High Resolution Imaging with Focused kV X-Rays for Small Animal Radio-Neuromodulation

PURPOSE/OBJECTIVE(S)

High precision radiotherapy for small animal radio-neuromodulation requires conformal treatment to very small targets down to 2.5 mm. A focused kV technique based on novel usage of polycapillary x-ray lenses can focus x-ray beams to <0.2 mm in diameter, which is ideal for such uses. Such application also requires high resolution CT images for treatment planning and setup, which was hard to achieve using conventional x-ray tube. In this work, we demonstrate the feasibility of using a virtual focal spot generated with an x-ray lens to perform high-resolution CBCT acquisition.

MATERIALS/METHODS

The experiment with x-ray lens was set up on an x-ray tabletop system to generate a virtual focal spot. A pinhole image was acquired for the virtual focal spot and compared with the one acquired with the conventional focal spot without the lens. The planar imaging resolution with and without the lens were evaluated using a line pair resolution phantom. The spatial resolution of the two settings were estimated by reconstructing a 0.15-mm wire phantom and comparing its full width half maximum (FWHM). A CBCT scan of a rodent head was also acquired to further demonstrate the improved resolution using the x-ray lens.

RESULTS

Compared to conventional imaging acquisition with a measured x-ray focal spot of 0.395 mm FWHM, the virtual focal spot size was measured at 0.175 mm. The reduction in focal spot size with lens leads to an almost doubled planar imaging resolution and a 26% enhancement in 3D spatial resolution. A realistic CBCT acquisition of a rodent head mimicked the imaging acquisition step for radio-neuromodulation and further showed the improved visualization for fine structures.

CONCLUSION

This work demonstrated that the focused kV x-ray technique was capable of generating small focal spot size of <0.2 mm. The proposed method provides an adaptive imaging platform to acquire x-ray and CBCT images for treatment planning and setup with improved spatial resolution compared to conventional CBCT image acquisition.

Physical activity promotion and adults with intellectual disabilities: A neglected area

BACKGROUND

The objective was to review physical activity (PA) promotion interventions among individuals with intellectual disability and provide recommendations for increasing PA.

METHODS

A systematic mapping review was conducted in which physical activity intervention studies for adults with a disability were identified, selected, and appraised. Data were extracted regarding the study design, results, and authors' recommendations. Data were analyzed using a social-ecological framework.

RESULTS

A comprehensive search of the peer reviewed literature yielded 5 studies (3 quantitative, 1 mixed methods, and 1 pre-post delayed). Studies used physical activity promotion strategies at the intrapersonal, interpersonal, organizational, community, and policy levels have been used to date.

CONCLUSIONS

Recommendations are presented for researchers and practitioners seeking to increase the level of PA of adults with intellectual disability.

Effect of grazing different forage systems prior to and during mating on the liveweight, condition score, conception and reproductive rate of maternal-composite ewe lambs

Context Economic modelling identified that mating of ewe lambs for lambing at 1 year of age has the potential to increase the profitability of sheep-production systems in south-western Victoria. In order to optimise reproductive rates, ewe lambs should weigh at least 35–40 kg, have a condition score (CS) of 3.0 at mating, and be gaining weight (100–150 g/day) during mating. However, typical perennial ryegrass (Lolium perenne L.) pastures in south-west Victoria do not support the attainment of these targets without additional supplementation. Aim Our research aimed to determine how grazing summer-active pastures or brassica (Brassica napus L.) forages affects the liveweight, CS, conception and reproductive rate of ewe lambs when offered before and during mating compared with a system using perennial ryegrass plus supplement. Methods A field experiment was conducted at Hamilton, Victoria, Australia, in 2014 and 2016 testing seven forage treatments replicated four times in a complete block design. The treatments were: canola (B. napus, two treatments of different cultivars), forage brassica, lucerne (Medicago sativa L.), chicory (Cichorium intybus L.), plantain (Plantago lanceolata L.) and perennial ryegrass. Key results Ewe lambs grazing canola or forage brassica had higher (P &lt; 0.05) liveweight gains during the pre-mating and mating periods than those grazing the perennial ryegrass treatment (148 vs 75 g/day in 2014, s.e.m. 17; 139 vs 54 g/day in 2016, s.e.m. 17). In 2014, spring-sown dual-purpose canola, lucerne and chicory resulted in higher (P &lt; 0.05) reproductive rates (144–151%) than the perennial ryegrass treatment (103%); forage brassica and plantain gave intermediate results (128% and 129%). Conclusion Brassica forages (including spring-sown canola), lucerne and chicory can support the attainment of key liveweight and CS targets for successful mating of ewe lambs in autumn. Implications Spring-sown canola is therefore a viable alternative forage for use by livestock producers in southern Australia and presents an opportunity to incorporate an alternative income stream in mixed-farming systems.

Effect of defoliation on spring-sown winter-type canola (Brassica napus) grain yield, quality and morphology

Context In Australia’s high-rainfall zone (&gt;550 mm/year), winter-type canola (Brassica napus L.) can be sown in spring and grazed as a forage crop during its vegetative phase, producing a canola grain crop in late spring of the second year. The timing, length and intensity of grazing or defoliation that can be imposed on canola before a grain yield penalty occurs remains largely unknown. Aim Our research aimed to determine the impact of grazing spring sown canola during summer and autumn on the subsequent canola grain yield. Methods A paddock-scale field experiment was conducted over 2 years, 2013–14 and 2015–2016, at Hamilton, Victoria, Australia, with two winter-type canola treatments and three grazing–defoliation sub-treatments replicated four times in a replicated block design. The canola cultivars used were Hyola971CL and Taurus in 2013–14 and Hyola971CL and Brazzil in 2015–16. The three grazing–defoliation sub-treatments were: NG, no grazing; VG, grazing with sheep for a 10-week period during the vegetative phase over summer–autumn; RG, grazing with sheep as per the VG sub-treatment and then in the reproductive phase, either cutting the canola for silage in August (2013–14) or grazing with sheep between 28 July and 17 August 2016 (2015–16). Key results The VG sub-treatment resulted in no grain-yield penalty (P &gt; 0.05) relative to NG in either year. In 2014, canola grain yields from VG for Hyola971CL and Taurus were 2.32 and 2.13 t/ha, compared with NG grain yields of 2.66 and 2.19 t/ha. In 2016, grain yields from VG for Hyola971CL and Brazzil were 2.14 and 1.74 t/ha, compared with NG grain yields of 1.87 and 1.90 t/ha. The RG sub-treatment reduced (P &lt; 0.05) canola grain yield by ~65% in 2014 and 80% in 2016 compared with NG and VG. Conclusions Spring-sown winter-type canola can be grazed during summer and autumn in southern Australia with no grain-yield penalty relative to ungrazed canola. However, further grazing or defoliation in winter once bud elongation commences can result in large grain-yield penalties. Implications Spring-sown winter-type canola is a viable forage option for filling the summer–autumn feed gap in southern Australia while also providing a dual-purpose income in mixed-farming systems.

