Acute Dysphagia Following Reperfusion Therapies: A Prospective Pilot Cohort Study

Dysphagia is a well-documented sequela of stroke. Recent advancements in medical treatments for stroke include reperfusion therapies (endovascular thrombectomy (EVT) and thrombolysis). As outcomes following reperfusion therapies are typically measured via general functional scales, the pattern and progression of acute dysphagia following reperfusion therapies is less known. To determine the progression of acute dysphagia (0-72 h) following reperfusion therapies and relationships between various stroke parameters and dysphagia, twenty-six patients were prospectively recruited across two EVT and thrombolysis centres in Brisbane, Australia. Dysphagia was screened via the Gugging Swallowing Screen (GUSS) at the bedside at three timepoints: 0-24 h, 24-48 h, and 48-72 h post-reperfusion therapies. Across three groups (EVT only, thrombolysis only, or both), the incidence of any dysphagia within the first 24 h of reperfusion therapy was 92.31% (n = 24/26), 91.30% (n = 21/23) by 48 h, and 90.91% (n = 20/22) by 72 h. Fifteen patients presented with severe dysphagia at 0-24 h, 10 at 24-48 h, and 10 at 48-72 h. Whilst dysphagia was not significantly correlated to infarct penumbra/core size, dysphagia severity was significantly related to the number of passes required during EVT (p = 0.009).Dysphagia continues to persist in the acute stroke population despite recent advancements in technology aimed to reduce morbidity and mortality post-stroke. Further research is required to establish protocols for management of dysphagia post-reperfusion therapies.

Oral biofilm dysbiosis during experimental periodontitis

OBJECTIVES

We have previously characterized the main osteoimmunological events that occur during ligature periodontitis. This study aims to determine the polymicrobial community shifts that occur during disease development.

METHODS

Periodontitis was induced in C57BL/6 mice using the ligature-induced periodontitis model. Healthy oral mucosa swabs and ligatures were collected every 3 days from 0 to 18 days post-ligature placement. Biofilm samples were evaluated by 16SrRNA gene sequencing (Illumina MiSeq) and QIIME. Time-course changes were determined by relative abundance, diversity, and rank analyses (PERMANOVA, Bonferroni-adjusted).

RESULTS

Microbial differences between health and periodontal inflammation were observed at all phylogenic levels. An evident microbial community shift occurred in 25 genera during the advancement of "gingivitis" (3-6 days) to periodontitis (9-18 days). From day 0 to 18, dramatic changes were identified in Streptococcus levels, with an overall decrease (54.04%-0.02%) as well an overall increase of Enterococcus and Lactobacillus (23.7%-73.1% and 10.1%-70.2%, respectively). Alpha-diversity decreased to its lowest at 3 days, followed by an increase in diversity as disease advancement. Beta-diversity increased after ligature placement, indicating that bone loss develops in response to a greater microbial variability (p = 0.001). Levels of facultative and strict anaerobic bacteria augmented over the course of disease progression, with a total of eight species significantly different during the 18-day period.

CONCLUSION

The data supports that murine gingival inflammation and alveolar bone loss develop in response to microbiome shifts. Bacterial diversity increased during progression to bone loss. These findings further support the utilization of the periodontitis ligature model for microbial shift analysis under different experimental conditions.

12 VACCINATION UP-TAKE IN DERMATOLOGY PATIENTS OVER THE AGE OF 65 YEARS ON BIOLOGICAL TREATMENT

Background

Biologic and immunosuppressive therapies play important roles in the management of a wide variety of dermatologic diseases. However, immunotherapies can negatively affect normal immune functioning, placing these patients at high risk of infection. The strength of the immune system also declines with increasing age. Thus, in accordance with the British Association of Dermatology guidelines (August 2021), patients taking biologic therapy can and should have their covid, influenza and pneumococcal vaccinations.

Methods

We conducted a retrospective audit of all patients over the age of 65 years on biological therapy in the dermatology clinic between March 2021 to March 2022. Data on patients covid, influenza and pneumococcal vaccination status was obtained from Dermatology database and patients medical records.

Results

A total of 18 patients over the age of 65 years, were on biological therapy in the Dermatology Department, between March 2021 to March 2022. The mean age was found to be 71 years with a standard deviation of 5.2 and there was equal gender distribution. 94% (n=17) of patients had psoriasis and 6% (n=1) had eczema. With regards to biological treatments, 17% (n=3) of patients were on Adalimumab,11% (n=2) on Etanercept and 28% (n=5) on Cosntyx. 100% (n=18) had all three of their covid-19 vaccines. 50% (n=8) are awaiting their 4th covid vaccination. 94% (n=17) of patients had their influenza vaccine. 66% (n=12) had their pneumococcal vaccination, the patients who had not had their pneumococcal vaccination were recommended and advised to have it.

Conclusion

This audit confirms dermatology patients over the age of sixty-five years, are compliant on receiving their covid vaccinations, as recommended by the BAD. However, only 66% of patients had their pneumococcal vaccination and 94% had their influenza vaccine, illustrating the need for educational intervention on the importance of vaccination. This will then be followed by a reaudit next year to complete the audit cycle.

