The effects of limb laterality and age on the inflammation and bone turnover of the acromioclavicular shoulder joint: 18 F-fluorodeoxyglucose and 18 F-sodium-fluoride-PET/computed tomography study

PURPOSE

The acromioclavicular (AC) joint is a common site of injury and degenerative changes such as osteoarthritis (OA) of the shoulder. Physical manifestations of OA are preceded by molecular changes, detection of which may enhance early prophylaxis and monitoring of disease progression. In this study, we investigate the use of 18 F-FDG and 18 F-NaF-PET/CT to assess the effects of limb laterality and age on the inflammation and bone turnover of the AC shoulder joint.

METHODS

We analyzed FDG and NaF-PET/CT scans of 41 females (mean age of 43.9 ± 14.2 years) and 45 males (mean age of 44.5 ± 13.8 years) using a semiquantitative technique based on predefined ROI.

RESULTS

There was a greater NaF uptake in the right side of the AC joint compared with the left in both females (left: 2.22 ± 1.00; right: 3.08 ± 1.18; P < 0.0001) and males (left: 2.57 ± 1.49; right: 2.99 ± 1.40; P = 0.003). No consistent correlation between age and NaF or FDG uptakes were found in both females and males. There was also a positive correlation between FDG and NaF uptakes in both left ( P = 0.01; r = 0.37) and right ( P = 0.0006; r = 0.53) AC joints of male subjects.

CONCLUSION

Our study is the first to reveal the varying effect of right-left limb laterality and aging on FDG and NaF uptake at the AC joint. Future studies correlating the history of shoulder trauma, pain, and degenerative change with FDG and NaF-PET/CT findings will be critical in the adoption of molecular imaging in the clinical setting.

Experiments from unfinished Registered Reports in the Reproducibility Project: Cancer Biology

As part of the Reproducibility Project: Cancer Biology, we published Registered Reports that described how we intended to replicate selected experiments from 29 high-impact preclinical cancer biology papers published between 2010 and 2012. Replication experiments were completed and Replication Studies reporting the results were submitted for 18 papers, of which 17 were accepted and published by eLife with the rejected paper posted as a preprint. Here, we report the status and outcomes obtained for the remaining 11 papers. Four papers initiated experimental work but were stopped without any experimental outcomes. Two papers resulted in incomplete outcomes due to unanticipated challenges when conducting the experiments. For the remaining five papers only some of the experiments were completed with the other experiments incomplete due to mundane technical or unanticipated methodological challenges. The experiments from these papers, along with the other experiments attempted as part of the Reproducibility Project: Cancer Biology, provides evidence about the challenges of repeating preclinical cancer biology experiments and the replicability of the completed experiments.

Systematic Review of the Impact on Return to Work of Return-to-Work Coordinators

Purpose We conducted a systematic review to understand the impact that return-to-work coordinators (RTWCs) have on return to work (RTW) outcomes for sick/injured workers. Methods MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, and ABI Inform were searched from January 1, 2000 to September 16, 2020. Of 2,927 retrieved and screened citations, 14 quantitative articles fulfilled the eligibility and quality criteria. Quality assessment, data extraction, and evidence synthesis followed article screening. Results We focused on the impact of RTWCs for outcomes of work absence, RTW rates, quality of life, and cost-benefit. Our final synthesis included 14 articles. We found strong evidence that work absence duration was reduced when workers had face-to-face contact with a RTWC. As well, there was strong evidence linking face-to-face RTWC interventions with higher RTW rates and moderate evidence that this reduced intervention costs. RTWC interventions involving the identification of barriers and facilitators to RTW also showed promising results. However, only limited evidence was found that RTWCs improved quality of life for workers. Conclusions Our synthesis identifies key features of RTW interventions that improve RTW outcomes. Future high-quality research should measure long-term outcomes of RTWC interventions to evaluate sustainability and consider the nature of work. They should also focus on RTWC impact on worker quality of life assessments and for older workers and workers with chronic health conditions.

