat-to-target urate monitoring. In ITSA models, no statistically significant improvements in ULT prescription or urate target attainment were observed after publication of updated EULAR (2016) or BSR (2017) gout management guidelines, relative to before publication of these guidelines. In multivariate logistic regression models, comorbidities including chronic kidney disease, heart failure and obesity, and diuretic use were associated with increased odds of ULT initiation but decreased odds of attaining target urate levels by 12 months.

Figure 1.

Proportion of patients newly diagnosed with gout who: i) were initiated on urate-lowering therapy (ULT) within 12 months of diagnosis (black line); ii) had a serum urate performed and attained a level ≤360 µmol/L (light blue) or ≤300 µmol/L (dark blue) within 12 months of diagnosis.

Conclusion

In this UK-wide study, we demonstrate that the initiation of ULT and attainment of serum urate targets following new gout diagnoses remain poor, despite the introduction of updated management guidelines. If the evidence-practice gap in gout management is to be bridged successfully, strategies to implement best practice gout care are urgently needed.

References

[1]Doherty M, et al. Efficacy and cost-effectiveness of nurse-led care involving education and engagement of patients and a treat-to-target urate-lowering strategy versus usual care for gout: a randomised controlled trial. Lancet 2018;392(10156):1403-12

[2]Kuo CF, et al. Rising burden of gout in the UK but continuing suboptimal management: a nationwide population study. Ann Rheum Dis 2015;74(4):661-7

Acknowledgements

This work is independent research supported by the National Institute for Health Research (NIHR) Doctoral Fellowship, Dr Mark Russell, NIHR300967. This study is based in part on data from the Clinical Practice Research Datalink obtained under licence from the UK Medicines and Healthcare products Regulatory Agency.

Disclosure of Interests

Mark Russell Speakers bureau: Lilly; Menarini, Andrew Rutherford: None declared, Benjamin Ellis: None declared, Sam Norton: None declared, Abdel Douiri: None declared, Martin Gulliford: None declared, Andrew Cope: None declared, James Galloway Speakers bureau: Abbvie, Biovitrum, BMS, Celgene, Chugai, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Sanofi, Sobi and UCB

AB1438 CARDIOVASCULAR RISK STRATIFICATION FOR TOFACITINIB PATIENTS IN A LARGE TEACHING HOSPITAL

Background

Tofacitinib is an oral JAK-Inhibitor often reserved for patients with treatment-resistant Rheumatoid Arthritis and Psoriatic Arthritis. Tofacitinib modulates cytokines crucial to the inflammatory response which characterises the above conditions, and inhibits certain pathways in the inflammatory response cascade. Rheumatoid and Psoriatic Arthritis are linked with an inherent increased risk for major cardiovascular events. Recent emerging data has evidenced increased cardiovascular risk associated with long-term use of tofacitinib.

Objectives

To identify all patients currently undergoing Tofacitinib treatment across all sites at King’s College Hospital NHS Foundation Trust.​

To risk-stratify all patients into three categories; low risk of developing major cardiovascular events, moderate risk of developing MACE (patients with modifiable risk factors​, eg. high cholesterol or a borderline blood pressure), and high risk of developing MACE (unmodifiable risk factors​).

To switch patients at high risk onto another treatment or alternative JAK-inhibitor.​

Methods

Patient data was obtained through electronic patient records including age, blood pressure reading, full lipid profile, smoking status, and comorbidities (hypertension, diabetes, chronic kidney disease, previous cardiovascular history and history of malignancy). A QRISK3 score was calculated.

Modifiable risk factors with a lower QRISK3 score were categorised as moderate risk.

Patients were considered at high risk if they had a previous cardiovascular event, or a QRISK3 score of more than 10%.

Results

A total of 40 patients were on tofacitinib; 64% with RA, 31% with PsA, and 5% for other reasons (interstitial lung disease and colitis). Of the rheumatoid arthritis cohort: 36% of patients were at high risk, 40% at moderate risk, and 24% low risk. Of the psoriatic arthritis cohort: 67% at high risk, 25% at moderate risk, 8% at low risk.

Figure 1.

Conclusion

A significant number of patients were deemed at moderate and high risk. Patients with moderate risk were advised to undergo lifestyle changes, like exercise and diet modification and smoking cessation.

Patients at high risk were discussed at the trust-wide Rheumatology local clinical governance meeting, and advised to switch onto an alternative treatment or alternative JAK-inhibitor.

A repeat audit will be made in a few months’ time to assess the impact of lifestyle changes and alteration of drugs on cardiovascular risk.

References

[1]MHRA/CHM advice: Tofacitinib: new measures to minimise risk of major adverse cardiovascular events and malignancies (October 2021)

Disclosure of Interests

None declared

OP0194 COMBINATION ANAKINRA AND TOCILIZUMAB TO TREAT REFRACTORY MACROPHAGE ACTIVATION SYNDROME TRIGGERED BY ADULT-ONSET STILL’S DISEASE

Background

Adult-onset Still’s disease (AOSD) is associated with the development of macrophage activation syndrome (MAS) [1], sometimes termed secondary haemophagocytic lymphohistiocytosis (sHLH), a severe hyperinflammatory state with high mortality. Successful management of AOSD and MAS is contingent on early identification and treatment of the syndromes and any triggers, with aggressive immunosuppression in acutely unwell patients [2].

