Pulmonary Function in Human Spaceflight

Human spaceflight is entering a time of markedly increased activity fueled by collaboration between governmental and private industry entities. This has resulted in successful mission planning for destinations in low Earth orbit, lunar destinations (Artemis program, Gateway station) as well as exploration to Mars. The planned construction of additional commercial space stations will ensure continued low Earth orbit presence and destinations for science but also commercial spaceflight participants. The human in the journey to space is exposed to numerous environmental challenges including increased gravitational forces, microgravity, altered human physiology during adaptation to weightlessness in space, altered ambient pressure, as well as other important stressors contingent on the type of mission and destination. This chapter will cover clinically important aspects relevant to lung function in a normally proceeding mission; emergency scenarios such as decompression, fire, etc., will not be covered as these are beyond the scope of this review. To date, participation in commercial spaceflight by those with pre-existing chronic medical conditions is very limited, and hence, close collaboration between practicing pulmonary specialists and aerospace medicine specialists is of critical importance to guarantee safety, proper clinical management, and hence success in these important endeavors.

Infective endocarditis in dogs in the UK: 77 cases (2009-2019)

OBJECTIVES

To determine the causative organisms, clinical features and outcome of canine infective endocarditis in the UK.

MATERIALS AND METHODS

Medical records of three veterinary referral hospitals were searched for dogs with infective endocarditis between December 2009 and December 2019. Signalment, clinical signs, causative organism, valve affected, treatment and survival data were recorded.

RESULTS

Seventy-seven cases with possible or definite infective endocarditis (according to the modified Duke criteria) were included. The majority were large breed (40/77 - 51.9%). There were 47 of 77 (61%) male dogs and the mean age was 7.3 ±3 years. A causative organism was identified in 26 of 77 (33.8%) cases. The most common organisms were Escherichia coli (7/27 - 25.9%), Pasteurella spp. (5/27 - 18.5%), Staphylococcus spp. (4/27 - 14.8%) and Corynebacterium spp. (4/27 - 14.8%). Bartonella spp. were not detected in any patients. The mitral valve was most commonly affected (48/77 - 62.3%). Clinical features were non-specific, with lethargy being the most common clinical sign observed (53/77 - 68.8%). Fifty-three dogs (68.8%) survived to discharge. The median survival time post discharge was 425 days (2 to 3650 days). The development of congestive heart failure was associated with a poorer outcome. Cardiac troponin concentration, antithrombotic use and the development of thromboembolism or arrhythmias were not significantly associated with outcome.

CLINICAL SIGNIFICANCE

Some dogs with infective endocarditis that survive to discharge can have a long lifespan. The inability to detect an underlying organism is common and Bartonella spp. may be a less prevalent cause of canine infective endocarditis in the UK than in the USA.

Evaluation of the Prevalence of Punctate White Matter Lesions in a Healthy Volunteer Neonatal Population

Hypoxic-ischemic injury is the most common cause of neonatal encephalopathy. T1-weighted punctate white matter lesions have been described in hypoxic-ischemic injury. We have reviewed a healthy volunteer neonatal population to assess the prevalence of punctate white matter lesions in neonates with no clinical signs of hypoxic-ischemic injury. Fifty-two subjects were scanned on a neonatal-specific 3T MR imaging scanner. Twelve patients were excluded due to the lack of T1-weighted imaging, leaving a total of 40 patients (35 term, 5 preterm) assessed in the study. One had a solitary T1-punctate white matter lesion. We concluded that solitary punctate white matter lesions have a low prevalence in healthy neonates.

POS1505-HPR FEASIBILITY OF AN ONLINE “FATIGUE AND ACTIVITY MANAGEMENT EDUCATION IN WORK” (FAME-W) INTERVENTION FOR INDIVIDUALS WITH INFLAMMATORY ARTHRITIS

Background

A FAtigue Management Education in Work (FAME-W) programme was developed for individuals with inflammatory arthritis to manage fatigue in work (McCormack et al, 2018).

Objectives

This study tested the feasibility and acceptability of an online format of FAME-W for a future definitive intervention trial.

Methods

This was a mixed methods study. Participants were randomly allocated to intervention (IG) or control group (CG). The IG received a four-week online FAME-W. The CG received a FAME-W handbook. Participants were required to complete questionnaires on work presenteeism, fatigue, mood, Health Related Quality of Life (HRQOL) and pain at baseline (T0), and two weeks following intervention (T1). They also attended a focus group and individual interviews. Data were analysed using descriptive statistics

Results

Seven of ten individuals recruited participated in the study (intervention = 3, control =4). The majority of participants in both groups had Rheumatoid Arthritis and were working full-time in non-manual jobs. The mean age of intervention participants was 53 ± 10.4 and 56.5 ± 3.7 for the controls. Most of the intervention group were males and the majority of controls were female. Disease activity at baseline was similar for both groups: 3.33 ±2.5 intervention; 3.0 ± 1.8 control. At follow-up, disease activity did not change for intervention group (3.3 ±.57) and reduced slightly for CG (2.7 ±2.4).

Slight improvements were noted for both groups in presenteeism and fatigue between T0 and T1 (Table 1). There was no change in anxiety levels of the intervention group, with improvements noted for controls. Greater improvements were noted for the intervention group for depression and HRQOL. Pain measures showed increased pain for controls at T1 in comparison to the intervention group.

