Efficacy and safety of a synthetic biotic for treatment of phenylketonuria: a phase 2 clinical trial

Despite available treatment options, many patients with phenylketonuria (PKU) cannot achieve target plasma phenylalanine (Phe) levels1. We previously modified Escherichia coli Nissle 1917 to metabolize Phe in the gut after oral administration (SYNB1618) and designed a second strain (SYNB1934) with enhanced activity of phenylalanine ammonia lyase2,3. In a 14-day open-label dose-escalation study (Synpheny-1, NCT04534842 ), we test a primary endpoint of change from baseline in labeled Phe (D5-Phe AUC0-24; D5-Phe area under the curve (AUC) over 24 hours after D5-Phe administration) in plasma after D5-Phe challenge in adult participants with screening Phe of greater than 600 µM. Secondary endpoints were the change from baseline in fasting plasma Phe and the incidence of treatment-emergent adverse events. A total of 20 participants (ten male and ten female) were enrolled and 15 completed the study treatment. Here, we show that both strains lower Phe levels in participants with PKU: D5-Phe AUC0-24 was reduced by 43% from baseline with SYNB1934 and by 34% from baseline with SYNB1618. SYNB1934 led to a decrease in fasting plasma Phe of 40% (95% CI, -52, -24). There were no serious adverse events or infections. Four participants discontinued because of adverse events, and one withdrew during the baseline period. We show that synthetic biotics can metabolize Phe in the gut, lower post-prandial plasma Phe levels and lower fasting plasma Phe in patients with PKU.

Assessing Changes in Stethoscope Hygiene During COVID-19: A Multicentre Cross-Sectional Study

Background

The COVID-19 (SARS-CoV-2) pandemic has increased infection control vigilance across several modes of patient contact. However, it is unknown whether hygiene pertaining to stethoscopes, which carry the potential for pathogenic contamination, has also shifted accordingly.

Aim

To characterize pandemic-related changes in stethoscope hygiene.

Methods

We surveyed healthcare providers at three major medical centres. Questions quantitatively (Likert scale and frequency) assessed stethoscope hygiene beliefs and practices with two components: before and during COVID-19. Participants were grouped based on performance of optimal stethoscope hygiene (after every patient) before and during COVID-19. Groups were compared using χ² and analysis of variance (ANOVA).

Findings

Of the 515 (10%) who completed the survey, 55 were excluded (N = 460). Optimal hygiene increased from 27.4% to 55.0% (P < 0.001). There were significant increases in Likert scores for all questions pertaining to knowledge of stethoscope contamination (P < 0.001). Belief in stethoscope contamination increased (P < 0.001) despite no change in perceived hygiene education. Resident physicians were less likely compared with attending physicians and nurses to have adopted optimal hygiene during COVID-19 (P < 0.001).

Conclusion

Despite a positive shift in stethoscope hygiene during COVID-19, optimal hygiene was still only performed by around half of providers. Educational interventions, particularly targeting early-career providers, are encouraged.

646 A Review of The Urodynamic Referral Pathway and The Accuracy of Urodynamic Study Requests

Aim

Urodynamic studies (UDS) are physiological measurements of voiding and storage function of the lower urinary tract that are commonly performed in clinical practice to investigate bothersome lower urinary tract symptoms. Despite considerable efforts to improve UDS, standardisation of the practice remains to be challenging. This audit thus, presents a review the current UDS referral process and analysis of the clinical details included on urodynamic requests.

Method

This audit included retrospective data from 112 patients between March and Oct 2020, 98 of which had UDS performed. Patient electronic records, referral forms and clinic letters were all used for data collection.

Results

Data shows that 47% of patients were females with average age of 56 years, range (16-86) years. The reason of UDS was clearly stated in 8 referrals only and the clinical examination findings were clearly mentioned in 31% only. More than three quarters of patients (i.e., 77%) had assessment of post void residual prior to UDS, but half of the proportion had no history of relevant medications. In 98 patients who had UDS done, the main findings showed that 4 patients had normal studies, 3 with dysfunctional voiding, 7 had bladder outflow obstruction, 32 patients were diagnosed with detrusor overactivity, 12 had stress incontinence and 7 showed detrusor underactivity.

Conclusions

Finding of this audit clearly suggest a level of unclarity in the great majority of referrals. Evidently, key history of relevant medication is overlooked in half of the referrals. Improvements to the current pathway to UDS is therefore pivotal.

Phenylketonuria

Phenylketonuria (PKU; also known as phenylalanine hydroxylase (PAH) deficiency) is an autosomal recessive disorder of phenylalanine metabolism, in which especially high phenylalanine concentrations cause brain dysfunction. If untreated, this brain dysfunction results in severe intellectual disability, epilepsy and behavioural problems. The prevalence varies worldwide, with an average of about 1:10,000 newborns. Early diagnosis is based on newborn screening, and if treatment is started early and continued, intelligence is within normal limits with, on average, some suboptimal neurocognitive function. Dietary restriction of phenylalanine has been the mainstay of treatment for over 60 years and has been highly successful, although outcomes are still suboptimal and patients can find the treatment difficult to adhere to. Pharmacological treatments are available, such as tetrahydrobiopterin, which is effective in only a minority of patients (usually those with milder PKU), and pegylated phenylalanine ammonia lyase, which requires daily subcutaneous injections and causes adverse immune responses. Given the drawbacks of these approaches, other treatments are in development, such as mRNA and gene therapy. Even though PAH deficiency is the most common defect of amino acid metabolism in humans, brain dysfunction in individuals with PKU is still not well understood and further research is needed to facilitate development of pathophysiology-driven treatments.

