Emergency department presentations with suicide and self-harm ideation: a missed opportunity for intervention?

AIMS

Suicidal ideation constitutes a central element of most theories of suicide and is the defining facet separating suicide from other causes of death such as accidents. However, despite a high worldwide prevalence, most research has focused on suicidal behaviours, such as completed suicide and suicide attempts, while the greater proportion who experienced ideation, which frequently precedes suicidal behaviour, have received much less attention. This study aims to examine the characteristics of those presenting to EDs with suicidal ideation and quantify the associated risk of suicide and other causes of death.

METHODS

Retrospective cohort study was performed based on population-wide health administration data linked to data from the Northern Ireland Registry of Self-Harm and centrally held mortality records from April 2012 to December 2019. Mortality data, coded as suicide, all-external causes and all-cause mortality were analysed using Cox proportional hazards. Additional cause-specific analyses included accidental deaths, deaths from natural causes and drug and alcohol-related causes.

RESULTS

There were 1,662,118 individuals aged over 10 years, of whom 15,267 presented to the ED with ideation during the study period. Individuals with ideation had a 10-fold increased risk of death from suicide (hazard ratio [HR_adj] = 10.84, 95% confidence interval [CI] 9.18, 12.80) and from all-external causes (HR_adj = 10.65, 95% CI 9.66, 11.74) and a threefold risk of death from all-causes (HR_adj = 3.01, 95% CI 2.84, 3.20). Further cause-specific analyses indicated that risk of accidental death (HR_adj = 8.24, 95% CI 6.29, 10.81), drug-related (HR_adj = 15.17, 95% CI 11.36, 20.26) and alcohol-related (HR_adj = 10.57, 95% CI 9.07, 12.31) has also significantly increased. There were few socio-demographic and economic characteristics that would identify which of these patients are most at risk of suicide or other causes of death.

CONCLUSIONS

Identifying people with suicidal ideation is recognized to be both important but difficult in practice; this study shows that presentations to EDs with self-harm or suicide ideation represent an important potential intervention point for this hard-to-reach vulnerable population. However, and unlike individuals presenting with self-harm, clinical guidelines for the management and recommended best practice and care of these individuals are lacking. Whilst suicide prevention may be the primary focus of interventions aimed at those experiencing self-harm and suicide ideation, death from other preventable causes, especially substance misuse, should also be a cause of concern.

Safe care transitions for patients receiving parenteral nutrition

Transitions of care require coordination between inpatient healthcare providers, care managers, outpatient/ambulatory providers, and the patient/caregiver and family members. Poor communication during transitions of care can affect health outcomes and economic costs for patients/caregivers, healthcare providers, and healthcare systems. The goal of this paper is to identify risk-prone processes in the transition of care for patients requiring parenteral nutrition (PN) between healthcare environments, including the hospital, home, skilled nursing facility, and long-term acute care hospital settings. To facilitate the evaluation of the transition, a sequential series of steps in the transition process were identified: initial notification, assessment in preparation for transfer, identifying the receiving organization, identifying accountable providers at each sending/receiving organization, communicating the nutrition care plan, implementing the plan and additional considerations regarding PN preparation and readmissions. Safety concerns with risk-prone processes are identified and recommended best practices are proposed for improving processes at each step of the transition. Pediatric considerations are included in the evaluation of the various steps in the transition of care. This paper was approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.

Rapid control of hospital-based SARS-CoV-2 Omicron clusters through daily testing and universal use of N95 respirators

The highly contagious SARS-CoV-2 Omicron variant increases risk for nosocomial transmission despite universal masking, admission testing, and symptom screening. We report large increases in hospital-onset infections and 2 unit-based clusters. The clusters rapidly abated after instituting universal N95 respirators and daily testing. Broader use of these strategies may prevent nosocomial transmissions.

Fractional urinary fluoride excretion and nail fluoride concentrations in normal, wasted and stunted 4-5 year-old children in Nepal

INTRODUCTION

It has been suggested that undernourished children are more likely to develop dental fluorosis. We investigated the effects of nutritional status on systemic fluoride metabolism including the proportion of ingested fluoride excreted through urine (i.e. fractional urinary fluoride excretion - FUFE) and fluoride concentration in nail clippings in children, aged 4-5 years, in Nepal.

METHODS

Nutritional status was evaluated using weight-for-age (wasting) and height-for-age (stunting) indices. Total daily fluoride intake (TDFI) was estimated from diet and toothpaste ingestion and 24 -h urine collected to assess daily urinary fluoride excretion (DUFE). FUFE was calculated by dividing DUFE by TDFI. Nail clippings (finger and toe) were collected and analysed for fluoride concentration.

RESULTS

Of the 100 children who participated, 89 provided information to assess FUFE and 51 children provided nail samples. Overall, 86.5 % of the 89 children were wasted and 39.3 % were stunted. When the samples were pooled into binary (affected and non-affected) categories, mean TDFI and mean DUFE were statistically significantly higher in the 77 wasted children (57.7 and 29.7 μg/kgbw/d, respectively) than the 12 non-wasted children (39.4 and 17.0 μg/kgbw/d, respectively). TDFI and DUFE were also statistically significantly higher in the 35 stunted children (65.1 and 34.5 μg/kgbw/d, respectively) than in the 54 non-stunted children (48.8 and 23.7 μg/kgbw/d, respectively). However, mean FUFE was similar in all groups. There were no statistically significant differences in fluoride concentration of either fingernails or toenails among the different categories of wasting, while mean fingernail fluoride concentration was statistically significantly higher in stunted (5.4 μg/g) than in non-stunted children (3.5 μg/g).