Table 1.MeasureIntervention (n=3) Median (min-max)Control (n=4) Median (min-max)T0T1T0T 1Work Role Function84.1 (81.9-92.1)85.7 (83.4-97.2)84.8 (63.7-93.9)84.9(72.9-94.5)Fatigue13.0 (8.0-14.0)10.0 (10.0-14.0)14.0 (12.0-17.0)12.5 (12.0-17.0)HADS Anxiety5.0 (3.0-6.0)5.0 (3.0-6.0)10.0 (7.0-14.0)8.0 (6.0-12.0)HADS Depression5.0 (3.0-5.0)3.0 (2.0-4.00)5.0 (3.0-11.0)6.0 (3.0-9.0)HRQOL68.0 (47.0-90.0)75.0 (65.0-90.0)70.00 (50.00-95.00)66.5 (50.0-95.0)Pain Level4.0 (100-5.0)2.0 (2.0-4.0)1.5 (1.0-4.0)4.5 (200-10.0)Pain Intensity1.0 (1.0-2.0)1.0 (1.0-2.0)0.5 (0.0-1.0)1.5 (0.0-2.0)

Those allocated to FAME-W attended all four sessions. FAME-W participants reported that the programme content was comprehensive and relevant. They stated that the occupational therapist facilitator was able to “see things from a different perspective for managing symptoms”. Participants also reported a better understanding of fatigue: “It helped me understand my fatigue. If you understand it you can manage it better”. The online delivery format was favored over attending a centre-based programme. Control participants reported the handbook content as “informative and reassuring”.

All participants fully completed all study questionnaires and attended focus groups and interviews.

Conclusion

This feasibility study showed that an online programme to improve work ability was feasible and acceptable to individuals with Rheumatic Diseases. Study measures were completed in full and adherence rate was 100% for the intervention. The findings support a definitive intervention trial of FAME-W.

References

[1]McCormack, RC, O’Shea, F, Doran, M, Connolly, D. Impact of a fatigue management in work programme on meeting work demands of individuals with rheumatic diseases: A pilot study. Musculoskeletal Care. 2018; 16: 398– 404.

[2]Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101.

Disclosure of Interests

None declared

POS1509-HPR CHANGES IN SELF-EFFICACY AND USE OF ENERGY CONSERVATION STRATEGIES FOLLOWING PARTICIPATION IN THE FATIGUE MANAGEMENT EDUCATION FOR INDIVIDUALS WITH SYSTEMIC SCLEROSIS (FAME-iSS)

Background

Fatigue is one of the most prevalent and disabling symptom of systemic sclerosis (SSc). No fatigue specific programs exist for people with SSc despite the negative impact on daily life activities. However, recent literature has shown that using pacing and other energy conservation strategies, has been associated with reduction in fatigue.

Objectives

The purpose of this pilot study was to evaluate changes in self-efficacy and use of energy conservation strategies after participation in Fatigue and Activity Management Education for Individuals with Systemic Sclerosis (FAME-iSS).

Methods

Adult participants were recruited from the Scleroderma Foundation chapters and social media to participate in a 6-week, virtual group program focused on SSc-related fatigue. Inclusion criteria: ≥18 years of age, access to device with videoconferencing capabilities, and at least moderate fatigue determined by degree, severity, and distress (scales: 1-10). The program, led by occupational therapists included sessions on factors related to fatigue, management of energy, pain, stress, physical activity and nutrition. At baseline, participants completed a demographic questionnaire, the Self-Efficacy for Performing Energy Conservation Strategies Assessment (SEPESCA) to measure confidence using energy conservation strategies. At post-intervention and 3-month follow-up, participants also completed the Energy Conservation Strategies Survey (ECSS) to identify use and effectiveness of 14 energy conservation strategies (e.g. changing body positions, planning and prioritizing, communicating needs) and a qualitative interview to contextualize their responses. Descriptive statistics (means, standard deviations) were used to analyze quantitative data.

Results

The sample for the pilot study included 18 participants (89% women; age 52 ± 11.6 years) with established SSc (disease duration= 13.7 ± 14.5 years). 83% participants completed 100% of FAME-iSS sessions.

Directly following the program all 14 energy conservation strategies were used by at least seven (39%) participants. The most frequently used strategy was “planned day to balance rest and activity” which was used by 17 participants post-intervention. (see Table 1). At the three-month follow-up the there was a decline in use for 50% of the strategies and an increase in use for the other 50%. Of those who reported not using energy conservation strategies, the most frequent reason provided by participants was that they were already using the strategy prior to attending FAME-iSS. The mean strategy effectiveness scores varied at both time points with “adjusting priorities” the most effective strategy at T2 and “delegating activities” the most effective at T3. While not statistically significant, participants trended towards improved self-efficacy scores for energy conservation strategies (baseline: 6.8 (2) post-intervention: 8.1 (1.4); 3-month follow-up: 8.4 (2.8) Participants qualitatively reported that FAME-iSS led to the sharing of new fatigue management strategies and increased attention to their daily activities.

Conclusion

This pilot study showed that FAME-iSS resulted in increased self-efficacy in use of energy conservation strategies in participants with established SSc. New behaviors were adapted that participants felt reduced their fatigue. The virtual format allowed for sharing of strategies and availability to more people.

Disclosure of Interests

None declared

Remote Design of a Smartphone and Wearable Detected Atrial Arrhythmia in Older Adults Case Finding Study: Smart in OAC – AFNET 9

Introduction

Screening for atrial fibrillation and timely initiation of oral anticoagulation, rhythm management, and treatment of concomitant cardiovascular conditions can improve outcomes in high-risk populations. Whether wearables can facilitate screening in older adults is not known.