The logistical management of tertiary urethral disease in the United Kingdom: Implications from an online audit of male reconstructive urethral surgery

Objective:

To determine those patient groupings, based on volume and risk, whose optimal urethral reconstructive management might be provided by a reorganisation of UK reconstructive surgeons.

Methods:

Between 2010 and 2017, ~689 men/year were enrolled onto an online audit platform collecting data about urethral reconstruction in the UK; this accrual was compared against hospital episode statistics (HES). The available workforce, and where this was based, was collected. Individual and institutional incumbent patient volumes, pathology, surgical complexity and outcomes from treatment were collated to stratify volume/risk groups.

Results:

More than 90% of all HES-recorded data were accrued, being provided by 50 surgeons at 39 operative sites. Most reconstructive surgery was provided at 10 centres performing >20 procedures/year. More than 50% of all interventions were of a high-volume low-risk type. Of activity, 32.3% was intermediate volume or moderate risk, and 12.5% of men presented for lower-volume or higher-risk procedures.

Conclusion:

Correlation of detailed volume/outcome data allows the definition of patient populations presenting for urethral reconstruction. Stratification of each group’s management, to optimise the surgical outcome, may be applied to a hierarchical service delivery model based on the complexity of the patient’s presenting urethral pathology.

Level of evidence:

Level IV

Long-term comparative effectiveness of pegvaliase versus standard of care comparators in adults with phenylketonuria

Phenylketonuria (PKU) is caused by phenylalanine hydroxylase (PAH) deficiency, resulting in high blood and brain Phenylalanine (Phe) concentrations that can lead to impaired brain development and function. Standard treatment involves a Phe-restricted diet alone or in conjunction with sapropterin dihydrochloride in responsive patients. The Food and Drug Administration approved pegvaliase enzyme substitution therapy for adults with blood Phe >600 μmol/L in the US. Recently, the European Commission also approved pegvaliase for treatment of PKU patients aged 16 years or older with blood Phe >600 μmol/L. The analyses presented below were conducted to provide comparative evidence on long-term treatment effectiveness of pegvaliase versus standard of care in adults with PKU. Adult patients (≥18 years) with baseline blood Phe >600 μmol/L who had enrolled in the pegvaliase phase 2 and phase 3 clinical trials were propensity score-matched to historical cohorts of patients treated with "sapropterin + diet" or with "diet alone". These cohorts were derived from the PKU Demographics, Outcome and Safety (PKUDOS) registry and compared for clinical outcomes including blood Phe concentration and natural intact protein intake after 1 and 2 years. Propensity scores were estimated using logistic regression with probability of treatment as outcome (i.e. pegvaliase, "sapropterin + diet", or "diet alone") and patient demographic and disease severity covariates as predictors. An additional analysis in adult PKU patients with baseline blood Phe ≤600 μmol/L comparing non-matched patient groups "sapropterin + diet" to "diet alone" using PKUDOS registry data only was also conducted. The analyses in patients with baseline blood Phe >600 μmol comparing pegvaliase with "sapropterin + diet" (N = 64 matched pairs) showed lower mean blood Phe concentrations after 1 and 2 years with pegvaliase (505 and 427 μmol/L) versus "sapropterin + diet" (807 and 891 μmol/L); mean natural intact protein intake after 1 and 2 years was 49 and 57 g/day respectively with pegvaliase versus 23 and 28 g/day with "sapropterin + diet". The analysis comparing pegvaliase with "diet alone" (N = 120 matched pairs) showed lower mean blood Phe at 1 and 2 years with pegvaliase (473 and 302 μmol/L) versus "diet alone" (1022 and 965 μmol/L); mean natural intact protein intake after 1 and 2 years was 47 and 57 g/day with pegvaliase and 27 and 22 g/day with "diet alone". Considerably more patients achieved blood Phe ≤600, ≤360, and ≤120 μmol/L and reductions from baseline of ≥20%, ≥30%, and ≥50% in blood Phe after 1 and 2 years of pegvaliase versus standard treatments. The analysis in patients with baseline blood Phe ≤600 μmol/L showed lower blood Phe after 1 and 2 years with "sapropterin + diet" (240 and 324 μmol/L) versus "diet alone" (580 and 549 μmol/L) and greater percentages of patients achieving blood Phe targets ≤600, ≤360, and ≤120 μmol/L and reductions from baseline of ≥20%, ≥30%, and ≥50% in blood Phe. These results support pegvaliase as the more effective treatment option to lower Phe levels in adults with PKU who have difficulty keeping blood Phe ≤600 μmol/L with "diet alone". For patients with blood Phe ≤600 μmol/L, adding sapropterin to dietary management is an appropriate treatment option, for those responsive to the treatment.

Long-term relationships between screening rates, breast cancer characteristics, and overdiagnosis in US counties, 1975-2009

Effects of mammography screening in the general population are disputed. Screening rates differ greatly between US counties, providing a natural opportunity to investigate effects of screening. We compared mammography screening rates with the types and outcomes of breast cancers diagnosed in US counties. The county screening rate was defined as the proportion of women age ≥40 with ≥1 mammogram in the past 2 years (range, 34-91%). Two periods were analyzed: 1975-2009 (612,941 breast cancer cases, 195 counties) and 1996-2009 (645,057 cases, 211-547 counties). Multiple signs of overdiagnosis were observed: First, breast cancer incidence increased as screening became common. Second, incidence stopped increasing once screening rates stabilized. Third, the increases in incidence were limited to age groups receiving screening. Fourth, the increases were larger in counties where screening became more common. Fifth, the increases were limited to small and early-stage breast cancers (which are consistent with overdiagnosis). Sixth, compensatory reductions in large and advanced-stage breast cancers were much smaller than the increases. Difference-in-differences regression analysis suggested 31% (95% CI: 28-34%) of breast cancers diagnosed in 1996-2009 were overdiagnosed. Screening rates correlated with increased incidence for all hormone receptor statuses, HER2 statuses, and grades. Reductions in breast cancer mortality during 1975-2009 were similar in screened and unscreened age groups. Overall, we found repeated signs that breast cancer overdiagnosis is widespread in the US, but the biological nature of overdiagnosed tumors remains unclear. Mortality benefits of screening, though they may be present and substantial, could not be detected at the population level.

