A machine learning approach to predict mortality due to immune-mediated thrombotic thrombocytopenic purpura

Background

Mortality due to immune-mediated thrombotic thrombocytopenic purpura (iTTP) remains significant. Predicting mortality risk may potentially help individualize treatment. The French Thrombotic Microangiopathy (TMA) Reference Score has not been externally validated in the United States. Recent advances in machine learning technology can help analyze large numbers of variables with complex interactions for the development of prediction models.

Objectives

To validate the French TMA Reference Score in the United States Thrombotic Microangiopathy (USTMA) iTTP database and subsequently develop a novel mortality prediction tool, the USTMA TTP Mortality Index.

Methods

We analyzed variables available at the time of initial presentation, including demographics, symptoms, and laboratory findings. We developed our model using gradient boosting machine, a machine learning ensemble method based on classification trees, implemented in the R package gbm.

Results

In our cohort (n = 419), the French score predicted mortality with an area under the receiver operating characteristic curve of 0.63 (95% CI: 0.50-0.77), sensitivity of 0.35, and specificity of 0.84. Our gradient boosting machine model selected 8 variables to predict acute mortality with a cross-validated area under the receiver operating characteristic curve of 0.77 (95% CI: 0.71-0.82). The 2 cutoffs corresponded to sensitivities of 0.64 and 0.50 and specificities of 0.76 and 0.87, respectively.

Conclusion

The USTMA Mortality Index was acceptable for predicting mortality due to acute iTTP in the USTMA registry, but not sensitive enough to rule out death. Identifying patients at high risk of iTTP-related mortality may help individualize care and ultimately improve iTTP survival outcomes. Further studies are needed to provide external validation. Our model is one of many recent examples where machine learning models may show promise in clinical prediction tools in healthcare.

Exploring experiences of living with removable dentures-A scoping review of qualitative literature

OBJECTIVE

Examine the literature on the experiences of living with removable dentures (complete or partial) to identify any gaps and provide a map for future research.

BACKGROUND

Increasing proportions of society are living partially dentate with some form of restoration, including removable dentures. Previous studies have reported on the location, materials and usage of these prostheses, along with effects on oral-health-related quality of life (OHRQoL). However, less is known about experiences with removable dentures from a patient-centred perspective.

METHODS

A scoping review of the qualitative literature was undertaken using the framework of Arksey and O'Malley, updated by Levac et al. Literature searches were carried out using Medline and Web of Science. Papers were screened by title and abstract using inclusion and exclusion criteria. Remaining papers were read in full and excluded if they did not meet the required criteria. Nine papers were included in the final review.

FINDINGS

Key themes from these papers were: impact of tooth loss and living without teeth, and its impacts in relation to social position, appearance, confidence and function (chewing and speaking); social norms and tooth loss, including attitudes to tooth retention and treatment costs, and changes in intergenerational norms towards dentures; expectations of treatment, including patients being more involved in decision making, viewing the denture as a "gift" and dentures helping to achieve "an ideal"; living with a removable denture (complete or partial), including patient preparedness for a denture, adaptation and impacts on activities and participation; and the dentist-patient relationship, including issues with information and communication, and differing priorities between patients and dentists.

CONCLUSION

Little qualitative research exists on experiences of living with a removable denture. Existing literature demonstrates the importance of dispersed activities in differing social, spatial and temporal contexts when wearing removable dentures. Focusing on processes of positive adaptation to dentures and OHRQoL, rather than deficits, is also required to fully understand patients' experiences. Additionally, more complex technological advances may not always be in the best interest of every patient.

Using the exploration, preparation, implementation, sustainment (EPIS) framework to assess the cooperative re-engagement controlled trial (CoRECT)

Background

"Data to Care" (D2C) is a strategy which relies on a combination of public health surveillance data supplemented by clinic data to support continuity of HIV care. The Cooperative Re-Engagement Controlled Trial (CoRECT) was a CDC-sponsored randomized controlled trial of a D2C model, which provided an opportunity to examine the process of implementing an intervention for people with HIV (PWH) who are out-of-care across three public health department jurisdictions. Using the EPIS (Exploration, Preparation, Implementation, Sustainment) framework, we aimed to retrospectively describe the implementation process for each site to provide insights and guidance to inform future D2C activities implemented by public health agencies and their clinical and community partners.

Methods

After completion of CoRECT, the three (Connecticut, Massachusetts, Philadelphia) trial sites reviewed study protocols and held iterative discussions to describe and compare their processes regarding case identification, interactions with partnering clinics and patients, and sustainability. The EPIS framework provided a structure for comparing key organizational and operational practices and was applied to the entire implementation process.