Methods and Analyses

The multicenter, international, investigator-initiated, single-arm case-finding Smartphone and wearable detected atrial arrhythmia in older adults case finding study (Smart in OAC – AFNET 9) evaluates the diagnostic yield of a validated, cloud-based analysis algorithm detecting atrial arrhythmias via a signal acquired by a smartphone-coupled wristband monitoring system in older adults. Unselected participants aged ≥65 years without known atrial fibrillation and not receiving oral anticoagulation are enrolled in three European countries. Participants undergo continuous pulse monitoring using a wristband with a photo plethysmography (PPG) sensor and a telecare analytic service. Participants with PPG-detected atrial arrhythmias will be offered ECG loop monitoring. The study has a virtual design with digital consent and teleconsultations, whilst including hybrid solutions. Primary outcome is the proportion of older adults with newly detected atrial arrhythmias (NCT04579159).

Discussion

Smart in OAC – AFNET 9 will provide information on wearable-based screening for PPG-detected atrial arrhythmias in Europe and provide an estimate of the prevalence of atrial arrhythmias in an unselected population of older adults.

Radiative Capture on Nuclear Isomers: Direct Measurement of the ^{26m}Al(p,γ)^{27}Si Reaction

We present the first direct measurement of an astrophysical reaction using a radioactive beam of isomeric nuclei. In particular, we have measured the strength of the key 447-keV resonance in the ^{26m}Al(p,γ)^{27}Si reaction to be 432_{-226}^{+146}  meV and find that this resonance dominates the thermally averaged reaction rate for temperatures between 0.3 and 2.5 GK. This work represents a critical development in resolving one of the longest standing issues in nuclear astrophysics research, relating to the measurement of proton capture reactions on excited quantum levels, and offers unique insight into the destruction of isomeric ^{26}Al in astrophysical plasmas.

Natriuretic peptides predict future heart failure and cardiovascular death in an unselected population of patients presenting to hospital: interactions with atrial fibrillation

Aims

Natriuretic peptides are routinely quantified to diagnose heart failure (HF). Their concentrations are also elevated in atrial fibrillation (AF). To clarify their interpretation, we measured natriuretic peptides in unselected patients with cardiovascular conditions and related their concentrations to AF and HF status and to outcomes.

Methods and results

Consecutive patients with cardiovascular conditions presenting to a large teaching hospital (median age 70 [IQR 60–78] years, 40% women) underwent clinical assessment, 7-day ECG-monitoring, and echocardiography to diagnose AF and HF. N-terminal pro B-type natriuretic peptide (NT-proBNP) was centrally quantified. Clinical characteristics and NT-proBNP concentrations were related to HF hospitalization or cardiovascular death. Follow-up data was available in 1611/1616 patients (99.7%) and analysis performed at 2.5 years. Based on a literature review, four NT-proBNP groups were defined (<300pg/ml, 300–999pg/ml, 1000–1999pg/ml and ≥2000pg/ml).

Multivariate Cox proportional hazards analysis of the composite outcome against AF and HF phenotype groups. This was adjusted for confounding factors including age, sex, race, body mass index, hypertension, diabetes, coronary artery disease, severe valvular heart disease, left bundle branch block, hyponatraemia, urea, haemoglobin, estimated glomerular filtration rate, NT-proBNP, medical treatment with ACE inhibitors or angiotensin receptor blockers, beta-blockers, diuretic (thiazide or loop diuretics), and anticoagulants (novel oral anticoagulant or vitamin K antagonist). Cox proportional hazards analysis adjusted for confounding variables for the composite outcome against baseline NT-proBNP concentration ranges was also performed in each patient group based on AF and HF status.

HF hospitalization or cardiovascular death increased from patients with neither AF nor HF (36/488, 3.2/100 person-years), to 55/353 (7.1/100 person-years) in patients with AF only, 91/366 (12.1/100 person-years) in patients with HF only, and, 128/404 (17.7/100 person-years) in patients with AF plus HF (p<0.001). Higher NT-proBNP concentrations predicted the outcome in patients with AF only (C-statistic 0.82 [95% CI 0.77 to 0.86], p-value<0.001) and in other phenotype groups (C statistic in AF plus HF 0.66 [95% CI 0.61 to 0.70], p-value<0.001)). Sensitivity analyses confirmed these findings.

Conclusion

Elevated NT-proBNP concentrations predict future HF events in patients with AF irrespective of the presence of HF. In line with previous studies in HF, an NT-proBNP threshold of 1000 pg/ml is useful to identify high-risk patients with AF whether or not they are diagnosed with HF at the time of assessment. Pending external validation, these findings encourage the routine quantification of NT-proBNP in the initial assessment of patients with AF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): 1) This study was partially supported by European Union BigData@Heart and 2) CATCH ME (Characterising Afib by Translating its Causes into Health Modifiers in the Elderly)

Fractional flow reserve derived from computed tomography coronary angiography in the assessment and management of stable chest pain: the FORECAST randomized trial

Aims 

Fractional flow reserve (FFR_CT) using computed tomography coronary angiography (CTCA) determines both the presence of coronary artery disease and vessel-specific ischaemia. We tested whether an evaluation strategy based on FFR_CT would improve economic and clinical outcomes compared with standard care.

Methods and results 

Overall, 1400 patients with stable chest pain in 11 centres were randomized to initial testing with CTCA with selective FFR_CT (experimental group) or standard clinical care pathways (standard group). The primary endpoint was total cardiac costs at 9 months. Secondary endpoints were angina status, quality of life, major adverse cardiac and cerebrovascular events, and use of invasive coronary angiography. Randomized groups were similar at baseline. Most patients had an initial CTCA: 439 (63%) in the standard group vs. 674 (96%) in the experimental group, 254 of whom (38%) underwent FFR_CT. Mean total cardiac costs were higher by £114 (+8%) in the experimental group, with a 95% confidence interval from −£112 (−8%) to +£337 (+23%), though the difference was not significant (P = 0.10). Major adverse cardiac and cerebrovascular events did not differ significantly (10.2% in the experimental group vs. 10.6% in the standard group) and angina and quality of life improved to a similar degree over follow-up in both randomized groups. Invasive angiography was reduced significantly in the experimental group (19% vs. 25%, P = 0.01).