Urinary tract infection management – do the guidelines agree?

Urinary tract infection (UTI) is defined as the inflammatory response of the urothelium to bacterial invasion. UTI in adults is one of the most prevalent infectious diseases worldwide with a substantial financial burden on society. There is mounting concern surrounding the ongoing development of microbial resistance. In addition, the increasing resistance of organisms to broad-spectrum antibiotics is worrying. There is a continuing drive for antibiotic stewardship and more prudent prescribing of antimicrobial agents. There is currently no national UK guideline on the management of UTI in adults but the EAU, AUA and SIGN all have their separate recommendations. In this review, we discuss the existing guideline recommendations particularly relating to lower UTIs (cystitis and epididymo-orchitis), upper UTIs (pyelonephritis) and catheter-associated infections (due to their large healthcare burden). The aims are to identify common recommendations and assess how they may apply for the UK setting. This review has highlighted considerable differences in practice recommendations between the major UK, European and American guidelines. Discrepancy exists in the choice of antibiotics and for some types of infection, whether or not any guidance for treatment is offered. Antibiotic avoidance and prudent antibiotic prescribing will be key components of future strategies in reducing antimicrobial resistance.

Using non-nutritive sucking to support feeding development for premature infants: A commentary on approaches and current practice

Non-nutritive sucking is often used with premature infants by either using a pacifier or an expressed breast nipple to support the introduction and development of early oral feeding. The pattern of non-nutritive sucking is distinct in that it involves two sucks per second in contrast to nutritive sucking which is one suck per second. Although some literature has identified that non-nutritive sucking has some benefit for the premature infant's feeding development, it is not entirely clear why such an approach is helpful as neurologically, activation of non-nutritive and nutritive skills are different. A summary is presented of the main approaches that use non-nutritive sucking with reference to the literature. This paper also considers other factors and beneficial approaches to managing the introduction of infant feeding. These are: the infant's toleration of enteral feeds pre oral trials, overall development and gestational age when introducing oral experiences, developing swallowing skills before sucking, physiological stability, health status, as well as the development and interpretation of infant oral readiness signs and early communication.

Publication rate of abstracts presented at the British Association of Urological Surgeons Annual Meeting – 10 years on

Introduction:

Acceptance of abstracts at the BAUS Annual Meeting is sought after by trainees and encouraged by trainers; however, it is the publication of this research in a peer-reviewed journal that validates the significance of the work. We aimed to compare current publication rates with those detailed in a previous study 10 years ago to examine for changes on the rate and time to peer-reviewed publications of abstracts presented. We also assessed whether there was a difference in the presentation and publication rates between UK deaneries.

Methods:

All abstracts accepted for presentation at the annual BAUS 2012 and 2013 meetings were identified from the published supplements in the BJU International journal. Listed abstracts were searched for in October 2015 using the Medline Plus (PubMed) database to assess for successful conversion to a peer-reviewed paper listed on the Medline database.

Results:

In total 281 abstracts were presented; of these, 265 (94.3%) were from the UK. A total of 24.2% of the abstracts presented over the two-year period resulted in a successful conversion to a peer-reviewed publication. Mean time to publication was 11.59 months and mean impact factor of the publishing journal was 3.854. There appeared to be no correlation between the number of abstracts presented per deanery and the subsequent successful conversion to peer-reviewed publication.

Conclusions:

There has been a decline over the past decade in the number of BAUS abstracts being successfully converted into peer-reviewed publications, from 42% to 24.2%. The quality of any scientific meeting can be quantified by the number of peer-reviewed publications arising from its abstracts. Possible reasons for this observed reduction include a lack of time to prepare manuscripts, the actual quality and relevance of work being presented and data that may be of questionable validity. In addition, indicative numbers set for publications to enable successful awarding of Certificate of Completion of Training are low.

Posterior tibial nerve stimulation in adults with overactive bladder syndrome: A systematic review of the literature

Overactive bladder (OAB) is a common condition that can significantly impact on a patient’s quality of life. Treatments include conservative methods (patient education, lifestyle modifications, bladder retraining), pharmacotherapy (anticholinergics and adrenoreceptor agonists), intravesical botulinum toxin A injections and surgical strategies (including neuromodulation, augmentation cystoplasty and urinary diversion). There has been increased interest in neuromodulation over recent years and accumulating evidence for percutaneous tibial nerve stimulation (PTNS). We have reviewed the currently available clinical evidence in a systematic, reproducible fashion. PTNS has been shown in randomised controlled studies (against sham/placebo and against anticholinergics) to be safe and effective in treating OAB. Cost effectiveness analyses for PTNS have shown mixed results depending on the length of follow-up. PTNS is a useful adjunct to therapy in OAB for patients who have failed conservative and pharmacotherapy. Further research is required to define its place in the OAB treatment algorithm.