Results

The trial sites varied in their implementation processes and the specific elements of the intervention. Factors including prior D2C experience, data management and analytic infrastructure, staff capacity, and relationships with clinic partners informed intervention development and implementation. Additionally, this review identified key lessons learned including to: (1) explore new supplemental sources for public health surveillance data; (2) work with stakeholders representing core functions/components in the early stages of the intervention design process; (3) build flexibility into all components of the follow-up activities; and (4) integrate data sharing, project management, and follow-up activities within existing DPH organizational structure.

Conclusion

The CoRECT study provides a general blueprint and lessons learned for implementing a D2C intervention for re-engagement in HIV care. Interventions should be tailored to local operational and structural factors, and responsive to evolving clinical and public health practices.

Complement activation and kidney transplantation; a complex relationship

Although kidney transplantation is the best treatment for end stage kidney disease, the benefits are limited by factors such as the short fall in donor numbers, the burden of immunosuppression and graft failure. Although there have been improvements in one-year outcomes, the annual rate of graft loss beyond the first year has not significantly improved, despite better therapies to control the alloimmune response. There is therefore a need to develop alternative strategies to limit kidney injury at all stages along the transplant pathway and so improve graft survival. Complement is primarily part of the innate immune system, but is also known to enhance the adaptive immune response. There is increasing evidence that complement activation occurs at many stages during transplantation and can have deleterious effects on graft outcome. Complement activation begins in the donor and occurs again on reperfusion following a period of ischemia. Complement can contribute to the development of the alloimmune response and may directly contribute to graft injury during acute and chronic allograft rejection. The complexity of the relationship between complement activation and allograft outcome is further increased by the capacity of the allograft to synthesise complement proteins, the contribution complement makes to interstitial fibrosis and complement's role in the development of recurrent disease. The better we understand the role played by complement in kidney transplant pathology the better placed we will be to intervene. This is particularly relevant with the rapid development of complement therapeutics which can now target different the different pathways of the complement system. Combining our basic understanding of complement biology with preclinical and observational data will allow the development and delivery of clinical trials which have best chance to identify any benefit of complement inhibition.

Gum health and quality of life—subjective experiences from across the gum health-disease continuum in adults

Background

There has been a lack of qualitative work investigating the effects of the wide range of gum-related symptoms, and the perceived everyday impacts associated with these including on quality of life. While periodontal disease has been shown to have significant effects on quality of life, fewer studies have researched the perceived impacts of gingivitis and symptoms from across the entire gum health-disease continuum, despite evidence that these can also negatively affect quality of life. The aim of this study was to investigate perceived everyday impacts and explore the subjective experiences of adults with a variety of symptoms from across the self-reported gum health-disease continuum, and how these may affect quality of life.

Methods

Participants were recruited at a large UK University using purposive sampling, for self-reported symptoms ranging from mild gingivitis to severe periodontal disease. Semi-structured interviews gathered details on symptom history, changes occurring over time and associated beliefs, as well as perceived impacts on everyday life, and links between these experiences and identity. Interviews were analysed using framework analysis based on the Wilson and Cleary health-related quality of life model.

Results

Twenty-seven participants were recruited − 15 with symptoms of gingivitis, 12 with more severe periodontal symptoms. Prominent themes included description of symptoms, changes in daily life, social impacts, psychological impacts, identity, and overall impacts and quality of life. Differences were noted in severity, extent and frequency of symptoms and participant experiences, with greater perceived impacts often felt by those with periodontal disease. However, participants from across the gum health-disease continuum often expressed similar experiences and concerns.

Conclusion

Findings demonstrate the range of experiences from participants with a variety of gum-related symptoms; notably, gingivitis was reported to have a range of perceived impacts on quality of life alongside those reported by periodontal disease sufferers. Future work should look to include symptoms from across the entire gum health-disease continuum when considering quality of life, as well as considering a more patient-centred approach which could be valuable in both clinical and research settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02507-5.

Race, rituximab, and relapse in TTP

Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is characterized by recurring episodes of thrombotic microangiopathy, causing ischemic organ impairment. Black patients are overrepresented in iTTP cohorts in the United States, but racial disparities in iTTP outcome and response to therapy have not been studied. Using the United States Thrombotic Microangiopathies Consortium iTTP Registry, we evaluated the impact of race on mortality and relapse-free survival (RFS) in confirmed iTTP in the United States from 1995 to 2020. We separately examined the impact of rituximab therapy and presentation with newly diagnosed (de novo) or relapsed iTTP on RFS by race. A total of 645 participants with 1308 iTTP episodes were available for analysis. Acute iTTP mortality did not differ by race. When all episodes of iTTP were included, Black race was associated with shorter RFS (hazard ratio [HR], 1.60; 95% CI, 1.16-2.21); the addition of rituximab to corticosteroids improved RFS in White (HR, 0.37; 95% CI, 0.18-0.73) but not Black patients (HR, 0.96; 95% CI, 0.71-1.31). In de novo iTTP, rituximab delayed relapse, but Black patients had shorter RFS than White patients, regardless of treatment. In relapsed iTTP, rituximab significantly improved RFS in White but not Black patients. Race affects overall relapse risk and response to rituximab in iTTP. Black patients may require closer monitoring, earlier retreatment, and alternative immunosuppression after rituximab treatment. How race, racism, and social determinants of health contribute to the disparity in relapse risk in iTTP deserves further study.