Feasibility of a Telerehabilitation Adaptation of the Be Clear Speech Treatment Program for Non-Progressive Dysarthria

This study evaluated the feasibility and outcomes of a telerehabilitation adaptation of the Be Clear speech treatment program for adults with non-progressive dysarthria to determine clinical delivery viability and future research directions. Treatment effects on speech clarity, intelligibility, communication effectiveness, and participation, as well as psychosocial outcomes in 15 participants with non-progressive dysarthria, were explored. Intervention involved daily 1-h online sessions (4 days per week for 4 weeks, totalling 16 sessions) and daily home practice. Outcome measures were obtained at baseline (PRE), post-treatment (POST), and 12 weeks following treatment (FUP). Feasibility measures targeting participant satisfaction, treatment adherence and fidelity, and technical viability were also employed. The programme was feasible concerning technical viability and implementation, treatment adherence and fidelity. High levels of participant satisfaction were reported. Increases in overall ratings of communication participation and effectiveness were identified at POST and FUP. Reductions in speech rate were identified at FUP. Improvements in aspects of lingual and laryngeal function were also noted after treatment. Over time, improvements relating to the negative impact of dysarthria were identified. Naïve listeners perceived negligible changes in speech clarity following treatment. Online delivery of the Be Clear speech treatment program was feasible, and some positive speech benefits were observed. Due to the small sample size included in this research, statistically significant findings related to speech outcomes must be interpreted with caution. An adequately powered randomised controlled trial of Be Clear online is warranted to evaluate treatment efficacy.

59 IMPROVED OUTCOMES WITH DELAYED ADMISSION TO POST-ACUTE CARE: RESULTS OF A NATURAL EXPERIMENT

Background

In Ireland, the national Health Service Executive developed a post-acute care (PAC) scheme in 2016 to provide funds to acute hospitals for beds in nursing homes to allow discharge of patients who would benefit from a period of recovery in a nursing home before returning home when medically fit for discharge with no need for rehabilitation or long-term care (LTC). However, budgetary restrictions introduced from June 2019 resulted in a delay in access to funding. This change in funding was used as a natural experiment of the effectiveness of this scheme in a single large general hospital before and after delays due to funding restrictions.

Methods

Data regarding PAC admissions for those aged 65 years or more from July to October 2017, when there were no budgetary restrictions, and from July to October 2019, when funding was delayed, were compared. Chi-square tests were used to compare proportions, and the nonparametric Mann–Whitney U test was used to compare continuous data.

Results

Compared with the 2017 cohort, those in 2019 spent 6 days longer in the acute hospital following a delay in 2019 between being approved clinically as needing PAC and subsequent admission to a facility. However, readmissions to hospital within 90 days of discharge and directly from PAC were significantly higher in 2017, as was discharge from PAC directly to LTC.

Conclusion

This retrospective study demonstrates restrictive practices regarding discharge to PAC introduced for budgetary reasons caused longer acute bed LOS with reduced LOS in PAC, reduced hospital RAR and reduced admissions to LTC suggesting that a pre-existing liberal selection process may result in poorer identification of appropriate patients for PAC.

Adaptations to a Secondary School-Based Citizen Science Project to Engage Students in Monitoring Well Water for Arsenic during the COVID-19 Pandemic

Secondary schools in Maine and New Hampshire have been involved in a citizen science program called "All About Arsenic" aimed at addressing arsenic contamination of well water, one of the most pressing public health issues in both states. Nearly half of the population of Maine and New Hampshire derive their drinking water from private wells which often have arsenic levels above the EPA limit of 10 ppb. Arsenic exposure can cause cancer, adverse cardiovascular effects, and other health problems. Addressing this issue in schools provides context and motivation for students to engage in scientific inquiry and acquire data literacy skills. This project involves students collecting well water samples for arsenic analysis, entering their data into an online citizen science data portal, Anecdata, and using Tuva online software tools to visualize and interpret their data. Students present their data at public meetings to inform community members of their findings with the goal of moving "data to action". The COVID-19 pandemic presented multiple challenges for teachers engaging their students in this citizen science project. We adapted our program and implemented a series of interventions aimed at supporting teachers in their continued efforts to engage their students the "All About Arsenic" project.

Whispering Tuberculosis

Presentation We describe a case of reactivation of latent pulmonary tuberculosis (TB) invading the larynx and causing dysphonia. Diagnosis A previously healthy 30-year old woman was found to have bilateral pulmonary TB 5-months after being thoroughly investigated for hoarseness. Initial chest x-ray (CXR) and CT-neck were normal. Vocal cord biopsies were negative for granulomata. Treatment The patient was commenced on standard four drug Anti-TB treatment (ATT) and completed a one-year course. Unfortunately, the development of a laryngeal web caused persistent dysphonia. Discussion Patients with laryngeal TB are more likely to present to ENT surgeons, because of the initial symptom of hoarseness. Multiple tests must be completed before out-ruling TB. HRCT or sputum culture is recommended, as TB may not be evident on initial CXR. A collaborative approach between Respiratory and ENT teams is required. Prompt diagnosis is essential. Speech therapy input will be important in our patient's recovery.