CONCLUSION

Our study found no significant effect of nutritional status on the proportion of ingested fluoride excreted in urine (and consequently the proportion retained in the body). These findings suggest that nutritional status may be less likely to be a main risk factor for the development of dental fluorosis than children's dietary habits or total fluoride intake.

Parenteral nutrition compatibility and stability: A comprehensive review

Several guidance documents support best practices across the stages of the parenteral nutrition (PN)-use process to optimize patient safety. The critical step of PN order verification and review by the pharmacist requires a contextual assessment of the compatibility and stability implications of the ordered PN prescription. This article will provide working definitions, describe PN component characteristics, and present a wide-ranging representation of compatibility and stability concerns that need to be considered prior to preparing a PN admixture. This paper has been approved by the ASPEN Board of Directors. This article is protected by copyright. All rights reserved.

Effect of altitude on urinary, plasma and nail fluoride levels in children and adults in Nepal

INTRODUCTION

A greater prevalence of dental fluorosis has been reported in higher- versus lower-altitude communities. This study, for the first time, examined several aspects of fluoride metabolism in children, aged 4-5 years, and their parent, living at lower altitude (<78 m) and higher altitude (>1487) areas in Nepal.

METHODS

The study assessed total daily fluoride intake (TDFI), 24 h urinary fluoride excretion (UFE), and fluoride concentrations of toe- and finger-nail (FC_toenail, FC_fingernail) in children and parents as well as fluoride concentration of plasma (FC_plasma) in parents. Fractional urinary fluoride excretion (FUFE) was calculated as the ratio between UFE and TDFI. FC_toenail, FC_fingernail and FC_plasma were normalised for TDFI by dividing the variables by TDFI and the ratio was reported as the percentage.

RESULTS

In total, 89 children and 80 parents took part in the study: 42 children and 41 parents from the lower altitude area; 47 children and 39 parents from the higher altitude area. Fluoride concentration of drinking water was significantly (P < 0.001) higher at lower altitude (0.395 mg F/l) than at higher altitude (0.104 mg F/l). TDFI was significantly (p < 0.001) higher in both children and parents living in lower altitude than those living at higher altitude. There was a statistically significant (p = 0.044) difference in the mean FUFE of children living at lower altitude (53%) and higher altitude (46%). However, no significant difference in FUFE was found between parents living at lower altitude (47%) compared with higher altitude (41%). In both children and parents, no statistically significant differences in normalised FC_toenail, FC_fingernail were found between the two altitude areas. However, normalised FC_plasma was statistically significantly (P = 0.005) higher in parents living at higher altitude (0.15%) compared with those living at lower altitude (0.11%).

CONCLUSION

The results suggest that higher altitude living results in decreased urinary fluoride excretion, and consequently increased fluoride retention in children for a given dose (amount) of fluoride.

Child Caries Management: A Randomized Controlled Trial in Dental Practice

This multicenter 3-arm, parallel-group, patient-randomized controlled trial compared clinical effectiveness of 3 treatment strategies over 3 y for managing dental caries in primary teeth in UK primary dental care. Participants aged 3 to 7 y with at least 1 primary molar with dentinal carious lesion were randomized across 3 arms (1:1:1 via centrally administered system with variable-length random permuted blocks): C+P, conventional carious lesion management (complete carious tooth tissue removal and restoration placement) with prevention; B+P, biological management (sealing in carious tooth tissue restoratively) with prevention; and PA, prevention alone (diet, plaque removal, fluorides, and fissure sealants). Parents, children, and dentists were not blind to allocated arm. Co–primary outcomes were 1) the proportion of participants with at least 1 episode of dental pain and/or infection and 2) the number of episodes of dental pain and/or infection during follow-up (minimum, 23 mo). In sum, 1,144 participants were randomized (C+P, n = 386; B+P, n = 381; PA, n = 377) by 72 general dental practitioners, of whom 1,058 (C+P, n = 352; B+P, n = 352; PA, n = 354) attended at least 1 study visit and were included in the primary analysis. The median follow-up was 33.8 mo (interquartile range, 23.8 to 36.7). Proportions of participants with at least 1 episode of dental pain and/or infection were as follows: C+P, 42%; B+P, 40%; PA, 45%. There was no evidence of a difference in incidence of dental pain and/or infection when B+P (adjusted risk difference [97.5% CI]: −2% [−10% to 6%]) or PA (4% [−4% to 12%]) was compared with C+P. The mean (SD) number of episodes of dental pain and/or infection were as follows: C+P, 0.62 (0.95); B+P, 0.58 (0.87); and PA, 0.72 (0.98). Superiority could not be concluded for number of episodes between B+P (adjusted incident rate ratio (97.5% CI): 0.95 [0.75 to 1.21]) or PA (1.18 [0.94 to 1.48]) and C+P. In conclusion, there was no evidence of a difference among the 3 treatment approaches for incidence or number of episodes of dental pain and/or infection experienced by these participants with high caries risk and established disease (trial registration: ISRCTN77044005).

Using Normalisation Process Theory to investigate the implementation of school-based oral health promotion

Despite the considerable improvement in oral health of children in the UK over the last forty years, a significant burden of dental caries remains prevalent in some groups of children, indicating the need for more effective oral health promotion intervention (OHPI) strategies in this population.

OBJECTIVE

To explore the implementation process of a community-based OHPI, in the North East of England, using Normalisation Process Theory (NPT) to provide insights on how effectiveness could be maximised.

METHODS

Utilising a generic qualitative research approach, 19 participants were recruited into the study. In-depth interviews were conducted with relevant National Health Service (NHS) staff and primary school teachers while focus group discussions were conducted with reception teachers and teaching assistants. Analyses were conducted using thematic analysis with emergent themes mapped onto NPT constructs.