Patients' ratings of genetic conditions validate a taxonomy to simplify decisions about preconception carrier screening via genome sequencing

Advances in genome sequencing and gene discovery have created opportunities to efficiently assess more genetic conditions than ever before. Given the large number of conditions that can be screened, the implementation of expanded carrier screening using genome sequencing will require practical methods of simplifying decisions about the conditions for which patients want to be screened. One method to simplify decision making is to generate a taxonomy based on expert judgment. However, expert perceptions of condition attributes used to classify these conditions may differ from those used by patients. To understand whether expert and patient perceptions differ, we asked women who had received preconception genetic carrier screening in the last 3 years to fill out a survey to rate the attributes (predictability, controllability, visibility, and severity) of several autosomal recessive or X-linked genetic conditions. These conditions were classified into one of five taxonomy categories developed by subject experts (significantly shortened lifespan, serious medical problems, mild medical problems, unpredictable medical outcomes, and adult-onset conditions). A total of 193 women provided 739 usable ratings across 20 conditions. The mean ratings and correlations demonstrated that participants made distinctions across both attributes and categories. Aggregated mean attribute ratings across categories demonstrated logical consistency between the key features of each attribute and category, although participants perceived little difference between the mild and serious categories. This study provides empirical evidence for the validity of our proposed taxonomy, which will simplify patient decisions for results they would like to receive from preconception carrier screening via genome sequencing.

A study examining the relationship between alexithymia and challenging behaviour in adults with intellectual disability

BACKGROUND

Research suggesting that people with intellectual disabilities (ID) have difficulties in recognising emotions provides a rationale for studying alexithymia in this population. A number of studies have found a relationship between alexithymia and challenging behaviours in various populations and this study aims to discover if this is the case for people with ID.

METHOD

Cross-sectional data were collected from 96 participants with ID and 95 of their carers. The service user participants completed an alexithymia questionnaire for children while carers completed the checklist for challenging behaviour and the observer alexithymia scale. Correlational analyses were employed to explore relationships between the variables.

RESULTS

The relationship between service user and carer-rated alexithymia was very weak. The analysis did show significant associations between observer-rated alexithymia and challenging behaviour frequency, management difficulty and severity, but there was no significant relationship between challenging behaviour and alexithymia as rated by service users themselves.

CONCLUSIONS

This study suggests that observer-rated alexithymia is important in understanding challenging behaviour presented by people with ID. Service user-rated alexithymia had no association with challenging behaviour, in contrast to the results from similar research with other challenging populations.

How does non-nutritive sucking support infant feeding?

Fifty nine premature infants participated in a randomized controlled study to determine the effectiveness of non-nutritive sucking (NNS). It was predicted that NNS would not accelerate the development of full oral feeding or early language skills as sometimes perceived in practice. However, it was predicted that using NNS as a strategy to support parents to identify and respond to early communication and oral readiness signs would increase confidence in infant management and enable quicker discharge home. Infants were aged 26-35 weeks gestation. Infants with no significant difficulties were randomly assigned to one of three groups; Group 1, NNS pre-tube feeding (n=19); Group 2, NNS on onset of tube feeding (n=20) and Group 3, Control (n=20). Follow-up occurred at 6 months. There were no significant differences with number of days to full oral feeding between the groups receiving NNS and the Control group, χ2(2, n=59)=4.33, p=.115. A significant difference in number of days in hospital between the Control group and the other two groups was found χ2 (2, n=59)=7.678, p=.022. Significant changes were noted with the development of more normal sucking patterns in Groups 1-3. At 6 months there were no significant differences in receptive or expressive language skills between all groups. NNS had no significant impact on the transition to full oral feeding or later language development. There was a significant difference in the number of days in hospital between the Control group and the other two groups which involved parents in identification of early communication signs. Possible reasons for this change and future directions are discussed.

Elevated phenylacetic acid levels do not correlate with adverse events in patients with urea cycle disorders or hepatic encephalopathy and can be predicted based on the plasma PAA to PAGN ratio

BACKGROUND

Phenylacetic acid (PAA) is the active moiety in sodium phenylbutyrate (NaPBA) and glycerol phenylbutyrate (GPB, HPN-100). Both are approved for treatment of urea cycle disorders (UCDs) - rare genetic disorders characterized by hyperammonemia. PAA is conjugated with glutamine in the liver to form phenylacetyleglutamine (PAGN), which is excreted in urine. PAA plasma levels ≥ 500 μg/dL have been reported to be associated with reversible neurological adverse events (AEs) in cancer patients receiving PAA intravenously. Therefore, we have investigated the relationship between PAA levels and neurological AEs in patients treated with these PAA pro-drugs as well as approaches to identifying patients most likely to experience high PAA levels.

METHODS

The relationship between nervous system AEs, PAA levels and the ratio of plasma PAA to PAGN were examined in 4683 blood samples taken serially from: [1] healthy adults [2], UCD patients of ≥ 2 months of age, and [3] patients with cirrhosis and hepatic encephalopathy (HE). The plasma ratio of PAA to PAGN was analyzed with respect to its utility in identifying patients at risk of high PAA values.

RESULTS

Only 0.2% (11) of 4683 samples exceeded 500 μg/ml. There was no relationship between neurological AEs and PAA levels in UCD or HE patients, but transient AEs including headache and nausea that correlated with PAA levels were observed in healthy adults. Irrespective of population, a curvilinear relationship was observed between PAA levels and the plasma PAA:PAGN ratio, and a ratio>2.5 (both in μg/mL) in a random blood draw identified patients at risk for PAA levels>500 μg/ml.

CONCLUSIONS

The presence of a relationship between PAA levels and reversible AEs in healthy adults but not in UCD or HE patients may reflect intrinsic differences among the populations and/or metabolic adaptation with continued dosing. The plasma PAA:PAGN ratio is a functional measure of the rate of PAA metabolism and represents a useful dosing biomarker.