Development of Privacy Features on Anecdata.org, a Free Citizen Science Platform for Collecting Datasets for Climate Change and Related Projects

The Anecdata website and its corresponding mobile app provide unique features to meet the needs of a wide variety of diverse citizen science projects from across the world. The platform has been developed with the help of continuous feedback from community partners, project leaders, and website users and currently hosts more than 200 projects. Over 8,000 registered users have contributed more than 30,000 images and over 50,000 observations since the platform became open to the public in 2014. From its inception, one of the core tenets of Anecdata's mission has been to make data from citizen science projects freely accessible to project participants and the general public, and in the platform's first few years, it followed a completely open data access model. As the platform has grown, hosting ever more projects, we have found that this model does not meet all project needs, especially where endangered species, property access rights, participant safety in the field, and personal privacy are concerned. We first introduced features for data and user privacy as part of "All About Arsenic," a National Institutes of Health (NIH)/National Institute of General Medical Sciences (NIGMS) Science Education Partnership Award (SEPA)-funded project at MDI Biological Laboratory, which engages middle and high school teachers and students from schools across Maine and New Hampshire in sampling their home well water for analysis of arsenic and other heavy metals. In order to host this project on Anecdata, we developed features for spatial privacy or "geoprivacy" to conceal the coordinates of samplers' homes, partial data redaction tools we call "private fields" to withhold certain sample registration questions from public datasets, and "participant anonymity" to conceal which user account uploaded an observation. We describe the impetus for the creation of these features, challenges we encountered, and our technical approach. While these features were originally developed for the purposes of a public health and science literacy project, they are now available to all project leaders setting up projects on Anecdata.org and have been adopted by a number of projects, including Mass Audubon's Eastern Meadowlark Survey, South Carolina Aquarium's SeaRise, and Coastal Signs of the Seasons (SOS) Monitoring projects.

Comparison of transarterial bland and chemoembolization for neuroendocrine tumours: a systematic review and meta-analysis

Background

Treatment of hepatic metastases from neuroendocrine tumours improves survival and symptom relief. Hepatic arterial embolotherapy techniques include transarterial chemoembolization (tace) and bland embolization (tae). The relative efficacy of the techniques is controversial. The purpose of the present study was to use a meta-analysis and systematic review to compare tace with tae in the treatment of hepatic metastases.

Methods

A literature search identified studies comparing tace and tae for treatment of hepatic metastases. Outcomes of interest included overall survival (os), progression-free survival (pfs), radiographic response, complications, and symptom control. The hazard ratios (hrs) and odds ratios (ors) were estimated and pooled.

Results

Eight studies and 504 patients were included. No statistically significant differences between tace and tae were observed for os at 1, 2, and 5 years or for hrs [1-year or: 0.72; 95% confidence interval (ci): 0.27 to 1.94; p < 0.52; 2-year or: 0.69; 95% ci: 0.43 to 1.11; p < 0.12; 5-year or: 0.91; 95% ci: 0.37 to 2.24; p < 0.85; hr: 0.96; 95% ci: 0.73 to 1.24; p < 0.74]. No statistically significant differences between tace and tae were observed for pfs at 1, 2, and 5 years or for hrs (1-year or: 0.71; 95% ci: 0.38 to 1.55; p < 0.30; 2-year or: 0.83; 95% ci: 0.33 to 2.06; p < 0.69; 5-year or: 0. 91; 95% ci: 0.37 to 2.24; p < 0.85; hr: 0.99-1.74; 95% ci: 0.74 to 1.73; p < 0.97). Both techniques are safe and effective for symptom control.

Conclusions

No statistically significant differences between tace and tae were observed for os and pfs.

Inter-rater reliability, intra-rater reliability and internal consistency of the Brisbane Evidence-Based Language Test

Purpose: To examine the inter-rater reliability, intra-rater reliability, internal consistency and practice effects associated with a new test, the Brisbane Evidence-Based Language Test.Methods: Reliability estimates were obtained in a repeated-measures design through analysis of clinician video ratings of stroke participants completing the Brisbane Evidence-Based Language Test. Inter-rater reliability was determined by comparing 15 independent clinicians' scores of 15 randomly selected videos. Intra-rater reliability was determined by comparing two clinicians' scores of 35 videos when re-scored after a two-week interval.Results: Intraclass correlation coefficient (ICC) analysis demonstrated almost perfect inter-rater reliability (0.995; 95% confidence interval: 0.990-0.998), intra-rater reliability (0.994; 95% confidence interval: 0.989-0.997) and internal consistency (Cronbach's α = 0.940 (95% confidence interval: 0.920-1.0)). Almost perfect correlations (0.998; 95% confidence interval: 0.995-0.999) between face-to-face and video ratings were obtained.Conclusion: The Brisbane Evidence-Based Language Test demonstrates almost perfect inter-rater reliability, intra-rater reliability and internal consistency. High correlation coefficients and narrow confidence intervals demonstrated minimal practice effects with scoring or influence of years of clinical experience on test scores. Almost perfect correlations between face-to-face and video scoring methods indicate these reliability estimates have direct application to everyday practice. The test is available from brisbanetest.org.Implications for RehabilitationThe Brisbane Evidence-Based Language Test is a new measure for the assessment of acquired language disorders.The Brisbane Evidence-Based Language Test demonstrated almost perfect inter-rater reliability, intra-rater reliability and internal consistency.High reliability estimates and narrow confidence intervals indicated that test ratings vary minimally when administered by clinicians of different experience levels, or different levels of familiarity with the new measure.The test is a reliable measure of language performance for use in clinical practice and research.