RESULTS

Participants highlighted the benefits of OHPI and the need for evidence in practice. However, implementation of 'best evidence' was hampered by lack of adequate synthesis of evidence from available clinical studies on effectiveness of OHPI as these generally have insufficient information on the dynamics of implementation and how effectiveness obtained in clinical studies could be achieved in 'real life'. This impacted on the decision-making process, levels of commitment, collaboration among OHP teams, resource allocation and evaluation of OHPI.

CONCLUSIONS

A large gap exists between available research evidence and translation of evidence in OHPI in community settings. Effectiveness of OHPI requires not only an awareness of evidence of clinical effectiveness but also synthesised information about change mechanisms and implementation protocols.

Fluoride intake and urinary fluoride excretion in 4- and 8-year-old children living in urban and rural areas of Southwest Nigeria

OBJECTIVES

To estimate and compare total daily fluoride intake (TDFI), daily urinary fluoride excretion (DUFE), daily fluoride retention (DFR), fractional urinary fluoride excretion (FUFE) and fractional fluoride retention (FFR) in 4- and 8 year-old Nigerians and explore associations between these outcomes to improve understanding of fluoride metabolism.

METHODS

Using a cross-sectional observational study, 72 four-year-olds and 72 eight-year-olds were recruited from nursery and primary schools (respectively) in lower and higher water F areas of urban and rural localities in Oyo State, southwest Nigeria. TDFI from diet and toothpaste ingestion was assessed using a validated Food Frequency Questionnaire and visual scale of toothpaste used during toothbrushing. DUFE was measured by collecting a 24-hour urine sample, FUFE estimated as the ratio between DUFE and TDFI, DFR estimated as TDFI-TDFE (where TDFE = DUFE + estimated faecal F excretion (ie TDFI × 10%), and FFR was estimated as [(TDFI-DFR)/TDFI] × 100. Data were analysed using ANOVA with post hoc tests and Student's t tests and strengths of associations between key variables measured.

RESULTS

Mean (SD) TDFI, DUFE, DFR, FUFE and FFR were 0.137 (0.169) mg/kg bw/d, 0.032 (0.027) mg/kg bw/d, 0.091 (0.147) mg/kg bw/d, 44% (44%) and 46% (44%), respectively, for 4-year-olds. Corresponding values for 8-year-olds (n = 63) were 0.106 (0.130) mg/kg bw/d, 0.022 (0.017) mg/kg bw/d, 0.073 (0.107) mg/kg bw/d, 36% (30%) and 54% (30%), respectively. Dietary contribution to TDFI was 79% and 75% (respectively), for 4- and 8-year-olds. Mean (SD) TDFI from toothpaste ingestion was 0.021 (0.013) mg/kg bw/d in 4-year-olds, 0.014 (0.010) mg/kg bw/d in 8-year-olds (P = .002) but with no differences between areas. Differences in dietary F intake determined the main differences in F exposure between areas. The positive correlation between TDFI and DUFE was weak for 4-year-olds (r = +.29) and strong for 8-year-olds (r = +.64). A strong positive correlation was observed between TDFI and DFR for both age groups: (r) = +.98 for 4-year-olds and (r) = +.99 for 8-year-olds.

CONCLUSION

Fluoride intake in these 4- and 8-year-old Nigerians was much higher than the "optimal range" of 0.05-0.07 mg/kg bw/d in rural, higher F water areas, with diet as the main contributor. F retention was similar in both age groups, with almost half of TDFI retained in the body. In terms of risk vs benefit for fluorosis and dental caries, this finding should be considered when mitigating against excessive fluoride exposure and planning F-based prevention.

Group O low titre only emergency donor panels for small combat teams

INTRODUCTION

Military elements increasingly operate in small teams in remote areas with no immediate blood product support. Planners and operators may endorse collection of fresh whole blood from pretested donors in emergency situations. The biggest risk of transfusion is the accidental use of ABO incompatible blood which can be fatal. The risk may be mitigated by using only group O LOw (OLO) titre donors with plasma containing low levels of the naturally occurring antibody to group A and B red cells. This paper reviews the ABO blood group distribution in potential blood donors from a high readiness UK medical regiment and explores the feasibility of using only group OLO donors in small teams.

METHODS

A retrospective review of routine volunteer blood donor samples was undertaken at 6 monthly intervals during a 2-year period. Personnel were tested in groups when available during training to create multiple donor panels to simulate small teams.

RESULTS

206 donation samples were collected from 157 potential donors. All donors were acceptable based on the lifestyle questionnaire, serology and microbiology screen. Of the 206 samples reviewed, 85 (41%) were group O (D pos and D neg). 14 group O (16.5%) were shown to have high titre of anti-A or B. Therefore, 71, that is, 34% overall were suitable as OLO donors. The donor panel size varied from 15 to 44. The absolute number of OLO donors in each panel ranged from 4 to 17 and the number of O neg donors was 0-3.

CONCLUSION

A third of samples were suitable as OLO donors; however, there were insufficient 'universal' donors within smaller subgroups (<10). In this situation, we recommend the careful use of both group O and group A donors or the use of a buddy-buddy blood group matrix.

