Solution NMR investigations of integral membrane proteins: Challenges and innovations

Compared to soluble protein counterparts, the understanding of membrane protein stability, solvent interactions, and function are not as well understood. Recent advancements in labeling, expression, and stabilization of membrane proteins have enabled solution nuclear magnetic resonance spectroscopy to investigate membrane protein conformational states, ligand binding, lipid interactions, stability, and folding. This review highlights these advancements and new understandings and provides examples of recent applications.

Supratherapeutic dabigatran: a cause of life-threatening haemorrhage

In this case report, we present a rare case of life-threatening gastrointestinal haemorrhage associated with deranged coagulation due to supratherapeutic levels of dabigatran. Dabigatran is a potent, synthetic, reversible non-peptide thrombin inhibitor which is increasingly used for stroke prevention in patients with non-valvular atrial fibrillation. It is generally accepted that dabigatran dosing does not require titration or the monitoring of plasma levels due to its predictable pharmacokinetics and pharmacodynamics. However, this case report challenges this viewpoint while identifying an important knowledge gap in relation to the effect of altered gastrointestinal motility on the absorption of direct oral anticoagulants. Furthermore, it demonstrates the successful use of high-dose idarucizumab in a critical care setting. Idarucizumab is a monoclonal antibody fragment that binds specifically to dabigatran and its metabolites, thereby reversing the anticoagulant effect.

24 REVERSING FRAILTY AND ENHANCING RESILIENCE WITH EXERCISE AND DIETARY EDUCATION (REFEREE): A PRIMARY CARE RANDOMISED CONTROLLED TRIAL

Background

There is a need for effective primary-care interventions that help older people combat frailty and build resilience. This study aims to test the effectiveness of a co-designed exercise and dietary protein intervention.

Methods

This was a multicentre, randomised-controlled, parallel-arm trial in six Irish primary-care practices. We enrolled adults aged 65+ with Clinical Frailty Scale score ≤5 from December 2020 to April 2021. Participants were randomised to intervention or usual care with allocation concealed until enrolment with a GP. Intervention comprised exercises, emphasising strength, and dietary protein guidance. At three-month follow-up, effectiveness was measured by comparing SHARE-Frailty Instrument between groups, on intention-to-treat basis. Secondary outcomes included muscle mass, bone mass and biological age measured by Bioelectrical Impedance Analysis (BIA). Ease of intervention and health difference were measured on Likert scales.

Results

359 adults were assessed for eligibility and 168 enrolled. 156 (92.9%) attended follow-up (mean age 77.1; 67.3% women; 79 intervention, 77 control). At baseline, frailty proportions were 17.7% in the intervention and 16.9% in the control group. At follow-up, they were 6.3% and 18.2%, respectively. The odds ratio (OR) of being frail for the intervention group was 0.23 times that of the control group (95% confidence interval: 0.07-0.72; P=0.011), adjusting for age, gender and site. Absolute risk reduction was 11.9% (CI: 0.8%-22.9%; P=0.018). Number needed to treat was 8.4. BIA parameters improved, bone mass significantly (P=0.040). 66.2% found the intervention easy, 69.0% reported feeling better.

Conclusion

A combination of exercises and dietary protein significantly reduced frailty and improved self-reported health. Frailty was reversed in more than 1 in 9 participants.

Bedside Ultrasound in the Emergency Department Enables Rapid Diagnosis of PUJ Obstruction Syndrome

Presentation A 27-year-old male presented to the Emergency Department with acute severe left flank pain following ingestion of 5 pints of beer. Approximately 20 bouts of similar episodes over the past year, in the setting of alcohol ingestion. Despite attending GP, no diagnosis reached yet. Diagnosis "Pelvo-ureteric junction (PUJ) obstruction Syndrome". Bedside ultrasound in the Emergency Department during the acute pain crisis: massive hydronephrosis left kidney. Finding confirmed on CT scan. Subsequent 99m-Tec renogram showed markedly decreased renal function on the left. Treatment Interval Pyeloplasty two months later. Conclusion Delayed recognition is the norm for PUJ obstruction syndrome, as CT/MRI/US studies often do not display hydronephrosis if the patient is asymptomatic. We could not find any reports in the literature of diagnosing PUJ obstruction syndrome using bedside ultrasound in the Emergency Department. We advise acquiring rapid bedside ultrasound imaging in suspected cases of PUJ obstruction syndrome, enabling earlier diagnosis.

112 INTEGRATED CARE PROGRAMME FOR OLDER PEOPLE (ICPOP) IN A RURAL SETTING—ROLE OF ADVANCED NURSE PRACTITIONER (ANP)

Background

Sláintecare advocates for right care, in the right place at the right time. ANPs for Older Persons in the community are uniquely placed to deliver care as close as possible to the older person’s home and to lead a holistic, flexible model of care minimising admission to acute care and maximising existing local resources. A pilot programme aimed at providing ANP led comprehensive geriatric assessment (CGA) (with Geriatrician support) to older people in a defined area commenced in June 2019. This pilot was part of a larger Hub and Spoke model funded by Sláintecare which gave additional MDT support.