Consensus Statement on Future Directions for the Behavioral and Social Sciences in Oral Health

The behavioral and social sciences are central to understanding and addressing oral and craniofacial health, diseases, and conditions. With both basic and applied approaches, behavioral and social sciences are relevant to every discipline in dentistry and all dental, oral, and craniofacial sciences, as well as oral health promotion programs and health care delivery. Key to understanding multilevel, interacting influences on oral health behavior and outcomes, the behavioral and social sciences focus on individuals, families, groups, cultures, systems, societies, regions, and nations. Uniquely positioned to highlight the importance of racial, cultural, and other equity in oral health, the behavioral and social sciences necessitate a focus on both individuals and groups, societal reactions to them related to power, and environmental and other contextual factors. Presented here is a consensus statement that was produced through an iterative feedback process. The statement reflects the current state of knowledge in the behavioral and social oral health sciences and identifies future directions for the field, focusing on 4 key areas: behavioral and social theories and mechanisms related to oral health, use of multiple and novel methodologies in social and behavioral research and practice related to oral health, development and testing of behavioral and social interventions to promote oral health, and dissemination and implementation research for oral health. This statement was endorsed by over 400 individuals and groups from around the world and representing numerous disciplines in oral health and the behavioral and social sciences. Having reached consensus, action is needed to advance and further integrate and translate behavioral and social sciences into oral health research, oral health promotion and health care, and the training of those working to ensure oral health for all.

Potential application of yeasts from Ecuadorian chichas in controlled beer and chicha production

The potential of yeasts isolated from traditional chichas as starter cultures, either for controlled production of the native beverage or for industrial beer production, has been investigated. Three S. cerevisiae strains and one T. delbrueckii strain isolated from four different Ecuadorian chichas were compared to ale and lager beer strains with respect to fermentation performance, sugar utilisation, phenolic off-flavour production, flocculation and growth at low temperature. Fermentations were performed in 15 °P all-malt wort and in a model chicha substrate at 12 °C and 20 °C. Tall-tube fermentations (1.5 L) were also performed with both substrates to assess yeast performance and beer quality. Among the strains tested, only one Ecuadorian S. cerevisiae strain was able to ferment the wort sugars maltose and maltotriose. Fermentations with all Ecuadorian strains were poor in wort at 12 °C relative to 20 °C, but were similar in model chicha substrate at both temperatures. The aromatic profile was different between species and strains. These results indicate the potential of yeasts derived from traditional Andean fermented beverages for commercial applications. One of the chicha strains demonstrated traits typical of domesticated brewery strains and could be suitable for ale fermentation, while the other strains may have potential for low-alcohol beer or chicha production.

Adaptive Laboratory Evolution of Ale and Lager Yeasts for Improved Brewing Efficiency and Beer Quality

Yeasts directly impact the efficiency of brewery fermentations as well as the character of the beers produced. In recent years, there has been renewed interest in yeast selection and development inspired by the demand to utilize resources more efficiently and the need to differentiate beers in a competitive market. Reviewed here are the different, non-genetically modified (GM) approaches that have been considered, including bioprospecting, hybridization, and adaptive laboratory evolution (ALE). Particular emphasis is placed on the latter, which represents an extension of the processes that have led to the domestication of strains already used in commercial breweries. ALE can be used to accentuate the positive traits of brewing yeast as well as temper some of the traits that are less desirable from a modern brewer's perspective. This method has the added advantage of being non-GM and therefore suitable for food and beverage production.

On the relevance of cocaine detection in a fingerprint

The finding that drugs and metabolites can be detected from fingerprints is of potential relevance to forensic science and as well as toxicology and clinical testing. However, discriminating between dermal contact and ingestion of drugs has never been verified experimentally. The inability to interpret the result of finding a drug or metabolite in a fingerprint has prevented widespread adoption of fingerprints in drug testing and limits the probative value of detecting drugs in fingermarks. A commonly held belief is that the detection of metabolites of drugs of abuse in fingerprints can be used to confirm a drug has been ingested. However, we show here that cocaine and its primary metabolite, benzoylecgonine, can be detected in fingerprints of non-drug users after contact with cocaine. Additionally, cocaine was found to persist above environmental levels for up to 48 hours after contact. Therefore the detection of cocaine and benzoylecgonine (BZE) in fingermarks can be forensically significant, but do not demonstrate that a person has ingested the substance. In contrast, the data here shows that a drug test from a fingerprint (where hands can be washed prior to donating a sample) CAN distinguish between contact and ingestion of cocaine. If hands were washed prior to giving a fingerprint, BZE was detected only after the administration of cocaine. Therefore BZE can be used to distinguish cocaine contact from cocaine ingestion, provided donors wash their hands prior to sampling. A test based on the detection of BZE in at least one of two donated fingerprint samples has accuracy 95%, sensitivity 90% and specificity of 100% (n = 86).