Return to Work for Mental Ill-Health: A Scoping Review Exploring the Impact and Role of Return-to-Work Coordinators

Purpose This scoping review was completed to explore the role and impact of having a return-to-work (RTW) coordinator when dealing with individuals with common mental ill-health conditions. Methods Peer reviewed articles published in English between 2000 and 2018 were considered. Our research team reviewed all articles to determine if an analytic focus on RTW coordinator and mental ill-health was present; consensus on inclusion was reached for all articles. Data were extracted for all relevant articles and synthesized for outcomes of interest. Results Our search of six databases yielded 1798 unique articles; 5 articles were found to be relevant. The searched yielded only quantitative studies. Of those, we found that studies grouped mental ill-health conditions together, did not consider quality of life, and used different titles to describe RTW coordinators. Included articles described roles of RTW coordinators but did not include information on their strategies and actions. Included articles suggest that RTW interventions for mental ill-health that utilize a RTW coordinator may result in delayed time to RTW. Conclusions Our limited findings suggest that interventions for mental ill-health that employ RTW coordinators may be more time consuming than conventional approaches and may not increase RTW rate or worker's self-efficacy for RTW. Research on this topic with long-term outcomes and varied research designs (including qualitative) is needed, as well as studies that clearly define RTW coordinator roles and strategies, delineate results by mental health condition, and address the impact of RTW coordinators on workers' quality of life.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Alopecia areata is characterized by dysregulation in systemic type 17 and type 2 cytokines, which may contribute to disease-associated psychological morbidity

BACKGROUND

Alopecia areata (AA) is a common autoimmune disease, causing patchy hair loss that can progress to involve the entire scalp (totalis) or body (universalis). CD8⁺ NKG2D⁺ T cells dominate hair follicle pathogenesis, but the specific mechanisms driving hair loss are not fully understood.

OBJECTIVES

To provide a detailed insight into the systemic cytokine signature associated with AA, and to assess the association between cytokines and depression.

METHODS

We conducted multiplex analysis of plasma cytokines from patients with AA, patients with psoriatic arthritis (PsA) and healthy controls. We used the Hospital Anxiety and Depression Scale (HADS) to assess the occurrence of depression and anxiety in our cohort.

RESULTS

Our analysis identified a systemic inflammatory signature associated with AA, characterized by elevated levels of interleukin (IL)-17A, IL-17F, IL-21 and IL-23 indicative of a type 17 immune response. Circulating levels of the type 2 cytokines IL-33, IL-31 and IL-17E (IL-25) were also significantly increased in AA. In comparison with PsA, AA was associated with higher levels of IL-17F, IL-17E and IL-23. We hypothesized that circulating inflammatory cytokines may contribute to wider comorbidities associated with AA. Our assessment of psychiatric comorbidity in AA using HADS scores showed that 18% and 51% of people with AA experienced symptoms of depression and anxiety, respectively. Using linear regression modelling, we identified that levels of IL-22 and IL-17E are positively and significantly associated with depression.

CONCLUSIONS

Our data highlight changes in both type 17 and type 2 cytokines among people with AA, suggesting that complex systemic cytokine profiles may contribute both to the pathogenesis of AA and to the associated depression. What's already known about this topic? NKG2D⁺ CD8⁺ T cells cause hair loss in alopecia areata (AA) but the immunological mechanisms underlying the disease are not fully understood. AA is associated with changes in levels of interleukin (IL)-6, tumour necrosis factor-α, IL-1β and type 17 cytokines. Psychiatric comorbidity is common among people with AA. What does this study add? People with AA have increased plasma levels of the type 2 cytokines IL-33, IL-31 and IL-17E (IL-25), in addition to the type 17 cytokines IL-17A, IL-21, IL-23 and IL-17F. Levels of IL-17E and IL-22 positively predict depression score. What is the translational message? AA is associated with increased levels of multiple inflammatory cytokines, implicating both type 17- and type 2 immune pathways. Our data indicate that therapeutic strategies for treating AA may need to address the underlying type 17- and type 2 immune dysregulation, rather than focusing narrowly on the CD8⁺ T-cell response. An immunological mechanism might contribute directly to the depression observed in people with AA.