Methods

A referral template was designed. Criteria for referral included; age > 75 years, Rockwood Frailty Scale 4–6 (focusing on Falls, Cognitive Impairment and Complex Frailty). Older people on the cusp of requiring long term care (LTC) were also prioritised. A prospective database of patients was maintained by the ANP to evaluate the service.

Results

From June 2019 to August 2021, 156 patients received an ANP led CGA, mostly conducted in the home. 247 reviews were conducted at the local spoke clinic and 46 joint ANP/Geriatrician home visits. Majority of referrals were from GP (n = 69), hospital (n = 30), LTC reviews (n = 22) and Community Nursing Units (CNUs) (n = 19). 449 outpatient appointments have been removed from the tertiary referral centre. Independent case load management from the ANP includes further appointments, telephone follow up/advice and she is a point of contact where crises arise before referral to acute services. 99% of patients surveyed reported satisfaction with the service especially the ease of local access and home visits.

Conclusion

Older Persons’ ANP can provide longitudinal care pathways for older adults in the community in conjunction with ICPOP and local CNUs, intervening before crises emerge and providing continuity of care and an alternative to acute care.

Abstract LB078: Hexyl-(cuban-1-yl-methyl)-biguanide (HCB) inhibits hormone therapy resistant breast cancer cells, in part by Inhibiting CYP3A4 arachidonic acid epoxygenase activity

Introduction: Small molecule therapeutics of estrogen receptor-positive/HER2-negative breast cancer remains an area of active investigation where novel agents are greatly needed for treatment of hormone therapy resistant metastatic disease. The biguanide hexyl-benzyl-biguanide (HBB) is a potent inhibitor of CYP3A4 arachidonic acid (AA) epoxygenase activity and inhibits breast cancer cell proliferation and MCF-7 breast cancer tumor growth in nude mice. To explore the impact of bioisosteric substitution of the benzyl moiety of HBB with a cubane moiety, we synthesized hexyl-(cuban-1-yl-methyl)-biguanide (HCB) and tested its potency for the inhibition of the cognate CYP3A4 target AA epoxygenase activity as well as breast cancer cell proliferation of hormone therapy sensitive and resistant cell lines.

Results: HCB selectively inhibited CYP3A4-mediated biosynthesis of (±)-14,15-EET with an IC50 of 4.7±0.2 uM vs. 64.8±6.5 uM for 8,9-EET and 26.5±1.9 uM for 11,12-EET. At 24 hours, HCB inhibited proliferation of MCF-7 (ER+HER2-), BT474 (ER+HER2+) and MDA-MB-231 (ER-HER2-) cells at IC50 of 8.4±1.2, 11±1.3 and 15±0.9 uM, respectively. At 48 hours, HCB inhibited proliferation of aromatase inhibitor and fulvestrant resistant (LR,FR), and cyclin dependent kinase inhibitor (CDKi) palbociclib resistant (LR,FR,PR) MCF-7 cell lines; LR,FR MCF-7AC1 (IC50 =1.34±0.1 uM) and LR,FR,PR MCF-7AC1 (IC50 =1.64±0.2 uM). Addition of 14,15-EET (1 uM) partially rescues MCF-7 cells from HCB-mediated inhibition of proliferation.

OXPHOS is promoted, in part, by EETs. HCB is a potent OXPHOS inhibitor and rapidly inhibits O2 consumption of the MCF-7 and ZR75 (ER+HER2-) cells in a dose-dependent fashion (P<0.05). HCB treatment (10 uM) reduces mitochondrial membrane potential to 57.4±15.3% (P<0.001) of vehicle control in MCF-7 cells. Treatment with HCB at 20 uM for 0.5 hour also causes mitochondrial swelling in MCF-7 cells. HCB (10 uM) activates AMPK within 0.5 hour and increases the level of phosphorylation from 2.4±0.3 to 25.1±6.0 folds in a time dependent fashion in MCF-7 cells from 0.5-24 hours.

Conclusion: These results show that HCB inhibits proliferation of ER+HER2- breast cancer cells, in part through inhibition of OXPHOS and suppression of the CYP product 14,15-EET. This inhibition is highly active in hormonal therapy and CDKi resistant ER+HER2- breast cancer cells. These results suggest that HCB is a novel and potent biguanide that has potential to be developed for inhibition of hormone therapy resistant and CDKi resistant breast cancer.

Citation Format: Zhijun Guo, Jianxun Lei, Kwon Ho Hong, Beverly Norris, Craig M. Flory, Swaathi Jayaraman, Connor McDermott, Elizabeth Ambrose, Irina Sevrioukova, Tom Poulos, Ilia Denisov, Stephen Sliga, Robert J. Schumacher, Gunda I. Georg, John R. Hawse, Matthew P. Goetz, David A. Potter. Hexyl-(cuban-1-yl-methyl)-biguanide (HCB) inhibits hormone therapy resistant breast cancer cells, in part by Inhibiting CYP3A4 arachidonic acid epoxygenase activity [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr LB078.

Perceived Weight Status Among College Students and Its Relationship with Life Satisfaction (FS10-08-19)

Objectives

As mistaken body weight perceptions have been linked to less healthy diet and activity behaviors, accurate weight perception may help individuals set appropriate, health-related weight goals. However, some data link poor weight perception with negative mental health. The purpose of this study is to examine the prevalence of body weight misperception and self-reported life satisfaction among undergraduate college students.

