The subacromial bursa modulates tendon healing after rotator cuff injury in rats

Rotator cuff injuries result in more than 500,000 surgeries annually in the United States, many of which fail. These surgeries typically involve repair of the injured tendon and removal of the subacromial bursa, a synovial-like tissue that sits between the rotator cuff and the acromion. The subacromial bursa has been implicated in rotator cuff pathogenesis and healing. Using proteomic profiling of bursa samples from nine patients with rotator cuff injury, we show that the bursa responds to injury in the underlying tendon. In a rat model of supraspinatus tenotomy, we evaluated the bursa's effect on the injured supraspinatus tendon, the uninjured infraspinatus tendon, and the underlying humeral head. The bursa protected the intact infraspinatus tendon adjacent to the injured supraspinatus tendon by maintaining its mechanical properties and protected the underlying humeral head by maintaining bone morphometry. The bursa promoted an inflammatory response in injured rat tendon, initiating expression of genes associated with wound healing, including Cox2 and Il6. These results were confirmed in rat bursa organ cultures. To evaluate the potential of the bursa as a therapeutic target, polymer microspheres loaded with dexamethasone were delivered to the intact bursae of rats after tenotomy. Dexamethasone released from the bursa reduced Il1b expression in injured rat supraspinatus tendon, suggesting that the bursa could be used for drug delivery to reduce inflammation in the healing tendon. Our findings indicate that the subacromial bursa contributes to healing in underlying tissues of the shoulder joint, suggesting that its removal during rotator cuff surgery should be reconsidered.

Hedgehog Activation for Enhanced Rotator Cuff Tendon-to-Bone Healing

BACKGROUND

Rotator cuff repair is a common orthopaedic procedure, yet the rate of failure to heal after surgery is high. Repair site rupture is due to poor tendon-to-bone healing and lack of regeneration of the native fibrocartilaginous enthesis. During development, the enthesis is formed and mineralized by a pool of progenitors activated by hedgehog signaling. Furthermore, hedgehog signaling drives regenerative enthesis healing in young animals, in contrast to older animals, in which enthesis injuries heal via fibrovascular scar and without participation of hedgehog signaling.

HYPOTHESIS

Hedgehog activation improves tendon-to-bone healing in an animal model of rotator cuff repair.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 78 adult Sprague-Dawley rats were used. Supraspinatus tendon injury and repair were completed bilaterally, with microsphere-encapsulated hedgehog agonist administered to right shoulders and control microspheres administered to left shoulders. Animals were sacrificed after 3, 14, 28, or 56 days. Gene expression and histological, biomechanical, and bone morphometric analyses were conducted.

RESULTS

At 3 days, hedgehog signaling pathway genes Gli1 (1.70; P = .029) and Smo (2.06; P = .0173), as well as Runx2 (1.69; P = .0386), a transcription factor of osteogenesis, were upregulated in treated relative to control repairs. At 14 days, transcription factors of tenogenesis, Scx (4.00; P = .041), and chondrogenesis, Sox9 (2.95; P = .010), and mineralized fibrocartilage genes Col2 (3.18; P = .031) and Colx (1.85; P = .006), were upregulated in treated relative to control repairs. Treatment promoted fibrocartilage formation at the healing interface by 28 days, with improvements in tendon-bone maturity, organization, and continuity. Treatment led to improved biomechanical properties. The material property strength (2.43 vs 1.89 N/m2; P = .046) and the structural property work to failure (29.01 vs 18.09 mJ; P = .030) were increased in treated relative to control repairs at 28 days and 56 days, respectively. Treatment had a marginal effect on bone morphometry underlying the repair. Trabecular thickness (0.08 vs 0.07 mm; P = .035) was increased at 28 days.

CONCLUSION

Hedgehog agonist treatment activated hedgehog signaling at the tendon-to-bone repair site and prompted increased mineralized fibrocartilage production. This extracellular matrix production and mineralization resulted in improved biomechanical properties, demonstrating the therapeutic potential of hedgehog agonism for improving tendon-to-bone healing after rotator cuff repair.

CLINICAL RELEVANCE

This study demonstrates the therapeutic potential of hedgehog agonist treatment for improving tendon-to-bone healing after rotator cuff injury and repair.

Red blood cell exposure increases chondrocyte susceptibility to oxidative stress following hemarthrosis

OBJECTIVE

The detrimental effects of blood exposure on articular tissues are well characterized, but the individual contributions of specific whole blood components are yet to be fully elucidated. Better understanding of mechanisms that drive cell and tissue damage in hemophilic arthropathy will inform novel therapeutic strategies. The studies here aimed to identify the specific contributions of intact and lysed red blood cells (RBCs) on cartilage and the therapeutic potential of Ferrostatin-1 in the context of lipid changes, oxidative stress, and ferroptosis.

METHODS

Changes to biochemical and mechanical properties following intact RBC treatment were assessed in human chondrocyte-based tissue-engineered cartilage constructs and validated against human cartilage explants. Chondrocyte monolayers were assayed for changes to intracellular lipid profiles and the presence of oxidative and ferroptotic mechanisms.

RESULTS

Markers of tissue breakdown were observed in cartilage constructs without parallel losses in DNA (control: 786.3 (102.2) ng/mg; RBCINT: 751 (126.4) ng/mg; P = 0.6279), implicating nonlethal chondrocyte responses to intact RBCs. Dose-dependent loss of viability in response to intact and lysed RBCs was observed in chondrocyte monolayers, with greater toxicity observed with lysates. Intact RBCs induced changes to chondrocyte lipid profiles, upregulating highly oxidizable fatty acids (e.g., FA 18:2) and matrix disrupting ceramides. RBC lysates induced cell death via oxidative mechanisms that resemble ferroptosis.

CONCLUSIONS

Intact RBCs induce intracellular phenotypic changes to chondrocytes that increase vulnerability to tissue damage while lysed RBCs have a more direct influence on chondrocyte death by mechanisms that are representative of ferroptosis.

The subacromial bursa is a key regulator of the rotator cuff and a new therapeutic target for improving repair

Rotator cuff injuries result in over 500,000 surgeries performed annually, an alarmingly high number of which fail. These procedures typically involve repair of the injured tendon and removal of the subacromial bursa. However, recent identification of a resident population of mesenchymal stem cells and inflammatory responsiveness of the bursa to tendinopathy indicate an unexplored biological role of the bursa in the context of rotator cuff disease. Therefore, we aimed to understand the clinical relevance of bursa-tendon crosstalk, characterize the biologic role of the bursa within the shoulder, and test the therapeutic potential for targeting the bursa. Proteomic profiling of patient bursa and tendon samples demonstrated that the bursa is activated by tendon injury. Using a rat to model rotator cuff injury and repair, tenotomy-activated bursa protected the intact tendon adjacent to the injured tendon and maintained the morphology of the underlying bone. The bursa also promoted an early inflammatory response in the injured tendon, initiating key players in wound healing. In vivo results were supported by targeted organ culture studies of the bursa. To examine the potential to therapeutically target the bursa, dexamethasone was delivered to the bursa, prompting a shift in cellular signaling towards resolution of inflammation in the healing tendon. In conclusion, contrary to current clinical practice, the bursa should be retained to the greatest extent possible and provides a new therapeutically target for improving tendon healing outcomes.

One Sentence Summary

The subacromial bursa is activated by rotator cuff injury and regulates the paracrine environment of the shoulder to maintain the properties of the underlying tendon and bone.

Blocking toll-like receptor 4 mitigates static loading induced pro-inflammatory expression in intervertebral disc motion segments

While the anabolic effects of mechanical loading on the intervertebral disc (IVD) have been extensively studied, inflammatory responses to loading have not been as well characterized. Recent studies have highlighted a significant role of innate immune activation, particularly that of toll-like receptors (TLRs), in IVD degeneration. Biological responses of intervertebral disc cells to loading depend on many factors that include magnitude and frequency. The goals of this study were to characterize the inflammatory signaling changes in response to static and dynamic loading of IVD and investigate the contributions of TLR4 signaling in response to mechanical loading. Rat bone-disc-bone motion segments were loaded for 3 hr under a static load (20 % strain, 0 Hz) with or without an additional low-dynamic (4 % dynamic strain, 0.5 Hz) or high-dynamic (8 % dynamic strain, 3 Hz) strain, and results were compared to unloaded controls. Some samples were also loaded with or without TAK-242, an inhibitor of TLR4 signaling. The magnitude of NO release into the loading media (LM) was correlated with the applied frequency and strain magnitudes across different loading groups. Injurious loading profiles, such as static and high-dynamic, significantly increased Tlr4 and Hmgb1 expression while this result was not observed in the more physiologically relevant low-dynamic loading group. TAK-242 co-treatment decreased pro-inflammatory expression in static but not dynamic loaded groups, suggesting that TLR4 plays a direct role in mediating inflammatory responses of IVD to static compression. Overall, the microenvironment induced by dynamic loading diminished the protective effects of the TAK-242, suggesting that TLR4 plays a direct role in mediating inflammatory responses of IVD to static loading injury.