Vulnerability to intimate partner violence and poor mental health in the first 4-year postpartum among mothers reporting childhood abuse: an Australian pregnancy cohort study

The purpose of this study was to investigate intergenerational patterns of abuse and trauma and the health consequences for women in the early childbearing years. A prospective pregnancy cohort of 1507 nulliparous women (≦24 weeks gestation) were recruited in Melbourne, Australia, 2003-2005. Follow-up was scheduled in late pregnancy, 3-, 6- and 12-month and 4-year postpartum. Childhood abuse was retrospectively reported at 4-year postpartum using the Child Maltreatment History Self Report. Intimate partner violence (IPV) was assessed at 1- and 4-year postpartum with the Composite Abuse Scale. Maternal depressive symptoms were assessed in all follow-ups using the Edinburgh Postnatal Depression Scale. Multivariable logistic regression was used to examine associations between childhood abuse, maternal mental health and IPV. Childhood abuse was reported by 41.1 % of women. In the 4 years after having their first child, 28.2 % of women reported IPV, 25.2 % depression and 31.6 % anxiety. Childhood abuse was associated with odds of depression or anxiety 1.5-2.6 times greater and 1.8-3.2 times greater for IPV. Childhood physical abuse remained significantly associated with depression and anxiety in pregnancy and postpartum after adjusting for IPV and stressful life events, while sexual abuse remained significantly associated only with anxiety. Women who begin childbearing with a history of childhood abuse are more vulnerable to IPV and poor mental health. All health care services and agencies in contact with children, young people and families should have adequate training to identify trauma associated with abuse and IPV and provide first line supportive care and referral.

Second generation tyrosine kinase inhibitors prevent disease progression in high-risk (high CIP2A) chronic myeloid leukaemia patients

High cancerous inhibitor of PP2A (CIP2A) protein levels at diagnosis of chronic myeloid leukaemia (CML) are predictive of disease progression in imatinib-treated patients. It is not known whether this is true in patients treated with second generation tyrosine kinase inhibitors (2G TKI) from diagnosis, and whether 2G TKIs modulate the CIP2A pathway. Here, we show that patients with high diagnostic CIP2A levels who receive a 2G TKI do not progress, unlike those treated with imatinib (P=<0.0001). 2G TKIs induce more potent suppression of CIP2A and c-Myc than imatinib. The transcription factor E2F1 is elevated in high CIP2A patients and following 1 month of in vivo treatment 2G TKIs suppress E2F1 and reduce CIP2A; these effects are not seen with imatinib. Silencing of CIP2A, c-Myc or E2F1 in K562 cells or CML CD34+ cells reactivates PP2A leading to BCR-ABL suppression. CIP2A increases proliferation and this is only reduced by 2G TKIs. Patients with high CIP2A levels should be offered 2G TKI treatment in preference to imatinib. 2G TKIs disrupt the CIP2A/c-Myc/E2F1 positive feedback loop, leading to lower disease progression risk. The data supports the view that CIP2A inhibits PP2Ac, stabilising E2F1, creating a CIP2A/c-Myc/E2F1 positive feedback loop, which imatinib cannot overcome.

Risk factors for TB and HIV coinfection in Scotland, 2001 to 2010

The number of patients with tuberculosis (TB) increased steadily in Scotland between 2005 and 2010. Human immunodeficiency virus (HIV) infection has been a contributory factor to increases in TB in a number of comparable industrialised countries. This study investigated the extent of, and risk factors for, TB and HIV coinfection in Scotland from 2001 to 2010. Patients with TB in the national TB database were linked to those in the national HIV database using probabilistic data linkage. Patient records were anonymised to maintain confidentiality. From 2001 to 2010, 106/4, 097 (2.6%, 95% CI: 2.1 to 3.1) TB patients matched with HIV patients, equating to a 10-year incidence of 2.1 cases per million population. Patients with both TB and HIV were more often born outside the United Kingdom,were of black African ethnicity, had refugee status and had extra-thoracic lymph node involvement or cryptic/disseminated TB disease. Individuals with TB and HIV coinfection were younger and symptomatic for a shorter time before their diagnosis of TB, compared with TB patients without HIV. TB and HIV coinfection was relatively uncommon in Scotland in the study period. Clinicians should recognise the potential for HIV infection among TB patients and the importance of offering an HIV test to all TB patients.

Autophagy is altered in skeletal and cardiac muscle of spontaneously hypertensive rats

AIM

Autophagy is a subcellular degradation mechanism important for muscle maintenance. Hypertension induces well-characterized pathological changes to the heart and is associated with impaired function and increased apoptotic signalling in skeletal muscle. We examined whether essential hypertension affects several autophagy markers in skeletal and cardiac muscle.