Objectives

To describe the case of a patient with newly diagnosed AOSD who developed severe MAS requiring ICU admission and immunosuppression with high-dose glucocorticoids, tocilizumab and anakinra.

Methods

Case report

Results

A 24-year-old woman attended hospital with a 4 month history of fever, arthralgia, rash and later dry cough. She became hypoxic and was admitted to the ICU for ventilation and vasopressor support. Imaging revealed splenomegaly, pleural effusions and lung consolidation but there was no response to antibiotics and no clear evidence of infection. Cytomegalovirus (CMV) DNA was initially absent, with IgG avidity indicating prior exposure. Bloods confirmed significant inflammation (CRP 107 mg/L, ferritin 6154 μg/L, ESR 47mm/hr) without disordered haematopoiesis. A bone marrow aspirate showed no haemophagocytosis. After extensive investigation a diagnosis of AOSD was made given the fulfilment of the Yamaguchi criteria and absence of evidence of an alternative driver of inflammation.

The patient deteriorated further, with deranged liver chemistry, rising CRP, triglycerides and ferritin (>100,000 μg /L), and trilineage cytopenia raising concern for MAS. This was managed by treating the presumed trigger (AOSD) with intravenous methylprednisolone (IVMP, 3x 500mg then 32mg daily) and anakinra (100mg twice daily). She developed a CMV viraemia that progressed despite aciclovir and later valganciclovir, which was switched to foscarnet and CMV immunoglobulin. The viraemia then stabilised and improved.

Due to persistent pyrexia, tachycardia, and elevated inflammatory markers, further IVMP (3x250mg), increased anakinra doses (100mg IV TDS) and intravenous immunoglobulin (2x60g) were given. A repeat bone marrow biopsy was consistent with MAS and testing for HLH-associated genes was negative.

The patient became increasingly hypoalbuminaemic and oedematous, developing acute kidney injury requiring continuous haemodiafiltration in the ICU. Anakinra was increased to 500mg daily in divided doses. The blood counts improved transiently, before the ferritin rose sharply again, with fevers and broad-spectrum antimicrobials continuing. Cytokine profile testing at this point revealed significant elevation in IL-1b and IL-6. Tocilizumab 8mg/kg fortnightly was added to existing therapy.

After tocilizumab initiation the inflammatory markers, blood counts and clinical state improved, though the patient remained hypertensive despite numerous antihypertensives. She left the ICU ten weeks after initial presentation. Corticosteroids and anakinra were weaned and she was discharged on tocilizumab monotherapy. Renal function did not return, and she continues outpatient haemodialysis.

Conclusion

The evidence base for effective therapies in MAS is poor. Reports exist of the use of either anakinra or tocilizumab [3] but not both agents in combination. In this case, cytokine blockade with both agents produced significant clinical improvement in a critically unwell patient.

References

[1]Carter, J et al. “Macrophage activation syndrome in adults: recent advances in pathophysiology, diagnosis and treatment.” Rheumatology (Oxford, England) vol. 58,1 (2019): 5-17.

[2]Buyse, S et al. “Critical care management of patients with hemophagocytic lymphohistiocytosis.” Intensive care medicine vol. 36,10 (2010): 1695-702.

[3]Gilboa, M et al. “Macrophage activation syndrome complicating rheumatic diseases in adults: case-based review.” Rheumatology international vol. 40,4 (2020): 663-669.

Acknowledgements

We acknowledge the kind permission of the patient for her case to be used for educational purposes, and to all those involved in her care during the acute admission

Disclosure of Interests

None declared

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

THU0438 INADEQUATE CARE FOR PATIENTS HOSPITALISED WITH GOUT: EVIDENCE THAT EULAR GUIDANCE IS NOT UTILISED

Background:

Hospitalisations due to gout have increased over the last decade, in direct contrast to declining admissions for other inflammatory arthritides including RA [1]. Gout is a treatable condition with recently published EULAR guidelines [2, 3]. Admissions could be avoided with effective use of urate-lowering therapies (ULT).

Objectives:

We hypothesised that the majority of patients attending hospital with acute gout attacks would not be on ULT. Furthermore, we hypothesised that the majority of patients would not be provided with a plan for ULT commencement and/or uptitration on discharge, leaving them at risk of further hospitalisations.

Methods:

We retrospectively analysed electronic health records for all patients presenting acutely with a primary admission diagnosis of gout (ICD-10 code: M10) at two hospitals in London, UK, from January – December 2017. Analyses of in-hospital gout management were performed for these patients, including to ascertain the number and proportion of patients who: i) had a known history of gout; ii) were receiving ULT at time of attendance; iii) were provided with a discharge plan for ULT commencement and/or uptitration.