Methods

Data were collected from undergraduate students (18–24 years) participating in an on-going cross-sectional health survey at a midsize, northeastern university between 2010–18 (n = 3921). Students self-reported their described weight status and life satisfaction via online questionnaire; body composition was assessed via bioelectrical impedance in a fasted state. Proportional differences between men and women were evaluated using chi-square analyses.

Results

More than a third (35.9%) of students misperceived their weight status. Among men (n = 1190), 31.7% misperceived their weight status. Among women (n = 2731), 37.6% misperceived their weight status. Compared with men, women had a higher prevalence of overestimating their weight status (31.7 vs. 11.1%, P < 0.01). Compared with women, men had a higher prevalence of underestimating weight status (20.7 vs. 5.9%, P < 0.01). No significant differences in life satisfaction were observed among individuals who correctly perceive their weight status versus those who misperceived.

Conclusions

Our results show a high prevalence of undergraduate college students who misperceive their weight status; however, misperception was not associated with differences in life satisfaction. As misperception of weight status differed between genders, targeted interventions related to the promotion of healthy weight may consider sex-specific messaging in college students.

Funding Sources

New Hampshire Agriculture Experiment Station and USDA National Institute of Food and Agriculture Hatch Project 1010738.

A Review of the Parenteral Nutrition Supply Service in an Irish Neonatal Unit

Background Neonatal Intensive Care (NICU) patients have individual nutritional requirements often requiring Patient Specific Parenteral Nutrition (PSPN). From October 2015, the national PSPN compounding service availability changed from 7 days per week service to 5 days per week (i.e. no weekend and limited bank holiday ordering available). The aim of this study was to examine the introduction of a 5 day only PSPN supply on neonatal patient parenteral nutrition availability in a tertiary NICU. Methods We performed a prospective assessment of the provision of a 5 day rather than 7 day ordering of PSPN over a one month period (June 2017). Results Fifteen neonatal patients received a cumulative 89 days of PN during June 2017. 10 (66%) patients received PSPN during this time period. There was same day availability of PSPN in 62 of 89 days of PN (69%). Conclusion Thorough education and training will help prescribers to make appropriate PSPN ordering decisions. Improvements to available stock bags may reduce the amount of PSPN that is required but a 7 day PSPN ordering service would improve efficient provision of clinically indicated PSPN to premature infants in NICU in Ireland.

Multiple births by a captive swellshark Cephaloscyllium ventriosum via facultative parthenogenesis

Using a novel set of 12 microsatellites, a captive, adult female swellshark Cephaloscyllium ventriosum that produced five pups via parthenogenesis is described; naturally occurring parthenogenesis has been observed in every vertebrate class with the exception of mammals. As demonstrated in this study, a captive environment is ideal for long-term monitoring of animals under controlled conditions, and easily allows the detection of particular facets of their biology.

An Evaluation of a Chronic Fatigue Lifestyle Management Programme Focusing on the Outcome of Return to Work or Training

This article presents the results of an audit of clinical outcomes from an occupational therapist led service for patients with chronic fatigue syndrome (CFS). The service offers group outpatient lifestyle management sessions, in which patients are encouraged to restructure lifestyle patterns in order to facilitate improvements in fatigue and function.

The cohort studied consisted of 98 consecutive patients attending the service who fulfilled the 1994 Centers for Disease Control criteria for CFS. The median illness duration was 5 years. The treatment offered consisted of six group sessions in lifestyle management together with three additional review sessions. The primary outcome measure was a return by the patient to employment, voluntary work or training. The cohort was followed up at a median of 18 months using a self-report questionnaire. Among the treated patients, 42% (31/74) reported new part-time or full-time employment, voluntary work or training.

The results of this study suggest that a lifestyle management programme offered by an occupational therapist led specialist service may provide positive outcomes, in terms of a return by patients to work and training, and indicates the need for a randomised controlled trial to provide definitive evidence of this.

18-month outcomes of a community-based treatment for childhood obesity

BACKGROUND

Few studies have evaluated community-based interventions for childhood obesity and even fewer provide efficacy data 1 year later.

OBJECTIVES

This study assessed changes in relative weight 1 year after a 6-month treatment for childhood obesity.

METHODS

Participants were 155 overweight/obese children/adolescents and their caregivers. The primary outcome was change in child percent over body mass index (BMI) from 6 to 18 months. The primary outcome was also assessed from 0 to 18 months and changes in secondary outcomes (BMI z-score, guardian weight, health-related quality of life [HRQoL]) were examined from 6-18 to 0-18 months.

RESULTS

From 6 to 18 months, there were no significant changes in any outcome. From 0 to 18 months, there were improvements in BMI z-score (P < 0.001), HRQoL (P < 0.001) and guardian weight (P = 0.02).

CONCLUSIONS

Changes in relative weight and HRQoL observed after 6 months persisted 1 year later. The programme produced reductions in BMI z-score and obesity prevalence but not in percent over BMI from 0 to 18 months.