Conclusion 

A strategy of CTCA with selective FFR_CT in patients with stable angina did not differ significantly from standard clinical care pathways in cost or clinical outcomes, but did reduce the use of invasive coronary angiography.

OP0265-HPR FACTORS ASSOCIATED WITH MEETING WORK DEMANDS FOR INDIVIDUALS WITH RHEUMATIC DISEASES

Background:

Almost 65% of individuals with rheumatic diseases have severe fatigue with the majority of these reporting difficulties in work leading to absenteeism and early retirement. However, there is a lack of research investigating how different types of fatigue impact on work ability.

Objectives:

To identify the prevalence of different types of fatigue and explore the association between different types of fatigue and various demands involved in work

Methods:

A cross-sectional study was carried out with 234 individuals with rheumatic diseases currently in employment. Study measures examined demographics, different types of fatigue (general, physical reduced activity, reduced motivation and mental), ability to meet work demands, disease activity and quality of life.

Results:

The majority of participants were female (70%), had rheumatoid arthritis (42.7%), were between 41-50 years (30.3%) and worked full-time (70%). One hundred and twenty-eight participants (55%) had severe fatigue. Physical fatigue was the most prevalent category of fatigue (Table 1). Participants reported managing 50% of their work demands with physical demands being the most challenging (Table 1). All types of fatigue were significantly associated with the total WRF score (Table 2). Mental fatigue had the strongest association with the total WRF score (r=0.53, p<0.001). On examining the impact of different types of fatigue on meeting work demands, mental fatigue was the most significant predictor of difficulty meeting work demands (β =1.6, SE=0.37, p<0.001)

Table 1.

MFI and WRF total and category scores

WRF n=212Total mean (SD)Work Scheduling Demands mean (SD)Output demands mean (SD)Physical Demands mean (SD)Mental Demands mean (SD)Social Demands mean (SD)50.3% (19.0)44.6% (25.8)52.9% (22.1)43.3% (27.9)53.4% (22.5)62.4% (17.7)MFIn=220Totalmean (SD)Physical fatigue mean (SD)Reduced activity mean (SD)Reduced motivation mean (SD)Mental fatigue mean (SD)13.4 (2.8)12.5 (4.3)10.1 (4.2)10.2 (3.5)10.3 (4.2)Table 2.

Correlations for WRF and MFI fatigue categories

MFI CategoryCorrelations with total WRFp-valuesGeneral fatigue.53<0.001Mental fatigue.57<0.001Physical fatigue.48<0.001Reduced motivation.48<0.001Reduced activity levels.41<0.001

Conclusion:

Fatigue interferes with many aspects of work performance. However, this study identifies that mental fatigue is the greatest predictor of difficulty in managing work. Self-management interventions focusing on mental fatigue and work ability are required for individuals with rheumatic diseases to manage the demands of their work.

Disclosure of Interests:

None declared

Multi-lumen capillary based trypsin micro-reactor for the rapid digestion of proteins

In this work we evaluated a novel microreactor prepared using a surface modified, high surface-to-volume ratio multi-lumen fused silica capillary (MLC). The MLC investigated contained 126 parallel channels, each of 4 μm internal diameter. The MLC, along with conventional fused silica capillaries of 25 μm and 50 μm internal diameter, were treated by (3-aminopropyl)triethoxysilane (APTES) and then modified with gold nanoparticles, of ∼20 nm in diameter, to ultimately provide immobilisation sites for the proteolytic enzyme, trypsin. The modified capillaries and MLCs were characterised and profiled using non-invasive scanning capacitively coupled contactless conductivity detection (sC4D). The sC4D profiles confirmed a significantly higher amount of enzyme was immobilised to the MLC when compared to the fused silica capillaries, attributable to the increased surface to volume ratio. The MLC was used for dynamic protein digestion, where peptide fragments were collected and subjected to off-line chromatographic evaluation. The digestion was achieved with the MLC reactor, using a residence time of just 1.26 min, following which the HPLC peak associated with the intact protein decreased by >70%. The MLC reactors behaved similarly to the classical in vitro or in-solution approach, but provided a reduction in digestion time, and fewer peaks associated with trypsin auto-digestion, which is common using in-solution digestion. The digestion of cytochrome C using both the MLC-IMER and the in-solution approach, resulted in a sequence coverage of ∼80%. The preparation of the MLC microreactor was reproducible with <2.5% RSD between reactors (n = 3) as determined by sC4D.

Direct Measurement of the Key E_{c.m.}=456 keV Resonance in the Astrophysical ^{19}Ne(p,γ)^{20}Na Reaction and Its Relevance for Explosive Binary Systems

We have performed a direct measurement of the ^{19}Ne(p,γ)^{20}Na reaction in inverse kinematics using a beam of radioactive ^{19}Ne. The key astrophysical resonance in the ^{19}Ne+p system has been definitely measured for the first time at E_{c.m.}=456_{-2}^{+5}  keV with an associated strength of 17_{-5}^{+7}  meV. The present results are in agreement with resonance strength upper limits set by previous direct measurements, as well as resonance energies inferred from precision (^{3}He, t) charge exchange reactions. However, both the energy and strength of the 456 keV resonance disagree with a recent indirect study of the ^{19}Ne(d, n)^{20}Na reaction. In particular, the new ^{19}Ne(p,γ)^{20}Na reaction rate is found to be factors of ∼8 and ∼5 lower than the most recent evaluation over the temperature range of oxygen-neon novae and astrophysical x-ray bursts, respectively. Nevertheless, we find that the ^{19}Ne(p,γ)^{20}Na reaction is likely to proceed fast enough to significantly reduce the flux of ^{19}F in nova ejecta and does not create a bottleneck in the breakout from the hot CNO cycles into the rp process.