Results:

Over a 12-month period, there were 234 emergency attendances for gout in 225 individuals. 80% were male, with a mean age of 58 years. 70/234 (30%) attendances resulted in admission to hospital (mean length of stay: 2 days; range: 0-31 days). 211 patients had routinely captured clinical data available for further analysis. 90/211 (43%) patients had prior diagnoses of gout, of whom 38% were on ULT at presentation (32 allopurinol, 2 febuxostat). 38% of patients were discharged with a plan for ULT commencement and/or uptitration. 20 patients re-presented to hospital with acute gout within 12 months (17/20 were not receiving ULT).

Conclusion:

Most patients hospitalised with gout were not receiving ULT, even those with a prior history of gout attacks. Few were provided with a ULT plan, leaving them at risk of re-admission to hospital. Hospital admissions are unpleasant for patients and incur a high economic burden for health services; if they are to be prevented, there must be a concerted effort to implement and follow gout management guidelines to ensure patients receive ULT at appropriate doses.

References:

[1]Russell M,et al. Return of the King: Rising Incidence of Acute Hospital Admissions due to Gout. J Rheum 2019 Sep 15.

[2]Richette P, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis 2017;76:29-42.

[3]Richette P, et al. 2018 updated European League Against Rheumatism evidence-based recommendations for the diagnosis of gout. Ann Rheum Dis 2020;79:31-38.

Disclosure of Interests: :

None declared

Intravenous tranexamic acid and lower limb arthroplasty-a randomised controlled feasibility study

Tranexamic acid (TA) is widely reported to reduce bleeding and the risk of blood transfusion in patients undergoing lower limb arthroplasty. No study in this setting has had adequate power to examine for the effect of TA on either uncommon, but clinically important, adverse events or patient-centric endpoints. A large randomised controlled trial (RCT) is required to address these questions. As a preliminary feasibility study, we conducted an investigator-initiated, prospective, randomised, double blind placebo-controlled trial in 140 patients, aged 45 years or older, undergoing elective primary or revision hip or knee joint replacement. Subjects were randomised to receive intravenous (IV) TA or a placebo. The primary endpoints were the proportion of patients receiving allogenic blood transfusion and the feasibility of extending our trial methodology to a large trial of TA in this population. Secondary endpoints included a range of adverse clinical and surgical events as well as several patient-centric questionnaires. Red blood cell transfusion occurred in 15% of all patients prior to discharge from hospital. Transfusion rates were significantly different between the TA and placebo groups (8.5% versus 21.7%, <i>P</i>=0.03). Three out of four feasibility endpoints were met, with recruitment being slower than expected. No significant differences were seen between groups in the secondary endpoints. Despite a lower rate of transfusion than that widely reported, IV TA reduced transfusion in patients undergoing lower limb arthroplasty. Our trial methodology would be feasible in the setting of a large multicentre study to investigate whether TA is safe and reduces bleeding in lower limb arthroplasty.

Environmental Context-Dependent Recognition Memory Effects: An Examination of ICE Model and Cue-Overload Hypotheses

The ICE model account (e.g., Murnane & Phelps, 1993; Murnane, Phelps, & Malmberg, 1999) of environmental context (EC)-dependent recognition memory is described, and new predictions concerning the effect of multiple presentation ECs are derived. Experiment 1 tested the ICE model predictions in relation to predictions derived from the cue-overload hypothesis (e.g., Watkins, 1979). In addition, the sensitivity of recognition reaction time (RT) as a measure of EC-dependent memory effects was examined. Minimal support was obtained for the ICE model, but greater support was provided for the cue-overload hypothesis. In Experiment 2, further manipulations were employed to test ICE model predictions and the cue-overload hypothesis, with relevance to the mental reinstatement and outshining hypotheses. Again support for the cue-overload hypothesis was obtained, and an EC reinstatement effect with RTs was detected. The ICE model is considered in respect of these findings.

Diagnostic yield of FDG-PET/CT in fever of unknown origin: a systematic review, meta-analysis, and Delphi exercise

AIM

To perform a systematic review, meta-analysis and Delphi exercise to evaluate diagnostic yield of combined 2-[¹⁸F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography and computed tomography (FDG-PET/CT) in fever of unknown origin (FUO).

MATERIALS AND METHODS

Four databases were searched for studies of FDG-PET/CT in FUO 1/1/2000-1/12/2015. Exclusions were non-English language, case reports, non-standard FDG radiotracer, and significant missing data. Quality was assessed by two authors independently using a standardised tool. Pooled diagnostic yield was calculated using a random-effects model. An iterative electronic and face-to-face Delphi exercise generated interspeciality consensus.

RESULTS

Pooled diagnostic yield was 56% (95% confidence interval [CI]: 50-61%, I²=61%) from 18 studies and 905 patients. Only five studies reported results of previous imaging, and subgroup analysis estimated diagnostic yield beyond conventional CT at 32% (95% CI: 22-44%; I²=66%). Consensus was established that FDG-PET/CT is increasingly available with an emerging role, but there is prevailing variability in practice.