Determining an Upper Reference Value for the Urinary Fluoride-Creatinine Ratio in Healthy Children Younger than 7 Years

The urinary fluoride/creatinine ratio (UF/Cr) in a spot urine sample could be a useful systemic F exposure monitoring tool. No reference value for UF/Cr currently exists, therefore this study aimed to establish an upper reference value for a UF/Cr, corresponding to excessive systemic F exposure, i.e., >0.07 mg F/kg body weight (b.w.)/day, in children. Subsidiary aims were to examine the relationship between (i) total daily F intake (TDFI) and 24-h urinary F excretion (DUFE); (ii) DUFE and UF/Cr, and (iii) TDFI and UF/Cr. Simultaneously collected TDFI, DUFE, and urinary creatinine (UCr) data in children <7 years were taken from UK studies conducted from 2002 to 2014 in order to calculate UF/Cr (mg/g) for each child. For the 158 children (mean age 5.8 years) included in the data analysis, mean TDFI and DUFE were 0.049 (SD 0.033) and 0.016 (SD 0.008) mg/kg b.w./day, respectively, and the mean UF/Cr was 1.21 (SD 0.61) mg/g. Significant (p < 0.001) positive linear correlations were found between TDFI and DUFE, DUFE and UF/Cr, and TDFI and UF/Cr. The estimated upper reference value for UF/Cr was 1.69 mg/g; this was significantly (p = 0.019) higher than the UF/Cr (1.29) associated with optimal F exposure (0.05-0.07 mg/kg b.w./day). In conclusion, the strong positive correlation between TDFI and UF/Cr confirms the strong association of these 2 F exposure variables and the value of a spot urine sample for prediction of TDFI (i.e., the most important risk factor in determining fluorosis occurrence and severity) in young children. Establishing an estimation of an upper reference value of 1.69 mg/g for UF/Cr in spot urine samples could simplify and facilitate their use as a valuable tool in large epidemiological studies.

The use of adjunctive antipsychotics to treat depression in UK primary care

OBJECTIVE

Adjunctive antipsychotic therapy can be prescribed to patients with depression who have inadequate response to antidepressants. This study aimed to describe the use of adjunctive antipsychotics over a time period that includes the authorization in 2010 of prolonged-release quetiapine as the first adjunct antipsychotic to be used in major depressive disorder in the UK.

RESEARCH DESIGN AND METHODS

Adults with an episode of depression between January 1, 2005 and July 31, 2013 were identified from antidepressant prescriptions and depression diagnoses in the UK Clinical Practice Research Datalink. Patients with prior records of bipolar disorder, schizophrenia, or antipsychotic prescriptions were excluded.

MAIN OUTCOME MEASURES

Rates of adjunct antipsychotic initiation and characteristics and management of patients with adjunct antipsychotics.

RESULTS

Of 224,353 adults with depression, 5,807 (2.6%) initiated adjunct antipsychotic therapy. Overall incidence of antipsychotic initiation was 7.4 per 1,000 patient-years (95% CI = 7.2-7.6). Between 2005-2013, the overall rate did not change, although initiation of typical antipsychotic prescribing decreased (57.7% to 29.1%), while atypical antipsychotics, especially quetiapine (14.1% to 49.7%), increased. Of those who initiated antipsychotics, 59.4% were women (typical antipsychotics = 62.8%, atypical antipsychotics = 56.1%) and median age was 46 years (typicals = 49 years, atypicals = 44 years).

CONCLUSIONS

Antipsychotics were rarely used to treat depression between 2005-2013 in UK primary care. The choice of adjunctive antipsychotic therapy changed over this time, with atypical antipsychotics now representing the preferred treatment choice. However, information on patients strictly cared for in other settings, such as by psychiatrists or in hospitals, potentially more severe patients, was unavailable and may differ. Nonetheless, the high off-label use in primary care, even after the authorization of quetiapine, suggests that there is a need for more licensed treatment options for adjunctive antipsychotic therapy in major depressive disorder.

Are Volunteering and Caregiving Associated with Suicide Risk? A Census-based Longitudinal Study

Background

This record linkage study explores the suicide risk of people engaged in caregiving and volunteering. Theory suggests opposing risks as volunteering is associated with better mental health and caregiving with a higher prevalence and incidence of depression.

Methods

A 2011 census-based study of 1,018,000 people aged 25–74 years (130,816 caregivers and 110,467 volunteers; 42,099 engaged in both). All attributes were based on census records. Caregiving was categorised as either light (1–19 hours/week) or more intense (20+ hours/week). Suicide risk was based on 45 months of death records and assessed using Cox proportional hazards models with adjustment for and stratification by mental health status at census.

Results

More intense caregiving was associated with worse mental health (ORadj = 1.15: 95%CI = 1.12, 1.18); volunteering with better mental health (OR 0.87; 95%CIs 0.84, 0.89). The cohort experienced 528 suicides during follow-up. Both volunteering and caregiving were associated with a lower risk of suicide though this was modified by baseline mental ill-health (P = 0.003), HR 0.66; 95%CIs 0.49, 0.88 for those engaged in either activity and with good mental health at baseline and HR 1.02; 95%CIs 0.69, 1.51 for their peers with poor mental health. There was some indication that those engaged in both activities had the lowest suicide risk (HR 0.34; 95%CIs 0.14, 0.84).

Conclusions

Despite the poorer mental health amongst caregivers they are not at increased risk of suicide. The significant overlap between caregiving and volunteering and the lower risk of suicide for those engaged in both activities may indicate a synergism of action.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Abstract P1-05-18: Genomic copy number alterations (CNA) associated with pCR in HER2-positive (HER2+) early-stage breast cancer (BrCa) patients receiving neoadjuvant trastuzumab (T)

Introduction: Genetic alterations such as amplifications and deletions frequently contribute to tumorigenesis. These alterations can change gene expression which alters the normal cell growth and survival regulatory mechanisms. Characterisation of DNA copy number alterations (CNA) is important to understand cancer progression and response to therapy. The aim of this study is to determine patterns of CNAs in HER2+ early-stage BrCa patients achieving pathological complete response (pCR) to neoadjuvant T therapy.