Lithium in patients with amyotrophic lateral sclerosis (LiCALS): a phase 3 multicentre, randomised, double-blind, placebo-controlled trial

Background

Lithium has neuroprotective effects in cell and animal models of amyotrophic lateral sclerosis (ALS), and a small pilot study in patients with ALS showed a significant effect of lithium on survival. We aimed to assess whether lithium improves survival in patients with ALS.

Methods

The lithium carbonate in amyotrophic lateral sclerosis (LiCALS) trial is a randomised, double-blind, placebo-controlled trial of oral lithium taken daily for 18 months in patients with ALS. Patients aged at least 18 years who had ALS according to the revised El Escorial criteria, had disease duration between 6 and 36 months, and were taking riluzole were recruited from ten centres in the UK. Patients were randomly assigned (1:1) to receive either lithium or matched placebo tablets. Randomisation was via an online system done at the level of the individual by block randomisation with randomly varying block sizes, stratified by study centre and site of disease onset (limb or bulbar). All patients and assessing study personnel were masked to treatment assignment. The primary endpoint was the rate of survival at 18 months and was analysed by intention to treat. This study is registered with Eudract, number 2008-006891-31.

Findings

Between May 26, 2009, and Nov 10, 2011, 243 patients were screened, 214 of whom were randomly assigned to receive lithium (107 patients) or placebo (107 patients). Two patients discontinued treatment and one died before the target therapeutic lithium concentration could be achieved. 63 (59%) of 107 patients in the placebo group and 54 (50%) of 107 patients in the lithium group were alive at 18 months. The survival functions did not differ significantly between groups (Mantel-Cox log-rank χ² on 1 df=1·64; p=0·20). After adjusting for study centre and site of onset using logistic regression, the relative odds of survival at 18 months (lithium vs placebo) was 0·71 (95% CI 0·40–1·24). 56 patients in the placebo group and 61 in the lithium group had at least one serious adverse event.

Interpretation

We found no evidence of benefit of lithium on survival in patients with ALS, but nor were there safety concerns, which had been identified in previous studies with less conventional designs. This finding emphasises the importance of pursuing adequately powered trials with clear endpoints when testing new treatments.

Funding

The Motor Neurone Disease Association of Great Britain and Northern Ireland.

Patients' hopes and expectations of a specialist chronic fatigue syndrome/ME service: a qualitative study

BACKGROUND

The 2007 National Institute for Health and Clinical Excellence guidelines on Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) recommend early management of the condition. Investment by the Department of Health has expanded the number of specialist U.K. CFS/ME services but there has been little research on what patients hope or expect from referral.

METHODS

A qualitative study exploring hopes and expectations of patients newly referred to a CFS/ME Service in the South of England. Interviews with 20 patients were analysed using the constant comparative method.

RESULTS

Participants hoped referral to a specialist service would clarify diagnosis, give guidance and support, assist in understanding the complexity of the illness and provide hope for the future. While many participants valued the support of their GP, all viewed referral as offering a level of specialist expertise beyond that available in primary care. Many participants expressed high levels of uncertainty about the nature of CFS/ME. While participants hoped that the service would be able to provide information and guidance, many expressed the view that more information earlier in their illness would make the waiting period less stressful and make it possible for them to do more to help themselves.

CONCLUSIONS

GP referral to a specialist service appeared to be highly valued by the participants in this study. The levels of uncertainty expressed by many patients about the nature of CFS/ME raises the issue of the role of information on CFS/ME during the early stages of the illness and suggests a need for more reassurance and positive advice during the waiting period.

Is non-invasive testing for sexually transmitted infections an efficient and acceptable alternative for patients? A randomised controlled trial

OBJECTIVES

A randomised controlled trial was conducted to assess and quantify the efficacy and acceptability of non-invasive testing (NIT) for sexually transmitted infections (STI) in asymptomatic patients within a genitourinary medicine clinic.

METHODS

Patients were randomly assigned to either standard of care (SOC-STI testing with genital examination) or NIT. The length of time patients spent in the clinic was recorded and patients were asked to complete a satisfaction survey.

RESULTS

391 participants were randomly assigned. The length of time male and female patients spent in the clinic was significantly shorter with NIT (men 26 min; women 23 min) compared with SOC (men 41 min; women 45 min, p<0.0001), but most of this decrease was due to reduced patient waiting time within the clinic, rather than less time spent with medical or nursing staff. Those randomly assigned to NIT were significantly more likely to state they were in clinic for less time than expected (p<0.01) and report that the tests were less uncomfortable than expected (p≤0.04). For both men and women, more patients in the SOC group declined testing for syphilis (14%) and HIV (20%) compared with NIT (7% and 13%, respectively), but this was only significantly different between treatments for female patients (p≤0.02).

CONCLUSIONS

NIT for STI in asymptomatic patients can reduce the time patients spend in the clinic when combined with appropriate patient care pathways, and is an acceptable alternative to physician-taken genital swabs.