Transnational corporations, oral health and human agency: a sociological perspective

This paper explores the range of approaches that might be adopted in order to take seriously the challenge that Transnational Corporations (TNCs) pose to inequalities in oral health. The challenge we must face together is the challenge of promoting freedom from disease and enabling all humans to flourish. The paper examines how the goals of the new public health might be better realised through consideration of the 'corporate determinants of health'. It is argued that in order to meaningfully engage with the challenge posed by TNCs in oral health we have to recognise that not all TNCs are evil. Indeed some TNCs have played a central role in the improvements in the oral health of populations over the last fifty or so years. The paper goes on to outline how an awareness of different professional strategies can be used to frame an interdisciplinary programme of work looking at the role of TNCs in oral health. These strategies involve a professional focus on data collection and analysis, a focus on policy, being critical, being publicly involved, and acting with foresight. The paper goes on to provide an outline of how these strategies might be pursued to engage TNCs in a programme of research around inequalities in oral health. It is proposed that we form a broad collaboration between appropriate TNCs, academics and funders. This paper provides a very brief sketch about how such a program might be envisaged.

Embarrassing Realities: the Portrayal of Dentistry in Reality TV 'Dentertainment'

BACKGROUND

Dentists are not common subjects within reality TV. When presented in film, the overall impression has been reported to be negative. The British reality TV show 'Embarrassing Bodies' includes within its format, cases where complex and extensive dental treatment is presented. This analysis examines how these cases frame dentistry, as a rare example of the profession and its activities upon the small screen.

METHODS

14 dental cases from the show were located and transcribed. Semiotic and thematic analysis was used to explore the deeper and hidden meanings and signs within the cases. This developed understanding of the implications of the show upon the public presentation of dentistry, oral health and disease, patients and dental professionals.

RESULTS

Five distinct themes were identified within the corpus of cases; Professional Values and Portrayal of Cosmetic Dentistry; The Presentation of Oral Health and Disease; Dental Physiognomy; Dentistry as Empowerment and Unequal Professional Relationships.

CONCLUSIONS

'Embarrassing Bodies' portrays a presentation of dentistry that focuses disproportionately upon restorative dental interventions, especially cosmetic dental therapies, in preference to preventative treatment. Dental disease is presented in a way that associates oral health conditions with dirt and as being caused by neglect and carelessness.

Diagnosis and severity criteria for sinusoidal obstruction syndrome/veno-occlusive disease in pediatric patients: a new classification from the European society for blood and marrow transplantation

The advances in hematopoietic cell transplantation (HCT) over the last decade have led to a transplant-related mortality below 15%. Hepatic sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD) is a life-threatening complication of HCT that belongs to a group of diseases increasingly identified as transplant-related, systemic endothelial diseases. In most cases, SOS/VOD resolves within weeks; however, severe SOS/VOD results in multi-organ dysfunction/failure with a mortality rate >80%. A timely diagnosis of SOS/VOD is of critical importance, given the availability of therapeutic options with favorable tolerability. Current diagnostic criteria are used for adults and children. However, over the last decade it has become clear that SOS/VOD is significantly different between the age groups in terms of incidence, genetic predisposition, clinical presentation, prevention, treatment and outcome. Improved understanding of SOS/VOD and the availability of effective treatment questions the use of the Baltimore and Seattle criteria for diagnosing SOS/VOD in children. The aim of this position paper is to propose new diagnostic and severity criteria for SOS/VOD in children on behalf of the European Society for Blood and Marrow Transplantation.

