672 ASSESSMENT OF THERAPEUTIC RESPONSE TO MELATONIN IN PARKINSON’S DISEASE PATIENTS WITH SLEEP DISORDERS, A QI PROJECT

Introduction

Holistic care of patients with Parkinson’s Disease (PD) addresses motor and non-motor features. With prevalence of around two-thirds of patients, sleep disorders; including REM Sleep behaviour Disorder (RBD); can have significant negative impact on quality of life. The naturally occurring neuro-hormone, melatonin plays a role in circadian rhythm; a process disrupted in PD. In 2017, NICE suggested to ‘consider clonazepam or melatonin to treat RBD.’ Melatonin has a more favourable side effect profile than clonazepam. This QI project qualitatively evaluates a geographical subset of PD patients treated with melatonin, assessing the clinical effect of treatment and whether this medication is being used optimally. PDSA methodology identified potential for introducing a sleep scale to allow more Objective future assessment.

Methods

A departmental database identified all current and deceased patients treated with melatonin since 2015. The electronic patient record of a total of 26 patients were reviewed. Data on indication, dosing, response (subjectively categorised as no effect, mild, moderate, or good impact) alongside demographics were collected.

Results

Analysis revealed poor sleep as the most common indication for melatonin. Melatonin was well tolerated with no reported side effects. Results showed benefit in 95% of patients with an initial dose of 2 mg. Dosing was reviewed in 81% of patients at next clinic appointment. For those patients who did not have ‘good’ effect dose was increased in 62% of patients.

Conclusion

The subjective nature of sleep assessment makes assessing therapeutic benefit challenging however data suggests melatonin does improve sleep, a finding consistent with current limited research. Implementation of a sleep scale questionnaire for patients commencing melatonin will allow Objective analysis by the multidisciplinary team of medication effect and aid dose titration. Ongoing review is required to assess effect due to the infrequency of included patients and protracted therapeutic response period.

A perspective on using experiment and theory to identify design principles in dye-sensitized solar cells

Dye-sensitized solar cells (DSCs) have been the subject of wide-ranging studies for many years because of their potential for large-scale manufacturing using roll-to-roll processing allied to their use of earth abundant raw materials. Two main challenges exist for DSC devices to achieve this goal; uplifting device efficiency from the 12 to 14% currently achieved for laboratory-scale 'hero' cells and replacement of the widely-used liquid electrolytes which can limit device lifetimes. To increase device efficiency requires optimized dye injection and regeneration, most likely from multiple dyes while replacement of liquid electrolytes requires solid charge transporters (most likely hole transport materials - HTMs). While theoretical and experimental work have both been widely applied to different aspects of DSC research, these approaches are most effective when working in tandem. In this context, this perspective paper considers the key parameters which influence electron transfer processes in DSC devices using one or more dye molecules and how modelling and experimental approaches can work together to optimize electron injection and dye regeneration.

The role of PKA in the translational response to heat stress in Saccharomyces cerevisiae

Cellular responses to stress stem from a variety of different mechanisms, including translation arrest and relocation of the translationally repressed mRNAs to ribonucleoprotein particles like stress granules (SGs) and processing bodies (PBs). Here, we examine the role of PKA in the S. cerevisiae heat shock response. Under mild heat stress Tpk3 aggregates and promotes aggregation of eIF4G, Pab1 and eIF4E, whereas severe heat stress leads to the formation of PBs and SGs that contain both Tpk2 and Tpk3 and a larger 48S translation initiation complex. Deletion of TPK2 or TPK3 impacts upon the translational response to heat stress of several mRNAs including CYC1, HSP42, HSP30 and ENO2. TPK2 deletion leads to a robust translational arrest, an increase in SGs/PBs aggregation and translational hypersensitivity to heat stress, whereas TPK3 deletion represses SGs/PBs formation, translational arrest and response for the analyzed mRNAs. Therefore, this work provides evidence indicating that Tpk2 and Tpk3 have opposing roles in translational adaptation during heat stress, and highlight how the same signaling pathway can be regulated to generate strikingly distinct physiological outputs.

The multicopper oxidase (CueO) and cell aggregation in Escherichia coli

cueO encodes a periplasmic multicopper oxidase, which is known to be involved in copper homeostasis and protection against oxidative stress in Escherichia coli K12. Transcriptional profiling showed that expression of genes associated with motility was lowered in a cueO mutant while expression of genes associated with autoaggregation was elevated. Increased aggregation was correlated with increased expression of cell surface proteins antigen 43 and curli. Changes in gene expression caused by the deletion of cueO were essentially independent of SoxR and OxyR, the global regulators of oxidative stress response.

Nurse-led management of carpal tunnel syndrome: an audit of outcomes and impact on waiting times

INTRODUCTION

This article describes the outcome of a nurse-led service developed to manage patients referred with a presumptive diagnosis of carpal tunnel syndrome.

PATIENTS AND METHODS

We developed a rapid-access service in response to unacceptable waiting times for patients with carpal tunnel syndrome. The service was developed around the role of a nurse practitioner providing a single practitioner pathway from first clinic appointment, through surgery to discharge.