UK healthcare workers' knowledge of meticillin-resistant Staphylococcus aureus practice guidelines; a questionnaire study

Effective infection control practice requires knowledge of and adherence to contemporary infection control guidelines. Utilising a novel questionnaire tool, we evaluated knowledge of recently published guidelines on meticillin-resistant Staphylococcus aureus (MRSA) precautions in a number of relevant healthcare worker (HCW) populations. The questionnaire was developed from national UK MRSA practice guidelines and consisted of 10 'true or false' statements. The questionnaire was utilised to assess knowledge in 293 participants from HCW and control populations. The participants included 188 doctors attending the British Medical Association's Annual Representatives Meeting, 52 trainee surgeons attending the Association of Surgeons in Training annual conference, 30 members of a non-clinical control population and 23 infection control nurses (ICNs). The mean (SD) score for knowledge levels obtained from doctors was 6.6 (1.68), for non-clinical control population was 4.7 (1.8) and for ICNs, 8.4 (1.12). There were significant differences in knowledge levels between different population groups (P<0.001), UK employment region of the participant (P=0.01) and the doctors' medical specialty (P=0.02). Career seniority and gender of the participant were not significantly associated with differences in levels of knowledge. This questionnaire study evaluates a novel discriminatory questionnaire tool which differentiates knowledge levels of MRSA practice guidelines among a non-clinical population, HCWs and specialist infection control staff, thus providing a means for the rapid assessment of MRSA educational interventions. We identify demographics within HCW target populations which are associated with low levels of such knowledge. Consideration towards revising current HCW educational programmes to improve knowledge and best practice in MRSA prevention is required.

National neonatal weight policy survey

This survey was conducted to review the current practice regarding frequency of weight measurement in neonatal units in the Republic of Ireland, and whether these practices are in keeping with best practice as described in the literature. There was an 88.5% (23 of 26) response rate to this survey. 6 (26%) units had a written policy, and 16 (70%) had an unwritten agreed practice. In the Vermont Oxford Network's potentially better practices daily weight measurements on newborn infants are recommended until the infant is stable and growing and then alternate day measurements The most common practices in this survey were to weigh infants on alternate days, this occurred in 9 (39%) units, and twice weekly in 6 (26%). Less than 31% of units had a separate policy for those less than 30 weeks, on assisted ventilation, or transitioning to enteral feeds. Most weigh infants on alternate days, and plot weights weekly, which is in keeping with best practice. Few units have separate policies for specific subgroups as is recommended in the limited literature. Consensus guidelines should be developed and promoted nationally.

Fact or infection: do surgical trainees know enough about infection control?

INTRODUCTION

There exists a high level of non-compliance with basic infection control measures by medical staff. One explanation may be a lack of familiarity with contemporary infection control guidelines. As surgical trainees represent a key group of stakeholders responsible for the delivery of recommended infection control practice, we assessed knowledge of infection control guidelines amongst current UK surgical trainees.

MATERIALS AND METHODS

Without warning, during the annual meeting of the UK Association of Surgeons in Training (ASiT), participating surgical trainees were asked to complete a questionnaire examining their basic knowledge of infection control and methicillin-resistant Staphylococcus aureus (MRSA) based on recently published guidelines.

RESULTS

A total of 52 trainees (13 higher surgical trainees [HSTs]; 39 basic surgical trainees [BSTs]) returned completed questionnaires in the study. BSTs demonstrated a higher level of knowledge of infection control, outperforming the HSTs in 7 out of 11 questions. Of surgical trainees, 61.5% were misinformed regarding the prevalence of MRSA blood-stream infections and 69% were unaware of policies for transfer of MRSA-positive patients. Analysis revealed areas of concern in regards to an adequate general level of knowledge of infection control in surgical trainees, particularly in some key areas.

CONCLUSIONS

To ensure patient safety and reduce hospital-acquired infections, it is vital that focused, co-ordinated programmes of education, in this rapidly changing field, are prioritised and formalised into surgical training, selection and assessment.

A prevalence screen of MRSA nasal colonisation amongst UK doctors in a non-clinical environment

Screening for methicillin-resistant Staphylococcus aureus (MRSA) carriage in healthcare workers (HCWs) is both contentious and confounded by a lack of knowledge of background prevalence rates. This study examines prevalence of nasal MRSA carriage amongst a spectrum of medical professionals in a non-clinical environment. Medical conference attendees volunteered for screening for nasal MRSA carriage, and anonymised demographic data and attitudes towards screening were recorded. Two hundred sixty volunteers participated. One hundred seventy-three participants (67%) were from the British Medical Association's Annual Representatives Meeting, and 87 participants (33%) were attending the Association of Surgeons in Training conference. Six (2%) participants were positive for MRSA nasal carriage (BMA = 1%, ASIT = 5%; p = 0.099). Participants from a surgical specialty (4.8%) were more likely to be MRSA positive (p = 0.039). All positive samples came from male participants (p = 0.182). However, there was no significant association with gender, seniority or country of employment and MRSA status. Routine screening for MRSA was supported by 63% of participants in HCWs; 36% had previously undergone such screening. MRSA nasal carriage rates within this cross-sectional study are lower than studies reporting carriage rates in HCWs within the clinical environment. Further research is required to examine the relationship between MRSA nasal colonisation status of a HCW and subsequent MRSA infection in patients.