Spring-sown winter-type canola (Brassica napus) as summer–autumn forage for sheep production in southern Australia

Context Filling the summer–autumn feed gap is a key priority for sheep producers in southern Australia’s high-rainfall zone. Aim Our research aimed to determine whether spring-sown winter-type canola (Brassica napus L.) could increase herbage mass and nutritive characteristics during summer and autumn relative to other forage options in southern Australia’s HRZ. Methods A field experiment was conducted at Hamilton, Victoria, Australia, in 2014 and 2016 testing seven forage treatments replicated four times in the complete block design. The treatments were: canola (two treatments of different cultivars), forage brassica (B. napus), lucerne (Medicago sativa L.), chicory (Cichorium intybus L.), plantain (Plantago lanceolata L.) and perennial ryegrass (Lolium perenne L.). Key results Herbage mass and nutritive characteristics of the canola varieties did not differ (P &gt; 0.05) from forage brassica. Herbage mass in March 2014 was 3.35–3.64 t dry matter (DM)/ha for brassicas; 1.05–1.37 t DM/ha for perennial ryegrass, plantain and chicory; and 2.94 t DM/ha for lucerne (P &lt; 0.001, l.s.d. = 1.20). In March 2016, herbage mass was 1.86–2.05 t DM/ha for brassicas and 2.14–2.49 for the other forage treatments (P &lt; 0.05; l.s.d. = 0.47). Brassicas had higher (P &lt; 0.05) metabolisable energy (ME) concentrations and lower (P &lt; 0.05) neutral detergent fibre (NDF) concentrations on most sampling dates than chicory, plantain, lucerne and perennial ryegrass. The crude protein (CP) concentration of the brassica treatments was not different (P &gt; 0.05) from that of the other forage treatments. Concentrations of ME, CP and NDF were very similar between years for the brassicas, with March ME, CP and NDF concentrations of 12.0–13.2 MJ/kg DM, 14.0–20.1% DM and 16.7–23.6% DM. Conclusion Canola provided increased or equivalent levels of herbage mass and nutritive characteristics compared with other forage options in south-western Victoria on most, but not all, sampling dates. However, the annual spring-sowing requirement is a challenge under variable spring-rainfall conditions and may limit productivity if there is poor establishment. Implications Spring-sown canola is a viable alternative forage for livestock producers and offers a potential second income stream in high-rainfall-zone livestock farming systems.

Characteristics of Indigenous healing strategies in Canada: a scoping review

OBJECTIVE

The objective of this review was to identify the characteristics of Indigenous healing strategies in Canada and culturally relevant approaches within Indigenous contexts.

INTRODUCTION

In responding to the Canadian Truth and Reconciliation Commission's Calls to Action, there is increasing interest in Indigenous healing strategies across clinical, policy, and community sectors. The high relevance of Indigenous healing has also encouraged exploration of new approaches to research that are responsive to, and inclusive of, Indigenous contexts. To date, there is no clear understanding of what characterizes Indigenous healing strategies in Canada.

INCLUSION CRITERIA

This review considered healing strategies for First Nations, Inuit, and Métis in Canada. Strategies examined included those related to health services and programs, policies and guidelines, models and frameworks, and Indigenous narratives and expert opinion in any service setting.

METHODS

This review employed the JBI approach to scoping reviews. Searches were performed in CINAHL Full Text, Sociological Abstracts, PsycINFO, MEDLINE, and Academic Search Premier in December 2018. Searches for gray literature were conducted in iPortal, Canadian Electronic Library, and a list of Canadian government and Indigenous organization websites in February 2019. This review was limited to publications from 2008 onward. Non-English articles and theses and dissertations were excluded.

RESULTS

Among the 59 articles included in this review, 41 were journal articles and 28 were published within the previous five years (i.e., 2014 and onward). The healing strategies were most frequently implemented in Ontario (n = 13), British Columbia (n = 8), and Manitoba (n = 5). The majority of strategies were utilized in the health settings (n = 37), which included mainstream treatment modalities as well as community-based healing initiatives. Services and programs (n = 24) were the predominant type of healing strategies, followed by models and frameworks (n = 9), policies and guidelines (n = 8), Indigenous narratives and expert opinion (n = 7), and others (n = 11). The most frequent guiding principles were identified as Honoring Cultures and Traditions (n = 14), Medicine Wheel (n = 12), and Strength-Based/Empowerment (n = 12). The most widely used main components were Artistic Expression (n = 16), Ceremonies (n = 15), and Games and Exercises (n = 12). As for human resources, Community Members (n = 19) were most frequently engaged, followed by Local Agencies (n = 12) and Knowledge Keepers (n = 12). Eight culturally relevant approaches were identified from 29 primary research studies, with the most popular being Consultation/Participatory Research (n = 20) and Indigenous Protocols (n = 5).