METHODS

Immunoblotting and qRT-PCR were used to measure autophagy-related proteins/mRNA in multiple skeletal muscles as well as left ventricle (LV) of spontaneously hypertensive rats (SHR) and normotensive Wistar-Kyoto rats (WKY).

RESULTS

Skeletal muscles of hypertensive rats had decreased (P < 0.01) cross-sectional area of type I fibres (e.g. soleus WKY: 2952.9 ± 64.4 μm(2) vs. SHR: 2579.9 ± 85.8 μm(2)) and a fibre redistribution towards a 'fast' phenotype. Immunoblot analysis revealed that some SHR skeletal muscles displayed a decreased LC3II/I ratio (P < 0.05), but none showed differences in p62 protein. LC3 and LAMP2 mRNA levels were increased approx. 2-3-fold in all skeletal muscles (P < 0.05), while cathepsin activity, cathepsin L mRNA and Atg7 protein were increased 16-17% (P < 0.01), 2-3-fold (P < 0.05) and 29-49% (P < 0.01), respectively, in fast muscles of hypertensive animals. Finally, protein levels of BAG3, a marker of chaperone-assisted selective autophagy, were 18-25% lower (P < 0.05) in SHR skeletal muscles. In the LV of SHR, LC3I and p62 protein were elevated 34% (P < 0.05) and 47% (P < 0.01), respectively. Furthermore, p62 mRNA was 68% higher (P < 0.05), while LAMP2 mRNA was 45% lower (P < 0.05), in SHR cardiac muscle. There was no difference in Beclin1, Atg7, Bnip3 or BAG3 protein in the LV between strains.

CONCLUSION

These results suggest that autophagy is altered in skeletal and cardiac muscle during hypertension.

Retrograde intramedullary nails with distal screws locked to the nail have higher fatigue strength than locking plates in the treatment of supracondylar femoral fractures

We investigated a new intramedullary locking nail that allows the distal interlocking screws to be locked to the nail. We compared fixation using this new implant with fixation using either a conventional nail or a locking plate in a laboratory simulation of an osteoporotic fracture of the distal femur. A total of 15 human cadaver femora were used to simulate an AO 33-A3 fracture pattern. Paired specimens compared fixation using either a locking or non-locking retrograde nail, and using either a locking retrograde nail or a locking plate. The constructs underwent cyclical loading to simulate single-leg stance up to 125 000 cycles. Axial and torsional stiffness and displacement, cycles to failure and modes of failure were recorded for each specimen. When compared with locking plate constructs, locking nail constructs had significantly longer mean fatigue life (75 800 cycles (sd 33 900) vs 12 800 cycles (sd 6100); p = 0.007) and mean axial stiffness (220 N/mm (sd 80) vs 70 N/mm (sd 18); p = 0.005), but lower mean torsional stiffness (2.5 Nm/° (sd 0.9) vs 5.1 Nm/° (sd 1.5); p = 0.008). In addition, in the nail group the mode of failure was either cut-out of the distal screws or breakage of nails, and in the locking plate group breakage of the plate was always the mode of failure. Locking nail constructs had significantly longer mean fatigue life than non-locking nail constructs (78 900 cycles (sd 25 600) vs 52 400 cycles (sd 22 500); p = 0.04).

The new locking retrograde femoral nail showed better stiffness and fatigue life than locking plates, and superior fatigue life to non-locking nails, which may be advantageous in elderly patients.

Cite this article: Bone Joint J 2014;96-B:114–21.

Comparison of a multifilament stainless steel suture with FiberWire for flexor tendon repairs--an in vitro biomechanical study

Our goal was to investigate and compare the mechanical properties of multifilament stainless steel suture (MFSS) and polyethylene multi-filament core FiberWire in flexor tendon repairs. Flexor digitorum profundus tendons were repaired in human cadaver hands with either a 4-strand cruciate cross-lock repair or 6-strand modified Savage repair using 4-0 and 3-0 multifilament stainless steel or FiberWire. The multifilament stainless steel repairs were as strong as those performed with FiberWire in terms of ultimate load and load at 2 mm gap. This study suggests that MFSS provides as strong a repair as FiberWire. The mode of failure of the MFSS occurred by the suture pulling through the tendon, which suggests an advantage in terms of suture strength.