Methods: Retrospective analysis of our database of 95 HER2+ BrCa (stages I-III) who received T neoadjuvantly revealed 46 % (44/95) achieved pCR compared with 53 % (51/95) who did not respond (NR). DNA from pre-treatment tumour biopsy specimens from neoadjuvant T therapy patients was extracted, and array-based comparative genomic hybridization (aCGH, n = 8; 6 pCR:2 NR) was used to identify CNAs, which correlated with pCR. Pathway analysis was then used to identify functionally relevant genes in aberrant regions.

Results: aCGH analysis of DNA from pCR and NR identified distinct patterns of CNAs. HER2 amplicon was confirmed by IHC and aCGH in all samples. Although there was no significant difference in the average CNAs between groups (20±17 vs 17±2), there was greater variation in the range of CNAs in pCR (8-56 CNA) compared to NR (15-19 CNA). More gains and amplifications were observed in pCR patients with more deletions in the NR group. The most common chromosomal amplification region included chr8q12.1-q24 with 87.5% of all cases displaying gains. Of the 6 patients who achieved pCR, 50% displayed a deletion in chr9 spanning p24.3-p21.3, consistent with a deletion of tumour suppressor CDKN2A. No aberrations in chr9 were observed in NR cohort. The deleted genomic region contained 65 common protein-coding genes, with the interferon biological pathway as the most significant (p=1.03E-36).

Conclusions: Distinct genomic CNAs were observed between patients achieving pCR compared to NR. However, of the 8 pts characterised here, none have relapsed. Follow-up data revealed a relapse rate of 6.8 % (3/44) vs 11.8 % (6/51) in the pCR and NR groups, respectively. To further elucidate the immunological response, we will present CNA data patterns on relapse and response and compare the impact of CNAs, immune-related proteins and pCR as surrogate predictors for outcome.

Citation Format: Walsh N, Gullo G, Maguire A, O'Donovan N, Quinn C, Crown J. Genomic copy number alterations (CNA) associated with pCR in HER2-positive (HER2+) early-stage breast cancer (BrCa) patients receiving neoadjuvant trastuzumab (T) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-05-18.

Bioavailability of Fluoride in Drinking Water: a Human Experimental Study

It has been suggested that systemic fluoride absorption from drinking water may be influenced by the type of fluoride compound in the water and by water hardness. Using a human double-blind cross-over trial, we conducted this study to measure cmax, Tmax, and Area Under the Curve (AUC) for plasma F concentration against time, following the ingestion of naturally fluoridated hard and soft waters, artificially fluoridated hard and soft waters, and a reference water. Mean AUC over 0 to 8 hours was 1330, 1440, 1679, 1566, and 1328 ng F•min•mL−1 for naturally fluoridated soft, naturally fluoridated hard, artificially fluoridated soft, artificially fluoridated hard, and reference waters, respectively, with no statistically significant differences among waters for AUC, cmax, or Tmax. Any differences in fluoride bioavailability between drinking waters in which fluoride is present naturally or added artificially, or the waters are hard or soft, were small compared with large within- and between-subject variations in F absorption. Abbreviations used: F, fluoride; AUC, Area under the Curve for plasma F concentration against time; AUC(0-3), Area under the Curve for plasma F concentration against time for 0 to 3 hours following water ingestion; AUC(0-8), Area under the Curve for plasma F concentration against time for 0 to 8 hours following water ingestion; cmax, maximum plasma F concentration corrected for baseline plasma F and dose ( i.e., F concentration of individual waters); Tmax, time of cmax.

Spatial variation of the colonic microbiota in patients with ulcerative colitis and control volunteers

OBJECTIVES

The relevance of spatial composition in the microbial changes associated with UC is unclear. We coupled luminal brush samples, mucosal biopsies and laser capture microdissection with deep sequencing of the gut microbiota to develop an integrated spatial assessment of the microbial community in controls and UC.

DESIGN

A total of 98 samples were sequenced to a mean depth of 31,642 reads from nine individuals, four control volunteers undergoing routine colonoscopy and five patients undergoing surgical colectomy for medically-refractory UC. Samples were retrieved at four colorectal locations, incorporating the luminal microbiota, mucus gel layer and whole mucosal biopsies.

RESULTS

Interpersonal variability accounted for approximately half of the total variance. Surprisingly, within individuals, asymmetric Eigenvector map analysis demonstrated differentiation between the luminal and mucus gel microbiota, in both controls and UC, with no differentiation between colorectal regions. At a taxonomic level, differentiation was evident between both cohorts, as well as between the luminal and mucosal compartments, with a small group of taxa uniquely discriminating the luminal and mucosal microbiota in colitis. There was no correlation between regional inflammation and a breakdown in this spatial differentiation or bacterial diversity.

CONCLUSIONS

Our study demonstrates a conserved spatial structure to the colonic microbiota, differentiating the luminal and mucosal communities, within the context of marked interpersonal variability. While elements of this structure overlap between UC and control volunteers, there are differences between the two groups, both in terms of the overall taxonomic composition and how spatial structure is ascribable to distinct taxa.

Does conurbation affect the risk of poor mental health? A population based record linkage study

To determine if urban residence is associated with an increased risk of anxiety/depression independent of psychosocial stressors, concentrated disadvantage or selective migration between urban and rural areas, this population wide record-linkage study utilised data on receipt of prescription medication linked to area level indicators of conurbation and disadvantage. An urban/rural gradient in anxiolytic and antidepressant use was evident that was independent of variation in population composition. This gradient was most pronounced amongst disadvantaged areas. Migration into increasingly urban areas increased the likelihood of medication. These results suggest increasing conurbation is deleterious to mental health, especially amongst residents of deprived areas.