The role of uroflowmetry in the assessment and management of men with lower urinary tract symptoms – revisiting the evidence

Uroflowmetry is variably used for the assessment of men with lower urinary tract symptoms (LUTS). There is discrepancy in practice guidelines regarding recommendations for use of uroflowmetry in the initial assessment of men with LUTS. To explain this discrepancy, we systematically reviewed relevant literature to detail currently available evidence and identify evidence gaps requiring further research. PubMED, EMBASE and Medline literature databases were searched for the period between January 1970 and July 2012 to identify articles pertaining to uroflowmetry and outcomes of treatment for men with LUTS. We identified 30 studies for inclusion – none of which had a randomised design. The majority of the studies were prospective or retrospective cohort studies with some cross-sectional and observational reports. The methodology of measurement and reporting urine flow rate has been standardised by reports from the International Continence Society. The current available literature on the reproducibility of urine flow rate is inconclusive and suggests that there may be variability between measurements for a number of different reasons and that repeated tests could be of value clinically. There is also general agreement that a Qmax cut-off of 10 ml/s−1 is suggestive of bladder outlet obstruction. Despite guideline recommendations, there remains a lack of high-quality evidence from studies with robust design to fully ascertain the clinical utility of uroflowmetry and its place in the care pathway for men with LUTS. Future well-designed studies should focus on this evidence gap.

Expanding research to provide an evidence base for nutritional interventions for the management of inborn errors of metabolism

A trans-National Institutes of Health initiative, Nutrition and Dietary Supplement Interventions for Inborn Errors of Metabolism (NDSI-IEM), was launched in 2010 to identify gaps in knowledge regarding the safety and utility of nutritional interventions for the management of inborn errors of metabolism (IEM) that need to be filled with evidence-based research. IEM include inherited biochemical disorders in which specific enzyme defects interfere with the normal metabolism of exogenous (dietary) or endogenous protein, carbohydrate, or fat. For some of these IEM, effective management depends primarily on nutritional interventions. Further research is needed to demonstrate the impact of nutritional interventions on individual health outcomes and on the psychosocial issues identified by patients and their families. A series of meetings and discussions were convened to explore the current United States' funding and regulatory infrastructure and the challenges to the conduct of research for nutritional interventions for the management of IEM. Although the research and regulatory infrastructure are well-established, a collaborative pathway that includes the professional and advocacy rare disease community and federal regulatory and research agencies will be needed to overcome current barriers.

Measures of the recovery orientation of mental health services: systematic review

PURPOSE

The review aimed to (1) identify measures that assess the recovery orientation of services; (2) discuss how these measures have conceptualised recovery, and (3) characterise their psychometric properties.

METHODS

A systematic review was undertaken using seven sources. The conceptualisation of recovery within each measure was investigated by rating items against a conceptual framework of recovery comprising five recovery processes: connectedness; hope and optimism; identity; meaning and purpose; and empowerment. Psychometric properties of measures were evaluated using quality criteria.

RESULTS

Thirteen recovery orientation measures were identified, of which six met eligibility criteria. No measure was a good fit with the conceptual framework. No measure had undergone extensive psychometric testing and none had data on test-retest reliability or sensitivity to change.

CONCLUSIONS

Many measures have been developed to assess the recovery orientation of services. Comparisons between the measures were hampered by the different conceptualisations of recovery used and by the lack of uniformity on the level of organisation at which services were assessed. This situation makes it a challenge for services and researchers to make an informed choice on which measure to use. Further work is needed to produce measures with a transparent conceptual underpinning and demonstrated psychometric properties.

Quantifying the effect of urodynamic catheters on urine flow rate measurement

INTRODUCTION

The effect of urodynamic catheters on urine flow rate (Q(max) ) is well documented but under-researched. Several studies show reduced Q(max) but methodologies and patient demographics differ. The aims of this study were to further quantify the effect of urodynamic catheters on Q(max) and to explore if this was consistent across different urodynamic diagnoses.

METHODS

Four groups of 50 consecutive men attending for urodynamic studies (UDS) were retrospectively analyzed: Group 1 comprised 50 men with normal UDS, Group 2 was 50 men with BOO, and Group 3 contained 50 men with detrusor underactivity. Groups 1-3 had UDS performed using both 10 Fr filling and 4 Fr measuring catheters in situ. Group 4 comprised 50 men who had UDS performed with a smaller catheter assembly (8 Fr dual-lumen). Values of Q(max) with and without catheters present were compared using paired Student's t-tests. Differences between groups were compared using ANOVA.

RESULTS

Q(max) measured during UDS in men from Groups 1-3 showed a mean reduction of 38% compared to Q(max) from "free" uroflowmetry. ANOVA indicated this reduction was significantly greater among men with normal UDS. Interestingly the group who underwent UDS with a smaller catheter assembly showed no significant reduction in Q(max) measured with catheters in situ.

CONCLUSION

Our findings are in line with previous work suggesting that smaller calibre urethral catheters do not cause a significant obstructive effect during voiding. In addition it would appear that the reduction in Q(max) with larger urethral catheters in situ is greatest in those with normal urodynamics.

An evaluation of the benefits of non-nutritive sucking for premature infants as described in the literature

Babies have specific needs that assist them in their development and enable them to thrive. Feeding is an important aspect of development. When feeding, there are opportunities for babies to develop a positive interactive bond with parents. This has a long-term impact on the well-being of infants in terms of emotional development, social learning, and health. Infants born prematurely and those born with specific needs making them vulnerable are likely to develop the necessary skills to allow them to mature, interact and thrive. Many premature infants may need alternative feeding methods until they are ready to develop the skills necessary for oral feeding. A beneficial approach for infants who are showing oral readiness is the use of a non-nutritive sucking programme. This paper explores the research that supports non-nutritive sucking, and considers other variables that need to be included in further research, including those infants who have neurodisability.