A placebo-controlled, double-blind, randomized controlled trial of a natural killer cell stimulant (BioBran MGN-3) in chronic fatigue syndrome

BACKGROUND

Previous research has suggested that natural killer (NK) cell activity may be reduced in patients with chronic fatigue syndrome (CFS).

AIM

To evaluate the effectiveness of a putative NK cell stimulant, BioBran MGN-3, in reducing fatigue in CFS patients.

DESIGN

Randomized, double-blind, placebo-controlled trial.

METHODS

We recruited 71 patients with CFS (according to the Centers for Disease Control 1994 criteria) attending an out-patient specialist CFS service. Participants were given oral BioBran MGN-3 for 8 weeks (2 g three times per day) or placebo equivalent. The primary outcome measure was the Chalder physical fatigue score. Self-reported fatigue measures, self-assessment of improvement, change in key symptoms, quality of life, anxiety and depression measures were also included.

RESULTS

Data were complete in 64/71 patients. Both groups showed marked improvement over the study duration, but without significant differences. Mean improvement in the Chalder fatigue score (physical scale) was 0.3 (95%CI -2.6 to 3.2) lower in the BioBran group.

DISCUSSION

The findings do not support a specific therapeutic effect for BioBran in CFS. The improvement showed by both groups over time highlights the importance of placebo controls when evaluating interventions in CFS.

Trampoline injuries in children

We reviewed the records of children referred to our hospital between April and September 2005 who had been injured whilst trampolining.

Of 88 such children there were 33 boys and 55 girls with a mean age of 8 years 6 months (2 years 4 months to 15 years 9 months). Most of the injuries (53; 60%) occurred when bouncing and 34 (39%) were secondary to falls from the trampoline. The cause of injury was unknown in one child. The injured child was supervised in only 35 cases (40%). In 31 (35%) cases, the injury was related to the presence of others on the trampoline. A total of 36 (40%) children required surgery. Fractures of the upper limbs occurred in 62 cases (70%).

Injuries related to the recreational use of trampolines are a significant cause of childhood injury. Our results suggest strongly that there is a need for clear guidelines on safe and responsible use of domestic trampolines.

Social isolation predicts re-hospitalization in a group of older American veterans enrolled in the UPBEAT Program. Unified Psychogeriatric Biopsychosocial Evaluation and Treatment

OBJECTIVES

Does social isolation predict re-hospitalization in a group of older men enrolled in Unified Psychogeriatric Biopsychosocial Evaluation and Treatment (UPBEAT), a mental health care-coordination project at nine Veterans Affairs Healthcare Centers nationwide?

METHODS

The current study examined 123 UPBEAT patients located at West Los Angeles, whose ratings were available on the Lubben Social Network Scale (LSNS), the SF-36 scale, the Cumulative Illness Rating Scale (CIRS) and the Mental Health Index (MHI-38) Depression and Anxiety subscales. Within one year of enrollment, 55% of patients were re-hospitalized. Odds of re-hospitalization were calculated using two logistic regression models. Social isolation risk (LSNS) and demographic covariates were included. In addition, Model 1 contained depression and anxiety measures (MHI-38) and physician-rated medical burden (CIRS), while in Model 2, patient-perceived physical (PCS) and mental health (MCS) subscales from the SF-36 were included.

RESULTS

The group of patients who were socially isolated or at high or moderate risk for isolation, were 4-5 times more likely to be re-hospitalized within the year, than low isolation risk patients. In both Models 1 (chi-square = 19.86; p = 0.031) and 2 (chi-square = 26.42; p = 0.002) demographic characteristics were not significant predictors of re-hospitalization, but social isolation risk was a significant predictor (Model 1: odds ratio (OR) = 5.31; 95% confidence intervals (CI) = 1.81-15.53; and Model 2: OR = 3.86; 95% CI = 1.39-10.73). In addition, MHI-Anxiety was a significant predictor (OR = 1.22; 95% CI = 1.05-1.43) in Model 1 and in Model 2, patient-perceived physical health significantly predicted re-hospitalization (OR = 0.91; 95% CI = 0.86-0.96).

CONCLUSION

When controlling for other covariates, social isolation, physical health and mental health were significant risk factors for re-hospitalization. These findings underline the importance of assessing and addressing lack of social support, along with other factors, in the health care of older male veterans.

Maternal worry about neonatal hearing screening

OBJECTIVE

To identify and compare the prevalence and degree of maternal worry about neonatal hearing screening at the time of an initial neonatal hearing screen and rescreen in 1997 and 1999.

STUDY DESIGN

We report on a prospective cross-sectional investigation of maternal worry about newborn hearing screening. Demographic data, maternal knowledge of hearing screening, and degree of maternal worry were collected on 307 mothers at the time of the neonatal screen and 40 mothers at the time of the rescreen.

RESULTS

Degree of maternal worry was significantly greater at the rescreen compared to the screen. Mothers who reported greater worry at the time of the screen were more likely to be socioeconomically disadvantaged. Although maternal knowledge about hearing screening increased between the two time periods, degree of worry remained unchanged.

CONCLUSION

Efforts to minimize the neonatal false-positive hearing screen rates and to educate mothers about hearing screening are indicated to minimize unnecessary worry.