Development and diagnostic validation of the Brisbane Evidence-Based Language Test

Purpose: To describe the development and determine the diagnostic accuracy of the Brisbane Evidence-Based Language Test in detecting aphasia.Methods: Consecutive acute stroke admissions (n = 100; mean = 66.49y) participated in a single (assessor) blinded cross-sectional study. Index assessment was the ∼45 min Brisbane Evidence-Based Language Test. The Brisbane Evidence-Based Language Test is further divided into four 15-25 min Short Tests: two Foundation Tests (severe impairment), Standard (moderate) and High Level Test (mild). Independent reference standard included the Language Screening Test, Aphasia Screening Test, Comprehensive Aphasia Test and/or Measure for Cognitive-Linguistic Abilities, treating team diagnosis and aphasia referral post-ward discharge.Results: Brisbane Evidence-Based Language Test cut-off score of ≤157 demonstrated 80.8% (LR+ =10.9) sensitivity and 92.6% (LR- =0.21) specificity. All Short Tests reported specificities of ≥92.6%. Foundation Tests I (cut-off ≤61) and II (cut-off ≤51) reported lower sensitivity (≥57.5%) given their focus on severe conditions. The Standard (cut-off ≤90) and High Level Test (cut-off ≤78) reported sensitivities of ≥72.6%.Conclusion: The Brisbane Evidence-Based Language Test is a sensitive assessment of aphasia. Diagnostically, the High Level Test recorded the highest psychometric capabilities of the Short Tests, equivalent to the full Brisbane Evidence-Based Language Test. The test is available for download from brisbanetest.org.Implications for rehabilitationAphasia is a debilitating condition and accurate identification of language disorders is important in healthcare.Language assessment is complex and the accuracy of assessment procedures is dependent upon a variety of factors.The Brisbane Evidence-Based Language Test is a new evidence-based language test specifically designed to adapt to varying patient need, clinical contexts and co-occurring conditions.In this cross-sectional validation study, the Brisbane Evidence-Based Language Test was found to be a sensitive measure for identifying aphasia in stroke.

Implementation of hospital wide dysphagia screening in a large acute tertiary teaching hospital

Purpose: There are no examples in the literature of successful long-term hospital-wide implementation of nurse-led dysphagia screening. This article aims to describe strategies used to implement hospital-wide dysphagia screening in a large acute tertiary teaching hospital in Australia. It reports on compliance, accuracy and nursing staff satisfaction using the validated Royal Brisbane and Women's Hospital Dysphagia Screening Tool (RBWH DST).Method: A retrospective observational study of audit data was conducted to examine hospital-wide compliance and accuracy of dysphagia screen completion. A nursing staff survey measured staff satisfaction. Implementation included: (1) utilisation of validated tool (RBWH DST); (2) key stakeholder engagement and strong governance; (3) policy development; (4) education; and (5) review and monitoring processes.Result: Audits conducted over a 9-year period (n = 3726) showed an average hospital-wide compliance rate of 74% and an accuracy rate of 82%. A nurse satisfaction survey (n = 109) showed high levels of satisfaction associated with using the RBWH DST.Conclusion: The RBWH DST was implemented in a large acute tertiary teaching hospital with acceptable compliance and accuracy rates and favourable nursing staff satisfaction. Further study is required to objectively evaluate patient health and cost benefits associated with using the RBWH DST.

Impact of carbonation on neurogenic dysphagia and an exploration of the clinical predictors of a response to carbonation

BACKGROUND

The need for effective compensatory strategies in neurogenic dysphagia management has led to the exploration of sensory enhancement strategies (SES), such as carbonated liquids. Despite some positive findings, evidence related to the efficacy of carbonation as an SES is limited.

AIMS

To determine if carbonated thin liquids reduced dysphagia symptoms and to explore clinical factors associated with response to carbonation.

METHODS & PROCEDURES

Participants (n = 29) with neurogenic dysphagia demonstrating deep penetration or aspiration on thin liquids during videofluoroscopic swallow studies (VFSS) completed a set protocol: discrete sips of non-carbonated thin fluids (DS-NC) followed by discrete sips of carbonated thin fluids (DS-C) and then consecutive sips of carbonated fluids (CS-C). The impact of carbonation was identified through changes to swallow physiology (videofluoroscopy dysphagia scale-VDS) and depth of airway compromise (penetration-aspiration scale-PAS). Demographic variables including genetic taste type, cranial nerve function and key results from the VDS were examined for association with carbonation response using both individual parameter analysis and exploratory cluster analysis.

OUTCOMES & RESULTS

Significant (p < 0.05) improvements in PAS scores were noted in DS-C and CS-C conditions compared with DS-NC. Total VDS score was also significantly (p < 0.05) reduced (i.e., improved function) in the DS-NC condition. Individual variability in response to carbonation was noted and no clear clinical factors associated with carbonation response in the current set of parameters were identified.

CONCLUSION & IMPLICATIONS

Findings support that carbonated thin fluids sometimes result in neurogenic dysphagia symptom reduction. However, identifying the clinical characteristics of patients who may benefit from trials of carbonation needs further investigation.

Diagnosis of aphasia in stroke populations: A systematic review of language tests

Background and purpose

Accurate aphasia diagnosis is important in stroke care. A wide range of language tests are available and include informal assessments, tests developed by healthcare institutions and commercially published tests available for purchase in pre-packaged kits. The psychometrics of these tests are often reported online or within the purchased test manuals, not the peer-reviewed literature, therefore the diagnostic capabilities of these measures have not been systematically evaluated. This review aimed to identify both commercial and non-commercial language tests and tests used in stroke care and to examine the diagnostic capabilities of all identified measures in diagnosing aphasia in stroke populations.