Polymer brush decorated nanoparticles immobilised on polymer monoliths for enhanced biopolymer elution

Polymer monoliths uniformly covered with polymer brush nanoparticles are fabricated and the elution properties investigated with myoglobin and blue dextran.

Direct Measurement of the Astrophysical ^{38}K(p,γ)^{39}Ca Reaction and Its Influence on the Production of Nuclides toward the End Point of Nova Nucleosynthesis

We have performed the first direct measurement of the ^{38}K(p,γ)^{39}Ca reaction using a beam of radioactive ^{38}K. A proposed ℓ=0 resonance in the ^{38}K+p system has been identified at 679(2) keV with an associated strength of 120_{-30}^{+50}  meV. Upper limits of 1.16 (3.5) and 8.6 (26) meV at the 68% (95%) confidence level were also established for two further expected ℓ=0 resonances at 386 and 515 keV, respectively. The present results have reduced uncertainties in the ^{38}K(p,γ)^{39}Ca reaction rate at temperatures of 0.4 GK by more than 2 orders of magnitude and indicate that Ar and Ca may be ejected in observable quantities by oxygen-neon novae. However, based on the newly evaluated rate, the ^{38}K(p,γ)^{39}Ca path is unlikely to be responsible for the production of Ar and Ca in significantly enhanced quantities relative to solar abundances.

Subjective and objective measures of relaxed +Gz tolerance following repeated +Gz exposure

BACKGROUND

Repeated exposure to +Gz acceleration provokes cardiovascular adaptations of potential benefit to pilots' +Gz tolerance, but whether such changes actually improve human tolerance to +Gz acceleration is uncertain. This study assessed +Gz tolerance before and after repeated exposure to +Gz at two different intensities as the role of frequency of +Gz exposure in adaptation also remains unknown.

METHODS

In a cross-over design, 10 experienced male centrifuge volunteers completed two experimental conditions separated by at least 3 wk. Subjects completed four simulated air combat maneuvers (SACM) on a human centrifuge, either twice or four times per week, for 3 consecutive weeks. Relaxed +Gz tolerance (RGT) during a gradual onset run (GOR, 0.1 G x s(-1)) and cardiovascular responses to rapid and incremental head-up tilt were assessed before and after each condition.

RESULTS

Rapid and incremental head-up tilt increased both mean arterial and diastolic blood pressures following +Gz exposure. +Gz exposure attenuated the increase in heart rate (+9 +/- 3 vs. +11 +/- 3 mmHg/Gz) and the decrease in eye-level systolic blood pressure (-11 +/- 3 vs. -14 +/- 4 mmHg/Gz) during GOR, but had no effect on RGT (4/wk: +3.88 +/- 0.56 vs. +3.92 +/- 0.63 Gz; 2/wk: +3.89 +/- 0.69 vs. +3.92 +/- 0.69 Gz).

DISCUSSION

Frequent +Gz acceleration, either as 2 (8 SACMs) or 4 sessions (16 SACMs) per week for 3 wk, enhances cardiovascular tolerance to orthostatic stress but does not improve RGT measured during a GOR.

Urethral metastasis from renal cell carcinoma: an unusual cause of visible painless haematuria

Urethral metastasis from renal cell carcinoma (RCC) is rare, with only six previously described cases.1–6 The authors report a case which presented eight months post laparoscopic radical nephrectomy with painless, visible haematuria. The epidemiology, potential pathophysiological mechanisms and treatment options are explored.

Lack of microsatellite instability in human prostate-cancer

DNA replication errors are especially frequent in repetitive DNA sequences, including microsatellites. Thus, microsatellites are sensitive indicators of the genetic instability observed in many types of human cancers, particularly colorectal cancer. We tested prostate carcinomas for the presence of microsatellite alleles not present in normal tissue from the same individuals. Analysis of 7 microsatellites in each of 30 patients revealed instability at only one microsatellite in one tumor. This level of microsatellite instability, considerably lower than that reported previously, may reflect differences in patient pools. We discuss the implications of the genetic stability of prostate cancers relative to other cancers.

Quality pork genes and meat production

Functional genomics, including analysis of the transcriptome and proteome, provides new opportunities for understanding the molecular processes in muscle and how these influence its conversion to meat. The Quality Pork Genes project was established to identify genes associated with variation in different aspects of raw material (muscle) quality and to then develop genetic tools that could be utilized to improve this quality. DNA polymorphisms identified in the porcine PRKAG3 and CAST genes illustrate the impact that such tools can have in improving meat quality. The resources developed in Quality Pork Genes provide the basis for identifying more of these tools.

Can general practice help address youth mental health? A retrospective cross-sectional study in Dublin's south inner city

AIMS

With general practice potentially having an important role in early intervention of mental and substance use disorders among young people, we aim to explore this issue by determining the prevalence of psychological problems and general practice/health service utilization among young people attending general practice.

METHODS

A retrospective cross-sectional study of patients attending three general practices in Dublin city.

RESULTS

Among a sample of young people (mostly women, 44% general medical services (GMS) eligible), we observed considerable contact with general practice, both lifetime and for the 2 years of the study. The mean consultation rate was 3.9 consultations in 2 years and psychosocial issues (most commonly stress/anxiety and depression) were documented in 35% of cases. Identification of psychosocial issues was associated with GMS eligibility, three or more doctor consultations, and documentation of smoking and drinking status.

CONCLUSIONS

Psychosocial issues are common among young people attending general practice and more work on their epidemiology and further identification in general practice are advocated.