Neonatal abstinence syndrome

A 12 month review of infants admitted with neonatal abstinence syndrome to a neonatal intensive care unit was undertaken. The relationship of maternal drug abuse to symptoms, the effectiveness of pharmacologic agents in controlling symptoms and the length of inpatient stay were investigated. A retrospective review of maternal and infant records was performed. Those infants with a serial Finnegan score greater than 8 were treated. Pharmacologic treatment was oral morphine sulphate (0.2 mg 4-6 hourly), phenobarbitone (3-7 mgs/kg/day), or combination of the above. 43 infants were admitted to the hospital during the year. The average maternal age was 24.6 years, (18-34 years). Drug use volunteered by the mothers was methadone alone in 6 cases, methadone and benzodiazepines in 14, methadone and heroin and benzodiazepines in 7, methadone and heroin in 10, heroin alone in 2, and other multiple drug use including oral morphine sulphate, dothiepin and cannabis in 4. Average gestational age was 40.3 (35-42 weeks). The average birthweight was 2.81 kgs (1.89-3.91 kgs). Time to onset of withdrawal symptoms was 2.8 (1-13) days. The duration of pharmacologic treatment (oral morphine sulphate and/or phenobarbitone) was 21.8 (1-62) days. The total hospital stay for the 43 infants was 1,011 days. This study confirms that polydrug abuse is the commonest type of drug abuse in Dublin. The duration of withdrawal symptoms is loosely related to drug type, but increasing duration of symptoms is noted for infants exposed to benzodiazepines. Our experience would favour the use of morphine sulphate to treat pure opiate withdrawal symptoms. Over the 12-month period, there was an average occupancy of 3 beds per day in the paediatric department.

Costs and cost effectiveness of cardiovascular screening and intervention: the British family heart study

OBJECTIVE

To measure costs and cost effectiveness of the British family heart study cardiovascular screening and intervention programme.

DESIGN

Cost effectiveness analysis of randomised controlled trial. Clinical and resource use data taken from trial and unit cost data from external estimates.

SETTING

13 general practices across Britain.

SUBJECTS

4185 men aged 40-59 and their 2827 partners.

INTERVENTION

Nurse led programme using a family centered approach, with follow up according to degree of risk.

MAIN OUTCOME MEASURES

Cost of the programme it self; overall short term cost to NHS; cost per 1% reduction in coronary risk at one year.

RESULTS

Estimated cost of putting the programme into practice for one year was 63 pounds per person (95% confidence interval 60 pounds to 65 pounds). The overall short term cost to the health service was 77 pounds per man (29 pounds to 124 pounds) but only 13 pounds per woman (-48 pounds to 74 pounds), owing to differences in utilisation of other health service resources. The cost per 1% reduction in risk was 5.08 pounds per man (5.92 pounds including broader health service costs) and 5.78 pounds per woman (1.28 pounds taking into account wider health service savings).

CONCLUSIONS

The direct cost of the programme to a four partner practice of 7500 patients would be approximately 58,000 pounds. Annually, 8300 pounds would currently be paid to a practice of this size working to the maximum target on the health promotion bands, plus any additional reimbursement of practice staff salaries for which the practice qualified. The broader short term costs to the NHS may augment these costs for men but offset them considerably for women.

What can be concluded from the Oxcheck and British family heart studies: commentary on cost effectiveness analyses

OBJECTIVES

To provide a commentary on the economic evaluations of the Oxcheck and British family heart studies: direct comparison of their relative effectiveness and cost effectiveness; comparisons with other interventions; and consideration of problems encountered.

DESIGN

Modelling from cost and effectiveness data to estimate of cost per life year gained.

SUBJECTS

Middle aged men and women.

INTERVENTIONS

Screening for cardiovascular risk factors followed by appropriate lifestyle advice and drug intervention in general practice, and other primary coronary risk management strategies.

MAIN OUTCOME MEASURES

Life years gained; cost per life year gained.

RESULTS

Depending on the assumed duration of risk reduction, the programme cost per discounted life year gained ranged from 34,800 pounds for a 1 year duration to 1500 pounds for 20 years for the British family heart study and from 29,300 pounds to 900 pounds for Oxcheck. These figures exclude broader net clinical and cost effects and longer term clinical and cost effects other than coronary mortality.

CONCLUSIONS

Despite differences in underlying methods, the estimates in the two economic analyses of the studies can be directly compared. Neither study was large enough to provide precise estimates of the overall net cost. Modelling to cost per life year gained provides more readily interpretable measures. These estimates emphasise the importance of the relatively weak evidence on duration effect. Only if the effect lasts at least five years is the Oxcheck programme likely to be cost effective. The effect must last for about 10 years to justify the extra cost associated with the British family heart study.