CONCLUSION

There is insufficient evidence to support the value of FDG-PET/CT in investigative algorithms of FUO. A paradigm shift in research is needed, involving prospective studies recruiting at diagnosis of FUO, with updated case definitions and hard outcome measures. Although these studies will be a significant undertaking with multicentre collaboration, their completion is vital for balancing both radiation exposure and costs against the possible benefits of utilising FDG-PET/CT.

Encoding instructions and stimulus presentation in local environmental context-dependent memory studies

Murnane and Phelps (1993) recommend word pair presentations in local environmental context (EC) studies to prevent associations being formed between successively presented items and their ECs and a consequent reduction in the EC effect. Two experiments were conducted to assess the veracity of this assumption. In Experiment 1, participants memorised single words or word pairs, or categorised them as natural or man made. Their free recall protocols were examined to assess any associations established between successively presented items. Fewest associations were observed when the item-specific encoding task (i.e., natural or man made categorisation of word referents) was applied to single words. These findings were examined further in Experiment 2, where the influence of encoding instructions and stimulus presentation on local EC dependent recognition memory was examined. Consistent with recognition dual-process signal detection model predictions and findings (e.g., Macken, 2002; Parks & Yonelinas, 2008), recollection sensitivity, but not familiarity sensitivity, was found to be local EC dependent. However, local EC dependent recognition was observed only after item-specific encoding instructions, irrespective of stimulus presentation. These findings and the existing literature suggest that the use of single word presentations and item-specific encoding enhances local EC dependent recognition.

Implementation of the NICE guideline – Recommendations from the British Fertility Society for national criteria for NHS funding of assisted conception

Assisted conception providers in England were surveyed to establish the uptake of NICE guideline for infertility particularly in respect of assisted conception and the criteria used to accept patients for NHS funded treatment. Detailed information on selection criteria was obtained from a group of commissioning consortia at an advanced stage in their arrangements. While there was an overall increase in the number of NHS IVF cycles purchased in England, implementation is stalled at one fresh cycle in the vast majority of Primary Care Trusts (PCTs). There is little consensus about the criteria used for acceptance into an NHS programme. This is particularly so in respect of social criteria which are often arbitrary and used as a rationing tool. This information complements that provided by the survey of Primary Care Trusts performed in March 2005 by the All Party Parliamentary Group on Infertility (APPGI) in partnership with the National Infertility Awareness Campaign (NIAC) which together provide a basis for recommendations for NHS funding. The recommendations presented should be applied across England and Wales to ensure consistency, fairness and equity of access.

Expression of genes involved in early cell fate decisions in human embryos and their regulation by growth factors

Little is understood about the regulation of gene expression in human preimplantation embryos. We set out to examine the expression in human preimplantation embryos of a number of genes known to be critical for early development of the murine embryo. The expression profile of these genes was analysed throughout preimplantation development and in response to growth factor (GF) stimulation. Developmental expression of a number of genes was similar to that seen in murine embryos (OCT3B/4,CDX2,NANOG). However,GATA6is expressed throughout preimplantation development in the human. Embryos were cultured in IGF-I, leukaemia inhibitory factor (LIF) or heparin-binding EGF-like growth factor (HBEGF), all of which are known to stimulate the development of human embryos. Our data show that culture in HBEGF and LIF appears to facilitate human embryo expression of a number of genes:ERBB4(LIF) andLIFRandDSC2(HBEGF) while in the presence of HBEGF no blastocysts expressedEOMESand when cultured with LIF only two out of nine blastocysts expressedTBN. These data improve our knowledge of the similarities between human and murine embryos and the influence of GFs on human embryo gene expression. Results from this study will improve the understanding of cell fate decisions in early human embryos, which has important implications for both IVF treatment and the derivation of human embryonic stem cells.

Neuropsychological Impairment as a Consequence of Football (Soccer) Play and Football Heading: Preliminary Analyses and Report on University Footballers

Previous research has claimed neuropsychological impairment occurs as a result of professional and amateur football play, and, specifically, football heading. However, much of this research exhibits substantial methodological problems. By investigating less committed amateur level footballers, the current study sought to gain some insight into the developmental history of any neuropsychological consequences of football play. University football, rugby and noncontact sports players were compared on a range of biographical and neuropsychological test variables. While playing their chosen sports, rugby players sustained many more head injuries than footballers and noncontact sportsmen, but footballers did not sustain significantly more head injuries than noncontact sportsmen. The number of head injuries sustained predicted Trails B and TAP Divided Attention latencies in a positive fashion. After controlling for the number of head injuries sustained, sport group effects were detected with TAP Divided Attention accuracy scores, with footballers exhibiting poorest performance. After controlling for the number of head injuries sustained, the total amount of heading done by footballers predicted the number of Wisconsin Card Sorting category shifts in a negative fashion. Nevertheless, over interpretation of all of these results should be resisted because of the exploratory nature of the analyses and the possibility that the sport groups may differ in ways other than just the nature of their sports activities.