Fractional Urinary Fluoride Excretion (FUFE) of 3-4 year children in the Gaza Strip

A positive association between dental fluorosis prevalence and fluoride (F) concentration in drinking waters has been detected in Gaza Strip. Total Daily Fluoride Retention (TDFR), and Fractional Urinary Fluoride Excretion (FUFE) indicate F body burden; important in assessing fluorosis risk in susceptible age groups.

OBJECTIVE

1, To determine and compare Daily Urinary Fluoride Excretion (DUFE) and FUFE of 3-4-year-olds living in lower (< 0.7), moderate (0.7-1.2) or higher (> 1.2 ) ppm F tap water areas; 2, To determine any relationship between i, DUFE and tap water F; ii, DUFE and Total Daily Fluoride Intake (TDFI); iii, TDFI and TDFR.

METHODS

24-hour urine and tap water samples were collected from 216 children exposed to lower (n = 81), moderate (n = 72), or higher (n = 63) tap water F. ANOVA with Tukey's Test and Pearson's correlation were used to examine differences in mean DUFE and FUFE and relationships between variables.

RESULTS

Mean drinking water F was 0.11(sd 0.17), 0.14 (sd 0.28) and 0.38 (sd 0.63) ppmF respectively. Differences (p < 0.0001) in mean DUFEs (0.17 (sd 0.13), 0.25 (sd 0.15) and 0.38 (sd 0.23) mg/day respectively) and mean FUFEs (48 (sd 39)%, 47 (sd 31)% and 63(sd 76)%) were found (p < 0.05). Significant (p < 0.0001) positive correlations were found between DUFE and tap water F; DUFE and TDFI, and; TDFI and TDFR.

CONCLUSION

DUFEs of children drinking waters with 0.11 and 0.14ppm F, represented low F usage. The group drinking 0.38ppm F water represented optimal F usage. The weak significant positive association of DUFE with home tap water F suggests low validity for tap water F in estimating F exposure.

Cellular discrimination using in vitro Raman micro spectroscopy: the role of the nucleolus

Raman micro spectroscopy is employed to discriminate between cell lines. Results show the importance of the nuclear sub-cellular organelle, the nucleoli, to differentiate between cancer cell lines with high specificity and sensitivity.

Competitive evaluation of data mining algorithms for use in classification of leukocyte subtypes with Raman microspectroscopy

In this study Raman spectral data from peripheral blood mononuclear cells (PBMCs) is used for the competitive evaluation of three data-mining models in discriminating a highly pure population of T-cell lymphocytes from other myeloid cells within the PBMCs fraction.

Correlations between colonic crypt mucin chemotype, inflammatory grade and Desulfovibrio species in ulcerative colitis

AIM

The colonic mucus gel layer is composed of mucins that may be sulphated or sialyated. Sulphated mucins predominate in health while in ulcerative colitis (UC) sulphation is reduced. These differences result directly from inflammatory events. It may also be hypothesized that they arise in part from alterations in the colonic microbiota, particularly changes in the burden of sulphated mucin-metabolizing species, such as Desulfovibrio (DSV) bacteria. The aim of this study was to correlate colonic mucin chemotypes and inflammatory scores in health and UC and relate these changes to changes in the colonization of colonic crypts by DSV.

METHOD

Paired colonic biopsies from 34 healthy controls (HC) and 19 patients with active UC were collected for the purpose of parallel histological and microbiological assessment. High-iron diamine and Alcian blue staining and haematoxylin and eosin of mucosal biopsy specimens were used to assess histological changes within the clinical spectrum of UC. Quantitative real-time polymerase chain reaction analysis was employed to determine the total and DSV copy number within the colonic crypts.

RESULTS

Compared with HC, the mucin chemotype in UC was less sulphated and inversely correlated with the degree of mucosal inflammation. A weak but significant negative correlation was found between the abundance of sulphated mucins and DSV burden.

CONCLUSION

Mucin composition strongly correlates with the degree of mucosal inflammation, and to a lesser extent with DSV burden. These data suggest that mucin chemotype and DSV burden are linked phenomena and highlight the need to consider changes in mucin chemotype in the setting of microbial dysbiosis occurring within the colitic colon. What does this paper add to the literature? Decreased sulphation of mucins has been associated with inflammation in ulcerative colitis. Currently there are few data describing the relationship between microbial species and changes in mucin chemotype. This study validates previous findings and presents evidence of changes in mucin chemotype occurring in tandem with coherent changes in the microbiota within crypt niches.

Rates and risk of hospitalisation among patients with type 2 diabetes: retrospective cohort study using the UK General Practice Research Database linked to English Hospital Episode Statistics

AIMS

To investigate the rates and risk of hospitalisations in patients with type 2 diabetes (T2D) mellitus in England.

METHODS

This retrospective population-based cohort study used computerised records from the General Practice Research Database linked to Hospital Episode Statistics data in England. Patients with T2D from January 2006 to December 2010 were selected. Primary outcome measures were all-cause, non-diabetes-related, diabetes-related and hypoglycaemia-related hospitalisations. Factors associated with all-cause and diabetes-related hospitalisations were investigated with Cox's proportional hazards models.

RESULTS

Amongst 97,689 patients with T2D, approximately 60% had at least one hospitalisation during the 4-year study period. Rates of hospitalisation were as follows: all-cause, 33.9 per 100 patient-years (pt-yrs); non-diabetes-related, 29.1 per 100 pt-yrs; diabetes-related, 18.8 per 100 pt-yrs and hypoglycaemia, 0.3 per 100 pt-yrs. The risk of all-cause hospitalisation increased with hospitalisation in the previous year, insulin use and the presence of major comorbidities. The risk of a diabetes-related hospitalisation increased with age, female gender, insulin use, chronic renal insufficiency, hypoglycaemia (as diagnosed by a general practitioner) and diabetes-related hospitalisation in the previous year.