Toward defining the role of the synovium in mitigating normal articular cartilage wear and tear

Cartilage repair has been studied extensively in the context of injury and disease, but the joint's management of regular sub-injurious damage to cartilage, or 'wear and tear,' which occurs due to normal activity, is poorly understood. We hypothesize that this cartilage maintenance is mediated in part by cells derived from the synovium that migrate to the worn articular surface. Here, we demonstrate in vitro that the early steps required for such a process can occur. First, we show that under physiologic mechanical loads, chondrocyte death occurs in the cartilage superficial zone along with changes to the cartilage surface topography. Second, we show that synoviocytes are released from the synovial lining under physiologic loads and attach to worn cartilage. Third, we show that synoviocytes parachuted onto a simulated or native cartilage surface will modify their behavior. Specifically, we show that synoviocyte interactions with chondrocytes lead to changes in synoviocyte mechanosensitivity, and we demonstrate that cartilage-attached synoviocytes can express COL2A1, a hallmark of the chondrogenic phenotype. Our findings suggest that synoviocyte-mediated repair of cartilage 'wear and tear' as a component of joint homeostasis is feasible and is deserving of future study.

Toward Development of a Diabetic Synovium Culture Model

Osteoarthritis (OA) is a degenerative joint disease characterized by articular cartilage degradation and inflammation of synovium, the specialized connective tissue that envelops the diarthrodial joint. Type 2 diabetes mellitus (DM) is often found in OA patients, with nearly double the incidence of arthritis reported in patients with diabetes (52%) than those without it (27%). The correlation between OA and DM has been attributed to similar risk factors, namely increasing age and joint loading due to obesity. However, a potential causative link is not well understood due to comorbidities involved with treating diabetic patients, such as high infection rates and poor healing response caused by hyperglycemia and insulin resistance. The purpose of this study was to investigate the effect of hyperglycemic and insulin culture conditions on synovium properties. It was hypothesized that modeling hyperglycemia-induced insulin resistance in synovium would provide novel insights of OA pathogenesis in DM patients. To simulate DM in the synovial joint, healthy synovium was preconditioned in either euglycemic (EG) or hyperglycemic (HG) glucose concentrations with insulin in order to induce the biological response of the diseased phenotype. Synovium biochemical composition was evaluated to determine ECM remodeling under hyperglycemic culture conditions. Concurrent changes in AKT phosphorylation, a signaling pathway implicated in insulin resistance, were measured along with gene expression data for insulin receptors, glucose transporters, and specific glycolysis markers involved in glucose regulation. Since fluid shear stress arising during joint articulation is a relevant upstream stimulus for fibroblast-like synoviocytes (FLS), the predominant cell type in synovium, FLS mechanotransduction was evaluated via intracellular calcium ([Ca²⁺]_i). Incidence and length of primary cilia, a critical effector of cell mechanosensing, were measured as potential mechanisms to support differences in [Ca²⁺]_i responses. Hyperglycemic culture conditions decreased collagen and GAG content compared to EG groups, while insulin recovered ECM constituents. FLS mechanosensitivity was significantly greater in EG and insulin conditions compared to HG and non-insulin treated groups. Hyperglycemic treatment led to decreased incidence and length of primary cilia and decreased AKT phosphorylation, providing possible links to the mechanosensing response and suggesting a potential correlation between glycemic culture conditions, diabetic insulin resistance, and OA development.

The impact of disability on performance in a high-stakes postgraduate surgical examination: a retrospective cohort study

OBJECTIVE

Despite rising numbers of doctors in the workforce with disabilities, little is known about the impact of disabilities on postgraduate performance. To ensure all groups are treated fairly in surgical training, it is essential to know whether any attainment differences exist in markers of surgical performance. To address this gap, we assessed the impact of disabilities on performance on the Intercollegiate Membership of the Royal College of Surgeons examination (MRCS).

DESIGN

Retrospective cohort study.

SETTING

Secondary care.

PARTICIPANTS

All UK MRCS candidates attempting Part A (n = 9600) and Part B (n = 4560) between 2007 and 2017 with linked disability data in the UK Medical Education Database (https://www.ukmed.ac.uk) were included.

MAIN OUTCOME MEASURES

Chi-square tests and correlation coefficients established univariate associations with MRCS performance, while multiple logistic regressions identified independent predictors of success.

RESULTS

Though MRCS Part B pass rates were similar (p = 0.339), candidates with registered disabilities had significantly lower first-attempt Part A pass rates (46.3% vs. 59.8%, p < 0.001). Candidates with disabilities also performed less well in examinations taken throughout school and medical school, and after adjusting for prior academic performance and sociodemographic predictors of success, logistic regression found that candidates with disabilities were no less likely to pass MRCS than their peers (odds ratio 1.04, 95% confidence interval 0.66 to 1.62). No significant variation was found in MRCS performance between type of disability or degree of limitations caused by disability (p > 0.05).

CONCLUSION

Although candidates with registered disabilities performed less well in formal, written examinations, our data indicate that they are as likely to pass MRCS at first attempt as their peers who achieved similar grades at high school and medical school. In order to enable equity in career progression, further work is needed to investigate the causes of attainment differences in early career assessments.

A cross-sectional study examining the association between MRCS performance and surgeons receiving sanctions against their medical registration

BACKGROUND

Fitness to practice (FtP) investigations by the General Medical Council (GMC) safeguard patients and maintain the integrity of the medical profession. The likelihood of FtP sanctions is influenced by specialty and socio-demographic factors and can be predicted by performance at postgraduate examinations. This is the first study to characterise the prevalence of FtP sanctions in early-career surgeons and to examine the association with performance at the Membership of the Royal College of Surgeons (MRCS) examination.

METHODS

All UK graduates who attempted MRCS between September 2007-January 2020 were matched to the GMC list of registered medical practitioners. Clinicians who had active FtP sanctions between 28th August 2018 and 28th August 2020 were identified. Data were anonymised by RCS England prior to analysis.

RESULTS

Of 11,660 candidates who attempted MRCS within the study period, only 31 (0.3%) had FtP sanctions between 2018 and 2020. Of these, 12 had active conditions on registration, seven had undertakings and 14 had warnings. There was no statistically significant difference in MRCS performance in either Parts A or B of the examination for those with and those free from FtP sanctions (P > 0.05).

CONCLUSIONS

In this, the largest study of MRCS candidates to date, the prevalence of active FtP sanctions in early-career surgeons was 0.3%, significantly lower than the prevalence of sanctions across more experienced UK surgeons (0.9%). These data highlight early-career surgeons as a low-risk group for disciplinary action and should reassure patients and medical professionals of the rarity of FtP sanctions.

Sustained Delivery of SB-431542, a Type I Transforming Growth Factor Beta-1 Receptor Inhibitor, to Prevent Arthrofibrosis

Fibrosis of the knee is a common disorder resulting from an aberrant wound healing response and is characterized by extracellular matrix deposition, joint contraction, and scar tissue formation. The principal regulator of the fibrotic cascade is transforming growth factor beta-1 (TGF-β1), a factor that induces rapid proliferation and differentiation of resident fibroblasts. In this study, we demonstrate successful inhibition of TGF-β1-driven myofibroblastic differentiation in human fibroblast-like synoviocytes using a small molecule TGF-β1 receptor inhibitor, SB-431542. We also demonstrate successful encapsulation of SB-431542 in poly(D,L-lactide-co-glycolide) (PLGA) as a potential prophylactic treatment for arthrofibrosis and characterize drug release and bioactivity in a three-dimensional collagen gel contraction assay. We assessed the effects of TGF-β1 and SB-431542 on cell proliferation and viability in monolayer cultures. Opposing dose-dependent trends were observed in cell proliferation, which increased in TGF-β1-treated cultures and decreased in SB-431542-treated cultures relative to control (p < 0.05). SB-431542 was not cytotoxic at the concentrations studied (0-50 μM) and inhibited TGF-β1-induced collagen gel contraction in a dose-dependent manner. Specifically, TGF-β1-treated gels contracted to 18% ± 1% of their initial surface area, while gels treated with TGF-β1 and ≥10 μM SB-431542 showed no evidence of contraction (p < 0.0001). Upon removal of the compound, all gels contracted to control levels after 44 h in culture, necessitating sustained delivery for prolonged inhibition. To this end, SB-431542 was encapsulated in PLGA microspheres (SBMS) that had an average diameter of 87.5 ± 24 μm and a loading capacity of 4.3 μg SB-431542 per milligram of SBMS. Functional assessment of SBMS revealed sustained inhibition of TGF-β1-induced gel contraction as well as hallmark features of myofibroblastic differentiation, including α-smooth muscle actin expression and connective tissue growth factor production. These results suggest that SB-431542 may be used to counter TGF-β1-driven events in the fibrotic cascade in the knee cartilage.