What is the role of general practice in addressing youth mental health? A discussion paper

BACKGROUND

Mental and substance use disorders are a leading cause of morbidity among young people. Policy and clinical services in Ireland are endeavouring to address these twin issues.

AIMS

To review the emerging literature on the role of general practice in addressing youth mental health and to discuss the implications of this literature for further research, education and service delivery.

METHODS

We conducted a review of 'PubMed' and a web search of relevant national/international primary/mental healthcare agencies and professional bodies.

RESULTS

Although general practice has an important role in addressing youth mental health, there are challenges in how young people seek help. Specifically, young people do not engage with healthcare agencies and many factors which act as barriers and enablers in this regard have been identified. The detection and treatment of mental and substance use disorders by GPs can be improved and implementing interventions to improve screening and early intervention are likely to be valuable.

CONCLUSIONS

General practice is a central agency in addressing youth mental health and complex multifaceted interventions (education, clinical guidelines, and promoting awareness) are likely to support its role. Further research exploring this issue is a priority.

Population characteristics and survival in 127 referred cats with hypertrophic cardiomyopathy (1997 to 2005)

OBJECTIVES

To evaluate the characteristics and survival of a recent population of cats with hypertrophic cardiomyopathy.

METHODS

Records at the Royal Veterinary College Queen Mother Hospital for Animals were searched for cats diagnosed with hypertrophic cardiomyopathy between 1997 and 2005. Referring veterinarians and owners were contacted to determine survival times.

RESULTS

Cats with hypertrophic cardiomyopathy were evaluated for population characteristics (n=127) and survival times (n=109). Overall median survival from date of hypertrophic cardiomyopathy diagnosis at the Queen Mother Hospital for Animals was 1276 days. Cats with hypertrophic cardiomyopathy were younger (P=0·009), and more likely to be male (P<0·001) compared to a hospital control group (n=1473), and Ragdolls were over-represented (P<0·05). Characteristics associated with increased survival in univariate analysis included younger age (P=0·007), asymptomatic status (P<0·001), normal left atrial size (P<0·001) and presence of systolic anterior motion of the mitral valve (P=0·003). Systolic anterior motion was associated with asymptomatic status, and did not influence survival in asymptomatic cats or those in congestive heart failure. Age, left atrial size and breed were significantly associated with survival time in a multivariate analysis.

CLINICAL SIGNIFICANCE

Cats with hypertrophic cardiomyopathy and left atrial enlargement have a poorer prognosis. The positive influence of systolic anterior motion on survival is likely to be linked to its association with asymptomatic status.

Daily, monthly and seasonal variation in PSA levels and the association with weather parameters

PSA levels have shown daily and seasonal variation, although data are conflicting regarding the season with higher PSA levels and the clinical relevance of this. We assessed the correlation of total PSA levels with meteorological data on a daily, weekly, monthly and seasonal basis. Data from 53,224 men aged 45-74 years, with an initial PSA <10.0 ng ml(-1) were correlated with temperature (°C), duration of bright sunshine (hours) and rainfall (mm). There was seasonal variation in PSA levels, with median PSA being higher in spring compared with other seasons (1.18 vs 1.10 ng ml(-1), P = 0.004). Seasonal variation was not apparent when PSA levels were age-adjusted (P = 0.112). Total PSA was not correlated with daily, weekly or monthly hours of sunshine, rainfall or mean temperature. In contrast, age-adjusted PSA varied with weekday, with higher PSA levels on Thursday and Friday compared with other days (1.16 vs 1.10 ng ml(-1), respectively). On multivariate analysis, only age predicted for PSA levels >3.0 ng ml(-1). In conclusion, PSA levels did show seasonal variation, although there was no direct correlation between PSA and any meteorological parameter. The degree of seasonal variation is small and the decision to proceed to prostate biopsy should be independent of season or weather parameters.

Impact of PSA testing and prostatic biopsy on cancer incidence and mortality: comparative study between the Republic of Ireland and Northern Ireland

OBJECTIVES

To investigate the impact of different PSA testing policies and health-care systems on prostate cancer incidence and mortality in two countries with similar populations, the Republic of Ireland (RoI) and Northern Ireland (NI).

METHODS

Population-level data on PSA tests, prostate biopsies and prostate cancer cases 1993-2005 and prostate cancer deaths 1979-2006 were compiled. Annual percentage change (APC) was estimated by joinpoint regression.

RESULTS

Prostate cancer rates were similar in both areas in 1994 but increased rapidly in RoI compared to NI. The PSA testing rate increased sharply in RoI (APC = +23.3%), and to a lesser degree in NI (APC = +9.7%) to reach 412 and 177 tests per 1,000 men in 2004, respectively. Prostatic biopsy rates rose in both countries, but were twofold higher in RoI. Cancer incidence rates rose significantly, mirroring biopsy trends, in both countries reaching 440 per 100,000 men in RoI in 2004 compared to 294 in NI. Median age at diagnosis was lower in RoI (71 years) compared to NI (73 years) (p < 0.01) and decreased significantly over time in both countries. Mortality rates declined from 1995 in both countries (APC = -1.5% in RoI, -1.3% in NI) at a time when PSA testing was not widespread.

CONCLUSIONS

Prostatic biopsy rates, rather than PSA testing per se, were the main driver of prostate cancer incidence. Because mortality decreases started before screening became widespread in RoI, and mortality remained low in NI, PSA testing is unlikely to be the explanation for declining mortality.

High-risk myocardial infarction patients appear to derive more mortality benefit from short door-to-balloon time than low-risk patients

OBJECTIVES

To evaluate reduction of door-to-balloon (DTB) time and its impact on in-hospital mortality of high-risk infarct patients in a collaboration of district general hospitals (DGH) with a physician-to-patient model.