A Delphi clinical practice protocol for the management of very long chain acyl-CoA dehydrogenase deficiency

INTRODUCTION

Very long chain acyl-CoA dehydrogenase (VLCAD) deficiency is a disorder of oxidation of long chain fat, and can present as cardiomyopathy or fasting intolerance in the first months to years of life, or as myopathy in later childhood to adulthood. Expanded newborn screening has identified a relatively high incidence of this disorder (1:31,500), but there is a dearth of evidence-based outcomes data to guide the development of clinical practice protocols. This consensus protocol is intended to assist clinicians in the diagnosis and management of screen-positive newborns for VLCAD deficiency until evidence-based guidelines are available.

METHOD

The Oxford Centre for Evidence-based Medicine system was used to grade the literature review and create recommendations graded from A (evidence level of randomized clinical trials) to D (expert opinion). Delphi was used as the consensus tool. A panel of 14 experts (including clinicians, diagnostic laboratory directors and researchers) completed three rounds of survey questions and had a face-to-face meeting.

RESULT

Panelists reviewed the initial evaluation of the screen-positive infant, diagnostic testing and management of diagnosed patients. Grade C and D consensus recommendations were made in each of these three areas. The panel did not reach consensus on all issues, particularly in the dietary management of asymptomatic infants diagnosed by newborn screening.

A Delphi-based consensus clinical practice protocol for the diagnosis and management of 3-methylcrotonyl CoA carboxylase deficiency

3-MCC deficiency is among the most common inborn errors of metabolism identified on expanded newborn screening (1:36,000 births). However, evidence-based guidelines for diagnosis and management of this disorder are lacking. Using the traditional Delphi method, a panel of 15 experts in inborn errors of metabolism was convened to develop consensus-based clinical practice guidelines for the diagnosis and management of 3-MCC screen-positive infants and their mothers. The Oxford Centre for Evidence-based Medicine system was used to grade the literature review and create recommendations graded from A (evidence level of randomized clinical trials) to D (expert opinion). Panelists reviewed the initial evaluation of the screen-positive infant-mother dyad, diagnostic guidelines, and management of diagnosed patients. Grade D consensus recommendations were made in each of these three areas. The panel did not reach consensus on all issues. This consensus protocol is intended to assist clinicians in the diagnosis and management of screen-positive newborns for 3-MCC deficiency and to encourage the development of evidence-based guidelines.

Genetic and clinical heterogeneity in eIF2B-related disorder

Eukaryotic initiation factor 2B (eIF2B)-related disorders are heritable white matter disorders with a variable clinical phenotype (including vanishing white matter disease and ovarioleukodystrophy) and an equally heterogeneous genotype. We report 9 novel mutations in the EIF2B genes in our subject population, increasing the number of known mutations to more than 120. Using homology modeling, we have analyzed the impact of novel mutations on the 5 subunits of the eIF2B protein. Although recurrent mutations have been found at CpG dinucleotides in the EIF2B genes, the high incidence of private or low frequency mutations increases the challenge of providing rapid genetic confirmation of this disorder, and limits the application of EIF2B screening in cases of undiagnosed leukodystrophy.

Treatment of a field case of avian intestinal spirochaetosis caused by Brachyspira pilosicoli with tiamulin

There has been much confusion over the significance of spirochaetes found in the caeca of laying hens and the impact they may have on egg production. In recent years, the situation has been made clearer and the presence of such species as Brachyspira pilosicoli have been shown to cause a mild, chronic disease in both layers and breeders and to reduce egg production by reportedly 5%. In the United Kingdom, a multi-age caged laying site with three separate flocks of approximately 12 000 birds each was chronically infected with B. pilosicoli but displayed few clinical signs except for a noticeable reduction in egg production and an increased mortality. The flocks were treated for 3 days in the drinking water with tiamulin at 12.5 mg/kg bodyweight, and a steady improvement in performance was recorded. The production results were compared with a flock that had been untreated with tiamulin previously, as a control, and one that had been treated at 25 and 45 weeks of age. A 9.8% improvement in egg production/hen housed up to 72 weeks of age and 9.7% in total egg weight was recorded, as well as an 8.6% reduction in actual hen mortality, in the tiamulin-treated flock in comparison with the untreated control. After taking into account the difference in breeds used, there was only a 6% reduction in egg production but an 8.84% increase in mortality in the untreated flock compared with the individual breed's standard production data. The cost of the disease was estimated at 14 million pound in the United Kingdom, based on a national laying flock of 30 million or 1.5% of production. Faecal examination for potentially pathogenic spirochaetes should be part of the differential diagnosis of under-performing laying flocks.

A NOMOGRAM TO CLASSIFY MEN WITH LOWER URINARY TRACT SYMPTOMS USING URINE FLOW AND NONINVASIVE MEASUREMENT OF BLADDER PRESSURE

PURPOSE

Bladder pressure during voiding can be estimated by a noninvasive technique using controlled inflation of a penile cuff. This test provides a valid and reliable estimate of isovolumetric bladder pressure but to our knowledge the role of the test for the routine clinical treatment of patients with lower urinary tract symptoms (LUTS) has yet to be demonstrated. As a first step, we evaluated a proposed nomogram for the diagnosis of bladder outlet obstruction in men with LUTS using noninvasive measurements of pressure and flow.

MATERIALS AND METHODS

Using a combination of theoretical calculation and experimental data the existing International Continence Society pressure flow nomogram was modified to allow noninvasive measurement of isovolumetric bladder pressure in place of detrusor pressure at maximum urine flow. Accuracy of the nomogram for classifying obstruction was then tested in a group of 144 men with LUTS who underwent an invasive and a noninvasive pressure flow study.