Methods

Language tests were identified through a systematic search of 161 publisher databases, professional and resource websites and language tests reported to be used in stroke care. Two independent reviewers evaluated test manuals or associated resources for cohort or cross-sectional studies reporting the tests’ diagnostic capabilities (sensitivity, specificity, likelihood ratios or diagnostic odds ratios) in differentiating aphasic and non-aphasic stroke populations.

Results

Fifty-six tests met the study eligibility criteria. Six “non-specialist” brief screening tests reported sensitivity and specificity information, however none of these measures reported to meet the specific diagnostic needs of speech pathologists. The 50 remaining measures either did not report validity data (n = 7); did not compare patient test performance with a comparison group (n = 17); included non-stroke participants within their samples (n = 23) or did not compare stroke patient performance against a language reference standard (n = 3). Diagnostic sensitivity analysis was completed for six speech pathology measures (WAB, PICA, CADL-2, ASHA-FACS, Adult FAVRES and EFA-4), however all studies compared aphasic performance with that of non-stroke healthy controls and were consequently excluded from the review.

Conclusions

No speech pathology test was found which reported diagnostic data for identifying aphasia in stroke populations. A diagnostically validated post-stroke aphasia test is needed.

Infections in the spinal cord-injured population: a systematic review

STUDY DESIGN

Spinal cord injury (SCI) patients are an increasing population due to recent military conflicts. SCI patients are at an increased risk of infection, but the epidemiology management and prevention strategies for these infections are unclear.

OBJECTIVE

To review the incidence, microbiology and management of pneumonia, skin and soft tissue infections (SSTI), urinary tract infections (UTI) and bloodstream infections in the SCI population via literature review.

METHODS

With the assistance of an experienced medical librarian, we developed a search strategy for the Ovid MEDLINE database and then adapted it for the Ovid Embase, Scopus and Web of Science databases. The databases were searched from their inception to April 2014 with no restrictions on language or time period. Data were extracted using a standardized form. All studies were reviewed by two independent investigators.

RESULTS

Forty-one studies reporting on the described infections were identified. UTIs were the most commonly identified infections, but studies failed to identify consistently effective preventive strategies. SSTIs were also common, and the best preventive strategies focused on decubitus ulcer prevention and skin decolonization protocols. Pneumonia management and course were not significantly different from the general population. Bloodstream infections were associated with delays in recognition, and were most often secondary to UTI, pneumonia or SSTI.

CONCLUSION

There is a paucity of literature on consistently effective infection prevention strategies in SCI patients. Identification and implementation of evidence-based interventions that optimize prevention and management of infections in this patient population are needed.

A Dynamic Image Quality Evaluation of Videofluoroscopy Images: Considerations for Telepractice Applications

High-quality fluoroscopy images are required for accurate interpretation of videofluoroscopic swallow studies (VFSS) by speech pathologists and radiologists. Consequently, integral to developing any system to conduct VFSS remotely via telepractice is ensuring that the quality of the VFSS images transferred via the telepractice system is optimized. This study evaluates the extent of change observed in image quality when videofluoroscopic images are transmitted from a digital fluoroscopy system to (a) current clinical equipment (KayPentax Digital Swallowing Workstation, and b) four different telepractice system configurations. The telepractice system configurations consisted of either a local C20 or C60 Cisco TelePresence System (codec unit) connected to the digital fluoroscopy system and linked to a second remote C20 or C60 Cisco TelePresence System via a network running at speeds of either 2, 4 or 6 megabits per second (Mbit/s). Image quality was tested using the NEMA XR 21 Phantom, and results demonstrated some loss in spatial resolution, low contrast detectability and temporal resolution for all transferred images when compared to the fluoroscopy source. When using higher capacity codec units and/or the highest bandwidths to support data transmission, image quality transmitted through the telepractice system was found to be comparable if not better than the current clinical system. This study confirms that telepractice systems can be designed to support fluoroscopy image transfer and highlights important considerations when developing telepractice systems for VFSS analysis to ensure high-quality radiological image reproduction.

General or Spinal Anaesthetic for Vaginal Surgery in Pelvic Floor Disorders (GOSSIP): a feasibility randomised controlled trial

INTRODUCTION AND HYPOTHESIS

Spinal anaesthesia (SA) and general anaesthesia (GA) are widely used techniques for vaginal surgery for pelvic floor disorders with inconclusive evidence of the superiority of either. We conducted a randomised controlled trial (RCT) to assess the feasibility of a full scale RCT aiming to examine the effect of anaesthetic mode for vaginal surgery on operative, patient reported and length of hospital stay (LOHS) outcomes.

METHODS

Patients undergoing vaginal surgery, recruited through a urogynaecology service in a University teaching hospital, were randomised to receive either GA or SA. Patients were followed up for 12 weeks postoperatively. Pain was measured on a visual analogue scale; nausea was assessed with a four-point verbal rating scale. Patient's subjective perception of treatment outcome, quality of life (QoL) and functional outcomes were assessed using the International Consultation on Incontinence Modular Questionnaire (ICIQ) on vaginal symptoms and the SF-36 questionnaire.