Does plugging unused combination screw holes improve the fatigue life of fixation with locking plates in comminuted supracondylar fractures of the femur?

Filling the empty holes in peri-articular locking plates may improve the fatigue strength of the fixation. The purpose of this in vitro study was to investigate the effect of plugging the unused holes on the fatigue life of peri-articular distal femoral plates used to fix a comminuted supracondylar fracture model.

A locking/compression plate was applied to 33 synthetic femurs and then a 6 cm metaphyseal defect was created (AO Type 33-A3). The specimens were then divided into three groups: unplugged, plugged with locking screw only and fully plugged holes. They were then tested using a stepwise or run-out fatigue protocol, each applying cyclic physiological multiaxial loads.

All specimens in the stepwise group failed at the 770 N load level. The mean number of cycles to failure for the stepwise specimen was 25 500 cycles (sd 1500), 28 800 cycles (sd 6300), and 26 400 cycles (sd 2300) cycles for the unplugged, screw only and fully plugged configurations, respectively (p = 0.16). The mean number of cycles to failure for the run-out specimens was 42 800 cycles (sd 10 700), 36 000 cycles (sd 7200), and 36 600 cycles (sd 10 000) for the unplugged, screw only and fully plugged configurations, respectively (p = 0.50). There were also no differences in axial or torsional stiffness between the constructs. The failures were through the screw holes at the level of comminution.

In conclusion, filling the empty combination locking/compression holes in peri-articular distal femur locking plates at the level of supracondylar comminution does not increase the fatigue life of the fixation in a comminuted supracondylar femoral fracture model (AO 33-A3) with a 6 cm gap.

Progressive resistance training did not improve walking but can improve muscle performance, quality of life and fatigue in adults with multiple sclerosis: a randomized controlled trial

BACKGROUND

Few high-quality trials have examined the effects of progressive resistance training (PRT) on people with multiple sclerosis (MS).

OBJECTIVE

To determine the effectiveness of PRT for people with MS, focusing on improving the gait deficits common in this population.

METHODS

Using a single blind randomized controlled trial, people with relapsing-remitting MS were randomly allocated to either a PRT program targeting the lower limb muscles twice a week for 10 weeks (n = 36), or usual care plus an attention and social program conducted once a week for 10 weeks (n = 35). Outcomes were recorded at baseline, week 10 and week 22.

RESULTS

Participants attended 92% of training sessions, with no serious adverse events. At 10 weeks, no differences were detected in walking performance. However, compared with the comparison group PRT demonstrated increased leg press strength (16.8%, SD 4.5), increased reverse leg press strength (29.8%, SD 12.7), and increased muscle endurance of the reverse leg press (38.7%, SD 32.8). Improvements in favor of PRT were also found for physical fatigue (Mean difference -3.9 units, 95%CI -6.6 to -1.3), and the physical health domain of quality of life (Mean difference 1.5 units, 95%CI 0.1 to 2.9). At week 22 almost no between-group differences remained.

CONCLUSION

PRT is a relatively safe intervention that can have short-term effects on reducing physical fatigue, increasing muscle endurance and can lead to small improvements in muscle strength and quality of life in people with relapsing-remitting MS. However, no improvements in walking performance were observed and benefits do not appear to persist if training is completely stopped.

Design of dental surgeries in relation to instrument decontamination

Recent guidelines advise that the decontamination of dental instruments should be undertaken outwith the treatment area. The aim of this study was to determine the physical area of rooms in dental surgeries that decontaminate instruments within and outwith the treatment area respectively, and other factors relating to practice layout and ventilation. Data were collected by interview and observation of dental healthcare workers in dental practice in Scotland, UK. Room layouts were recorded and measured at floor, benchtop and above benchtop heights. Thirteen surgeries with instrument decontamination processes occurring in the treatment area and seven surgeries with instrument decontamination outwith the treatment area were selected at random for detailed analysis of room dimensions. Of the 179 dental surgeries surveyed, 55% were located in converted residential premises and most practitioners (91%) did not share premises with other healthcare providers. The median number of rooms in the practices was 8 (range: 2-21) and the median number of surgeries present was 3 (range: 1-6). Regardless of whether instrument decontamination facilities were housed within the treatment area or not, the average treatment area room size for both was 15.8m(2) (range: 7.3-23.9) (P=0.862), with 20% of the room area available as work surfaces. The median size of the seven instrument decontamination rooms (local decontamination units) was 7.6m(2) (range: 2.9-16.0), with, on average, 63% of the room used for work surfaces. This survey suggests that the historical location of dental surgeries in converted residential properties places many restrictions on appropriate design for healthcare premises.