Predicting the chances of having a baby with or without treatment at different time points in couples with unexplained subfertility

STUDY QUESTION

Can we develop a prediction model that can estimate the chances of conception leading to live birth with and without treatment at different points in time in couples with unexplained subfertility?

SUMMARY ANSWER

Yes, a dynamic model was developed that predicted the probability of conceiving under expectant management and following active treatments (in vitro fertilisation (IVF), intrauterine insemination with ovarian stimulation (IUI + SO), clomiphene) at different points in time since diagnosis.

WHAT IS KNOWN ALREADY

Couples with no identified cause for their subfertility continue to have a realistic chance of conceiving naturally, which makes it difficult for clinicians to decide when to intervene. Previous fertility prediction models have attempted to address this by separately estimating either the chances of natural conception or the chances of conception following certain treatments. These models only make predictions at a single point in time and are therefore inadequate for informing continued decision-making at subsequent consultations.

STUDY DESIGN, SIZE, DURATION

A population-based study of 1316 couples with unexplained subfertility attending a regional clinic between 1998 and 2011.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A dynamic prediction model was developed that estimates the chances of conception within 6 months from the point when a diagnosis of unexplained subfertility was made. These predictions were recomputed each month to provide a dynamic assessment of the individualised chances of conception while taking account of treatment status in each month. Conception must have led to live birth and treatments included clomiphene, IUI + SO, and IVF. Predictions for natural conception were externally validated using a prospective cohort from The Netherlands.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 554 (42%) couples started fertility treatment within 2 years of their first fertility consultation. The natural conception leading to live birth rate was 0.24 natural conceptions per couple per year. Active treatment had a higher chance of conception compared to those who remained under expectant management. This association ranged from weak with clomiphene to strong with IVF [clomiphene, hazard ratio (HR) = 1.42 (95% confidence interval, 1.05 to 1.91); IUI + SO, HR = 2.90 (2.06 to 4.08); IVF, HR = 5.09 (4.04 to 6.40)]. Female age and duration of subfertility were significant predictors, without clear interaction with the relative effect of treatment.

LIMITATIONS, REASONS FOR CAUTION

We were unable to adjust for other potentially important predictors, e.g. measures of ovarian reserve, which were not available in the linked Grampian dataset that may have made predictions more specific. This study was conducted using single centre data meaning that it may not be generalizable to other centres. However, the model performed as well as previous models in reproductive medicine when externally validated using the Dutch cohort.

WIDER IMPLICATIONS OF THE FINDINGS

For the first time, it is possible to estimate the chances of conception following expectant management and different fertility treatments over time in couples with unexplained subfertility. This information will help inform couples and their clinicians of their likely chances of success, which may help manage expectations, not only at diagnostic workup completion but also throughout their fertility journey.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a Chief Scientist Office postdoctoral training fellowship in health services research and health of the public research (ref PDF/12/06). B.W.M. is supported by an NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for ObsEva, Merck, and Guerbet. None of the other authors declare any conflicts of interest.

Sustained low-dose dexamethasone delivery via a PLGA microsphere-embedded agarose implant for enhanced osteochondral repair

Articular cartilage defects are a common source of joint pain and dysfunction. We hypothesized that sustained low-dose dexamethasone (DEX) delivery via an acellular osteochondral implant would have a dual pro-anabolic and anti-catabolic effect, both supporting the functional integrity of adjacent graft and host tissue while also attenuating inflammation caused by iatrogenic injury. An acellular agarose hydrogel carrier with embedded DEX-loaded poly(lactic-co-glycolic) acid (PLGA) microspheres (DLMS) was developed to provide sustained release for at least 99 days. The DLMS implant was first evaluated in an in vitro pro-inflammatory model of cartilage degradation. The implant was chondroprotective, as indicated by maintenance of Young's modulus (EY) (p = 0.92) and GAG content (p = 1.0) in the presence of interleukin-1β insult. In a subsequent preliminary in vivo experiment, an osteochondral autograft transfer was performed using a pre-clinical canine model. DLMS implants were press-fit into the autograft donor site and compared to intra-articular DEX injection (INJ) or no DEX (CTL). Functional scores for DLMS animals returned to baseline (p = 0.39), whereas CTL and INJ remained significantly worse at 6 months (p < 0.05). DLMS knees were significantly more likely to have improved OARSI scores for proteoglycan, chondrocyte, and collagen pathology (p < 0.05). However, no significant improvements in synovial fluid cytokine content were observed. In conclusion, utilizing a targeted DLMS implant, we observed in vitro chondroprotection in the presence of IL-1-induced degradation and improved in vivo functional outcomes. These improved outcomes were correlated with superior histological scores but not necessarily a dampened inflammatory response, suggesting a primarily pro-anabolic effect. STATEMENT OF SIGNIFICANCE: Articular cartilage defects are a common source of joint pain and dysfunction. Effective treatment of these injuries may prevent the progression of osteoarthritis and reduce the need for total joint replacement. Dexamethasone, a potent glucocorticoid with concomitant anti-catabolic and pro-anabolic effects on cartilage, may serve as an adjuvant for a variety of repair strategies. Utilizing a dexamethasone-loaded osteochondral implant with controlled release characteristics, we demonstrated in vitro chondroprotection in the presence of IL-1-induced degradation and improved in vivo functional outcomes following osteochondral repair. These improved outcomes were correlated with superior histological cartilage scores and minimal-to-no comorbidity, which is a risk with high dose dexamethasone injections. Using this model of cartilage restoration, we have for the first time shown the application of targeted, low-dose dexamethasone for improved healing in a preclinical model of focal defect repair.

Prediction of success at UK Specialty Board Examinations using the mandatory postgraduate UK surgical examination

Background

While performance in other mandatory examinations taken at the beginning of a doctor's career are predictive of final training outcomes, the influence early postgraduate surgical examinations might have on success at Specialty Board Exams in the UK is currently unknown. The aim was to investigate whether performance at the mandatory Membership of the Royal College of Surgeons (MRCS) examination, and other variables, are predictive of success at the Fellowship of the Royal College of Surgeons (FRCS) examination, thus potentially identifying those who may benefit from early academic intervention.

Methods

Pearson correlation coefficients examined the linear relationship between both examinations and logistic regression analysis identified potential independent predictors of FRCS success. All UK medical graduates who attempted either section of FRCS (Sections 1 and 2) between 2012 and 2018 were included.

Results

First attempt pass rates for Sections 1 and 2 FRCS were 87.4 per cent (n = 854) and 91.8 per cent (n = 797) respectively. In logistic regression analysis, sex (male: odds ratio (OR) 2.32, 95 per cent c.i 1.43 to 3.76), age (less than 29 years at graduation: OR 3.22, 1.88 to 5.51), Part B MRCS attempts (1 attempt: OR 1.77, 1.08 to 3.00), Part A score (OR 1.14, 1.09 to 1.89) and Part B score (OR 1.06, 1.03 to 1.09) were independent predictors of Section 1 FRCS success. Predictors of Section 2 FRCS success were age (less than 29 years at graduation: OR 3.55, 2.00 to 6.39), Part A score (OR 1.06, 1.02 to 1.11) and Section 1 FRCS score (OR 1.13, 1.07 to 1.18).

Conclusion

Part A and B MRCS performance were independent predictors of FRCS success, providing further evidence to support the predictive validity of this mandatory postgraduate exam. However, future research must explore the reasons between the attainment gaps observed for different groups of doctors.

Cartilage Wear Particles Induce an Inflammatory Response Similar to Cytokines in Human Fibroblast-Like Synoviocytes

The synovium plays a key role in the development of osteoarthritis, as evidenced by pathological changes to the tissue observed in both early and late stages of the disease. One such change is the attachment of cartilage wear particles to the synovial intima. While this phenomenon has been well observed clinically, little is known of the biological effects that such particles have on resident cells in the synovium. The present work investigates the hypothesis that cartilage wear particles elicit a pro-inflammatory response in diseased and healthy human fibroblast-like synoviocytes, like that induced by key cytokines in osteoarthritis. Fibroblast-like synoviocytes from 15 osteoarthritic human donors and a subset of three non-osteoarthritic donors were exposed to cartilage wear particles, interleukin-1α or tumor necrosis factor-α for 6 days and analyzed for proliferation, matrix production, and release of pro-inflammatory mediators and degradative enzymes. Wear particles significantly increased proliferation and release of nitric oxide, interleukin-6 and -8, and matrix metalloproteinase-9, -10, and -13 in osteoarthritic synoviocytes, mirroring the effects of both cytokines, with similar trends in non-osteoarthritic cells. These results suggest that cartilage wear particles are a relevant physical factor in the osteoarthritic environment, perpetuating the pro-inflammatory and pro-degradative cascade by modulating synoviocyte behavior at early and late stages of the disease. Future work points to therapeutic strategies for slowing disease progression that target cell-particle interactions. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1979-1987, 2019.