CONCLUSIONS

The findings of this review collectively support a decolonizing approach that upholds Indigenous knowledge, respects Indigenous rights to self-determination, and recognizes Indigenous resilience and agency. More research is needed with a focus on Inuit or Métis healing, and innovative knowledge synthesis methods inclusive of diverse Indigenous ways of knowing.

Characteristics of Indigenous healing strategies in Canada: a scoping review protocol

OBJECTIVE

The objective of this review is to identify the characteristics of Indigenous healing strategies in Canada and approaches to improving cultural relevance to local Indigenous contexts.

INTRODUCTION

In the previous 150 years, Indigenous peoples of Canada have experienced colonization, forced assimilation, cultural oppression and violence, and these are associated with high rates of social distress and health disparities. Today, legacies of colonization continue to marginalize Indigenous peoples, creating healthcare institutions devoid of Indigenous worldviews. Despite the growing number of Indigenous healing strategies currently in existence, literature describing these strategies has not been systematically scoped. To address this gap, this scoping review will identify characteristics of Indigenous healing strategies in Canada, and explore culturally relevant approaches used in research process.

INCLUSION CRITERIA

This review will consider literature that describes Indigenous healing strategies in Canada and will include First Nations, Inuit and Métis as the population of interest. Strategies may include, but are not limited to, health services and programs, policies and guidelines, models and frameworks, and Indigenous narratives and expert opinions. Healing strategies delivered in all service settings are eligible for inclusion.

METHODS

The databases/sources to be searched will include: CINAHL, Sociological Abstracts, PsycINFO, MEDLINE and Academic Search Premier. Searches for gray literature will be conducted in iPortal, Canadian Electronic Library, and a list of Canadian government and Indigenous organization websites. Retrieval of full-text studies and data extraction will be performed independently by two reviewers. Findings will be summarized in tabular forms accompanied by narrative text.

New decade, new response: Altering the public health response to toxigenic cutaneous diphtheria

Background

Classical diphtheria is a potentially fatal respiratory disease mediated by the diphtheria toxin of Corynebacterium diphtheriae. Due to high vaccination rates against this toxin in Canada, the national incidence of respiratory diphtheria is near zero, and the toxin plays no recognized role in cutaneous diphtheria. Therefore, in this study, we assessed the diagnostic and public health benefits of diphtheria toxin testing and cutaneous diphtheria investigations in a highly vaccinated population.

Methods

Over the last 10 years, we retrospectively determined: the number of C. diphtheriae isolates identified in the province of Alberta, Canada; the disease state of each individual tested (disease vs asymptomatic carrier); the source (cutaneous vs respiratory); and the number of toxin tests performed.

Results

In 10 years, zero cases of respiratory diphtheria and three cases of toxigenic cutaneous diphtheria were identified. Despite zero cases of respiratory disease, diphtheria toxin testing significantly increased (p = 0.0001), with 86% of toxin tests performed on cutaneous isolates. Subsequent public health investigations of each case of toxigenic cutaneous diphtheria mandated the collection of 315 total specimens from 92 individuals, revealing low rates of C. diphtheriae colonization among contacts and no further cases.

Conclusions

This study challenges the value of reflexive diphtheria toxin testing in uncomplicated cutaneous diphtheria among highly vaccinated populations. Cutaneous diphtheria investigations demanded disproportionate public health and laboratory resources and demonstrated a discrepancy between toxin pathophysiology and disease. Therefore, we recommend stewarding diphtheria toxin tests for toxin-mediated disease forms and ensuring adequate vaccination. This approach would spare public health and laboratory resources by customizing responses around the role of the diphtheria toxin in each form of disease.

Key messages

Investigations for cutaneous diphtheria increased demand for toxin testing in Alberta, Canada, though the toxin plays no role in this form of disease. In populations with high vaccination rates against diphtheria toxoid, cutaneous diphtheria cases do not require additional laboratory testing for the presence of the diphtheria toxin.

P12.02 Glioblastoma Multiforme immunological blockades and the implications of glioma cancer stem cells

BACKGROUND

Glioblastoma Multiforme (GBM) is classified as a WHO grade IV astrocytoma that continues to circumvent classical and novel chemo-, radio- and immuno-therapies. The recent FDA approvals for the use of targeted immunotherapies against inhibitory checkpoint ligands (for melanoma; ipilimumab and nivolumab) have brought the use of monoclonal antibody therapies to the forefront of GBM research. However, poor immunological responses, exemplified by down-regulation of anti-tumour T-cell activity, and up-regulation of immunosuppressive cells and secreted factors within the tumour micro-environment, have limited the effectiveness of immunotherapy in GBM to date. Therefore, understanding how GBM modulates an extensive repertoire of immune checkpoint ligands and the functional consequence on immune evasion is necessary to develop more targeted immuno-therapeutics.

MATERIAL AND METHODS

Patient derived glioblastoma cell lines were cultured using established serum-based or glioma cancer stem cell (gCSC) conditions. The phenotypes of resultant GBM cells and gCSC’s were characterised using flow cytometry and immunocytochemistry, to assess expression of neural lineage and stem cell-associated markers. Thereafter, cells were screened for the expression of an extensive range of inhibitory checkpoint ligands by flow cytometry. Finally, the secretion of immune modulating factors by GBM cells and gCSC’s were evaluated by using XL cytokine proteome arrays. Cytokines that appeared to be differentially expressed were subsequently measured using Cytometric Bead Arrays.

RESULTS

Adherent gCSC’s and gCSC derived glioma-spheres express nestin, CD44, A2B5 and vimentin, consistent with a stem cell phenotype. Furthermore, the gCSC’s exhibited reduced expression of the neural lineage markers NeuN and OSP. Flow cytometry analyses revealed that glioblastoma cells expressed all 11 checkpoint ligands investigated. Interestingly, gCSC’s showed higher levels of PD-L1, B7-H3, CD155 and HVEM expression than GBM cells.