METHODS

Primary percutaneous coronary interventions (PPCI) with short DTB time offer mortality benefit for ST-segment elevation myocardial infarction but literatures are conflicting on this benefit for high- vs. low-risk patients. In a unique model at Sandwell and West Birmingham Hospitals, five interventional cardiologists provide 24-h PPCI at whichever one of its two DGH that patients present to. A retrospective audit was performed on 3 years (July 2005-June 2008) of PPCI data in the British Cardiovascular Intervention Society database. Data were analysed in four periods corresponding to change from daytime-only to 24-h PPCI. DTB time and in-hospital mortality were the main outcome measures.

RESULTS

Of the 459 patients, median DTB time improved from 89 min (interquartile range: 49-120) to 68 min (50-91) (p = 0.005) and proportion of patients achieving target 90-min DTB time increased from 53% (21/40) to 75% (93/124) (p = 0.005). In-hospital mortality was less for short DTB time [4.6% (13/284) vs. 11.5% (20/174); odds ratio (OR) 0.37, 95% confidence interval (CI): 0.18-0.75; p = 0.008]. With the proviso that our study was limited in power, long DTB time (> 90 min vs. < or = 90 min) was associated with higher in-hospital mortality in high-risk patients [15.6% (20/128) vs. 7.1% (12/168); OR 2.41, 95% CI: 1.14-5.06; p = 0.024] and not in low-risk patients [0% (0/46) vs. 0.9% (1/117); OR 0, 95% CI: 0-9.88; p = 1.000].

CONCLUSIONS

A collaboration of DGH with a physician-to-patient model can deliver timely PPCI that appear to translate into mortality benefit more so in high-risk patients. Low-risk patients would therefore probably tolerate delays associated with transfer to large centres while high-risk patients would not and need alternative strategy. A collaboration of smaller hospitals with a pool of mobile interventional cardiologists could be such an alternative.

Endovascular treatment of anterior communicating artery aneurysms: results of clinical and radiological outcome in Newcastle

The results of endovascular management of anterior communicating artery aneurysms (ACoAA) using Guglielmi Detachable Coils (GDC) are presented. We detail the clinical and radiological features, and postoperative clinical and radiological outcome in a consecutive series of patients. We have prospectively collected comprehensive data on our patients with SAH since 1989. This study reports on patients admitted between January 1990 and December 1998, and focuses on 30 patients who had their ACoAA endovascularly treated. An independent observer (TE) carried out long-term follow-up in January 2002. Statistical analysis was performed to study the relationship between clinical factors, the radiological morphology of aneurysms and the long-term outcome. The age ranged from 25 to 74 years (median: 54) and endovascularly treated ACoAA were more common in women, 19 (63%) compared with men, 11 (37%). Seventy-seven per cent were in good grade (WFNS 1 & 2) before treatment. Three patients rebled before treatment. The aneurysms were less than 10 mm in maximal diameter in 27/30 patients. The follow-up period was from 1 to 53 months (mean 32.5, median 36.6 months). Excellent outcome was recorded for 11 patients (36.7%), good in seven patients (23.3%), fair in three patients (10%) and poor in four cases (13.3%). Five patients had died (mortality 16.7%). Favourable outcome was achieved in younger patients, women, and in those who presented in grades 1 and 2. The long-term radiological follow-up revealed residual necks in 13 patients. Only one has required retreatment and no rebleed has occurred in 3-6 years. This study reports a contemporary experience with the endovascular management of ACoAA. Long-term stability of the coil and good outcome is demonstrated. Endovascular treatment using GDC is an efficient technique for treating acutely ruptured ACoAA with little additional morbidity. The clinical and radiological results are comparable with those in the literature.

Quantitative Correlation of Hyperventilation with Flicker Sensitivity

PURPOSE

The relationship between hyperventilation and the associated increase in flicker sensitivity is poorly defined but may be relevant to display viewing. This exploratory study investigates the potential for quantifying the relationship between the severity of hypocapnia and critical flicker frequency (CFF).

METHOD

Repeated ascending (fusion) and descending (flicker) measurements were made while breathing normally (normocapnia), and at four levels of progressive, mild to moderate hypocapnia that were induced by voluntary hyperventilation and controlled using continuous respiratory mass spectrometry. The mesopic stimulus was a 2.6 degree-Gaussian blob viewed through a 5.2-mm-diameter artificial pupil.

RESULTS

Five discrete respiratory conditions were generated. The influences of intersubject variability and severity of hypocapnia upon mean CFF were examined using two-way analysis of variance, demonstrating a statistically significant effect of target end-tidal partial pressure of carbon dioxide [F(4,40) = 4.63, p = 0.005]. The relationship between decreasing mean end-tidal partial pressure of carbon dioxide and increasing mean CFF was consistent with a linear correlation (Pearson R = -0.949, p = 0.013).

CONCLUSIONS

The results support a close relationship between the respiratory partial pressure of carbon dioxide and flicker sensitivity. However, the absolute magnitude of the underlying increase in flicker sensitivity with hypocapnia is small and the effect is unlikely to be relevant in aviation.

Teaching basic life support to school children using medical students and teachers in a 'peer-training' model--results of the 'ABC for life' programme

BACKGROUND

The 'ABC for life' programme was designed to facilitate the wider dissemination of basic life support (BLS) skills and knowledge in the population. A previous study demonstrated that using this programme 10-12-year olds are capable of performing and retaining these vital skills when taught by medical students. There are approximately 25,000 year 7 school children in 900 primary schools in Northern Ireland. By using a pyramidal teaching approach involving medical students and teachers, there is the potential to train BLS to all of these children each year.

AIMS

To assess the effectiveness of a programme of CPR instruction using a three-tier training model in which medical students instruct primary school teachers who then teach school children.