Orientation selection in photosynthetic PS I multilayers: structural investigation of the charge separated state P(700)(+z.rad;)A(1)(-z.rad;) by high-field/high-frequency time-resolved EPR at 3.4 T/95 GHz

The radical-pair state of the primary electron donor and the secondary electron acceptor (P(700)(+z.rad;)A(1)(-z.rad;)) of the photosynthetic reaction center (RC) photosystem I (PS I) of Synechocystis PCC 6803 was studied by time-resolved electron paramagnetic resonance (TREPR) at high field/high frequency (3.4 T/95 GHz) using orientation selection in multilayers. The goal of the present article is to work out the basis for future studies, in which the improved resolution of such multilayers may be used to detect mutation-induced structural changes of PS I in membrane preparations. This approach is particularly interesting for systems that cannot be prepared as single crystals. However, in order to use such multilayers for structural investigations of protein complexes, it is necessary to know their orientation distribution. PS I was chosen as a test example because the wild type was recently crystallized and its X-ray structure determined to 2.5 A resolution [Nature 411 (2001) 909]. On the basis of our experimental results we determined the orientation distribution. Furthermore, a simulation model for the general case in which the orientation distribution is not axially symmetric about the C(2) symmetry axis of the RC is developed and discussed. Spectra simulations show that changes in the TREPR spectra of PS I are much more significant for these oriented multilayers than for disordered samples. In this way the use of oriented multilayers, in conjunction with multifrequency TREPR measurements on oriented as well as on disordered samples, is a promising approach for studies of structural changes of PS I systems that are induced by point mutations.

Expression of cell adhesion molecules during human preimplantation embryo development

Formation of a fully differentiated, implantation competent blastocyst requires the expression of a complex repertoire of molecules. However, the events that drive morphogenesis are poorly elucidated in the human embryo. In this work, we describe the amplification of representative cDNAs from morphologically and developmentally normal, individual human embryos at all stages from pronucleate to blastocyst. These cDNAs were probed to reveal the temporal expression pattern of cell adhesion molecules thought to play a key role in murine preimplantation embryo development. We demonstrated constitutive expression of beta actin, beta 1 and alpha 6 integrins, ZO-1 and E-cadherin, as shown previously in mouse embryos. No expression of beta 3, alpha 2, alpha 3 or alpha 7 integrins nor of L or P selectin was detected at any stage of preimplantation development. beta 5 integrin showed a regulated pattern of expression and was not expressed in blastocysts, while desmocollin-2 could only be detected at the blastocyst stage. Expression and localization of beta 1, beta 5 and alpha 6 integrins and ZO-1 and E-cadherin proteins was confirmed in blastocyst stage embryos by immunocytochemistry. We have identified differences in the expression of integrin molecules between mouse and human embryos, and propose a role for alpha v beta 5 and alpha 6 beta 1 integrin dimers in the human embryo at implantation.

General practitioners and hospitals. Continuity of care

BACKGROUND

The study aimed to improve continuity of care for patients undergoing major gynaecological surgery, by increasing their general practitioners' contact with the hospital and providing a comprehensive discharge summary.

METHODS

Prospective randomised study of 200 patients admitted to a gynaecological oncology ward, and their GPs. Visits and telephone calls by GPs to hospital during their patients' admission were measured, with and without invitation and offer of payment for contact. A discharge summary was distributed. Postdischarge questionnaires surveyed patient satisfaction with care, confidence in future management by the GPs, and GP confidence in continuing patient care.

RESULTS

Significant increases in contact rates by the GPs followed invitation. The discharge summary was not effectively distributed. No significant differences in patient satisfaction and confidence in future management by their GPs were found. General practitioners valued hospital contact most in meeting their patients' needs for information.

CONCLUSION

Personal invitation increases GP contact with hospitals. While no statistically significant improvements in patient satisfaction or GP confidence were shown, the data suggested that GPs value contact to meet patient information needs.

Temporal and spatial expression patterns of the CRX transcription factor and its downstream targets. Critical differences during human and mouse eye development

Cone--rod homeobox (CRX), a paired-like homeobox transcription factor, plays a major role in photoreceptor development and maintenance of the retina. Fifteen different mutations in the CRX gene have been identified as a cause of blinding retinal dystrophy. As a step towards characterizing the underlying pathophysiology of disease, temporal and spatial gene expression patterns during human and mouse eye development were investigated for CRX and for downstream retinally expressed genes, postulated to be transactivated by CRX. We found that human CRX was expressed at 10.5 weeks post-conception (p.c.). This was significantly later than observed in mouse development. Immunocytochemistry in human retina showed that CRX protein was not detected until >4 weeks later at 15 weeks p.c., implying that it would be unable to transactivate PDEB, IRBP and arrestin, which were all expressed before 15 weeks. These data therefore eliminate CRX as the major transcriptional activator of these three genes from a wide group of retinal genes that can be transactivated by CRX in vitro. Additionally, PDEB was expressed 2 weeks before CRX whereas murine Pdeb was expressed after Crx, highlighting a potential difference for the role of PDEB in human eye development. Previous data had shown CRX expression in the adult human retina to be photoreceptor-specific; however, we demonstrate that this gene is also expressed in the inner nuclear layer (INL) of the human and mouse retina by in situ hybridization and immunocytochemistry. INL localization of murine Crx was confirmed in rd/rd,cl mice, as in this mouse model the photoreceptors are absent. We have found important differences in the temporal expression of this gene in human and mouse retina, although spatial expression of the CRX gene appears to be conserved. In addition, downstream targets of CRX in vitro might not represent in vivo function during development. These data support concerns about the extent to which we can extrapolate from rodent models regarding embryonic development and disease pathophysiology.