A Functional Tissue-Engineered Synovium Model to Study Osteoarthritis Progression and Treatment

IMPACT STATEMENT

The synovium envelops the diarthrodial joint and plays a key regulatory role in defining the composition of the synovial fluid through filtration and biosynthesis of critical boundary lubricants. Synovium changes often precede cartilage damage in osteoarthritis. We describe a novel in vitro tissue engineered model, validated against native synovium explants, to investigate the structure-function of synovium through quantitative solute transport measures. Synovium was evaluated in the presence of a proinflammatory cytokine, interleukin-1, or the clinically relevant corticosteroid, dexamethasone. We anticipate that a better understanding of synovium transport would support efforts to develop more effective strategies aimed at restoring joint health.

The effects of human factor related issues on assessors during the recruitment process for general and vascular surgery in the UK

INTRODUCTION

Healthcare professionals increasingly recognise how human factors (HF) can contribute to medical error. An understanding of HF is also important during other high stakes activities such as summative assessments or examinations. National organisations hosting such events need to be aware of potential fatigue, boredom and stress that can occur in interviewers during these often repetitive activities.

METHODS

A previously validated questionnaire based around the well known HF analysis and classification system (HFACS) was used to evaluate four factors (care and support, asking questions about the role as an interviewer, working within the rules and boundaries, and stress and pressure) at the 2018 UK general and vascular surgery trainee national selection process.

RESULTS

A total of 92 questionnaires were completed and analysed (48% response rate). After recoding for negative phrased questions, no significant differences were found between years of experience in the selection process and mean scores obtained for all four factor items. Interviewers had a positive experience during national selection with mean factor scores ranging from 3.84 to 3.98 (out of a maximum satisfaction score of 5).

CONCLUSIONS

Organisations need to plan carefully and recognise the human element to ensure that their interviewers are cared for during any high stakes assessment such as national selection. Our work suggests that a positive assessor experience will further help contribute to a reliable and fair recruitment process.

Does the Intercollegiate Membership of the Royal College of Surgeons (MRCS) examination predict 'on-the-job' performance during UK higher specialty surgical training?

INTRODUCTION

The Intercollegiate Membership of the Royal College of Surgeons (MRCS) is a mandatory examination to enter higher surgical specialty training in the UK. It is designed to help to ensure that successful candidates are competent to practice as higher surgical trainees. The annual review of competence progression (ARCP) assesses trainees' competence to progress to the next level of training and can be interpreted as a measure of 'on-the-job' performance. We investigated the relationship between MRCS performance and ARCP outcomes.

MATERIALS AND METHODS

All UK medical graduates who passed MRCS (Parts A and B) from 2007 to 2016 were included. MRCS scores, attempts and sociodemographics for each candidate were crosslinked with ARCP outcomes (satisfactory, unsatisfactory and insufficient evidence). Multinomial logistic regression was used to identify potential independent predictors of ARCP outcomes.

RESULTS

A total of 2570 trainees underwent 11,064 ARCPs; 1589 (61.8%) had only satisfactory outcomes recorded throughout training; 510 (19.9%) had at least one unsatisfactory outcome; and 471 (18.3%) supplied insufficient evidence. After adjusting for age, gender, first language and Part A performance, ethnicity (non-white vs white, OR 1.36, 95% CI 1.08 to 1.71), Part B passing score (OR 0.98, 95% CI 0.98 to 1.00) and number of attempts at Part B (two or more attempts vs one attempt, OR 1.50, 95% CI 1.16 to 1.94) were found to be independent predictors of an unsatisfactory ARCP outcome.

CONCLUSIONS

This is the first study to identify predictors of ARCP outcomes during higher surgical specialty training in the UK and provides further evidence of the predictive validity of the MRCS examination.

Smoking, Haemostatic Factors and the Severity of Aorto-lliac and Femoro-Popliteal Disease

To determine relationships between haemostatic and rheological factors and severity of peripheral atherosclerosis and differences by site, an angiographic cross-sectional survey was carried out on 192 men and women with intermittent claudication or rest pain. 34 patients were classified as having aorto-iliac disease, 85 femoro-popliteal disease and 73 dual-site disease. Mean levels of haemostatic or rheological factors did not differ significantly between the three site groups. In all 192 patients, disease severity in the femoro-popliteal segments was correlated with plasma nephelometric fibrinogen (r = 0.20, p ≤0.01), von Willebrand factor (r = 0.14, p ≤0.05) and fibrin D-dimer (r = 0.22, p ≤0.001). On multiple regression analyses, fibrinogen was independently associated with disease severity in the femoro-popliteal segments (p ≤0.05), but not in the aorto-iliac segments. Adjustment for packyears or serum thiocyanate had little effect on the association of fibrinogen with severity of disease. An inverse relationship between plasminogen activator inhibitor and disease severity in the femoro-popliteal segments was found only in men (r = -0.24, p ≤0.01). We conclude that elevated fibrinogen and disturbed fibrinolytic activity may be related to the extent of disease within the femoro-popliteal arteries, more so than in the aorto-iliac arteries.

Proton pump inhibitor and histamine-2 receptor antagonist use and risk of liver cancer in two population-based studies

BACKGROUND

Proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) are commonly used. PPIs have been shown to promote liver cancer in rats; however, only one study has examined the association in humans.

AIMS

To investigate PPIs and H2RAs and risk of primary liver cancer in two large independent study populations.

METHODS

We conducted a nested case-control study within the Primary Care Clinical Informatics Unit (PCCIU) database in which up to five controls were matched to cases with primary liver cancer, recorded by General Practitioners. Odds ratios (ORs) and 95% confidence intervals (95% CIs) for associations with prescribed PPIs and H2RAs were calculated using conditional logistic regression. We also conducted a prospective cohort study within the UK Biobank using self-reported medication use and cancer-registry recorded primary liver cancer. Hazard ratios (HRs) and 95% CIs were calculated using Cox regression.

RESULTS

In the PCCIU case-control analysis, 434 liver cancer cases were matched to 2103 controls. In the UK Biobank cohort, 182 of 475 768 participants developed liver cancer. In both, ever use of PPIs was associated with increased liver cancer risk (adjusted OR 1.80, 95% CI 1.34, 2.41 and adjusted HR 1.99, 95% CI 1.34, 2.94 respectively). There was little evidence of association with H2RA use (adjusted OR 1.21, 95% CI 0.84, 1.76 and adjusted HR 1.70, 95% CI 0.82, 3.53 respectively).

CONCLUSIONS

We found some evidence that PPI use was associated with liver cancer. Whether this association is causal or reflects residual confounding or reverse causation requires additional research.

Factors predicting success in the Intercollegiate Membership of the Royal College of Surgeons (MRCS) examination: a summary for OMFS

The Intercollegiate Membership of the Royal College of Surgeons (MRCS, parts A and B) is a mandatory examination for entry into higher surgical training in the UK. We investigated which factors predict success in both the written (Part A) and clinical (Part B) parts of the examination, and provide a summary for oral and maxillofacial surgeons (OMFS). All UK graduates who attempted both parts between 2007 and 2016 were included. There was a positive correlation between the scores in parts A and B (r=0.41, p<0.01). For Part A, men (odds ratio (OR) 2.78; 95% CI 1.83 to 4.19), white candidates (OR 1.70; 95% CI 1.52 to 1.89), and younger graduates (under 29years of age), were more likely to pass (OR 2.60; 95% CI 1.81 to 3.63). Foundation year one (FY1) doctors had higher pass rates than all other grades (e.g. core surgical trainee 2 compared with FY1 OR 0.50; 95% CI 0.32 to 0.77). The number of attempts at Part A and the final score, as well as ethnicity and stage of training, were independent predictors of success in Part B. Candidates who did well in Part A were more likely to do well in Part B. Several independent predictors of success were identified, but only the stage of training and ethnicity were common predictors in both parts. Higher scores obtained by younger candidates might be relevant to OMFS trainees who take Part A after studying medicine as a second degree.