A cluster of Legionnaires' disease caused by Legionella longbeachae linked to potting compost in Scotland, 2008-2009

Three cases of Legionnaires disease caused by Legionella longbeachae Sg 1 associated with potting compost have been reported in Scotland between 2008 and 2009. The exact method of transmission is still not fully understood as Legionnaires disease is thought to be acquired by droplet inhalation. The linked cases associated with compost exposure call for an introduction of compost labelling, as is already in place in other countries where L. longbeachae outbreaks have been reported.

Issues and challenges for systematic reviews in indigenous health

This essay outlines key issues raised during a project that aimed to (1) identify the gaps in the international evidence base of systematic reviews of intervention effectiveness relevant to public health decision making to address health inequalities experienced by indigenous people, and (2) identify priority areas and topics for future reviews. A number of indigenous researchers and clinicians invited to participate in the project expressed reservations about the appropriateness and value of conventional systematic reviews of intervention evidence to indigenous health. Ensuring that systematic review methods for indigenous health research meet the needs of those that use them, including indigenous communities themselves, needs to be a key area of ongoing work. The public health group within the Cochrane Collaboration has recognised this as a priority area and initiated exploration of these issues.

Identification of primary HIV-1C infection in Botswana

Methods for identification of primary HIV infections seem increasingly important to understand pathogenesis, and to prevent transmission, which is particularly efficient during acute infection. Most current algorithms for HIV testing are based on detection of HIV antibodies and are unable to identify early infections before seroconversion. The efficiency of prospective cohorts, which is a standard approach for identifying primary HIV-1 infection, depends on a variety of epidemiological and cultural factors including HIV incidence and stigma and, not surprisingly, varies significantly in different geographical areas. We report a voluntary counseling and testing (VCT)-based approach to identifying primary HIV-1C infection that was developed as part of a primary HIV-1 subtype C infection study in Botswana. The referral strategy was based on: (1) collaboration with VCT centers at city clinics operated by the Ministry of Health; (2) partnering with the busiest non-government VCT center; (3) educating healthcare workers and the community about primary HIV infection; and (4) pairing with diverse VCT providers, including NGOs and private-sector organizations. Acute HIV-1 infections were defined by a negative HIV-1 serology combined with a positive HIV-1 RT-PCR test. Recent HIV-1 infections were identified by detuned EIA testing according to the classic STARTH algorithm. The VCT-based referral strategy resulted in the successful identification of 57 cases of acute and early HIV infection. A referral strategy of expanded VCT with viral RNA (Ribonucleic acid) testing to a national program in Botswana may be a promising approach for identification of primary HIV infections on a countrywide level. The program should offer VCT with viral RNA testing to the general public, facilitate proper counseling and risk reduction, and allow initiation of early HAART, and may reduce new viral transmissions.

Gait and balance impairment in early multiple sclerosis in the absence of clinical disability

This study evaluated the gait and balance performance of two clinically distinct groups of recently diagnosed and minimally impaired multiple sclerosis (MS) patients (Expanded Disability Status Scale range 0-2.5), compared to control subjects. Ten MS patients with mild pyramidal signs (Pyramidal Functional Systems 1.0), 10 MS patients with no pyramidal signs (Pyramidal Functional Systems 0) and 20 age- and gender-matched control subjects were assessed using laboratory-based gait analysis and clinical balance measures. Both MS groups demonstrated reduced speed and stride length (P < 0.001), and prolonged double limb support (P <0.02), compared to the control group, along with alterations in the timing of ankle muscle activity, and the pattern of ankle motion during walking, which occurred independent of gait speed. The pyramidal MS group walked with reduced speed (P = 0.03) and stride length (P = 0.04), and prolonged double limb support (P =0.01), compared to the non-pyramidal group. Both MS groups demonstrated concomitant balance impairment, performing poorly on the Functional Reach Test compared to the control group (P <0.05). The identification of incipient gait and balance impairment in MS patients with recent disease onset suggests that motor function may begin to deteriorate in the early stages of the disease, even in the absence of clinical signs of pyramidal dysfunction.