RESULTS

The modified nomogram identified men with obstruction with 68% positive predictive value and 78% negative predictive value. Predictive accuracy could be improved by adding an additional criterion of obstruction, that is maximum urine flow less than 10 ml second, whereby an identifiable 69% of all cases could be classified as obstructed (88% positive predictive value) or not obstructed (86% negative predictive value). In the remaining 31% of patients invasive pressure flow studies would provide additional information, although some results would remain equivocal.

CONCLUSIONS

The proposed nomogram combined with the additional flow rate criterion can classify more than two-thirds of cases without recourse to invasive pressure flow studies. We must now evaluate the usefulness of this classification for the treatment of men with LUTS.

African and African Caribbean users' perceptions of inpatient services

It has been suggested that well-documented differences in African and African Caribbean people's contact with mental health services may stem from the organization, processes and practices of services themselves. This article presents the findings of a qualitative study which explored the inpatient experiences of a sample of African and African Caribbean people. Although some positive experiences were described, in the main, participants' accounts revolved around a sense of loss of control and around experiences of overt and implicit racism. Underpinning these experiences were relationships with staff that were perceived to be unhelpful. On the basis of both the positive and negative experiences described, we draw conclusions about the changes required to ensure that inpatient services more effectively meet the needs of this group.

Water modulation of stratum corneum chymotryptic enzyme activity and desquamation

Exposure to a dry environment leads to depletion of water from the peripheral stratum corneum layers in a process dependent on the relative humidity (RH) and the intrinsic properties of the tissue. We hypothesized that by modulating the water content of the stratum corneum in the surface layers, RH effects the rate of desquamation by modulating the activity of the desquamatory enzymes, and specifically stratum corneum chymotryptic enzyme (SCCE). Using a novel air interface in vitro desquamatory model, we demonstrated RH-dependent corneocyte release with desquamatory rates decreasing below 80% RH. Application of 10% glycerol or a glycerol-containing moisturizing lotion further increased desquamation, even in humid conditions, demonstrating that water was the rate-limiting factor in the final stages of desquamation. Furthermore, even in humid conditions desquamation was sub-maximal. In situ stratum corneum SCCE activity showed a dependence on RH: activity was significantly higher at 100% than at 44% RH. Further increases in SCCE activity were induced by applying a 10% glycerol solution. Since SCCE, a water-requiring enzyme, must function in the water-depleted outer stratum corneum, we sought to determine whether this enzyme has a tolerance to lowered water activity. Using concentrated sucrose solutions to lower water activity, we analysed the activity of recombinant SCCE and compared it to that of trypsin and chymotrypsin. SCCE activity demonstrated a tolerance to water restriction, and this may be an adaptation to maintain enzyme activity even within the water-depleted stratum corneum intercellular space. Overall these findings support the concept that in the upper stratum corneum, RH modulates desquamation by its effect upon SCCE activity, and possibly other desquamatory hydrolases. In addition, SCCE may be adapted to function in the water-restricted stratum corneum intercellular space.

The urgent postoperative CT scan: a critical appraisal of its impact

Urgent CT scanning of critically ill neurosurgical patients is costly, labour intensive and associated with some risk. A study of urgent postoperative CT scans was carried out to assess the proportion that changed patient management. A further study evaluated the accuracy of predicting a haematoma. A retrospective analysis was carried out over a 6-month period of all scans performed within 48 h of craniotomy. This was followed by a prospective comparison between the surgeon's estimate of the chance of a haematoma on the scan and the scan result. Of 184 patient undergoing craniotomy, 40 patients (22%) were scanned within 48 h. Five patients were re-operated for haematoma formation. Prospective assessment showed that surgeons consistently over-estimated the risk at haematoma (mean prescan estimate 63%, actual risk 8%, p = 2.5 x 10(-12)). Less than 1 in 10 postoperative scans show a neurosurgical target. Other changes in management following scanning were slight.

Hormonally-regulated proteins in breast secretions are markers of target organ sensitivity

Anti-oestrogen therapy is being used in an attempt to prevent breast cancer but no intermediate end points of the effect of tamoxifen on the normal breast are available. Therefore, the purpose of this study was to develop a physiological measure of oestrogen action on the breast. We measured oestrogen-stimulated and -inhibited proteins in breast secretions from women on and off anti-oestrogen therapy. Two oestrogen-stimulated proteins (pS2 and cathepsin D) and oestrogen-inhibited proteins (CP15, gross cystic disease fluid protein 15; Apo,: apolipoprotein D) were measured. Premenopausal women had significantly higher pS2 and cathepsin D in association with lower Apo D and CP15 secretion levels compared to post-menopausal women. Sequential nipple aspirates from women treated with the luteinizing hormone releasing hormone agonist goserelin (n = 9), tamoxifen (n = 9) and hormone replacement therapy (HRT) (n = 26) were measured. Following treatment with goserelin, median nipple secretion levels of pS2 fell (P < 0.02) and Apo D and CP15 rose significantly (P < 0.03 and P < 0.05 respectively). Similar changes were seen on tamoxifen therapy but not in untreated control women. Treatment with HRT resulted in a rise of pS2 (P < 0.001) and a fall in Apo D (P < 0.05). Measurement of pS2 and Apo D in nipple aspirates may prove useful intermediate end point of breast responsiveness to anti-oestrogens.