RESULTS

Sixty women were randomised, 29 to GA and 31 to SA. The groups were similar in terms of age and type of vaginal surgery performed. No statistically significant differences were noted between the groups with regard to pain, nausea, quality of life (QoL), functional outcomes as well as length of stay in the postoperative recovery room, use of analgesia postoperatively and LOHS.

CONCLUSION

This study has demonstrated that a full RCT is feasible and should focus on the length of hospital stay in a subgroup of patients undergoing vaginal surgery where SA may help to facilitate enhanced recovery or day surgery.

Expression and localization of a UT-B urea transporter in the human bladder

Facilitative UT-B urea transporters have been shown to play an important role in the urinary concentrating mechanism. Recent studies have now suggested a link between UT-B allelic variation and human bladder cancer risk. UT-B1 protein has been previously identified in the bladder of various mammalian species, but not yet in humans. The aim of the present study was to investigate whether any UT-B protein was present in the human bladder. First, RT-PCR results confirmed that UT-B1 was strongly expressed at the RNA level in the human bladder, whereas UT-B2 was only weakly present. Initial Western blot analysis confirmed that a novel UT-B COOH-terminal antibody detected human UT-B proteins. Importantly, this antibody detected a specific 40- to 45-kDa UT-B signal in human bladder protein. Using a peptide-N-glycosidase F enzyme, this bladder UT-B signal was deglycosylated to a core 30-kDa protein, which is smaller than the predicted size for UT-B1 but similar to many proteins reported to be UT-B1. Finally, immunolocalization experiments confirmed that UT-B protein was strongly expressed throughout all urothelium layers except for the apical membrane of the outermost umbrella cells. In conclusion, these data confirm the presence of UT-B protein within the human bladder. Further studies are now required to determine the precise nature, regulation, and physiological role of this UT-B.

Effects of neurosurgical management of Parkinson's disease on speech characteristics and oromotor function

The present study examined the effects of neurosurgical management of Parkinson's disease (PD), including the procedures of pallidotomy, thalamotomy, and deep-brain stimulation (DBS) on perceptual speech characteristics, speech intelligibility, and oromotor function in a group of 22 participants with PD. The surgical participant group was compared with a group of 25 non-neurologically impaired individuals matched for age and sex. In addition, the study investigated 16 participants with PD who did not undergo neurosurgical management to control for disease progression. Results revealed that neurosurgical intervention did not significantly change the surgical participants' perceptual speech dimensions or oromotor function despite significant postoperative improvements in ratings of general motor function and disease severity. Reasons why neurosurgical intervention resulted in dissimilar outcomes with respect to participants' perceptual speech dimensions and general motor function are proposed.

Substrate-dependent autoaggregation of Pseudomonas putida CP1 during the degradation of mono-chlorophenols and phenol

A bacterium, CP1, identified as Pseudomonas putida strain, was investigated for its ability to grow on and degrade mono-chlorophenols and phenols as sole carbon sources in aerobic shaking batch culture. The organism degraded up to 1.56 mM 2- and 3-chlorophenol, 2.34 mM 4-chlorophenol and 8.5 mM phenol using an ortho-cleavage pathway. P. putida CP1, acclimated to degrade 2-chlorophenol, was capable of 3-chlorocatechol degradation, while P. putida, acclimated to 4-chlorophenol degradation, degraded 4-chlorocatechol. Growth of P. putida CP1 on higher concentrations of the mono-chlorophenols, >or=1.56 mM 4-chlorophenol and >or=0.78 mM 2- and 3-chlorophenol, resulted in decreases in cell biomass despite metabolism of the substrates, and the formation of large aggregates of cells in the culture medium. Increases in cell biomass with no clumping of the cells resulted from growth of P. putida CP1 on phenol or on lower concentrations of mono-chlorophenol. Bacterial adherence to hydrocarbons (BATH) assays showed cells grown on the higher concentrations of mono-chlorophenol to be more hydrophobic than those grown on phenol and lower concentrations of mono-chlorophenol. The results suggested that increased hydrophobicity and autoaggregation of P. putida CP1 were a response to toxicity of the added substrates.

Should the food intake of patients admitted to acute hospital services be routinely supplemented? A randomized placebo controlled trial

BACKGROUND

Many patients admitted to acute hospital services are underweight or harbour vitamin deficiencies.

OBJECTIVES

To determine the effect on patient throughput of a policy of routine vitamin supplementation, and of early routine sipfeed supplementation in 'thin' patients (5-10% weight loss or body mass index 18-22).

DESIGN

Factorial randomized placebo controlled trial of oral multivitamins from the first day of admission, and, after nutritional screening, of a nutritionally complete sipfeed from the second day in 'thin' patients.

SETTING

Acute medical, surgical and orthopaedic hospital services of a London teaching hospital.

PARTICIPANTS

1561 patients admitted as emergencies were included in the vitamin study of which 549 were included in the sipfeed study.

MAIN OUTCOME MEASURE

Length of hospital stay (LOS).

RESULTS

Offering multivitamins to acute admissions resulted in a mean change (reduction) in LOS of -0.4 days 95% CI (-2-1.2days). The results suggest greater reductions for those discharged after 10 days: mean change=-2.3 days 95% CI (-5.7 to 1.2). Sipfeed supplementation was associated with an increased mean length of stay 2.8 days 95% CI (-0.8-6.3). 18% of acute admissions were classified undernourished on the basis of BMI, MUAC or percent weight loss combined.