Conventional in-vitro fertilisation versus intracytoplasmic sperm injection for the treatment of non-male-factor infertility: a randomised controlled trial

BACKGROUND

Intracytoplasmic sperm injection (ICSI) is a more invasive option than conventional in-vitro fertilisation (IVF), which can be successful even when semen characteristics are poor. Reports of higher fertilisation rates after ICSI suggest that this technique may be better than the conventional method for all couples seeking IVF. We undertook a multicentre randomised controlled trial comparing clinical outcome after ICSI or traditional IVF in couples with non-male-factor infertility.

METHODS

415 eligible and consenting couples at four UK centres were randomly assigned IVF or ICSI (total 435 treatment cycles: IVF 224; ICSI 211). Usual clinical and laboratory protocols for the two treatment procedures were followed in each of four participating centres. The primary outcome was the implantation rate (number of gestation sacs per embryo replaced expressed as a percentage). Secondary outcomes were pregnancy and fertilisation rates associated with each treatment. Analyses were by intention to treat.

FINDINGS

The implantation rate was higher in the IVF group than in the ICSI group (95/318 [30%] vs 72/325 [22%]; relative risk 1.35 [95% CI 1.04-1.76]). The pregnancy rate per cycle was also higher after IVF (72 [33%] vs 53 [26%]; 1.17 [0.97-1.35]). Mean associated laboratory time was significantly shorter with IVF than with ICSI (22.9 [SD 12.1] vs 74.0 [38.1] min; 95% CI for difference 45.6-56.6).

INTERPRETATION

ICSI offers no advantage over IVF in terms of clinical outcome in cases of non-male-factor infertility. Our results support the current practice of reserving ICSI only for severe male-factor problems.

Cryopreservation of human ovarian tissue

As survival rates for young cancer patients continue to improve, protection against iatrogenic infertility caused by chemotherapy and/or radiotherapy assumes a higher priority. As things stand, women patients have few options to preserve their fertility while children have none at all.

Human oocyte cryopreservation

Despite early success with sperm and embryo cryopreservation, human oocyte cryopreservation has met with limited success both in terms of survival and subsequent fertilization. However, compared with embryo cryopreservation, oocyte freezing has great potential for eliminating the ethical and legal problems of embryo storage.

The ability of familiarity, disruption, and the relative strength of nonenvironmental context cues to explain unreliable environmental-context-dependent memory effects in free recall

The ability of environmental-context (EC) familiarity, movement disruption, and the relative strength of memory cues to explain unreliable EC-dependent free-recall memory effects was examined in two experiments. Experiment 1 replicated Smith's (1979, Experiment 1) results confirming that familiarity and disruption cannot account for free-recall EC-reinstatement effects. In Experiment 2, a level of processing manipulation varied stimulus item memory cue strengths, and memory was again assessed by free recall. Contrary to Murnane and Phelps's (1995) and Dougal and Rotello's (1999) recognition findings, an EC-reinstatement effect was observed with low, but not high, levels of processing. However, comparisons across the two experiments revealed inconsistencies with the relative cue strength hypothesis. Consequently, a variant of the relative cue strength hypothesis that highlights the role of retrieval processes was proposed to explain the interaction between the levels of processing and the EC-reinstatement effect.

Radical behaviorism and psychology's public: B. F. Skinner in the popular press, 1934-1990

B. F. Skinner is perhaps 2nd only to Freud among the most publicly identifiable psychological figures of the last century. This article reviews the popular press coverage of Skinner between 1934 and 1990 to examine how radical behaviorism was interpreted, portrayed, and received by psychology's public. Reactions to Skinner were often skeptical or condemnatory. It is suggested that some members of the public had difficulty accepting his views because of the disparities between the philosophy of radical behaviorism and the phenomenology of everyday experience. Furthermore, Skinner's status as a psychological expert was inextricably linked to the public's perception of his credibility not only as a scientist but also as a human being.

Does etomidate increase postoperative nausea? A double-blind controlled comparison of etomidate in lipid emulsion with propofol for balanced anaesthesia

In a double-blind randomized study, the incidence and severity of postoperative nausea and vomiting was investigated with a new formulation of etomidate (Etomidate-(R)Lipuro, B. Braun Melsungen AG, Germany) compared with propofol for induction of a balanced anaesthesia with isoflurane/fentanyl in air. The incidence and intensity of nausea was examined by use of a visual analogue scale (VAS; 0-100 mm) at 1, 2, between 6 and 8, and 24 h postoperatively. One-hundred-and-sixty-four patients undergoing orthopedic procedures were studied. For etomidate vs. propofol, 14.6% vs. 14.2% male and 26.8% vs. 27.5% female patients were nauseated during the first two postoperative hours. The median rating for nausea remained below 5 mm at any time in both groups, i.e. the intensity of nausea was very low. The incidence of vomiting was higher in women receiving etomidate (26.8% vs. 10%). We conclude that etomidate does not increase nausea during the early postoperative period.