CONCLUSION

Glioblastoma Multiforme is highly immuno-suppressive, which is reinforced by this study. Glioblastoma cells express all the inhibitory checkpoint ligands investigated and glioma cancer stem cell cultures up-regulate expression levels further. This implies that GBM cells are heavily equipped to inhibit infiltrating T-cells, exemplifying the need to find suitable therapeutics that target multiple immuno-suppressive mechanisms simultaneously.

Management of ureteropelvic junction obstruction in children-a roundtable discussion

The investigation, management and follow-up of paediatric ureteropelvic junction obstruction is not standardized. The Young Pediatric Urology Committee of the European Society of Pediatric Urology interviewed five experts in the field on various aspects of management and compared this with published literature.

A “two-eyed seeing” approach to Indigenizing nursing curricula

Educational institutions, including schools of nursing, find themselves in significant times, as they work to Indigenize programs, and strive to repair and heal relationships with Indigenous peoples as recommended in the Truth and Reconciliation Commission of Canada (2015). Educators question where to begin the process, how such Indigenization should occur, and what the curricular end result should look like. In response, the authors considered many aspects from the literature, specific to nursing programs. The following themes were explored: partnering with community, cultural relevance, and faculty development. Through the utilization of a “two-eyed seeing” approach, institutional administrators need to partner with Indigenous Elders and community members to facilitate relationships required to provide the knowledge necessary to bring about change within educational programs. It is through such an approach that nursing curricula can be designed to be culturally safe and relevant for both Indigenous and non-Indigenous learners, and faculty can be supported in their growth and development in Indigenous knowledge. The authors propose that through “two-eyed seeing” and the integration of the Aboriginal Nurses Association of Canada (2009) core competencies, Indigenization of nursing curricula may ultimately move forward in a culturally reciprocal and respectful way.

A systematic review and meta-analysis revealing realistic outcomes following paediatric torsion of testes

INTRODUCTION

Reported testicular loss rates following paediatric testicular torsion often reflect the surgical decision-making process, rather than long-term survival of the testes.

OBJECTIVES

We aim to perform systematic analysis and meta-analysis to investigate testicular salvage rates and to assess predictors of long-term viability.

STUDY DESIGN

Systematic review according to PRISMA guidelines was performed to investigate immediate and long-term (>12 months) testicular loss rates following torsion in the paediatric population. Literature search and study inclusion were performed by two investigators. A study quality score was derived and attributed to each study. Predictors of testicular loss were described. Proportions meta-analysis was performed with random effects modelling, and testing for heterogeneity.

RESULTS

Twelve studies were includedm, 6 reporting early orchidectomy rates, and 6 reporting long-term outcomes. Study quality was generally low.

DISCUSSION

The mean early testicular loss rate was 39%, whereas meta-analysis revealed late loss to approach 50%. Predictors of outcomes include prehospital symptom duration, location of presentation, transfer to a tertiary centre, social affluence and use of ultrasound prior to diagnosis or transfer.

CONCLUSIONS

This study has shown a considerable late testicular loss rate, which must be relayed to families even after testicular salvage. Delay in time to presentation is consistently found to predict poor outcomes.

Blending Simulation-Based Learning and Interpretative Pedagogy for Undergraduate Leadership Competency Development

BACKGROUND

Effective leadership is an essential component guiding nursing activity and influencing health systems, health workers, and patient outcomes. Despite this evidence, undergraduate nursing programs may not be adequately preparing graduates to effectively engage in leadership practice.

METHOD

This article describes an educational innovation designed to support prelicensure leadership competency development. The authors blended simulation-based learning (SBL) with an interpretative pedagogical frame in a senior nursing leadership course at a primarily undergraduate university.

RESULTS

The innovation involves a break from traditional nursing educational pedagogy by bringing SBL into the leadership classroom. Using interpretative pedagogy to purposefully create different relationships in the learning space supported deeper personal and professional transformation for the students.

CONCLUSION

Nurse educators must purposefully design leadership curricula using active educational strategies that adequately prepare nurses for complex health systems. Integrating SBL within an interpretative pedagogy for leadership development moves students from merely knowing theory to informed and effective action. [J Nurs Educ. 2017;56(1):49-54.].

The advantage of early plication in children diagnosed with diaphragm paresis

BACKGROUND

In this single-center study, we sought to determine the frequency of phrenic nerve injury leading to diaphragm paresis (DP) in children following open cardiac surgery over the last 10 years, and to identify possible variables that predict the need for plication and associated clinical outcomes.

METHODS

Patients diagnosed with DP were identified from departmental databases and a review of clinical diaphragm ultrasound images. A cohort was analyzed for predictors of diaphragm plication and associations with clinical outcomes. Cumulative proportion graphs modeled the association between plication and length of stay.

RESULTS

DP was diagnosed in 161 of 6448 patients (2.5%) seen between January 2002 and December 2012. All diagnoses but 1 were confirmed by ultrasound. Plication of the diaphragm was performed in 30 patients (19%); compared with patients who did not undergo plication, these patients were younger (median age, 10 days vs 138 days; P < .001), more likely to have undergone deep hypothermic circulatory arrest (47% vs 18%; P = .005), had a longer duration of positive pressure ventilation (median, 15 days vs 7 days; P < .001), and had longer lengths of stay in both the intensive care unit (median, 23 days vs 8 days; P < .0001) and the hospital (median, 37 days vs 15 days; P < .0001). Early plication was associated with reduction in all intervals of care.

CONCLUSIONS

Early plication should be considered for patients with diaphragm paresis requiring prolonged respiratory support after cardiac bypass surgery. Longer follow-up evaluation is required to better define the long-term implications of plication.

Autologous tolerogenic dendritic cells for rheumatoid and inflammatory arthritis

Objectives

To assess the safety of intra-articular (IA) autologous tolerogenic dendritic cells (tolDC) in patients with inflammatory arthritis and an inflamed knee; to assess the feasibility and acceptability of the approach and to assess potential effects on local and systemic disease activities.