Two-week dietary soy supplementation has an estrogenic effect on normal premenopausal breast

An association has been reported between consumption of a high soy diet and a low incidence of breast cancer within populations of Southeast Asia. Phytoestrogens present in soy act as partial estrogen agonists or antagonists and can inhibit breast cancer cell proliferation in vitro. The effect of 14-day dietary soy supplementation with 60 g (45 mg isoflavones) on the normal breast of 84 premenopausal patients was determined. Serum concentrations of the isoflavanoids, genistein, daidzein, and equol, were raised in patients after soy supplementation (P < or = 0.025). Nipple aspirate (NA) levels of genistein and daidzein were higher than paired serum levels, both before (P < 0.001 and P = 0.001, respectively) and after soy supplementation (P < 0.001 and P = 0.049, respectively); however, there was no significant increase in NA isoflavone levels in response to soy. NA levels of apolipoprotein D were significantly lowered and pS2 levels raised in response to soy supplementation (P < or = 0.002), indicative of an estrogenic stimulus. No effect of soy supplementation on breast epithelial cell proliferation, estrogen and progesterone receptor status, apoptosis, mitosis, or Bcl-2 expression was detected. In conclusion, short term dietary soy has a weak estrogenic response on the breast, as measured by nipple aspirate apolipoprotein D and pS2 expression. No antiestrogenic effect of soy on the breast was detected.

The value of program certification for performance contracting

A survey of clubhouses listed in the 1996 ICCD Clubhouse Directory provided a research sample of 80 ICCD-certified clubhouses and 88 non-certified clubhouses with which to test the discriminant validity of ICCD certification. A statistically significant logistic regression model revealed that ICCD certification status could be clearly predicted for 78% of the clubhouses in the survey sample on the basis of director-reported compliance with representative measures of the Standards for Clubhouse Programs. The predictive power of compliance with the Standards was obtained even while controlling for other organizational variables, including clubhouse age, total staff salaries, and receipt of Medicaid funding. These findings provide support for the practical utility of adopting program certification as a performance indicator in an era of managed care, as well as the specific value of relying on ICCD certification as a quality assurance indicator.

Dietary management of long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHADD). A case report and survey

Current dietary management of long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD; long-chain-(S)-3-hydroxyacyl-CoA:NAD+ oxido-reductase, EC 1.1.1.211) deficiency (LCHADD) is based on avoiding fasting, and minimizing energy production from long-chain fatty acids. We report the effects of various dietary manipulations on plasma and urinary laboratory values in a child with LCHADD. In our patient, a diet restricted to 9% of total energy from long-chain fatty acids and administration of 1.5 g medium-chain triglyceride oil per kg body weight normalized plasma acylcarnitine and lactate levels, but dicarboxylic acid excretion remained approximately ten times normal. Plasma docosahexaenoic acid (DHA, 22:6n-3) was consistently low over a 2-year period; DHA deficiency may be related to the development of pigmentary retinopathy seen in this patient population. We also conducted a survey of metabolic physicians who treat children with LCHADD to determine current dietary interventions employed and the effects of these interventions on symptoms of this disease. Survey results indicate that a diet low in long-chain fatty acids, supplemented with medium-chain triclyceride oil, decreased the incidence of hypoketotic hypoglycaemia, and improved hypotonia, hepatomegaly, cardiomyopathy, and lactic acidosis. However, dietary treatment did not appear to effect peripheral neuropathy, pigmentary retinopathy or myoglobinuria.

Effects of soy-protein supplementation on epithelial proliferation in the histologically normal human breast

A high dietary intake of soy products (eg, as in Japan and Singapore) has been associated with a reduction in the incidence of breast cancer in premenopausal women. Phytoestrogens present in soybeans inhibit human breast cancer cell proliferation in vitro and breast cancer development in animal models, but no data exist on the effects of phytoestrogens on histologically normal human breasts. This study examines the effects of dietary soy supplementation on the proliferation rate of premenopausal, histologically normal breast epithelium and the expression of progesterone receptor. Women (n = 48) with benign or malignant breast disease were randomly assigned to receive their normal diet either alone or with a 60-g soy supplement (containing 45 mg isoflavones) taken daily for 14 d. Biopsy samples of normal breasts were labeled with [3H]thymidine to detect the number of cells in S phase and were immunocytochemically stained for the proliferation antigen Ki67. The phytoestrogens genistein, daidzein, equol, enterolactone, and enterodiol were measured in serum samples obtained before and after supplementation. Serum concentrations of the isoflavones genistein and daidzein increased in the soy group at 14 d. Results showed a strong correlation between Ki67 and the thymidine labeling index (r = 0.868, P < or = 0.001). The proliferation rate of breast lobular epithelium significantly increased after 14 d of soy supplementation when both the day of menstrual cycle and the age of patient were accounted for. Progesterone receptor expression increased significantly in the soy group. Short-term dietary soy stimulates breast proliferation; further studies are required to determine whether this is due to estrogen agonist activity and to examine the long-term effects of soy supplementation on the pituitary gland and breast.

Stratum corneum lipids: the effect of ageing and the seasons

Stratum corneum lipids play a predominant role in maintaining the water barrier of the skin. In order to understand the biological variation in the levels and composition of ceramides, ceramide 1 subtypes, cholesterol and fatty acids, stratum corneum lipids collected from tape strippings from three body sites (face, hand, leg) of female Caucasians of different age groups were analysed. In addition, we studied the influence of seasonal variation on the lipid composition of stratum corneum from the same body sites. The main lipid species were quantified using high-performance thin-layer chromatography and individual fatty acids using gas chromatography. Our findings demonstrated significantly decreased levels of all major lipid species, in particular ceramides, with increasing age. Similarly, the stratum corneum lipid levels of all the body sites examined were dramatically depleted in winter compared with spring and summer. The relative levels of ceramide 1 linoleate were also depleted in winter and in aged skin whereas ceramide 1 oleate levels increased. The other fatty acid levels remained fairly constant with both season and age, apart from lignoceric and heptadecanoic acid which showed a decrease in winter compared with summer. The decrease in the mass levels of intercellular lipids and the altered ratios of fatty acids esterified to ceramide 1, are likely to contribute to the increased susceptibility of aged skin to perturbation of barrier function and xerosis, particularly during the winter months.