Human microphthalmia associated with mutations in the retinal homeobox gene CHX10

Isolated human microphthalmia/anophthalmia, a cause of congenital blindness, is a clinically and genetically heterogeneous developmental disorder characterized by a small eye and other ocular abnormalities. Three microphthalmia/anophthalmia loci have been identified, and two others have been inferred by the co-segregation of translocations with the phenotype. We previously found that mice with ocular retardation (the or-J allele), a microphthalmia phenotype, have a null mutation in the retinal homeobox gene Chx10 (refs 7,8). We report here the mapping of a human microphthalmia locus on chromosome 14q24.3, the cloning of CHX10 at this locus and the identification of recessive CHX10 mutations in two families with non-syndromic microphthalmia (MIM 251600), cataracts and severe abnormalities of the iris. In affected individuals, a highly conserved arginine residue in the DNA-recognition helix of the homeodomain is replaced by glutamine or proline (R200Q and R200P, respectively). Identification of the CHX10 consensus DNA-binding sequence (TAATTAGC) allowed us to demonstrate that both mutations severely disrupt CHX10 function. Human CHX10 is expressed in progenitor cells of the developing neuroretina and in the inner nuclear layer of the mature retina. The strong conservation in vertebrates of the CHX10 sequence, pattern of expression and loss-of-function phenotypes demonstrates the evolutionary importance of the genetic network through which this gene regulates eye development.

Retinoschisin, the X-linked retinoschisis protein, is a secreted photoreceptor protein, and is expressed and released by Weri-Rb1 cells

X-linked retinoschisis is characterized by microcystic-like changes of the macular region and schisis within the inner retinal layers, leading to visual deterioration in males. Many missense and protein-truncating mutations of the causative gene RS1 have now been identified and are thought to be inactivating. RS1 encodes a 224 amino acid protein, retinoschisin, which contains a discoidin domain but is of unknown function. We have generated a polyclonal antibody against a peptide from a unique region within retinoschisin, which detects a protein of approximately 28 kDa in retinal samples reduced with dithiothreitol, but multimers sized >40 kDa under non-reducing conditions. A screen of human tissues with this antibody reveals retinoschisin to be retina specific and the antibody detects a protein of similar size in bovine and murine retinae. We investigated the expression pattern in the retina of both RS1 mRNA (using in situ hybridization with riboprobes) and retinoschisin (using immunohistochemistry). The antisense riboprobe detected RS1 mRNA only in the photoreceptor layer but the protein product of the gene was present both in the photoreceptors and within the inner portions of the retina. Furthermore, differentiated retinoblastoma cells (Weri-Rb1 cells) were found to express RS1 mRNA and to release retinoschisin. These results suggest that retinoschisin is released by photo-receptors and has functions within the inner retinal layers. Thus, X-linked retinoschisis is caused by abnormalities in a putative secreted photoreceptor protein and is the first example of a secreted photo-receptor protein associated with a retinal dystrophy.

Beck depression inventory: exploring its dimensionality in a nonclinical population

The Beck Depression Inventory (BDI) was factor analyzed to examine its potential multidimensionality. Results indicate that the items on the BDI assess two primary dimensions of depression: cognitive-affective and physiological symptoms. Reliabilities for the items comprising each of the factors were acceptable. Between-groups analyses showed that women scored significantly higher than men on both of the factors and on total depression. Within-group analyses showed that levels of cognitive-affective and physiological depression did not differ significantly within the total sample, or for men or women. In future revisions of the BDI, it may be useful to develop scoring systems based on these two dimensions, both to differentiate between types and levels of depression, and to consider implications for prognosis and treatment response.

Comparison of FISH PRINS, and conventional and fluorescent PCR for single-cell sexing: suitability for preimplantation genetic diagnosis

PURPOSE

Although conventional polymerase chain reaction (PCR) was the first method used for sexing in preimplantation genetic diagnosis, fluorescent in situ hybridization (FISH) has become the method of choice. Recently two new techniques, primed in situ synthesis (PRINS) and fluorescent PCR, have been developed. This study compares the reliability and accuracy of these four techniques in single cells.

RESULTS

In buccal cells, fluorescent PCR and FISH had similar reliability (94 and 93%) and accuracy (97 and 96%) rates. The reliability and accuracy of PRINS (91 and 25%) and conventional PCR (79 and 89%) were lower. In human blastomeres, FISH and fluorescent PCR had similar reliability (100%, 717; 95%, 190/201) rates. Accuracy rates were 71% (517) and 99% (188/190) for FISH and fluorescent PCR, respectively, however, too few blastomeres were analyzed by FISH for meaningful comparison. However, when these data are compared with published data, the method of choice for blastomere sexing appears to be fluorescent PCR.

CONCLUSIONS

Flouroscent PCR has major implications for PGD.