CONCLUSIONS

No benefit was observed for sipfeed intervention although a small benefit of less than one day is not excluded. Vitamin supplementation may have slight but economically important benefit.

Variability in measurement of internal carotid artery stenosis by arch angiography and duplex ultrasonography--time for a reappraisal?

OBJECTIVES

to determine the inter- and intra-observer variability of ICA stenosis measurement using duplex, ECST and NASCET methods.

DESIGN

a retrospective review of arch angiograms and carotid duplex scans in 50 patients.

MATERIALS AND METHODS

carotid stenoses were calculated by three independent observers according to NASCET and ECST methods. Variation between observers for NASCET and ECST was determined. For each observer, the variation between NASCET and ECST was determined. The variation between duplex and both NASCET and ECST was determined.

RESULTS

inter-observer agreement on the degree of ICA stenosis was clinically and statistically good for NASCET but was poorer for ECST. For each observer, comparison between NASCET and ECST showed 95% limits of agreement of around 50 percentage points. Comparison of duplex with NASCET and ECST showed similar 95% limits of agreement.

CONCLUSIONS

arch angiography allows reproducible measurement of carotid stenosis by the NASCET method between different observers. For the ECST method, reproducibility is not so good. Variations in results between NASCET and ECST and between angiography and duplex are significant. In view of the similar results of the NASCET and ECST trials, this suggests that degree of stenosis may only be a surrogate marker for outcome following carotid endarterectomy.

Gene therapy for myocardial protection: transfection of donor hearts with heat shock protein 70 gene protects cardiac function against ischemia-reperfusion injury

BACKGROUND

Heat shock protein 70 (HSP70) gene transfection has been shown to enhance myocardial tolerance after normothermic ischemia-reperfusion. We investigated the effect of HSP70 gene transfection on mechanical and endothelial function in a protocol mimicking clinical heart preservation.

METHODS AND RESULTS

Rat hearts were infused ex vivo with Hemagglutinating Virus of Japan-liposome complex containing HSP70 gene (HSP, n=8) or no gene (CON, n=8), and heterotopically transplanted into recipient rats. Four days after surgery, transfected hearts were perfused on a Langendorff apparatus for 45 minutes, arrested with St Thomas' No. 1 cardioplegia for 4 hours at 4 degrees C, and reperfused for 1 hour. Mechanical and endothelial function was studied before and after ischemia. Creatine kinase was measured in reperfusion effluent. Hearts underwent Western blotting and immunohistochemistry to confirm HSP70 overexpression. Postischemic recovery of mechanical function (% preischemic+/-SEM) was greater in HSP versus CON: Left ventricular developed pressure recovery was 76.7+/-3.9% versus 60. 5+/-3.1% (P:<0.05); dP/dtmax recovery was 79.4+/-4.9% versus 56. 2+/-3.2% (P:<0.05); dP/dtmin recovery was 74.8+/-4.6% versus 57. 3+/-3.6% (P:<0.05). Creatine kinase release was attenuated in HSP versus CON: 0.22+/-0.02 versus 0.32+/-0.04 IU/min/g wet wt. (P:<0. 05). Recovery of coronary flow was greater in HSP versus CON: 76. 5+/-3.8% versus 59.2+/-3.2% (P:<0.05). Recovery of coronary response to 5-hydroxytryptamine (5 x 10(-)(5) mol/L) was 55.6+/-4.7% versus 23. 9+/-3.2% (P:<0.05); recovery of coronary response to glyceryltrinitrate (15 mg/L) was not different between HSP and CON: 87.4+/-6.9% versus 84.3+/-5.8% (NS).

CONCLUSIONS

In a clinically relevant donor heart preservation protocol, HSP70 gene transfection protects both mechanical and endothelial function.

Degradation of mono-chlorophenols by a mixed microbial community via a meta- cleavage pathway

A mixed microbial community, specially designed to degrade a wide range of substituted aromatic compounds, was examined for its ability to degrade mono-chlorophenols as sole carbon source in aerobic batch cultures. The mixed culture degraded 2-, 3-, and 4-chlorophenol (1.56 mM) via a meta- cleavage pathway. During the degradation of 2- and 3-chlorophenol by the mixed culture, 3-chlorocatechol production was observed. Further metabolism was toxic to cells as it led to inactivation of the catechol 2,3-dioxygenase enzyme upon meta- cleavage of 3-chlorocatechol resulting in incomplete degradation. Inactivation of the meta- cleavage enzyme led to an accumulation of brown coloured polymers, which interfered with the measurement of cell growth using optical density. Degradation of 4-chlorophenol by the mixed culture led to an accumulation of 5-chloro-2-hydroxymuconic semialdehyde, the meta- cleavage product of 4-chlorocatechol. The accumulation of this compound did not interfere with the measurement of cell growth using optical density. 5-chloro-2-hydroxymuconic semialdehyde was further metabolized by the mixed culture with a stoichiometric release of chloride, indicating complete degradation of 4-chlorophenol by the mixed culture via a meta- cleavage pathway.

MRI measurements correctly predict the relative effects of tumor oxygenating agents on hypoxic fraction in rodent BA1112 tumors

PURPOSE

We evaluate whether magnetic resonance imaging (MRI) with blood oxygenation level-dependent (BOLD) contrast correctly predicts the relative effects of tumor-oxygenating agents on hypoxic fraction in BA1112 rhabdomyosarcomas in WAG/Rij rats.