CONCLUSIONS

Patients with T2D are hospitalised at a considerably high rate for causes directly related with diabetes complications and stay longer in hospital. History of hospitalisation and complications of diabetes were found to be predictive of inpatient hospitalisations suggesting previous hospitalisation episodes could serve as points of intervention. This study highlights important areas for healthcare intervention and provides a reminder for vigilance when risk factors for hospitalisation in patients with T2D are present.

Abstract P2-18-05: Axillary nodal burden in patients with a positive pre-operative ultrasound guided fine needle aspiration cytology

Introduction

Recent years have seen a dramatic shift to more conservative management of the axilla and the presence of a positive sentinel lymph node biopsy does not now automatically mandate an axillary clearance. This is based largely on data from the American College of Surgeons Oncology Group (ACOSOG) Z11 study, which failed to demonstrate a difference in local recurrence or overall survival when an axillary clearance was omitted in a highly selective group of patients with a positive sentinel lymph node. However, the presence of a positive pre-operative ultrasound guided axillary FNAC(Fine Needle Aspiration Cytology) may be representative of a higher burden of axillary disease.

Aim

Therefore, the aims of this study were firstly to quantify the actual nodal burden in breast cancer patients with a positive pre-operative ultrasound guided axillary FNAC and secondly to identify the number of patients who may have been spared an axillary clearance based on Z11 eligibility criteria.

Methods

A retrospective review of a prospectively maintained database within a tertiary breast cancer referral centre was performed. All patients with a positive pre-operative axillary FNAC were identified within a five year period (2007 – 2011). Demographic, tumour and biological characteristics and final nodal status were analysed. Eligibility for randomisation according to the Z11 criteria was assessed based on the final pathology and the number of patients who could have been spared an axillary clearance was identified.

Results

A total of 360 patients were identified with a positive axillary ultrasound guided FNAC. Sixty-three patients had no axillary surgery and three patients had recurrent disease, leaving a total of 294 for analysis. The mean age was 56 years (range 22 – 87). The mean size of the tumour was 31.3mm (range 4mm – 132mm) and the majority were an invasive grade 3 (57%) ductal carcinoma (84%). Luminal A (63%) was the commonest sub-type. The mean number of nodes removed at axillary clearance was 24 (range 7 – 58) while the mean number of positive nodes excised was 6 (range 0 – 47). Of these, the mean number of level I positive nodes was 4, level II was 1 and level III nodes was &lt;1.

Overall a total of 78 patients had less than three positive nodes identified in the axilla and potentially may have been eligible for the Z11 study. However, when patients who had a mastectomy, neo-adjuvant chemotherapy were excluded and the presence of extra-capsular nodal involvement was accounted for only 19 (6.4%) patients may have been spared an axillary clearance.

Conclusions

The presence of nodal positivity on a pre-operative FNAC is associated with a higher burden of axillary disease. Only a minority of these patients would be able to avoid an axillary clearance in the setting of the recent Z11 study. Performing an axillary ultrasound and FNAC of suspicious nodes allows patients to avoid an unnecessary sentinel lymph node biopsy and proceed directly to an axillary clearance.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-18-05.

Total fluoride intake and excretion in children up to 4 years of age living in fluoridated and non-fluoridated areas

Fractional fluoride retention is important during the early years of life when considering the risk of development of dental fluorosis. This study aimed to measure fractional fluoride retention in young children. The objectives were to investigate the relationships between fractional fluoride retention and total daily fluoride intake, age, and body mass index (BMI). Twenty-nine healthy children, up to 4 yr of age, participated; 14 lived in a fluoridated area (0.64 μg ml(-1) of fluoride in drinking water) and 15 lived in a non-fluoridated area (0.04 μg ml(-1) of fluoride in drinking water). The total daily fluoride intake of each child was calculated from the daily dietary fluoride intake and toothpaste ingestion (if fluoride toothpaste was used). Total daily fluoride excretion was measured by collecting voided urine and faeces over a 24-h period, and fractional fluoride retention was calculated by dividing the amount of fluoride retained in the body (total daily fluoride intake minus total daily fluoride excretion) by the total daily fluoride intake. Nine children were excluded from data analysis because of suspected invalid samples. Mean (range) fractional fluoride retention for the remaining 20 children was 0.61 (0.06-0.98). There were no statistically significant correlations between fractional fluoride retention and either age or BMI. However, fractional fluoride retention was correlated with total daily fluoride intake: fractional fluoride retention = 1 - exp (-C × total daily fluoride intake), where C = 28.75 (95% CI = 19.75-37.75). The wide variation in fluoride retention in young children could have important implications when recommendations for fluoride use are being considered.

Urinary fluoride excretion in 6- to 7-year-olds ingesting milk containing 0.5 or 0.9 mg fluoride

Effectiveness of 0.5 mg fluoride (F) milk ingestion in preventing caries has been termed only 'moderate'. In this 3-arm partial cross-over intervention, 32 children aged 6-7 years in a non-F area were recruited and urinary F excretion (UFE) measured before and after ingestion of 0.5 or 0.9 mg F milk. Maintaining customary dietary and oral hygiene habits, children underwent a 2-week 'wash-in' with non-F milk, providing a 24-hour urine sample on day 4 of non-F (baseline) and F milk ingestion containing either (i) 0.5 mg or (ii) 0.9 mg F (intervention). A comparative group of thirteen 6- to 7-year-olds living in fluoridated areas provided a 24-hour urine sample on day 4 of daily non-F milk ingestion, following a 2-week non-F milk wash-in. Valid urine samples were analysed for F and UFE estimated from corrected 24-hour urine volume and F concentration. For the 24 test children providing 2 valid urine samples, mean (95% CI) change in corrected 24-hour UFE was 0.130 (0.049, 0.211) and 0.153 (0.062, 0.245) mg/day for 0.5 mg (p < 0.007) and 0.9 mg F (p < 0.001) groups, respectively. Post-intervention, mean (SD) corrected 24-hour UFE was 0.437 (0.153) mg/day and 0.420 (0.188) mg/day for the 0.5 and 0.9 mg F groups, respectively, which were lower than the WHO provisional standards (0.48-0.60 mg F/day). F milk consumption significantly increased UFE; however, the F content of 0.5 and 0.9 mg F milk may be too low to achieve WHO provisional UFE standards concomitant with optimal F exposure in children aged ≥6 years.