RESULTS

Waiting times improved considerably whilst the standard and quality of care was maintained.

CONCLUSIONS

There is a role for nurses to perform certain surgical procedures within a well-defined environment.

Clinical and radiological outcome following total hip arthroplasty with an uncemented trabecular metal monoblock acetabular cup

Uncemented acetabular components are associated with a significant incidence of polyethylene wear and secondary osteolysis. The new tantalum/polyethylene composite (Hedrocel) acetabular component is designed to reduce the polyethylene wear and to increase the longevity of the acetabular cups. We report our short- term clinical outcome and patient satisfaction following use of an uncemented tantalum acetabular component in a single centre. During 1999 to 2002, 113 uncemented tantalum acetabular cups were implanted in 105 patients in our institution. The average age at operation was 56.8 years. All patients were assessed pre- and post-operatively with the Oxford 12 item hip questionnaire and standard radiographs of the pelvis. At a mean follow-up of 32 months (range: 18 to 48), 112 Hedrocel cups were assessed in 104 patients. Subjective patient's satisfaction was also assessed. At the time of evaluation, one patient had died due to an unrelated cause. Eight patients had bilateral acetabular cups implanted. The mean Oxford hip score improved from 45 preoperatively to 14 post-operatively. Subjectively 99% were very satisfied or satisfied. Only one patient expressed dissatisfaction about the outcome of this surgery. Radiologically, there were no signs of cup loosening or wear. This study shows that at short-term the new uncemented tantalum/polyethylene composite (Hedrocel) acetabular component can yield a satisfactory clinical and radiological outcome and has a high patient satisfaction. Although the short-term result from our centre is very encouraging, similar results from other centres and longer follow-up are required.

Multicenter evaluation of the Abbott LCx Mycobacterium tuberculosis ligase chain reaction assay

Four Australian hospital laboratories evaluated the performance of the Abbott LCx Mycobacterium tuberculosis assay with 2,347 specimens (2,083 respiratory and 264 nonrespiratory specimens) obtained from 1, 411 patients. A total of 152 specimens (6.5%) were culture positive for Mycobacterium tuberculosis complex (MTBC); of these, 79 (52%) were smear positive. After resolution of discrepant data, the overall sensitivity, specificity, and positive and negative predictive values for the LCx assay were 69.7, 99.9, 99.1, and 97.7% respectively. For smear-positive respiratory specimens that were culture positive for MTBC, the values were 98.5, 100, 100, and 98.4%, respectively, while the values for smear-negative respiratory specimens were 41.5, 99.9, 96.4, and 98%, respectively. Relative operating characteristic curves were constructed to demonstrate the relationship between sensitivity and specificity for a range of possible cutoff values in the LCx assay. These graphs suggested that the assay sensitivity for respiratory samples could be increased from 70.2 to 78.6%, while the specificity would be reduced from 99.9 to 99.4% by inclusion of a grey zone (i.e., LCx assay values of between 0.2 and 0.99). An algorithm is presented for the handling of specimens with LCx assay values within this grey zone.

Adenoid cystic carcinoma of the head and neck: predictors of morbidity and mortality

OBJECTIVES

To review 160 patients treated at a single institution for adenoid cystic carcinoma during the 20 years between 1977 and 1996, applying a consistent treatment of surgery and postoperative radiation therapy to 140 patients. To analyze factors governing treatment failure, treatment-related morbidity, and mortality.

DESIGN

Retrospective review.

SETTING

Tertiary referral center.

PATIENTS

Seventy-seven males and 83 females aged 13 to 89 years (average age, 49.5 years).

RESULTS AND CONCLUSIONS

Combined treatment yielded an 85% locoregional freedom from relapse and disease-specific survival at 5, 10, and 15 years was 89%, 67.4%, and 39.6%, respectively. Thirty-five patients (21.9%) had distant metastases as the only site of failure. Patients treated for paranasal sinus tumor experienced the most treatment-related morbidity vs other sites. Perineural invasion of major nerves, positive margins at surgery, and solid histological features were associated with increased treatment failures. Four or more symptoms present at diagnosis, positive lymph nodes, solid histology, and perineural invasion of major nerves were associated with increased mortality from disease.

PIS and DRGs: coding inaccuracies and their consequences for resource management

Accurate information is important for the successful implementation of the Resource Management Initiative and the NHS White Paper. A review of 153 joint replacements performed in a three-month period in Leicester showed that 24 per cent of 139 procedures for which medical notes were available had been given incorrect Diagnosis-Related Groupings (DRGs). Of these, 64 per cent could be ascribed to errors in allocating OPCS-3 codes and 36 per cent to errors in converting OPCS-3 codes to DRGs by computer. It is of concern that inaccurate information may in future be used to allocate resources. The resource implications of assiduous quality control of recording, coding and computing is pointed out, and it is suggested that improved classification systems should be assessed for use in the NHS.