Methods

An unblinded, randomised, controlled, dose escalation Phase I trial. TolDC were differentiated from CD14+ monocytes and loaded with autologous synovial fluid as a source of autoantigens. Cohorts of three participants received 1×10⁶, 3×10⁶ or 10×10⁶ tolDC arthroscopically following saline irrigation of an inflamed (target) knee. Control participants received saline irrigation only. Primary outcome was flare of disease in the target knee within 5 days of treatment. Feasibility was assessed by successful tolDC manufacture and acceptability via patient questionnaire. Potential effects on disease activity were assessed by arthroscopic synovitis score, disease activity score (DAS)28 and Health Assessment Questionnaire (HAQ). Immunomodulatory effects were sought in peripheral blood.

Results

There were no target knee flares within 5 days of treatment. At day 14, arthroscopic synovitis was present in all participants except for one who received 10×10⁶ tolDC; a further participant in this cohort declined day 14 arthroscopy because symptoms had remitted; both remained stable throughout 91 days of observation. There were no trends in DAS28 or HAQ score or consistent immunomodulatory effects in peripheral blood. 9 of 10 manufactured products met quality control release criteria; acceptability of the protocol by participants was high.

Conclusion

IA tolDC therapy appears safe, feasible and acceptable. Knee symptoms stabilised in two patients who received 10×10⁶ tolDC but no systemic clinical or immunomodulatory effects were detectable.

Trial registration number

NCT01352858.

Detection of (135) Cs by accelerator mass spectrometry

RATIONALE

The ability to measure both (135) Cs and (137) Cs can provide an estimate of the age and source of Cs isotopes in an environmental sample. Accelerator mass spectrometry (AMS) consistently reports lower abundance sensitivities than other techniques and, with the addition of an on-line reaction cell, simpler isobaric suppression. Therefore, an AMS methodology was developed to measure Cs isotopes using CsF2- as the initial anion.

METHODS

The ion beam is passed through the Isobar Separator for Anions (ISA) where it is captured by radiofrequency quadrupoles in a gas cell before injection into the tandem accelerator. In the ISA, the beam reacts with O2 gas, selectively removing the BaF2- and leaving the Cs analyte to be reaccelerated and sent through the remainder of the AMS system.

RESULTS

The BaF2- signal was attenuated by a factor of 10(5) in the ISA while 25% of the original CsF2- current was transmitted into the accelerator. (135) Cs was measured without any interference from (133) Cs to an abundance sensitivity of 1.3 × 10(-10) . The abundances of four stable Ba isotopes (masses 133, 134, 135 and 137) were measured and no isotope-dependent bias was detected using the ISA in vacuum.

CONCLUSIONS

The results demonstrate the feasibility of measuring long-lived Cs isotopes without Ba interference by AMS with on-line isobar separation and the ability to use shorter lived Cs isotopes for yield tracing.

Discovery and evolution of phenoxypiperidine hydroxyamide dual CCR3/H₁ antagonists. Part I

The discovery of potent small molecule dual antagonists of the human CCR3 and H(1) receptors is described for the treatment of allergic diseases, for example, asthma and allergic rhinitis. Optimizing in vitro potency and metabolic stability, starting from a CCR1 lead compound, led to compound 20 with potent dual CCR3/H(1) activity and in vitro metabolic stability.

Endoscopic retrograde cholangio-pancreatography practice in district general hospitals in North East England: a Northern Regional Endoscopy Group (NREG) study

AIM

Endoscopic retrograde cholangio-pancreatography (ERCP) is an important tool for the management of pancreato-biliary disease. The aim of this study was to compare the current practice of ERCP in North East England against the key 2004 National Confidential Enquiry Report into Patient Outcome and Death (NCEPOD) recommendations and the standards set by the Joint Advisory Group on Gastrointestinal Endoscopy (JAG).

METHODS

This was a prospective multicentre study involving all hospitals in North East England, coordinated through the Northern Regional Endoscopy Group (NREG).

RESULTS

Fourteen endoscopy units submitted data for 481 ERCPs. Mean dose of midazolam was 3.24 mg (standard deviation 1.35; range 1-8 mg). Coagulation profile results were available on 469 patients (97%). Radiological investigations were documented in 96% of the procedures (463 of 481) prior to ERCP. The most common indication for ERCP was related to choledocholithiasis and its complications.  All procedures were performed with a therapeutic intent. A total of 84% of all patients were either American Society of Anesthesiologists grade I or II. The selective biliary cannulation rate was 87.3%. The total completion rate of all procedures was 80.2% (381 of 475) and completion of therapy was 89.5% (425 of 475). The 30-day mortality rate was 2% (ten patients) and procedure-related complications occurred in 5% of patients. There were no deaths directly as a result of ERCP; all deaths were related to underlying medical conditions.

CONCLUSIONS

The practice of ERCP in North East England adheres to the key recommendations of the NCEPOD and the standards set by JAG. The rates of complications compare favourably with those reported internationally.

Identification and quantification of glutathione adducts of clozapine using ultra-high-performance liquid chromatography with orthogonal acceleration time-of-flight mass spectrometry and inductively coupled plasma mass spectrometry

The application of sulphur-specific detection via ultra-performance liquid chromatography coupled to inductively coupled plasma mass spectrometry (UPLC/ICPMS) to detect and quantify the glutathione (GSH)-adducts produced via the in vitro formation of reactive metabolites is demonstrated. The adducts were formed in human liver microsomes supplemented with unlabelled GSH for clozapine. The calculation of adduct concentration was performed via comparison of the peak areas to calibration curves constructed from omeprazole, a sulphur-containing compound over the range of 0.156 to 15.62 μM of sulphur with a detection limit of 1.02 ng of sulphur on-column. Identification of the adducts was performed using conventional UPLC/time-of-flight (TOF)-MS with the calculation of clozapine intrinsic clearance carried out by high-performance liquid chromatography/tandem mass spectrometry (HPLC/MS/MS). The use of ICPMS in this way appears to offer a novel, rapid and sensitive means of determining the quantity of GSH conjugates with the combined adducts producing 0.9 μM of reactive metabolite out of a total of 3.5 μM of metabolites. The GSH adduct therefore represents 26% of this total produced as a result of the metabolism of drug to reactive species.