Predictors of success in the Intercollegiate Membership of the Royal College of Surgeons (MRCS) examination

Introduction The Intercollegiate Membership of the Royal College of Surgeons (MRCS, Parts A and B) is designed to safeguard patients and ensure high standards for trainees wishing to pursue a surgical career. We investigated which factors predict Part A and B success. Methods UK graduates who had attempted both parts of MRCS from September 2007 to February 2016 were included. Pearson correlation coefficients were used to examine the linear relationship between each part of MRCS and logistic regression analysis to identify potential independent predictors of MRCS pass/fail outcome. Results A positive correlation between Part A and B score was identified (r = 0.41, P < 0.01). In Part A, males had higher pass rates than females (odds ratio, OR, 2.78, 95% confidence interval, CI, 1.83-4.19), white candidates were more likely to pass than black minority and ethnic doctors (OR 1.70, 95% CI 1.52-1.89), foundation year 1 doctors had higher pass rates than all other grades (e.g. core surgical year 2 trainees vs. foundation year 1 doctors, OR 0.50, 95% CI 0.32-0.77) and younger graduates were more likely to pass than older graduates (OR 2.60, 95% CI 1.81-3.63). In addition to ethnicity and stage of training, Part A performance (number of attempts and score) was an independent predictor for Part B. Conclusions Part A performance is related to Part B score. Many independent predictors of MRCS success were identified, but only stage of training and ethnicity were found to be common predictors of both parts. This article summarises the findings of our most recent MRCS study which was published in The Surgeon (online) in October 2017. ¹.

Impact of performance in a mandatory postgraduate surgical examination on selection into specialty training

Background

The Intercollegiate Membership of the Royal College of Surgeons (MRCS) examination is undertaken by large numbers of trainees in the UK and internationally as a mandatory step within surgical training. Unlike some high-stakes medical examinations, the MRCS is yet to be validated. A quantitative study was undertaken to assess its predictive validity by investigating the relationship between MRCS (Parts A and B) and national selection interview scores for general and vascular surgery in the UK.

Methods

Pearson correlation coefficients were used to examine the linear relationship between each assessment, and linear regression analyses were employed to identify potential independent predictors of the national selection score. All UK medical graduates who attempted the interview in 2011-2015 were included.

Results

Some 84·4 per cent of the candidates (1231 of 1458) were matched with MRCS data. There was a significant positive correlation between the first attempt score at Part B of the MRCS examination and the national selection score (r = 0·38, P < 0·001). In multivariable analysis, 17 per cent of variance in the national selection first attempt score was explained by the Part B MRCS score and number of attempts (change in R ² value of 0·10 and 0·07 respectively; P < 0·001). Candidates who required more than two attempts at Part B were predicted to score 8·1 per cent less than equally matched candidates who passed at their first attempt.

Conclusion

This study supports validity of the MRCS examination, and indicates its predictive value regarding entry into specialist training.

Neuropsychological Functioning following Fetal Striatal Transplantation in Huntington's Chorea: Three Case Presentations

Neurotransplantation has been proposed as a potential treatment for the neurodegenerative disorder of Huntington's disease (HD), which currently has no effective therapy. While patients with Parkinson's disease have received neurotransplantation, until recently no HD patients have undergone transplantation for HD with standardized evaluations of their progress following surgery. The current report presents the cognitive changes in three patients with HD who underwent bilateral transplantation of human fetal striatal tissue. As part of the pre- and postsurgical evaluation, all three patients were administered a neuropsychological battery sensitive to the cognitive effects of HD within 2 mo prior to surgery and at 4-6 mo following transplantation. Four to 6 mo subsequent to surgery, all patients demonstrated increased scores on some measures of cognitive functioning. However, the pattern of changes was not uniform across subjects. These findings suggest that fetal striatal transplantation may improve some of the cognitive symptoms associated with HD in the three reported patients.

A comprehensive approach for evaluating telemedicine-delivered multidisciplinary breast cancer meetings in southern Scotland

Multidisciplinary team (MDT) meetings for decisions on cancer management are a cornerstone of UK cancer policy. We have proposed a comprehensive methodology to assess the clinical and economic effectiveness of telemedicine in this setting, which is being tested in a randomized breast cancer trial. Pre- and post-telemedicine assessment includes attitudes to and expectations of telemedicine, based on semistructured interviews. The communication content of videotapes of the MDT meeting is being scored using Borgatta's revised Interaction Process Analysis System. The technical performance of the telemedicine equipment is reported on a standardized pro forma. A short questionnaire captures key elements of professional satisfaction for each patient discussion (consensus on future management, confidence in and sharing of decision), added value of linkage, group atmosphere, overall conduct of the meeting and compliance with SIGN guidelines. A cost-minimization analysis will be used for economic assessment.

Multi-layer compression: comparison of four different four-layer bandage systems applied to the leg

Objective: To compare on standardized laboratory models the performance of four commercially available four-layer bandage systems.

Methods: Four experienced bandagers applied each of the four systems [Profore® Regular (Smith & Nephew, Hull, UK), Ultra Four (Robinsons, Chesterfield, UK), System 4 (SSL International, Knutsford, UK) and K-Four® (Parema, Loughborough, UK)] to two models: a 12.5 cm diameter padded cylinder and a 9.5-14.5 cm padded cone. Bandages were applied individually in single layers and as a completed system using standard application techniques. Pressures were measured by the Borgnis Medical Stocking Tester at positions corresponding to ankle, gaiter and mid-calf areas as determined by the pressure sensor.

Results: A total of 768 observations were made: 384 for each model, 192 for each bandaging system, 192 for each bandager and 128 for each measuring point. The increase in pressure produced by each additional layer was in the range of 50-60% of the pressure achieved by the same bandage when used as a single layer. Each bandage system and each bandager produced a gradient of final mean pressure irrespective of whether the bandage was applied to a cylinder or a cone. However, there were no significant differences in the gradients between the four bandage systems or between the four bandagers. There were significant differences in the final pressures achieved among the bandage systems when applied as completed systems (mean: Profore® = 42 mmHg; System 4 = 45 mmHg; K-Four® = 48 mmHg; and Ultra Four = 51 mmHg; P<0.001).

Conclusions: These results challenge a commonly-held assumption concerning the additive effect of pressures generated by successive bandage layers. When applied as part of a multi-layered system each bandage adds just over half the pressure achieved by the same bandage when applied alone. The four completed systems produced pressures within a range appropriate for ulcer therapy, although there were significant differences in mean pressures. This capability of the systems to produce different pressures could be clinically important in the hands of inexperienced bandagers or with patients at risk of pressure damage..

General practice performance in referral for suspected cancer: influence of number of cases and case-mix on publicly reported data

Background:

Publicly available data show variation in GPs' use of urgent suspected cancer (USC) referral pathways. We investigated whether this could be due to small numbers of cancer cases and random case-mix, rather than due to true variation in performance.

Methods:

We analysed individual GP practice USC referral detection rates (proportion of the practice's cancer cases that are detected via USC) and conversion rates (proportion of the practice's USC referrals that prove to be cancer) in routinely collected data from GP practices in all of England (over 4 years) and northeast Scotland (over 7 years). We explored the effect of pooling data. We then modelled the effects of adding random case-mix to practice variation.

Results:

Correlations between practice detection rate and conversion rate became less positive when data were aggregated over several years. Adding random case-mix to between-practice variation indicated that the median proportion of poorly performing practices correctly identified after 25 cancer cases were examined was 20% (IQR 17 to 24) and after 100 cases was 44% (IQR 40 to 47).

Conclusions:

Much apparent variation in GPs' use of suspected cancer referral pathways can be attributed to random case-mix. The methods currently used to assess the quality of GP-suspected cancer referral performance, and to compare individual practices, are misleading. These should no longer be used, and more appropriate and robust methods should be developed.

Time from first presentation in primary care to treatment of symptomatic colorectal cancer: effect on disease stage and survival

Background:

British 5-year survival from colorectal cancer (CRC) is below the European average, but the reasons are unclear. This study explored if longer provider delays (time from presentation to treatment) were associated with more advanced stage disease at diagnosis and poorer survival.

Methods:

Data on 958 people with CRC were linked with the Scottish Cancer Registry, the Scottish Death Registry and the acute hospital discharge (SMR01) dataset. Time from first presentation in primary care to first treatment, disease stage at diagnosis and survival time from date of first presentation in primary care were determined. Logistic regression and Cox survival analyses, both with a restricted cubic spline, were used to model stage and survival, respectively, following sequential adjustment of patient and tumour factors.

Results:

On univariate analysis, those with <4 weeks from first presentation in primary care to treatment had more advanced disease at diagnosis and the poorest prognosis. Treatment delays between 4 and 34 weeks were associated with earlier stage (with the lowest odds ratio occurring at 20 weeks) and better survival (with the lowest hazard ratio occurring at 16 weeks). Provider delays beyond 34 weeks were associated with more advanced disease at diagnosis, but not increased mortality. Following adjustment for patient, tumour factors, emergency admissions and symptoms and signs, no significant relationship between provider delay and stage at diagnosis or survival from CRC was found.

Conclusions:

Although allowing for a nonlinear relationship and important confounders, moderately long provider delays did not impact adversely on cancer outcomes. Delays are undesirable because they cause anxiety; this may be fuelled by government targets and health campaigns stressing the importance of very prompt cancer diagnosis. Our findings should reassure patients. They suggest that a health service's primary emphasis should be on quality and outcomes rather than on time to treatment.