Laboratory validation of a point velocity probe for measuring horizontal flow from any direction

The point-velocity probe (PVP) quantifies groundwater speed and flow direction, i.e., velocity, at the centimeter scale. The first probe designs required that the flow direction be known a priori, within about 100° in order to position the probe during installation. This study introduces and assesses a '360° PVP' that measures flow from any direction without foreknowledge of the groundwater velocity. In tests conducted in a Nested Storage Tank (NeST) aquifer simulator packed with sand, PVP-measured velocities matched expected velocities within ±9° in direction and ±15% in magnitude, on average, consistent with previously reported PVP performances in laboratory studies. In tests involving 17 repacked NeSTs, the measured and expected velocities were within ±30° and ±30% on average, illustrating the sensitivity of flow to porous medium packing, and the probes' ability to sense these changes; the porosity was found to vary considerably between packings i.e., n=0.34±0.2. For flow directions between 0° and 80° of an injection port, the experimental error on velocity magnitude was within the ranges reported above. At higher flow angles, experimental sources of error contributed to greater uncertainties. Fortunately, in these cases there were always alternative injection ports (with lower angles to flow) that could be used to circumvent any biases. At low experimental flow angles (<10°) the calculated values tended to overestimate the actual flow angles. Fortunately, these cases were identifiable by the detection of tracer at detectors on either side of the active injection port. In several tests designed with an expected flow direction of 0°, averaging the calculated directions from each side of the injection port resulted in improved matches to the expected flow direction.

Fertility preservation issues in pediatric hematopoietic stem cell transplantation: practical approaches from the consensus of the Pediatric Diseases Working Party of the EBMT and the International BFM Study Group

Fertility preservation is an urgent challenge in the transplant setting. A panel of transplanters and fertility specialists within the Pediatric Diseases Working Party of the European Society for Blood and Marrow Transplantation (EBMT) and the International BFM Study Group provides specific guidelines. Patients and families should be informed of possible gender- and age-specific cryopreservation strategies that should be tailored according to the underlying disease, clinical condition and previous exposure to chemotherapy. Semen collection should be routinely offered to all postpubertal boys at the diagnosis of any disease requiring therapy that could potentially impair fertility. Testicular tissue collection might be offered to postpubertal boys; nevertheless, its use has been unsuccessful to date. Oocyte collection after hormonal hyperstimulation should be offered to postpubertal girls facing gonadotoxic therapies that could be delayed for the 2 weeks required for the procedure. Ovarian tissue collection could be offered to pre-/post-pubertal girls. Pregnancies have been reported after postpubertal ovarian tissue reimplantation; however, to date, no pregnancy has been reported after the reimplantation of prepubertal ovarian tissue or in vitro maturation of pre-/post-pubertal ovarian tissue. Possible future advances in reproductive medicine could change this scenario. Health authorities should prioritize fertility preservation projects in pediatric transplantation to improve patient care and quality of life.

Oral Health in Young Australian Aboriginal Children

Despite dedicated government funding, Aboriginal Australians, including children, experience more dental disease than other Australians, despite it being seen as mostly preventable. The ongoing legacy of colonization and discrimination against Aboriginal Australians persists, even in health services. Current neoliberal discourse often holds individuals responsible for the state of their health, rather than the structural factors beyond individual control. While presenting a balanced view of Aboriginal health is important and attests to Indigenous peoples’ resilience when faced with persistent adversity, calling to account those structural factors affecting the ability of Aboriginal people to make favorable oral health choices is also important. A decolonizing approach informed by Indigenous methodologies and whiteness studies guides this article to explore the perceptions and experiences of Aboriginal parents ( N = 52) of young children, mainly mothers, in Perth, Western Australia, as they relate to the oral health. Two researchers, 1 Aboriginal and 1 non-Aboriginal, conducted 9 focus group discussions with 51 Aboriginal participants, as well as 1 interview with the remaining individual, and independently analyzed responses to identify themes underpinning barriers and enablers to oral health. These were compared, discussed, and revised under key themes and interpreted for meanings attributed to participants’ perspectives. Findings indicated that oral health is important yet often compromised by structural factors, including policy and organizational practices that adversely preclude participants from making optimal oral health choices: limited education about prevention, prohibitive cost of services, intensive marketing of sugary products, and discrimination from health providers resulting in reluctance to attend services. Current government intentions center on Aboriginal–non-Aboriginal partnerships, access to flexible services, and health care that is free of racism and proactively seeks and welcomes Aboriginal people. The challenge is whether these good intentions are matched by policies and practices that translate into sustained improvements to oral health for Aboriginal Australians.

Knowledge Transfer Statement: Slow progress in reducing persistent oral health disparities between Aboriginal and non-Aboriginal Australians calls for a new approach to this seemingly intractable problem. Findings from our qualitative research identified that structural factors—such as cost of services, little or no education on preventing oral disease, and discrimination by health providers—compromised Aboriginal people’s optimum oral health choices and access to services. The results from this study can be used to recommend changes to policies and practices that promote rather than undermine Aboriginal health and well-being and involve Aboriginal people in decisions about their health care.

Shaping dental contract reform: a clinical and cost-effective analysis of incentive-driven commissioning for improved oral health in primary dental care

OBJECTIVE

To evaluate the clinical and cost-effectiveness of a new blended dental contract incentivising improved oral health compared with a traditional dental contract based on units of dental activity (UDAs).