Working with Children in End-of-Life Decision Making

Traditionally, physicians and parents made decisions about children’s health care based on western practices. More recently, with legal and ethical development of informed consent and recognition for decision making, children are becoming active participants in their care. The extent to which this is happening is however blurred by lack of clarity about what children — of diverse levels of cognitive development — are capable of understanding. Moreover, when there are multiple surrogate decision makers, parental and professional conflict can arise concerning children’s ‘best interest’. Giving children a voice and offering choice promotes their dignity and quality of life. Nevertheless, it also presents with many challenges. Case studies using pseudonyms and changed situational identities are used in this article to illuminate the complexity of ethical challenges facing nurses in end-of-life care with children and families.

Understanding gastro-oesophageal reflux disease: a patient-cluster analysis

OBJECTIVE

To determine whether patients with gastro-oesophageal reflux disease (GERD) can be grouped according to the physical and psychological impact of their disease.

METHODS

In this multinational study, 7713 primary care physicians (PCPs) and gastrointestinal (GI) specialists took part in a structured online survey to determine how they perceive the clinical and psychological needs of their GERD patients, based on their three most recent consultations. Patients were grouped according to one of the five clusters that were subjectively developed based on preceding qualitative research.

RESULTS

Findings are reported for 1157 respondents (875 PCPs, 282 GI specialists), who reviewed 3471 patient records. Two of the five original clusters were collapsed because of overlapping characteristics, giving rise to three patient clusters. Patients with 'long-term, disrupting GERD' (39%) had symptoms considered to have not only high physical but also psychological impact. Patients with 'recurrent, distressing GERD' (14%) experienced both physical and psychological impact and were worried about the recurrent, restrictive nature of their disease or the possibility of having a more serious underlying condition. Patients with 'inconveniencing GERD' (48%) had less frequent symptoms with overall lower impact. Overall, there was a trend for GI specialists to more likely see patients at higher clinical need than PCPs.

CONCLUSIONS

Patients with GERD can generally be classified according to the physical and psychological impact of their disease. Recognition that such patients have different needs may facilitate improved management of GERD by allowing treatment to be tailored according to the patient's need.

CT of the chest in the evaluation of idiopathic pulmonary arterial hypertension in children

BACKGROUND

Idiopathic pulmonary arterial hypertension (IPAH) is a rare disease in children. By definition it is a diagnosis of exclusion, and CT of the chest is primarily performed to exclude other causes. Previous studies have defined CT features suggestive of the diagnosis of IPAH, but these have all been limited to the adult population.

OBJECTIVE

Contrast-enhanced chest CT and high-resolution CT findings in IPAH were evaluated in an attempt to define features consistently seen in children with this condition.

MATERIALS AND METHODS

The chest CT scans performed at initial presentation were reviewed in 17 children with echocardiographic or angiographic evidence of IPAH.

RESULT

There were nine boys and eight girls, ranging in age from 1 month to 17 years. The extrapulmonary findings included cardiomegaly with right-sided cardiac enlargement, which was seen in 13 children. The central pulmonary arteries were enlarged in 15 children, with peripheral enlargement in two. In six children this resulted in bronchial compression. In addition, mediastinal and hilar lymphadenopathy was noted in three children. Prominent intrapulmonary features included a peripheral vasculopathy, with enlarged tortuous vessels, seen in eight children. Ill-defined ground-glass centrilobular opacities were also noted in eight children, representing the most common parenchymal abnormality. Other findings included septal lines in five, diffuse ground-glass opacification in four and focal hyperlucent zones in three. Mosaic attenuation was seen in one child.

CONCLUSION

A variety of imaging findings are identified in IPAH. Features particularly consistent with the diagnosis include peripheral vasculopathy and centrilobular opacities in the setting of cardiomegaly and central pulmonary arterial enlargement.

Factors associated with poor asthma control in children aged five to 13 years

BACKGROUND

Most children with asthma should be able to achieve acceptable control. However, are there differences between those with acceptable and poor control, and if so, how can health care approaches be modified accordingly?

OBJECTIVE

To examine the characteristics of elementary school children aged five to 13 years with acceptable and poor levels of asthma control.

METHODS

The present cross-sectional study of children with asthma used five indicators of control, as outlined by the Canadian Asthma Consensus Report, to categorize acceptable and poor asthma control.

RESULTS

Of 153 children, 115 (75%) were rated as having poorly controlled asthma. Of those with poor control, 65 (64%) children were currently using inhaled corticosteroids, and 65% of those reported using inhaled corticosteroids daily versus as needed. Fifty-one per cent of the children with poorly controlled asthma had exposure to tobacco smoke, whereas 79% of the children with asthma under acceptable control were from households with no smokers (P=0.002). The poor control group also had significantly worse parental perceptions of the psychosocial impact of asthma on their child. No significant difference was found in the percentage of those who had written action plans in the poor control group (28%) compared with the acceptable control group (26%), and similar percentages in each group stated that they used the plans.

CONCLUSIONS

Despite the high use of inhaled corticosteroids, the majority of children had poorly controlled asthma. The poor control group had more exposure to tobacco smoke and a worse psychosocial impact due to asthma. Few children had past asthma education and action plans, suggesting that there is a need to improve access to and tools for education.

Independent factors associated with mortality, reintervention, and achievement of complete repair in children with pulmonary atresia with ventricular septal defect

OBJECTIVES

We described morphologic characteristics, particularly pulmonary anatomy, and determined the prevalence of definitive end states and their determinants in children with pulmonary atresia associated with ventricular septal defect (PAVSD).

BACKGROUND

Pulmonary atresia associated with ventricular septal defect represents a broad morphologic spectrum that greatly influences management and outcomes.

METHODS

From 1975 to 2004, 220 children with PAVSD presented to our institution. Blinded angiographic review (n = 171) characterized bronchopulmonary segment arterial supply.