Dental erosion among 12 year-old Libyan schoolchildren

OBJECTIVE

As there are limited data on dental erosion in Libya, the aim of this study was to assess the prevalence and severity of dental erosion in a sample of 12 year-old children in Benghazi, Libya.

BASIC RESEARCH DESIGN

Cross-sectional observational study.

CLINICAL SETTING

Elementary schools in Benghazi, Libya.

PARTICIPANTS

A random sample of 791 12 year-old children (397 boys and 394 girls) attending 36 schools.

METHODS

Clinical dental examination for erosion using UK National Diet and Nutrition Survey (2000) criteria and self-completion questionnaire.

MAIN OUTCOME MEASURES

The area and depth of dental erosion affecting the labial and palatal surfaces of the upper permanent incisors and occlusal surfaces of the first permanent molars.

RESULTS

Dental erosion was observed in 40.8% of subjects; into enamel affecting 32.5%, into dentine affecting 8.0% and into pulp affecting 0.3% of subjects. Based on area affected, 323 subjects (40.8%) exhibited dental erosion (code > 0), with 32.6% of these subjects having erosion affecting more than two thirds of one or more surfaces examined. Mean total scores for dental erosion for all surfaces per mouth by area and by depth were both 2.69 (sd 3.81). Of the 9492 tooth surfaces examined, 2128 surfaces (22.4%) had dental erosion. Girls had more experience of erosion than boys at all levels of severity (p = 0.001).

CONCLUSIONS

In a cohort of 12 year-old Libyan schoolchildren, more than one third of children examined showed dental erosion, requiring clinical preventive counselling. Significantly more erosion occurred in girls than boys.

A retrospective database study of insulin initiation in patients with Type 2 diabetes in UK primary care

AIMS

This study characterized UK primary care patients with Type 2 diabetes who initiated insulin treatment, and described the initial insulin regimens used, overall metabolic changes and health-care resource usage.

METHODS

A retrospective cohort study was performed using quality-checked patient data from The Health Improvement Network database. Eligible patients who initiated insulin for the first time between 2004 and 2006 were grouped into four cohorts according to the type of insulin regimen initiated. Data on patient characteristics, metabolic and clinical outcomes and health-care resource use were collected at baseline and during 6 months of follow-up.

RESULTS

In total, 4045 eligible adults [2269 male, 1776 female; mean age 62.6 ± 13.3 years; mean baseline HbA(1c) 82 ± 22 mmol/mol (9.6% ± 2.0%)] initiated insulin. Approximately half (52.4%) initiated insulin as basal insulin only, 41.6% as premixed only, 4.0% as basal-bolus and 2.1% as prandial insulin only. Among patients with ≥ 180 days follow-up (n=3815), the initial insulin regimen was not changed during follow-up in 75.1% of patients, while 13.7% discontinued, 7.0% switched and 4.7% intensified insulin therapy. The mean change in HbA(1c) was -14 mmol/mol (-1.3%, n=2881), with 17.3% of patients achieving an HbA(1c) of <53 mmol/mol (7%, n=3024). The mean weight change was +0.9 kg (n=2345).

CONCLUSIONS

Basal and premixed insulin were the most common types of insulin initiated and in most patients no changes were made to the initial regimen over 6 months. However, few patients achieved glycemic control targets.

Compliance with school F-milk and non-F milk intake in 3 to 4 and 6 to 7-year-old children

BACKGROUND

Fluoridated (F) milk schemes are employed in six countries to reduce dental caries in children. To maximise their benefits considerable uptake is required. Measuring compliance and understanding contributing factors is important in evaluating the effectiveness of schemes since it can be unclear whether reported sub-optimal fluoride (F) intakes, measured through urinary F excretion, are due to sub-optimal F contents of milks or lack of compliance with consumption.

OBJECTIVES

To determine compliance with milk consumption for children receiving non-F or F milk (containing 0.5 or 0.9 mgF per 189 ml carton) and rationalise the use of compliance data for clinical observational or intervention studies involving F milk schemes.

RESEARCH DESIGN

Partially randomised, partial cross-over study.

PARTICIPANTS

50 children aged 3-4 and 6-7y consuming non-F (n=50) and F milk (0.5 mgF; n=15 children; 0.9mg F; n=16 children) at school.

RESULTS

Mean compliance for both non-F and F milk was > or =90% in each of the groups studied and showed no statistically significant difference for children using both milks. The 95% central range of proportions of milk consumed for groups of individuals was wider for 0.9mgF milk (25% to 100%) than for 0.5 mgF milk (81% to 100%) although the greatest range of variation in compliance for within individual observations was seen for non-F milk consumption and in older children.

CONCLUSION

Assessment of compliance with consumption should be included when dental efficacy of F milk consumption is being investigated or evaluated to quantify F exposure from milk. This is important, particularly if a change in the F dose of F milk might be under consideration.