Rapid genetic diagnosis at 7-9 weeks gestation: diagnosis of sex, single gene defects and DNA fingerprint from coelomic samples

Prenatal diagnosis (chorionic villus sampling (CVS) or amniocentesis) is performed at a relatively late stage of pregnancy (11-18 weeks). Such tests have significant disadvantages including increased risk of miscarriage and delay before results are known. Earlier prenatal diagnosis (< 11 weeks) has been discontinued because of the risk of fetal abnormalities. Recently fetal cells have been recovered from the coelomic cavity at 7-12 weeks gestation (coelocentesis). This study has established that highly sensitive fluorescent polymerase chain reaction (PCR) can provide rapid (4-5 h), reliable and accurate multiple genetic diagnoses (sexing and single-gene diagnosis) from coelomic cells. As prenatal diagnosis has a significant risk of contamination, we have also shown that coelomic cells can be simultaneously DNA fingerprinted to determine that contamination has not occurred. This earlier method of prenatal diagnosis would be very valuable, as it may overcome some problems of later conventional prenatal diagnosis and allow reassurance/treatment to be undertaken at a much earlier stage. Successful application of these techniques may supersede alternative methods of prenatal diagnosis. Although these techniques appear very promising, extensive clinical trials must be undertaken to determine safety of coelocentesis, diagnostic reliability and accuracy in a clinical setting.

TCR- and IL-1-mediated co-stimulation reveals an IL-4-independent way of Th2 cell proliferation

Previously, it has been shown that Th1 cells, when triggered solely via their TCR, are blocked from proliferation in response to IL-2. Herein, we describe a similar characteristic for Th2 cells in that immobilized mAb directed to the TCR blocked proliferation of Th2 cells in response to IL-4. This "proliferative block' was observed in all four Th2 cell clones tested, but not in a subline of one of the clones which has been cultured in vitro for several years. Addition of IL-1 neutralized the proliferative block in all four Th2 cell clones. Surprisingly, blocking experiments with sIL-4R and anti-IL-4 mAb revealed that in three out of four Th2 cell clones this effect of IL-1 was IL-4-independent and could also not be blocked by cyclosporin A (CsA). In contrast, the proliferation of one Th2 cell clone in response to the TCR- and IL-1-mediated signals was indeed inhibited by sIL-4R, anti-IL-4 mAb and CsA. Thus, our data illustrate that in addition to the well-known IL-4-dependent proliferation, there also exists an IL-4-independent, IL-1-mediated way of Th2 cell proliferation.

Low temperature storage and grafting of human ovarian tissue

Ovarian tissue storage at low temperatures is a promising new method for protecting young cancer patients from the sterilizing effects of chemotherapy and/or radiotherapy. Tissue can be stored and returned to the body in due course as a thin cortical graft since the primordial follicles are distributed peripherally and are relatively resistant to ischaemia. Slices of tissue donated by healthy patients were trimmed to a uniform size and preserved by slow freezing to liquid nitrogen temperatures for up to 2 months in one of the following cryoprotectants: dimethylsulphoxide, ethylene glycol, glycerol, propylene glycol. Their viability was assessed by counting follicles in histological sections 18 days after grafting under the kidney capsules of severe combined immunodeficiency (SCID) mice, and the results were expressed as percentages of the numbers in comparable pieces of ungrafted tissue. While only 10% of the total number of follicles was found in the glycerol group compared to controls, significantly higher percentages (44-84%) survived cryopreservation in the other media. The tissues were sterile when frozen and thawed without a cryoprotectant. These results suggest that if comparable results could be achieved by autografting, a patient's fertility should be safeguarded from cytotoxic treatment.

Fluorescent PCR: a new technique for PGD of sex and single-gene defects

BACKGROUND

For single-cell diagnosis, particularly preimplantation genetic diagnosis to be successful four main criteria must be achieved: sensitivity, reliability, accuracy, and identification/elimination of contamination.

METHODS AND RESULTS

Fluorescent PCR achieves all four necessary criteria and, in addition, currently allows genes on up to nine chromosomes to be simultaneously investigated. Fluorescent PCR has high sensitivity (approximately 1000 x conventional analysis systems), high reliability (97%), and high accuracy (97%) rates for both sex and CF diagnosis in single somatic cells. The low detection threshold allows allelic dropout (one of the main causes of misdiagnosis) to be easily distinguished from PCR phenomena such as preferential amplification. High reliability (90%) and accuracy (97-100%) have been achieved in sex and CF diagnosis in human blastomeres. Fluorescent PCR can also be used to DNA fingerprint (STR profiling) single cells to identify the source/origin of the cell and determine if contamination has occurred.

CONCLUSIONS

Fluorescent PCR is therefore a suitable method for PGD.

Understanding cortical visual impairment in children

This article presents a review of the literature and a case study on a child with cortical visual impairment. The literature review covers the diagnosis, etiology, prevalence, prognosis, and a comparison of the differences between children with cortical visual impairment and those with ocular impairment. The case study presents occupational therapy intervention strategies specific to cortical visual impairment and results of treatment.