Incidence and risk factors for venous reflux in the general population: Edinburgh Vein Study

OBJECTIVE/BACKGROUND

Chronic venous disease (CVD) is common, but the incidence of venous reflux, a precursor to this condition, is unknown. This study measured the incidence of venous reflux and associated risk factors, and examined the association between venous reflux and the incidence of CVD.

METHODS

In the Edinburgh Vein Study, a random sample of 1566 men and women aged 18-64 years were examined at baseline. Eight hundred and eighty of these patients were followed up 13 years and underwent an examination comprising clinical classification of CVD and duplex scanning of the deep and superficial systems to measure venous reflux ≥0.5 s.

RESULTS

The 13-year incidence of reflux was 12.7% (95% confidence interval [CI] 9.2-17.2), equivalent to an annual incidence of 0.9% (95% CI 0.7-1.3). The 13-year incidence of isolated superficial, isolated deep, and combined deep and superficial reflux was 8.8% (95% CI 5.6-12.0), 2.6% (95% CI 1.2-5.0), and 1.3% (95% CI 0.4-3.2), respectively. The highest incidence was in the great saphenous vein in the lower thigh (8.1%, 95% CI 5.4-11.8). There were no age or sex differences (p > .050). The risk of developing reflux was associated with being overweight (odds ratio [OR] 2.1, 95% CI 1.0-4.4) and with history of deep vein thrombosis (OR 11.3, 95% CI 1.0-132.3). Venous reflux at baseline was associated with new varicose veins at follow up (p < .001): the age- and sex-adjusted OR was 4.4 (95% CI 1.8-10.8) in those with isolated superficial reflux and 7.3 (95% CI 2.6-22.5) in those with combined deep and superficial reflux.

CONCLUSION

For every year of follow-up, around 1% of this adult population developed venous reflux. In two thirds of cases, the superficial system was affected. Venous reflux increased the risk of developing varicose veins, especially when combined deep and superficial reflux was present.

BOADICEA breast cancer risk prediction model: updates to cancer incidences, tumour pathology and web interface

BACKGROUND

The Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA) is a risk prediction model that is used to compute probabilities of carrying mutations in the high-risk breast and ovarian cancer susceptibility genes BRCA1 and BRCA2, and to estimate the future risks of developing breast or ovarian cancer. In this paper, we describe updates to the BOADICEA model that extend its capabilities, make it easier to use in a clinical setting and yield more accurate predictions.

METHODS

We describe: (1) updates to the statistical model to include cancer incidences from multiple populations; (2) updates to the distributions of tumour pathology characteristics using new data on BRCA1 and BRCA2 mutation carriers and women with breast cancer from the general population; (3) improvements to the computational efficiency of the algorithm so that risk calculations now run substantially faster; and (4) updates to the model's web interface to accommodate these new features and to make it easier to use in a clinical setting.

RESULTS

We present results derived using the updated model, and demonstrate that the changes have a significant impact on risk predictions.

CONCLUSION

All updates have been implemented in a new version of the BOADICEA web interface that is now available for general use: http://ccge.medschl.cam.ac.uk/boadicea/.

Patchiness of ion-exchanged mica revealed by DNA binding dynamics at short length scales

The binding of double-stranded (ds) DNA to mica can be controlled through ion-exchanging the mica with divalent cations. Measurements of the end-to-end distance of linear DNA molecules discriminate whether the binding mechanism occurs through 2D surface equilibration or kinetic trapping. A range of linear dsDNA fragments have been used to investigate length dependences of binding. Mica, ion-exchanged with Ni(II) usually gives rise to kinetically trapped DNA molecules, however, short linear fragments (<800 bp) are seen to deviate from the expected behaviour. This indicates that ion-exchanged mica is heterogeneous, and contains patches or domains, separating different ionic species. These results correlate with imaging of dsDNA under aqueous buffer on Ni(II)-mica and indicate that binding domains are of the order of 100 nm in diameter. Shorter DNA fragments behave intermediate to the two extreme cases of 2D equilibration and kinetic trapping. Increasing the incubation time of Ni(II) on mica, from minutes to hours, brings the conformations of the shorter DNA fragments closer to the theoretical value for kinetic trapping, indicating that long timescale kinetics play a role in ion-exchange. X-ray photoelectron spectroscopy (XPS) was used to confirm that the relative abundance of Ni(II) ions on the mica surface increases with time. These findings can be used to enhance spatial control of binding of DNA to inorganic surfaces with a view to patterning high densities arrays.

Development and validation of an ankle brachial index risk model for the prediction of cardiovascular events

BACKGROUND

The ankle brachial index (ABI) is related to risk of cardiovascular events independent of the Framingham risk score (FRS). The aim of this study was to develop and evaluate a risk model for cardiovascular events incorporating the ABI and FRS.

DESIGN

An analysis of participant data from 18 cohorts in which 24,375 men and 20,377 women free of coronary heart disease had ABI measured and were followed up for events.

METHODS

Subjects were divided into a development and internal validation dataset and an external validation dataset. Two models, comprising FRS and FRS + ABI, were fitted for the primary outcome of major coronary events.

RESULTS

In predicting events in the external validation dataset, C-index for the FRS was 0.672 (95% CI 0.599 to 0.737) in men and 0.578 (95% CI 0.492 to 0.661) in women. The FRS + ABI led to a small increase in C-index in men to 0.685 (95% CI 0.612 to 0.749) and large increase in women to 0.690 (95% CI 0.605 to 0.764) with net reclassification improvement (NRI) of 4.3% (95% CI 0.0 to 7.6%, p = 0.050) and 9.6% (95% CI 6.1 to 16.4%, p < 0.001), respectively. Restricting the FRS + ABI model to those with FRS intermediate 10-year risk of 10 to 19% resulted in higher NRI of 15.9% (95% CI 6.1 to 20.6%, p < 0.001) in men and 23.3% (95% CI 13.8 to 62.5%, p = 0.002) in women. However, incorporating ABI in an improved newly fitted risk factor model had a nonsignificant effect: NRI 2.0% (95% CI 2.3 to 4.2%, p = 0.567) in men and 1.1% (95% CI 1.9 to 4.0%, p = 0.483) in women.

CONCLUSIONS

An ABI risk model may improve prediction especially in individuals at intermediate risk and when performance of the base risk factor model is modest.

Pregnancy outcomes of women with and without a history of anorexia nervosa

BACKGROUND

When women have a history of anorexia nervosa (AN), the advice given about becoming pregnant, and about the management of pregnancies, has usually been cautious. This study compared the pregnancy outcomes of women with and without a history of AN.

METHOD

Women with a confirmed diagnosis of AN who had presented to psychiatric services in North East Scotland from 1965 to 2007 were identified. Those women with a pregnancy recorded in the Aberdeen Maternal and Neonatal Databank (AMND) were each matched by age, parity and year of delivery of their first baby with five women with no history of AN. Maternal and foetal outcomes were compared between these two groups of women. Comparisons were also made between the mothers with a history of AN and all other women in the AMND.

RESULTS

A total of 134 women with a history of AN delivered 230 babies and the 670 matched women delivered 1144 babies. Mothers with AN delivered lighter babies but this difference did not persist after adjusting for maternal body mass index (BMI) in early pregnancy. Standardized birthweight (SBW) scores suggested that the AN mothers were more likely to produce babies with intrauterine growth restriction (IUGR) [relative risk (RR) 1.54, 95% confidence interval (CI) 1.11-2.13]. AN mothers were more likely to experience antepartum haemorrhage (RR 1.70, 95% CI 1.09-2.65).

CONCLUSIONS

Mothers with a history of AN are at increased risk of adverse pregnancy outcomes. The magnitude of these risks is relatively small and should be appraised holistically by psychiatric and obstetric services.

Telangiectasia and venous reflux in the Edinburgh Vein Study

Objective

The purpose of this study was to correlate the clinical findings in the Edinburgh Vein Study with the results of duplex scanning of the deep and superficial venous systems.

Methods

An age-stratified random sample of 1566 people (699 men and 867 women) aged 16–64 were selected from computerized age–sex registers of participating practices (twelve general practices with catchment areas geographically and socioeconomically distributed throughout Edinburgh). Screening included clinical examination, photography and duplex ultrasonography of the superficial veins and the deep veins down to popliteal level. Telangiectasia and varicose veins were graded 1–3 according to severity.

Results

Since there was good agreement between the duplex findings of the right versus left legs, the current analyses are based on 1092 subjects (486 men and 606 women) with complete duplex scan data in their left legs. There was no significant trend of increasing incompetence in either the deep veins only ( P = 0.214) or in the combined deep and superficial veins ( P = 0.111) with increasing severity of the telangiectasia. There was a statistically significant trend for increasing incompetence in (a) the superficial veins ( P = 0.006) and (b) either the superficial or deep veins ( P < 0.001) to be associated with advancing grade of telangiectasia. When stratified by gender, significant trends were maintained for male superficial vein incompetence and for either superficial or deep incompetence in both genders. Examination of incompetence in individual venous segments showed that increasing severity of telangiectasia was significantly associated with an increasing proportion of reflux in the upper and lower great saphenous and femoral vein segments. There was no significant association between small saphenous incompetence and increasing grade of telangiectasia.