DESIGN

Non-randomised controlled study.

SETTING

Six UK primary care dental practices, three working under a new blended dental contract; three matched practices under a traditional contract.

PARTICIPANTS

550 new adult patients.

INTERVENTIONS

A new blended/incentive-driven primary care dentistry contract and service delivery model versus the traditional contract based on UDAs.

MAIN OUTCOME MEASURES

Primary outcome was as follows: percentage of sites with gingival bleeding on probing. Secondary outcomes were as follows: extracted and filled teeth (%), caries (International Caries Detection and Assessment System (ICDAS)), oral health-related quality of life (Oral Health Impact Profile-14 (OHIP-14)). Incremental cost-effective ratios used OHIP-14 and quality adjusted life years (QALYs) derived from the EQ-5D-3L.

RESULTS

At 24 months, 291/550 (53%) patients returned for final assessment; those lost to follow-up attended 6.46 appointments on average (SD 4.80). The primary outcome favoured patients in the blended contract group. Extractions and fillings were more frequent in this group. Blended contracts were financially attractive for the dental provider but carried a higher cost for the service commissioner. Differences in generic health-related quality of life were negligible. Positive changes over time in oral health-related quality of life in both groups were statistically significant.

CONCLUSIONS

This is the first UK study to assess the clinical and cost-effectiveness of a blended contract in primary care dentistry. Although the primary outcome favoured the blended contract, the results are limited because 47% patients did not attend at 24 months. This is consistent with 39% of adults not being regular attenders and 27% only visiting their dentist when they have a problem. Promotion of appropriate attendance, especially among those with high need, necessitates being factored into recruitment strategies of future studies.

Occult Metastases in Pelvic Lymphadenectomy Specimens From Patients With Urothelial Carcinoma of the Bladder

OBJECTIVE

To identify occult metastases within lymph nodes (LNs) reported as negative by routine histologic evaluation. In patients with high-grade, muscle-invasive urothelial carcinoma (UC) of the bladder, pelvic lymphadenectomy during radical cystectomy demonstrates a survival advantage, increasing with the number of LNs removed, even if negative for metastatic disease. This finding may potentially be explained by the presence of occult metastases.

MATERIALS AND METHODS

Radical cystectomy specimens with high-grade UC invading the perivesical tissue and negative LNs (pT3N0) between 2000 and 2014 were reviewed. Five levels were cut for each LN block. Two sections were cut per level: 1 stained for hematoxylin and eosin and 1 for AE1/AE3. Micrometastases were defined as tumor deposits >0.2 mm but <2 mm. Isolated tumor cells were defined as ≤0.2 mm. Medical records and survival data were reviewed.

RESULTS

We identified 21 cases, consisting of 370 lymph nodes. Six of 21 patients (29%) had occult metastases, including 5 occult metastatic UC and 1 occult metastatic prostate adenocarcinoma. There were 10 positive LNs; 2 macrometastases, 2 micrometastases, and 6 with ITCs. Two of 6 patients (33%) had lymphovascular invasion identified in the primary tumor. Kaplan-Meier analysis showed no significant difference in overall survival between the group of patients who remained N0 versus those upstaged due to discovery of occult metastases (P-value = .42).

CONCLUSION

In patients with pT3 UC undergoing cystectomy, we demonstrated the presence of occult metastases in 29% of patients. The high percentage of occult metastases present in these cases possibly explains the proven survival advantage of removing "negative" LNs. This finding might also have implications in the histologic evaluation of LNs.

Lothian and Forth Valley Leg Ulcer Healing Trial, Part 2: Knitted Viscose Dressing versus a Hydrocellular Dressing in the Treatment of Chronic Leg Ulceration

Objective:

To compare a new ‘advanced’ hydrocellular Polyurethane dressing (HPD) (Allevyn) with a traditional simple non-adherent knitted viscose dressing (KDV) (Tricotex) in the treatment of chronic venous leg ulcers.

Design:

A randomized trial of factorial design, with interaction testing, to allow the evaluation of two different therapeutic components (dressing and bandages) within a single trial. The treatment period was 12 weeks or until healing, whichever occurred sooner.

Setting:

The Leg Ulcer Clinics of Edinburgh and Falkirk and District Royal Infirmaries, Scotland.

Patients:

132 patients with chronic venous leg ulcers were randomized, 66 to HPD and 66 to KVD. Principal exclusions were patients with diabetes, rheumatoid disease or Doppler ankle/brachial pressure indices of less than 0.8. There were 28 withdrawals (15 KVD, 13 HPD). These were considered as treatment failures.