RESULTS

A total of 185 patients underwent surgery, and repair was definitive in 75%. Initial operations included systemic-pulmonary artery shunt in 57%, complete primary repair in 31%, or right ventricular outflow tract reconstruction in 12%. Based on angiographic review, 118 patients had simple PAVSD and 53 patients had PAVSD with major aortopulmonary collateral arteries (MAPCAs). Overall survival from initial operation was 71% at 10 years. Risk factors for death after initial operation included younger age at repair, earlier birth cohort, fewer bronchopulmonary segments supplied by native pulmonary arteries, and initial placement of a systemic-pulmonary artery shunt. Competing-risks analysis for initially palliated patients predicted that after 10 years, 68% achieved complete repair (with associated factors including later birth cohort and more bronchopulmonary segments supplied by native pulmonary arteries), 22% died without repair, and 10% remained alive without repair. Reoperations after complete repair occurred in 38 children (27%), with risk factors including older age at palliation, MAPCAs, and more segments supplied by collaterals.

CONCLUSIONS

Outcomes in children with PAVSD have improved over time, and are better in completely repaired cases. Bronchopulmonary arterial supply is an important determinant of mortality, achievement of definitive repair, and post-repair reoperation.

Proteomic analysis for the early detection and rational treatment of cancer--realistic hope?

Proteomics is an emerging field in medical science focused on the library of proteins specific to a given biosystem, the proteome, and understanding relationships therein. This field incorporates technologies that can be applied to serum and tissue in order to extract important biological information to aid clinicians and scientists in understanding the dynamic biology of their system of interest, such as a patient with cancer. These tools include laser capture microdissection, tissue lysate arrays and mass spectrometry approaches. These new technologies are more potent coupled with advanced bioinformatics analysis. They are used to characterize the content of, and changes in, the proteome induced by physiological changes, benign and pathologic. The application of these tools has assisted in the discovery of new biomarkers and may lead to new diagnostic tests and improvements in therapeutics. These tools additionally can provide a molecular characterization of cancers, which may allow for individualized molecular therapy. Understanding the basic concepts and tools used will illustrate how best to apply these technologies for patient benefit for the early detection of cancer and improved patient care.

Determinants of quality of life in first-episode psychosis

OBJECTIVE

To assess patient and/or illness characteristics associated with aspects of quality of life (QOL) in first-episode psychosis (FEP).

METHOD

Patient characteristics, symptom ratings and Wisconsin QOL scale (client version) were assessed. Data were analysed with correlation coefficients and a hierarchical regression analysis.

RESULTS

Patients presented with varying levels of QOL on different domains. The level of 'general satisfaction' was related to age of onset and social premorbid adjustment; 'weighted index of QOL' to social premorbid adjustment and inversely to educational premorbid adjustment; 'social relations' inversely to duration of untreated psychosis (DUP), length of prodrome and negative symptoms; 'psychological well-being' inversely to depression and educational premorbid adjustment; 'activities of daily living' to social premorbid adjustment and inversely to negative symptoms; and 'outlook on symptoms' to level of depression.

CONCLUSION

Domains of self-rated QOL in FEP patients are differentially associated with malleable and non-malleable aspects of patient and illness characteristics.

Insulin signalling: effects of prior exercise

After the discovery and clinical use of insulin for treatment of diabetes it became clear that some of the biological effect of insulin was dependent on the circumstances under which it was given. Relevant for this review is the notion that physical activity, in addition to its own direct metabolic effects also markedly affects the ability of insulin to stimulate a range of metabolic processes. More specifically, during and for a prolonged period after, exercise elicits effects on processes such as insulin-induced muscle glucose uptake and glucose metabolism which influence systemic glucose homeostasis. These phenomena are probably responsible for the improvement in glucose homeostasis and metabolic control that typically occurs with exercise in people with insulin resistance and probably contributes to the reduced risk for development of type 2 diabetes in individuals who engage in regular exercise. Here we focus on the influence of a single bout of exercise on the action of insulin on processes such as glucose uptake and glucose storage in skeletal muscle.

Client and staff views on facilities and services, before and after the convergence of sexual, reproductive and women's services

OBJECTIVE

To evaluate client and staff views on existing facilities and services, before and after the convergence of sexual, reproductive and women's services.

METHODS

Evaluation involved questionnaire survey of clients and staff, one-to-one interviews with staff and review of routinely collected clinical activity data.

RESULTS

The integration of the three services led to a reduction in stigma associated with attending sexual health services. Despite some staff concerns, the number of men attending the services did not decrease. There was increased satisfaction with the new service, especially the quality of facilities. There were increased numbers of referrals between clinical services in the Sandyford Initiative.

CONCLUSIONS

Sexual, reproductive and women's services can be integrated to provide improved facilities for clients.

Contrast-enhanced MR angiography of pulmonary venous abnormalities in children

BACKGROUND

Echocardiography and X-ray angiography have been considered as gold standards for evaluation of pulmonary venous abnormalities. However, each technique has its own limitations, such as limitation in visualization of the pulmonary veins within the lungs by echocardiography, and the invasive nature of and use of ionizing radiation in X-ray angiography. Contrast-enhanced MR angiography (MRA) is a fast noninvasive method of visualization of the vessels including the pulmonary arteries and veins.

OBJECTIVES

To evaluate the utility of contrast-enhanced MRA in the evaluation of pulmonary venous abnormalities in pediatric patients and to compare its diagnostic accuracy with that of transthoracic echocardiography.

MATERIALS AND METHODS

In 30 pediatric patients 31 contrast-enhanced MRA studies were performed for evaluation of pulmonary venous abnormalities. Each of 124 pulmonary veins was evaluated for site of connection, course within the lung, presence of obstruction, and topographic relationship with the adjacent structures. The findings of MRA were compared with echocardiographic findings for 116 veins in 29 studies in 28 patients.