METHODS AND MATERIALS

The response of ten tumors to carbogen (95% O(2)/5% CO(2)), a perfluorocarbon emulsion (PFC), and the combination of PFC + carbogen was studied with high spectral and spatial resolution MR imaging of the water resonance at 4.7 Tesla. Decreases in MR signal linewidth indicate increases in tumor blood oxygen levels.

RESULTS

Average MR signal linewidth was decreased 2.0% by carbogen, 2.5% by PFC + air, and 4.9% by PFC + carbogen. PFC + carbogen caused a larger linewidth decrease than either treatment alone (p < 0.04 by ANOVA). Maps of pixels responding to treatment indicate that combining PFC with carbogen significantly enlarges the area of the tumor in which oxygen levels are increased (p < 0.01 by ANOVA).

CONCLUSION

MRI predicts that PFC + carbogen will increase radiosensitivity more than either treatment alone; this agrees with the known effects of these treatments on hypoxic fraction. Utilizing MRI to choose the treatment that maximizes the size and extent of increases in tumor oxygenation could reduce hypoxic fraction.

Relationship between endothelial cell markers and arterial stenosis in peripheral and carotid artery disease

Damage to the endothelium is an important component of atherosclerosis and can be quantified by measuring plasma markers, such as von Willebrand factor, thrombomodulin, intercellular adhesion molecule-1, and E-selectin. We hypothesized that increased levels of these markers would be related to objectively defined disease severity among patients with peripheral atherosclerosis or carotid atherosclerosis. To test this, we measured the markers by using ELISA in the plasma of 45 patients with intermittent claudication alone and in 53 patients presenting with transient ischemic attack. Disease severity in the former was by ankle-brachial pressure index and in the latter by ultrasound defined % stenosis. Any symptomatic dual disease or history or present coronary atherosclerosis warranted exclusion. Data were correlated according to Spearman's method. The only significant correlation was between von Willebrand factor and ankle-brachial pressure index (r = -0.39, p = 0.008). Our data suggest that von Willebrand factor is the most sensitive marker of peripheral atherosclerosis and that none of the plasma markers seems to be a useful marker of the degree of carotid artery stenosis.

Cdc37 promotes the stability of protein kinases Cdc28 and Cak1

In the budding yeast Saccharomyces cerevisiae, Cdc37 is required for the productive formation of Cdc28-cyclin complexes. The cdc37-1 mutant arrests at Start with low levels of Cdc28 protein, which is predominantly unphosphorylated at Thr169, fails to bind cyclin, and has little protein kinase activity. We show here that Cdc28 and not cyclin is specifically defective in the cdc37-1 mutant and that Cdc37 likely does not act as an assembly factor for Cdc28-cyclin complex formation. We have also found that the levels and activity of the protein kinase Cak1 are significantly reduced in the cdc37-1 mutant. Pulse-chase analysis indicates that Cdc28 and Cak1 proteins are both destabilized when Cdc37 function is absent during but not after translation. In addition, Cdc37 promotes the production of Cak1, but not that of Cdc28, when coexpressed in insect cells. We conclude that budding yeast Cdc37, like its higher eukaryotic homologs, promotes the physical integrity of multiple protein kinases, perhaps by virtue of a cotranslational role in protein folding.

Do some men with acne vulgaris have raised levels of LH?

OBJECTIVE

Acne vulgaris is androgen related and in some cases is associated with excess androgen production, which in men would be mainly testicular or adrenal in origin. Ordinarily, testosterone synthesis in the testis is controlled by serum LH. In order to ascertain whether acne vulgaris in men might be consequent on abnormalities at the hypothalmic/pituitary level we have compared serum LH levels in men with and without acne.

DESIGN AND PATIENTS

111 men with acne vulgaris were compared with 51 acne-free men.

MEASUREMENTS

Serum levels of LH, FSH and oestradiol were measured by automated ELISA. Dehydroepiandrosterone sulphate (DHEA-S), 17 alpha-hydroxyprogesterone, 11-deoxycortisol, androstenedione and testosterone were measured by radioimmunoassay, and SHBG by immunoradiometric assay.

RESULTS

The controls showed a fall in serum LH with age: the rate of fall was less in the acne patients (difference between the slopes 0.073 U/year (95% confidence interval (CI), 0.016 to 0.130)). The age distributions in the acne and control groups differed. In order to compare means, standardizations were used to assess the difference in the means in populations of men with age distributions similar to the cases and controls. After standardization to the age distribution of the controls, the acne patients had higher means of serum LH, difference between the means 0.80 U/I (95% CI, 0.31 to 1.30), androstenedione, 1.09 nmol/l (95% CI, 0.15 to 2.03) and testosterone levels, 2.74 nmol/l (95% CI, 0.53 to 4.95) and a lower mean BMI, -1.30 kg/m2 (95% CI, -2.40 to -0.19). After standardization to the age distribution of the acne patients the means of LH, androstenedione and testosterone were still higher in the acne patients but not necessarily significantly so.

CONCLUSION

LH fell more slowly with age in the men with acne as compared to the controls. In our heterogeneous group of patients with acne vulgaris the findings suggest that a sub-group of men with acne have raised serum LH levels.