Interventions:

Dressings and bandaging were applied by specialist leg ulcer nurses using standard techniques throughout, the bandaging being randomized to either elastic or non-elastic multilayer systems.

Main outcome measure:

The principal end-point was ulcer healing. Also monitored were healing rates, pain and the frequency of dressing changes.

Results:

Pain relief was significantly better in the HPD group ( p=0.01). Thirty-one (47%) of the HPD patients healed within 12 weeks compared with only 23 (35%) of the those treated with KVD (95% confidence limits for difference, −5% to +29%). The higest healing rates (61% for all ulcers and 74% for those less than 10 cm2) were observed in the subgroup in which HPD was used in combination with an elastic bandaging system.

Conclusion:

Patients treated with HPD did significantly better in terms of pain relief, although the higher healing rates observed in this group failed to reach significance at the 5% level.

Lothian and Forth Valley Leg Ulcer Healing Trial, Part 1: Elastic versus Non-Elastic Bandaging in the Treatment of Chronic Leg Ulceration

Objective:

To determine whether elastic or non-elastic bandaging is more effective in healing chronic venous ulcers.

Design:

Randomized trial with factorial design and interaction analysis, enabling independent evaluation of both bandaging and dressings within the single-trial format. The duration of treatment was 12 weeks or until ulcer-healing, whichever occurred sooner.

Setting:

The Leg Ulcer Clinics of Edinburgh and Falkirk and District Royal Infirmaries, Scotland.

Patients:

132 patients with chronic leg ulcers and clinical evidence of chronic venous disease, and excluding those with Doppler ultrasound ankle/brachial pressure indices of less than 0.8, diabetes or rheumatoid disease. There were 28 withdrawals who were classified for analysis as treatment failures.

Interventions:

Elastic or non-elastic multilayer bandage systems were applied using similar application techniques by a team of trained nurse specialists. All other treatments were standardized, including the randomization of dressings to either a knitted viscose or a hydrocellular polyurethane dressing.

Main outcome measure:

Complete ulcer healing.

Results:

In the elastic group 35 out of 65 ulcers (54%) healed within 12 weeks compared with 19 out of 67 (28%) in the non-elastic group (95% confidence limits for percentage healed, 9% to 42%). Ulcer pain was also reported significantly less often in the elastic group (48% of visits versus 29%; p=0.03).

Conclusion:

When applied by similar multilayer bandaging techniques, elastic bandaging was significantly better than non-elastic bandaging in the treatment of chronic venous leg ulcer.

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

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

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

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

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

Overcoming structural inequalities in oral health: the role of dental curricula

To date the role of health professional schools in addressing oral health inequalities have been minimal, as attempts have focused principally upon systemic reform and broader societal obligations. Professionalism is a broad competency that is taught throughout dental schools and encompasses a range of attributes. Professionalism as a competency draws some debate and appears to be a shifting phenomenon. We may ask if professionalism in the dental curricula may be better addressed by social accountability? Social accountability directs oral health professional curricula (education, research, and service activities) towards addressing the priority health concerns of the community, in our case oral health inequalities. Although working toward dental schools becoming more socially accountable seems like a sensible way to address oral health inequalities, it might have limitations. We will consider some of the challenges in the dental curricula by considering some of the political, structural, social and ethical factors that influence our institutions and our graduates.

Aroma formation by immobilized yeast cells in fermentation processes

Immobilized cell technology has shown a significant promotional effect on the fermentation of alcoholic beverages such as beer, wine and cider. However, genetic, morphological and physiological alterations occurring in immobilized yeast cells impact on aroma formation during fermentation processes. The focus of this review is exploitation of existing knowledge on the biochemistry and the biological role of flavour production in yeast for the biotechnological production of aroma compounds of industrial importance, by means of immobilized yeast. Various types of carrier materials and immobilization methods proposed for application in beer, wine, fruit wine, cider and mead production are presented. Engineering aspects with special emphasis on immobilized cell bioreactor design, operation and scale-up potential are also discussed. Ultimately, examples of products with improved quality properties within the alcoholic beverages are addressed, together with identification and description of the future perspectives and scope for cell immobilization in fermentation processes.

Graduate nurses' learning trajectories and experiences of problem based learning: a focused ethnography study

BACKGROUND

Problem-based learning seeks to foster active, collaborative and self directed learning. It is increasingly utilized in health professional education; however, it is difficult to ascertain effectiveness. Empirically, student satisfaction does not match academic achievement but the reasons for this are unclear.

OBJECTIVE

To explore the experience trajectories and satisfaction of graduates who had completed an undergraduate problem-based learning nursing program.

DESIGN AND METHODS

Qualitative focused ethnography using individual and group semi-structured interviews. Categories and themes were identified using inductive constant comparison. A comparative matrix analysis of differing levels of the two core processes illuminated specific experience profiles.