RESULTS

Contrast-enhanced MRA visualized 99% (123 of 124) of the pulmonary veins investigated, while echocardiography visualized 89% (103 of 116). Exact agreement was found between the two methods in 72% of the veins with a weighted kappa of 0.60 (0.47-0.73, 95% CI). Echocardiography failed to diagnose an abnormal connection in 2 of 15 pulmonary veins, a discrete stenosis in 2 of 19 veins, and diffuse hypoplasia in 10 of 14 veins. In 29% of patients, MRA made the uncertain echocardiographic findings clear. In another 29%, MRA provided a new diagnosis.

CONCLUSIONS

Contrast-enhanced MRA is a powerful, safe, and accurate fast-imaging technique for the anatomical evaluation of pulmonary venous abnormalities. MRA may obviate the need for conventional X-ray angiography. Cardiac catheterization may be reserved for those patients in whom pulmonary vascular resistance needs to be determined.

Intraspecific molecular variation in the seaweed fly Coelopa frigida consistent with behavioural distinctness of British and Swedish populations

The major aim of this study was to compare the intraspecific variation and genetic structure of the behaviourally distinct British and Swedish populations of the seaweed fly Coelopa frigida. C. frigida has been the subject of intense study into the basis of female choice. The behaviour of British females is consistent with a 'good genes' model, whereas that of the Swedish flies suggests a Fisher process, in which the difference between the former and the latter is defined by female choice increasing offspring viability in 'good genes' models. Through a study of variability in the mitochondrial cytochrome oxidase II gene from more than 600 flies, we show that there is clear differentiation at the molecular level between the two countries' populations, with an FST of > 75% and no shared haplotypes. Tajima's test reveals an excess of rare variants relative to expectation, which, if not the result of selective sweep, indicates either a population expansion or purifying selection against weakly deleterious variants. Within the two populations, substantial subpopulation differentiation is observed in the UK, where there is also evidence of isolation by distance. Swedish populations exhibit lower variability, and no evidence of isolation by distance, with the latter result possibly being related to the continuous distribution of suitable habitat. The pattern of intraspecific variation is explainable by a combination of contemporary and also historical factors. British and Swedish populations may have been descended from at least two separate founding populations during the recolonization of these areas following Pleistocene glaciations.

Immortalisation of primary cells

Knowledge of the target cells is fundamental to maximise efficiency in attempts at immortalisation of specific cell types. It is also important to optimise the primary cell culture system to promote the survival of the target cell population. Other important factors that may influence the success in obtaining immortalised cells include the toxicity and efficiency of the immortalisation procedure. These can be assessed experimentally and if necessary appropriate techniques can be employed to purify the target cells. When cell lines have been established it is vital to assess them at an early stage for desired scientific and practical features as well as determining their stability and life-span. Furthermore, early characterisation of cell line authenticity (e.g. genetic characters, species of origin) and quality control testing will avoid wasted time and resources should contamination with micro-organisms or another cell line occur. Establishing a programme of immortalisation is a serious undertaking that should only be considered when there are no candidate continuous cell lines available. However, new approaches to modify the biology of cells to give extended life-span, whilst retaining the characteristics of differentiated cells in vivo, will hopefully provide valuable new substrates for in vitro toxicology.

Utility scores of symptom profiles in major depression

Utility is a measure of undesirability for a specific health state. This study determines the utility scores for the individual symptoms of depression, and examines the impact that personal experience with depression has on these scores. Seventy-five subjects (19 with current depression, 21 with past depression, and 35 healthy controls) assigned utility scores to each of 10 individual symptoms of depression, and three depression severity profiles. Utility scores were measured using the standard gamble technique. Mean utility scores were used to list the symptoms of depression from most to least undesirable. The three diagnostic groups were compared with respect to the magnitude of undesirability of the depressive symptoms. The results of this study found that individuals assigned different utility scores to different symptoms of depression. The psychological symptoms of depression such as suicidal ideation, guilt and depressed mood were ranked as more undesirable than the somatic symptoms of depression. Each diagnostic group ranked the symptoms of depression in a similar manner. Patients with a current depression were willing to accept a greater risk of death to avoid suffering from lifelong depressive symptoms as compared to patients with a past depression or healthy controls.

Defining guilt in depression: a comparison of subjects with major depression, chronic medical illness and healthy controls

BACKGROUND

Although guilt is a widely accepted feature of depression, there is limited and inconsistent data defining the nature of this symptom. The purpose of the current study was to examine the specificity and nature of guilt in subjects with major depression as compared to patients with another chronic medical illness and healthy controls.

METHODS

Outpatients with current major depressive episode (MDE; n=34), past-MDE (n=22), chronic cardiac illness (n=20) and healthy controls (n=59) were administered the following measures: The Guilt Inventory (GI), State Shame and Guilt Scale (SSGS), 17-item Hamilton Rating Scale for Depression (Ham-D) and the Structured Clinical Interview for DSM-IV.

RESULTS

Overall multivariate analysis of covariance comparing mean scores for the six guilt subscales [state-guilt, trait-guilt, moral standards (from the GI); state-guilt, -pride, and -shame (from the SSGS)] across the four groups was significant (F=9.1, df=6:121, p<0.0001). Post-hoc analysis revealed the following differences (each at least p<0.01): for state-guilt (GI), current-MDE>past-MDE>cardiac=healthy controls; for trait-guilt (GI), current-MDE=past-MDE>cardiac=healthy controls; for state-shame, -guilt and -pride (SSGS), current-MDE>past-MDE, past-MDE=cardiac, past-MDE>healthy, cardiac=healthy controls. Among depressed patients, there was significant correlation between Ham-D score and all guilt sub-scales (p<0.01), except moral standards.

LIMITATIONS

The cardiac group may have less illness burden than currently depressed.

CONCLUSIONS

State expression of guilt, shame and low pride distinguish acutely depressed from all other groups, and are highly influenced by severity of depression. Trait-guilt does not differentiate acute from past depressed. Data suggests guilt may represent both an enduring and fluctuating feature of depressive illness over its longitudinal course.