Conclusion

There is a significant, but not wholly consistent, association between grade of telangiectasia and reflux in both the deep and superficial systems. This association does not apply to the small saphenous system.

Evaluating the effectiveness of a web-based intervention to promote mental wellbeing in women and partners following miscarriage, using a modified patient preference trial design: an external pilot

This article describes an external pilot study of a modified 'partially randomised patient preference' trial comparing a web-based intervention (designed to promote mental wellbeing) with standard care post-miscarriage. Assessment comprised an online administration of baseline measures with follow-up at 3 months following registration. Baseline data were obtained from 60 women (and seven partners) post-discharge from one of two Early Pregnancy Assessment Units. 'Intention to treat' versus a 'per protocol' sensitivity analysis showed the effects of introducing a 'preference' option post-randomisation, and highlights the benefits compared with a randomised controlled trial design to enable a robust evaluation of the website in promoting mental wellbeing after miscarriage.

Hysterectomy, endometrial ablation and Mirena® for heavy menstrual bleeding: a systematic review of clinical effectiveness and cost-effectiveness analysis

OBJECTIVE

The aim of this project was to determine the clinical effectiveness and cost-effectiveness of hysterectomy, first- and second-generation endometrial ablation (EA), and Mirena® (Bayer Healthcare Pharmaceuticals, Pittsburgh, PA, USA) for the treatment of heavy menstrual bleeding.

DESIGN

Individual patient data (IPD) meta-analysis of existing randomised controlled trials to determine the short- to medium-term effects of hysterectomy, EA and Mirena. A population-based retrospective cohort study based on record linkage to investigate the long-term effects of ablative techniques and hysterectomy in terms of failure rates and complications. Cost-effectiveness analysis of hysterectomy versus first- and second-generation ablative techniques and Mirena.

SETTING

Data from women treated for heavy menstrual bleeding were obtained from national and international trials. Scottish national data were obtained from the Scottish Information Services Division.

PARTICIPANTS

Women who were undergoing treatment for heavy menstrual bleeding were included.

INTERVENTIONS

Hysterectomy, first- and second-generation EA, and Mirena.

MAIN OUTCOME MEASURES

Satisfaction, recurrence of symptoms, further surgery and costs.

RESULTS

Data from randomised trials indicated that at 12 months more women were dissatisfied with first-generation EA than hysterectomy [odds ratio (OR): 2.46, 95% confidence interval (CI) 1.54 to 3.93; p = 0.0002), but hospital stay [WMD (weighted mean difference) 3.0 days, 95% CI 2.9 to 3.1 days; p < 0.00001] and time to resumption of normal activities (WMD 5.2 days, 95% CI 4.7 to 5.7 days; p < 0.00001) were longer for hysterectomy. Unsatisfactory outcomes associated with first- and second-generation techniques were comparable [12.2% (123/1006) vs 10.6% (110/1034); OR 1.20, 95% CI 0.88 to 1.62; p = 0.2). Rates of dissatisfaction with Mirena and second-generation EA were similar [18.1% (17/94) vs 22.5% (23/102); OR 0.76, 95% CI 0.38 to 1.53; p = 0.4]. Indirect estimates suggested that hysterectomy was also preferable to second-generation EA (OR 2.32, 95% CI 1.27 to 4.24; p = 0.006) in terms of patient dissatisfaction. The evidence to suggest that hysterectomy is preferable to Mirena was weaker (OR 2.22, 95% CI 0.94 to 5.29; p = 0.07). In women treated by EA or hysterectomy and followed up for a median [interquartile range (IQR)] duration of 6.2 (2.7-10.8) and 11.6 (7.9-14.8) years, respectively, 962/11,299 (8.5%) women originally treated by EA underwent further gynaecological surgery. While the risk of adnexal surgery was similar in both groups [adjusted hazards ratio 0.80 (95% CI 0.56 to 1.15)], women who had undergone ablation were less likely to need pelvic floor repair [adjusted hazards ratio 0.62 (95% CI 0.50 to 0.77)] and tension-free vaginal tape surgery for stress urinary incontinence [adjusted hazards ratio 0.55 (95% CI 0.41 to 0.74)]. Abdominal hysterectomy led to a lower chance of pelvic floor repair surgery [hazards ratio 0.54 (95% CI 0.45 to 0.64)] than vaginal hysterectomy. The incidence of endometrial cancer following EA was 0.02%. Hysterectomy was the most cost-effective treatment. It dominated first-generation EA and, although more expensive, produced more quality-adjusted life-years (QALYs) than second-generation EA and Mirena. The incremental cost-effectiveness ratios for hysterectomy compared with Mirena and hysterectomy compared with second-generation ablation were £1440 per additional QALY and £970 per additional QALY, respectively.

CONCLUSIONS

Despite longer hospital stay and time to resumption of normal activities, more women were satisfied after hysterectomy than after EA. The few data available suggest that Mirena is potentially cheaper and more effective than first-generation ablation techniques, with rates of satisfaction that are similar to second-generation techniques. Owing to a paucity of trials, there is limited evidence to suggest that hysterectomy is preferable to Mirena. The risk of pelvic floor surgery is higher in women treated by hysterectomy than by ablation. Although the most cost-effective strategy, hysterectomy may not be considered an initial option owing to its invasive nature and higher risk of complications. Future research should focus on evaluation of the clinical effectivesness and cost-effectiveness of the best second-generation EA technique under local anaesthetic versus Mirena and types of hysterectomy such as laparoscopic supracervical hysterectomy versus conventional hysterectomy and second-generation EA.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Asthma control with extrafine-particle hydrofluoroalkane-beclometasone vs. large-particle chlorofluorocarbon-beclometasone: a real-world observational study

BACKGROUND

The extrafine-particle formulation of hydrofluoroalkane-beclometasone (EF HFA-BDP; Qvar®) demonstrates improved total and small airway deposition compared with large-particle chlorofluorocarbon (CFC)-BDP. In some short-term studies, EF HFA-BDP provides greater effects on lung function than CFC-BDP, and hence is recommended to be prescribed at a lower dose, but whether there are differences in asthma outcomes during long-term treatment is unknown.

OBJECTIVE

To compare the effectiveness of EF HFA-BDP vs. CFC-BDP over 1 year.

METHODS

This retrospective matched cohort study examined outcomes in a large primary care database for patients aged 5-60 years with asthma receiving their first inhaled corticosteroid (ICS) prescription (initiation population) or first ICS dose increase (step-up population) by a pressurized metered-dose inhaler (pMDI) as EF HFA-BDP or CFC-BDP. Patients were matched on baseline demographic and asthma severity measures in EF HFA-BDP:CFC-BDP ratios of 1:3 and 1:2 for initiation and step-up populations, respectively. Step-up patients were matched also on ICS dose during a baseline year. Co-primary endpoints were asthma control (composite measure comprising no recorded hospital attendance for asthma, oral corticosteroids, or antibiotics for lower respiratory infection) and exacerbation rate during the outcome year.

RESULTS

For the initiation population (EF HFA-BDP n=2882; CFC-BDP n=8646), adjusted odds of achieving asthma control with EF HFA-BDP vs. CFC-BDP was 1.15 (95% CI 1.02-1.28). For the step-up population (n=258 and 516), adjusted odds of asthma control with EF HFA-BDP was 1.72 (95% CI 1.14-2.56). EF HFA-BDP was prescribed at a median dose half that of CFC-BDP.

CONCLUSION AND CLINICAL RELEVANCE

During 1 year after initiating or stepping up ICS therapy by pMDI, patients who received EF HFA-BDP were more likely to achieve asthma control than those receiving CFC-BDP. These findings suggest that ICS formulation, particle size, and deposition characteristics play important roles in real-life effectiveness of asthma therapy. This study shows that an EF-particle formulation of beclometasone can be used at half the dose of the large-particle formulation with at least as good clinical outcomes.

Modifiable and fixed factors predicting quality of life in people with colorectal cancer

Background:

People with colorectal cancer have impaired quality of life (QoL). We investigated what factors were most highly associated with it.

Methods:

Four hundred and ninety-six people with colorectal cancer completed questionnaires about QoL, functioning, symptoms, co-morbidity, cognitions and personal and social factors. Disease, treatment and co-morbidity data were abstracted from case notes. Multiple linear regression identified modifiable and unmodifiable factors independently predictive of global quality of life (EORTC-QLQ-C30).