PARTICIPANTS AND SETTING

Forty five program graduates who had graduated between one and nine years previously from a Western Canadian program offered at four academic sites. The sample was mostly female (n=37), aged 26-30 years (n=23) and graduated 5-8 years previously (n=20).

RESULTS

Levels of satisfaction with the program varied markedly. Two core processes contributed to this: "understanding" and "valuing" problem-based learning. Specific experience profiles included: "Happy as fish in water" which represents those who understood and valued the approach, and flourished; "I'll do it but I won't like it" reflects those who understood and could adjust to the academic context but did not particularly value it; "I just want to be a nurse" characterized those who consistently disliked and resisted the process but endured in order to graduate. Each profile was characterized by attitudes, intentions, learning preferences and program satisfaction.

CONCLUSIONS

We theorize an underlying mechanism explaining these diverse levels of satisfaction are differing orientations to studying. This approach to understanding how students typically approach learning is strongly linked to perceptions of academic quality and program satisfaction in higher education research, although it has been neglected in nursing problem-based learning research. Orientations to studying include reproductive surface learning, deep learning for understanding and meaning, and strategic approaches to maximize desired objectives. These orientations are congruent with the descriptive typologies developed in this research. This provides an effective explanation as to why some students adapt easily and flourish in problem-based learning contexts, while others continually struggle to adapt. Further research is needed to determine the relationship between deep, surface, and strategic orientations to study and student satisfaction in nursing programs.

Retrospective study of alemtuzumab vs ATG-based conditioning without irradiation for unrelated and matched sibling donor transplants in acquired severe aplastic anemia: a study from the British Society for Blood and Marrow Transplantation

This retrospective national study compared the use of alemtuzumab-based conditioning regimens for hematopoietic SCT (HSCT) in acquired severe aplastic anemia with antithymocyte globulin (ATG)-based regimens. One hundred patients received alemtuzumab and 55 ATG-based regimens. A matched sibling donor (MSD) was used in 87 (56%), matched unrelated donor (MUD) in 60 (39%) and other related or mismatched unrelated donor (UD) in 8 (5%) patients. Engraftment failure occurred in 9% of the alemtuzumab group and 11% of the ATG group. Five-year OS was 90% for the alemtuzumab and 79% for the ATG groups, P=0.11. For UD HSCT, OS of patients was better when using alemtuzumab (88%) compared with ATG (57%), P=0.026, although smaller numbers of patients received ATG. Similar outcomes for MSD HSCT using alemtuzumab or ATG were seen (91% vs 85%, respectively, P=0.562). A lower risk of chronic GVHD (cGVHD) was observed in the alemtuzumab group (11% vs 26%, P=0.031). On multivariate analysis, use of BM as stem cell source was associated with better OS and EFS, and less acute and cGVHD; young age was associated with better EFS and lower risk of graft failure. This large study confirms successful avoidance of irradiation in the conditioning regimens for MUD HSCT patients.

Video diaries to capture children's participation in the dental GA pathway

AIM

To explore children's experiences of having teeth extracted under general anaesthetic, with a focus on opportunities to participate in their care pathway.

STUDY DESIGN

Qualitative study where analysis was informed by a narrative approach.

METHODS

Ten fit and healthy children, aged 6-11 years, who required multiple dental extractions under general anaesthesia at a UK Children's Hospital, participated in the study. Participants were invited to keep a video diary of their thoughts and experiences leading up to, and following, their hospital admission. Data collection was supported by two semi-structured home interviews.

RESULTS

Three themes emerged relating to participation: (i) children's prior knowledge and expectations of the dental general anaesthetic (DGA); (ii) their role in decision-making about the DGA and (iii) opportunities identified by children to actively participate in their care pathway. Children's feedback suggested that they did not feel fully informed or involved in decisions about the procedure and were upset about not being able to keep their extracted teeth.

CONCLUSIONS

Child-centred resources and decision-aids may be helpful in providing greater opportunities for children to participate in their DGA pathway. However, considerable challenges lie in engaging children without increasing pre-DGA anxiety or conflicting with parents' views about what is best for their child.

Social reinforcement delays in free-flying honey bees (Apis mellifera L.)

Free-flying honey bees (Apis mellifera L.) reactions were observed when presented with varying schedules of post-reinforcement delays of 0 s, 300 s, or 600 s. We measured inter-visit-interval, response length, inter-response-time, and response rate. Honey bees exposed to these post-reinforcement delay intervals exhibit one of several patterns compared to groups not encountering delays, and had longer inter-visit-intervals. We observed no group differences in inter-response time. Honey bees with higher response rates tended to not finish the experiment. The removal of the delay intervals increased response rates for those subjects that completed the trials.