Neutrophil activation associated with increased neutrophil acyloxyacyl hydrolase activity during inflammation in cattle

Acyloxyacyl hydrolase (AOAH) is a lysosomal enzyme found in neutrophils and macrophages that acts to partially deacylate the lipid-A component of the endotoxin of gram-negative bacteria rendering it less toxic, yet maintaining much of its immunostimulatory potential. We have found that the activity of neutrophil AOAH per cell increased during localized inflammation. The purpose of this study was to determine the mechanism(s) responsible for these increases in neutrophil AOAH activity. Because changes in neutrophil maturity commonly are associated with inflammation, intravascular infusion of purified gram-negative bacterial lipopolysaccharide and SC injection of bovine recombinant granulocyte colony-stimulating factor was used to induce large numbers of circulating immature neutrophils. Immature neutrophils were found to have AOAH activity equal to that of mature cells; however, when neutrophils were stimulated in vitro with known activators, AOAH activity of activated cells was more than that of unstimulated cells. The increase in AOAH activity was inversely related to prestimulation activity. Increases in AOAH activity after neutrophil activation were not a result of de novo synthesis of the enzyme, because cycloheximide did not prevent activation-induced increases in activity.

The Minnesota Child Development Inventory: validity and reliability for assessing development in infancy

The concurrent validity and reliability of the Minnesota Child Development Inventory (MCDI) was assessed by comparing the MCDI general development index score, and each of the seven subscale scores, with the mental and psychomotor age equivalents achieved on the Bayley Scales of Infant Development. In addition, the co-positivity, co-negativity, positive and negative predictive values of the MCDI in identifying infants with a mental development index (MDI), or psychomotor development index (PDI) of greater than 2 SD below the mean were assessed. Subjects were 101 infants (8 to 19 months old) who were seen at a neonatal developmental follow-up clinic after discharge from the neonatal intensive care unit. Correlations were obtained for the entire sample as well as for the two chronological age groups (i.e., 8 to 10 months and 17 to 19 months) within the sample. A strong correlation between the MCDI scales and the Bayley Mental and Psychomotor Scales was documented for the entire population as well as for the individual age groups. The overall validity of the MCDI in identifying infants with a MDI or PDI of greater than 2 SD below the mean was limited due to relatively poor co-positivity and positive predictive value. Although the MCDI may yield consistent information about the development of an infant's skills, this research suggests the MCDI has limited capacity to discern infants having delayed development.

Nosocomial bloodstream infection at a veterans hospital; 1979 to 1987

Studies of nosocomial bloodstream infection (NBI) have come primarily from university, municipal or community hospitals with little specific information from veterans hospitals. The objective of this study was to define trends in NBI at a tertiary care veterans hospital. Patients with NBI were identified by retrospective review of microbiology records and of infection control surveillance records from 1979 to 1987 at the Buffalo Veterans Administration Medical Center (VAMC). Between 1979 and 1985 there was no significant upward or downward trend. Beginning in early 1986 a significant increase in NBI was noted. This increase was because of changes in incidence of gram-positive NBI (primarily Staphylococcus aureus [corrected] and enterococcus) while there was no change in incidence of gram-negative NBI. The most common source of NBI were similar to previous studies and included urinary tract infection, pneumonia, surgical wound infections and intravenous catheter related infections. The frequency of various organisms causing NBI was likewise similar to other studies except for pneumonia in which Streptococcus pneumoniae most commonly was isolated. The yearly incidence of gentamicin resistance among gram-negative NBI isolates demonstrated no significant trend. In conclusion, there was a significant increase in incidence of NBI at the Buffalo VAMC between 1979 and 1987 that occurred primarily in the last two years studied. The importance of gram-positive organisms as a cause of NBI at the Buffalo VAMC has been clearly documented as a recent phenomenon.

Recurrent gram-negative bacteremia

PURPOSE

Recurrent gram-negative bacteremia is defined as two or more episodes of bacteremia occurring in the same patient with an infection-free interval between each episode. Our purpose was to identify patients with recurrent gram-negative bacteremia in order to define possible risk factors for its recurrence.

PATIENTS AND METHODS

During a recently completed prospective study of all episodes of gram-negative bacteremia at the Buffalo Veterans Administration Center between April 1, 1984, and May 31, 1987, 35 patients with 74 episodes of gram-negative bacteremia were identified. The following information was obtained from all 35 patients: age, service, date of hospital admission, date of the bacteremia, underlying diseases, initial antimicrobial therapy, focus of infection, the presence or absence of shock, antimicrobial susceptibility of the blood isolate, and outcome.

RESULTS

All 35 patients were men, had a mean age of 69 years, and all had one or more underlying diseases; 45 percent had a malignancy. The duration of time between a pair of episodes was four weeks or more for 74 percent of 38 pairs of episodes. In 25 of 38 (66 percent) pairs of episodes, the focus of infection was the same; in 80 percent of these 25 pairs, the urinary tract was the focus. Overall, the urinary tract was the focus of gram-negative bacteremia in almost 50 percent. Escherichia coli was the single most common organism isolated (28 percent of all episodes), followed by Proteus mirabilis (17.5 percent) and Pseudomonas aeruginosa (17.5 percent). Six of 35 (17 percent) patients died due to gram-negative bacteremia; five of these six had a respiratory tract focus of infection.

CONCLUSIONS

In a population of veterans, recurrent gram-negative bacteremia was identified in almost 10 percent of all patients with gram-negative bacteremia during a 37-month study period. Recurrent gram-negative bacteremia most frequently occurred in the setting of underlying malignancy with the urinary tract as a common focus of infection. The mortality rate of 17 percent was similar to that of all patients with gram-negative bacteremia reported in previous studies.