Results:

Of unmodifiable factors, female sex (P<0.001), more self-reported co-morbidities (P=0.006) and metastases at diagnosis (P=0.036) significantly predicted poorer QoL, but explained little of the variability in the model (R²=0.064). Adding modifiable factors, poorer role (P<0.001) and social functioning (P=0.003), fatigue (P=0.001), dyspnoea (P=0.001), anorexia (P<0.001), depression (P<0.001) and worse perceived consequences (P=0.013) improved the model fit considerably (R²=0.574). Omitting functioning subscales resulted in recent diagnosis (P=0.002), lower perceived personal control (P=0.020) and travel difficulties (P<0.001) becoming significant predictors.

Conclusion:

Most factors affecting QoL are modifiable, especially symptoms (fatigue, anorexia, dyspnoea) and depression. Beliefs about illness are also important. Unmodifiable factors, including metastatic (or unstaged) disease at diagnosis, have less impact. There appears to be potential for interventions to improve QoL in patients with colorectal cancer.

Patient satisfaction with GP-led melanoma follow-up: a randomised controlled trial

BACKGROUND

There are no universally accepted guidelines for the follow-up of individuals with cutaneous melanoma. Furthermore, to date, there have been no randomised controlled trials of different models of melanoma follow-up care. This randomised controlled trial was conducted to evaluate the effects of GP-led melanoma follow-up on patient satisfaction, follow-up guideline compliance, anxiety and depression, as well as health status.

METHODS

A randomised controlled trial of GP-led follow-up of cutaneous melanoma was conducted over a period of 1 year with assessment by self-completed questionnaires and review of general practice-held medical records at baseline and 12 months later. It took place in 35 general practices in North-east Scotland. Subjects were 142 individuals (51.4% women 48.6% men; mean (s.d.) age 59.2 (15.2) years previously treated for cutaneous melanoma and free of recurrent disease. The intervention consisted of protocol-driven melanoma reviews in primary care, conducted by trained GPs and supported by centralised recall, rapid access pathway to secondary care and a patient information booklet. The main outcome measure was patient satisfaction measured by questionnaire. Secondary outcomes were adherence to guidelines, health status measured by Short Form-36 and the Hospital Anxiety and Depression Scale.

RESULTS

There were significant improvements in 5 out of 15 aspects of patient satisfaction during the study year in those receiving GP-led melanoma follow-up (all P<or=0.01). The intervention group was significantly more satisfied with 7 out of 15 aspects of care at follow-up after adjustment for potential confounders. There was significantly greater adherence to guidelines in the intervention group during the study year. There was no significant difference in health status or anxiety and depression between intervention and control groups at either baseline or outcome.

CONCLUSIONS

GP-led follow-up is feasible, engenders greater satisfaction in those patients who receive it, permits closer adherence to guidelines and does not result in adverse effects on health status or anxiety and depression when compared with traditional hospital-based follow-up for melanoma.

Symptoms of depression but not anxiety are associated with central obesity and cardiovascular disease in people with type 2 diabetes: the Edinburgh Type 2 Diabetes Study

AIMS/HYPOTHESIS

The aim of the study was to identify risk factors for depression and anxiety in a well-characterised cohort of individuals with type 2 diabetes mellitus.

METHODS

We used baseline data from participants (n = 1,066, 48.7% women, aged 67.9 +/- 4.2 years) from the Edinburgh Type 2 Diabetes Study. Symptoms of anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS). Obesity was characterised according to both overall (body mass index, fat mass) and abdominal (waist circumference) measurements. Cardiovascular disease was assessed by questionnaire, physical examination and review of medical records. Stepwise multiple linear regression was performed to identify explanatory variables related to either anxiety or depression HADS scores.

RESULTS

Abdominal obesity (waist circumference) and cardiovascular disease (ischaemic heart disease and ankle-brachial pressure index) were related to depression but not anxiety. Lifetime history of severe hypoglycaemia was associated with anxiety. Other cardiovascular risk factors or microvascular complications were not related to either anxiety or depressive symptoms.

CONCLUSIONS/INTERPRETATION

Depression but not anxiety is associated with abdominal obesity and cardiovascular disease in people with type 2 diabetes mellitus. This knowledge may help to identify depressive symptoms among patients with type 2 diabetes who are at greatest risk.

A remedial intervention linked to a formative assessment is effective in terms of improving student performance in subsequent degree examinations

BACKGROUND

Intervention may help weaker medical students improve their performance. However, the effectiveness of remedial intervention is inconclusive due to small sample sizes in previous studies. We asked: is remedial intervention linked to a formative assessment effective in terms of improving student performance in subsequent degree examinations?

METHODS

This was a retrospective, observational study of anonymous databases of student assessment outcomes. Data were analysed for students due to graduate in the years 2005-2009 (n = 909). Exam performance was compared for students who received remediation versus those who did not. The main outcome measure was summative degree examination marks.

RESULTS

After adjusting for cohort, gender, overseas versus home funding, previous degree and previous performance in the corresponding baseline third year summative exam, students receiving a remedial intervention (after poor performance on a formative objective structured clinical examination and written exams mid-fourth year) were significantly more likely to obtain an improved mark on end-of-fourth year summative written (p = 0.005) and OSCE (p = 0.001) exams compared to those students who did not receive remediation.

CONCLUSION

A remedial intervention linked to poor assessment performance predicted improved performance in later examination. There is a need for prospective studies in order to identify the effective components of remedial interventions.

The epidemiology of infertility in the North East of Scotland

BACKGROUND

There is a perception that the prevalence of infertility is on the rise. This study aimed to determine the current prevalence of infertility in a defined geographical population, ascertain changes in self-reported infertility over time and identify risk factors associated with infertility.

METHODS

A postal questionnaire survey of a random population-based sample of women aged 31-50 years was performed in the Grampian region of Scotland. Questions addressed the following areas: pregnancy history, length of time taken to become pregnant each time, whether medical advice had been sought and self-reported exposure to factors associated with infertility.

RESULTS

Among 4466 women who responded, 400 (9.0%) [95% CI 8.1, 9.8] had chosen not to have children. Of the remaining 4066 women, 3283 (80.7%) [95% CI 79.5, 82.0] reported no difficulties in having children and the remaining 783 (19.3%) [95% CI 18.1, 20.5] had experienced infertility, defined as having difficulty in becoming pregnant for more than 12 months and/or seeking medical advice. In total 398 (9.8%) [95% CI 8.9, 10.7] women had primary infertility, 285 (7.0%) [95% CI 6.2, 7.8] had secondary infertility, 100 (2.5%) [95% CI 2.0, 2.9] had primary as well as secondary infertility. A total of 342 (68.7%) and 208 (73.0%) women with primary and secondary infertility, respectively, sought medical advice and 202 (59.1%) and 118 (56.7%) women in each group subsequently conceived. History of pelvic surgery, Chlamydial infection, endometriosis, chemotherapy, long-term health problems and obesity were associated with infertility. In comparison with a similar survey of women aged 46-50 from the same geographical area, the prevalence of both primary infertility (>24 months) [70/1081, (6.5%) versus 68/710 (9.6%) P = 0.02] and secondary infertility [29/1081 (2.7%) versus 40/710 (5.6%) P = 0.002] were significantly lower.

CONCLUSIONS

Nearly one in five women attempting conception sampled in this study experienced infertility, although over half of them eventually conceived. Fertility problems were associated with endometriosis, Chlamydia trachomatis infection and pelvic surgery, as well as obesity, chemotherapy and some long-term chronic medical conditions. There is no evidence of an increase in the prevalence of infertility in this population over the past 20 years.

Systematically missing confounders in individual participant data meta-analysis of observational cohort studies

One difficulty in performing meta-analyses of observational cohort studies is that the availability of confounders may vary between cohorts, so that some cohorts provide fully adjusted analyses while others only provide partially adjusted analyses. Commonly, analyses of the association between an exposure and disease either are restricted to cohorts with full confounder information, or use all cohorts but do not fully adjust for confounding. We propose using a bivariate random-effects meta-analysis model to use information from all available cohorts while still adjusting for all the potential confounders. Our method uses both the fully adjusted and the partially adjusted estimated effects in the cohorts with full confounder information, together with an estimate of their within-cohort correlation. The method is applied to estimate the association between fibrinogen level and coronary heart disease incidence using data from 154 012 participants in 31 cohorts.† Copyright © 2009 John Wiley & Sons, Ltd.

High efficiency, multi-Watt CW yellow emission from an intracavity-doubled self-Raman laser using Nd:GdVO4

Efficient multi-Watt continuous-wave (CW) yellow emission at 586.5 nm is demonstrated through intracavity frequency-doubling of a Nd:GdVO(4) self-Raman laser pumped at 880 nm. 2.51 W of CW yellow emission with an overall diode-to-yellow conversion efficiency of 12.2% is achieved through the use of a 20 mm long Nd:GdVO(4) self-Raman crystal and an intracavity mirror which facilitates collection of yellow emission generated within the resonator, and reduces thermal loading of the laser crystal.