SETTINGS

School children and teachers in the Western Education and Library Board in Northern Ireland.

METHODS

A course of instruction in cardiopulmonary resuscitation (CPR)--the 'ABC for life' programme--specifically designed to teach 10-12-year-old children basic life support skills. Medical students taught teachers from the Western Education and Library Board area of Northern Ireland how to teach basic life support skills to year 7 pupils in their schools. Pupils were given a 22-point questionnaire to assess knowledge of basic life support immediately before and after a teacher led training session.

RESULTS

Children instructed in cardiopulmonary resuscitation using this three-tier training had a significantly improved score following training (57.2% and 77.7%, respectively, p<0.001).

CONCLUSION

This study demonstrates that primary school teachers, previously trained by medical students, can teach BLS effectively to 10-12-year-old children using the 'ABC for life' programme.

The ‘ABC for life’ programme—Teaching basic life support in schools

BACKGROUND

Less than 1% of the general public know how to assess or manage someone who has collapsed. It has been estimated that if 15-20% of the population were capable of performing cardiopulmonary resuscitation (CPR), mortality of out of hospital cardiac arrest could be decreased significantly. Training basic life support (BLS) skills to school children would be the most cost effective way of achieving this goal and ensuring that a large proportion of the population acquire basic life saving skills.

AIMS

To assess retention of knowledge of basic life support 6 months after a single course of instruction in cardiopulmonary resuscitation designed specifically for school children.

SETTING

School pupils in a rural location in one region of the United Kingdom.

METHODS

A course of instruction in cardiopulmonary resuscitation - the 'ABC for life' programme - specifically designed to teach 10-12-year-old school children basic life support skills. The training session was given to school pupils in a rural location in Northern Ireland. A 22 point questionnaire was used to assess acquisition and retention of basic life support knowledge.

RESULTS

Children instructed in cardiopulmonary resuscitation showed a highly significant increase in level of knowledge following the training session. While their level of knowledge decreased over a period of 6 months it remained significantly higher than that of a comparable group of children who had never been trained.

CONCLUSION

A training programme designed and taught as part of the school curriculum would have a significant impact on public health.

Inflamed solitary caecal diverticulum - it is not appendicitis, what should I do?

We describe three cases that presented with symptoms suggestive of appendicitis but were found at operation to have an inflamed solitary caecal diverticulum. All were treated successfully with diverticulectomy or inversion of the diverticulum. We wish to highlight this diagnosis and its surgical management so that informed decisions can be made if this is first encountered in the operating theatre.

Comparison of image quality, diagnostic confidence and interobserver variability in contrast enhanced MR angiography and 2D time of flight angiography in evaluation of carotid stenosis

The aim of this study was to compare image quality, level of diagnostic confidence and interobserver agreement in assessment of carotid stenosis with contrast enhanced MR angiography (CE MRA) in comparison with 2D time of flight MR angiography (2D TOF MRA). 60 carotid arteries in 30 patients were examined by three observers. Image quality and diagnostic confidence were assessed on the basis of a visual analogue scale. Interobserver variability was assessed with the help of intraclass correlation coefficient. Median values on the visual analogue scale for image quality and diagnostic confidence were higher for CE MRA compared with 2D TOF MRA for all three observers. Higher intraclass correlation values were recorded for interobserver variability for CE MRA compared with 2D TOF MRA both for visual estimation of carotid stenosis as well as for measurement of carotid stenosis on the basis of North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) criteria. CE MRA provides better image quality, higher level of diagnostic confidence and more interobserver agreement compared with 2D TOF MRA.

Progress in ovarian cancer research: Proceedings of the 5th Biennial Ovarian Cancer Research Symposium

Ovarian cancer remains the most lethal gynecological malignancy. The 5th Biennial Symposium overviewed the progress of ovarian cancer research over the last few years. Molecularly based technologies have allowed the identification of multiple biomarkers to aid in ovarian cancer diagnosis and treatment. Furthermore, data analysis systems evaluating the behavior of these markers have been designed. Therapeutic use of ovarian cancer protein markers has been fueled by the development of animal models that more closely simulate the pathogenesis of ovarian cancer, and multiple new therapies are being developed that may have impact against the disease. Finally, the design of clinical trials both for ovarian cancer treatment and prevention are key in advancing the science of ovarian cancer into the clinic. The need for strategies that would optimize patient participation in clinical trials is paramount.

Migration of Filshie clips--report of two cases and review of the literature

Images

Radial artery mycotic pseudoaneurysm in a haemophiliac: a potentially fatal complication of arterial catheterization

We present a case of radial artery pseudoaneurysm formation in a haemophiliac patient, which developed after radial artery cannulation. Haematologists and anaesthetists should be aware of this potentially fatal condition.

Does eye gaze indicate implicit knowledge of false belief? Charting transitions in knowledge

Three-year-olds sometimes look to the correct location but give an incorrect verbal answer in a false belief task. We examined whether correct eye gaze among 3- to 5-year-old children indexed unconscious knowledge or low confidence conscious knowledge. Children "bet" counters on where they thought a story character would go. If children were conscious of the knowledge conveyed by their eye gaze then they should have bet modestly on their explicit answer (i.e., been unsure whether this answer or the answer conveyed through eye direction was correct). We found that children bet very highly on the location consistent with their explicit answer, suggesting that they were not aware of the knowledge conveyed through their eye gaze. This result was supported by a number of conditions that showed that betting was a sensitive measure of even small degrees of uncertainty. The results shed light on false-belief understanding, the implicit-explicit distinction, and transitional knowledge. We argue that the transition to a full understanding of false belief is marked by periods of implicit knowledge and explicit understanding with low confidence.