Minimizing errors of omission: Behavioural rEenforcement of Heparin to Avert Venous Emboli: The BEHAVE Study*

OBJECTIVE

To improve patient safety by increasing heparin thromboprophylaxis for medical-surgical intensive care unit patients using a multiple-method approach to evidence-based guideline development and implementation.

DESIGN

Prospective longitudinal observational study.

SETTING

Medical-surgical intensive care unit.

PARTICIPANTS

Multidisciplinary clinicians caring for critically ill patients in a 15-bed medical-surgical closed intensive care unit.

INTERVENTIONS

Phase 1 was a 3-month baseline period during which we documented anticoagulation and mechanical thromboprophylaxis. Phase 2 was a 1-yr period in which we implemented a thromboprophylaxis guideline using a) interactive multidisciplinary educational in-services; b) verbal reminders to the intensive care unit team; c) computerized daily nurse recording of thromboprophylaxis; d) weekly graphic feedback to individual intensivists on guideline adherence; and e) publicly displayed graphic feedback on group performance. Phase 3 was a 3-month follow-up period 10 months later, during which we documented thromboprophylaxis. Computerized daily nurse recording of thromboprophylaxis continued in this period.

MEASUREMENTS AND MAIN RESULTS

Intensive care unit and hospital mortality rates were similar across phases, although patients in phase 2 had higher Acute Physiology and Chronic Health Evaluation II scores than patients in phases 1 and 3. The proportion (median % [interquartile range]) of intensive care unit patient-days of heparin thromboprophylaxis in phases 1, 2, and 3 was 60.0 (0, 100), 90.9 (50, 100), and 100.0 (60, 100), respectively (p=.01). The proportion (median % [interquartile range]) of days during which heparin thromboprophylaxis was omitted in error in phases 1, 2, and 3 was 20 (0, 53.8), 0 (0, 6.3), and 0 (0, 0), respectively (p<.001).

CONCLUSIONS

After development and implementation of an evidence-based thromboprophylaxis guideline, we found significantly more patients receiving heparin thromboprophylaxis. Guideline adherence was maintained 1 yr later. Further research is needed on which are the most effective strategies to implement patient safety initiatives in the intensive care unit.

A fluorescence polarization assay for inhibitors of Hsp90

Hsp90 encodes a ubiquitous molecular chaperone protein conserved among species which acts on multiple substrates, many of which are important cell-signaling proteins. Inhibition of Hsp90 function has been promoted as a mechanism to degrade client proteins involved in tumorigenesis and disease progression. Several assays to monitor inhibition of Hsp90 function currently exist but are limited in their use for a drug discovery campaign. Using data from the crystal structure of an initial hit compound, we have developed a fluorescence polarization assay to monitor binding of compounds to the ATP-binding site of Hsp90. This assay is very robust (Z' > 0.9) and can detect affinity of compounds with IC50s to 40 nM. We have used this assay in conjunction with cocrystal structures of small molecules to drive a structure-based design program aimed at the discovery and optimization of a novel class of potent Hsp90 inhibitors.

Towards consensus in the long-term management of relapse prevention in schizophrenia

APPROACH TO DEVELOPING GUIDANCE: When developing guidance for the long-term management of schizophrenia, one approach is to adopt a proactive strategy that sets out clear treatment goals and strategies. This should involve a broad view being taken, embracing overall mental and physical well-being rather than simply the absence of illness. Although relapse prevention is an important goal of any long-term management strategy, there are other aspects that need to be considered, such as reintegration into society, regaining independence and quality of life.

CURRENT TREATMENT

To help achieve these goals, a range of interventions can be incorporated into long-term management strategies for schizophrenia, including pharmacological interventions, psychosocial therapies and alliance-building initiatives. The current UK National Institute for Clinical Excellence guidelines already recommend that continuous therapy should be practised using an atypical (second-generation) antipsychotic drug, whenever possible, in preference to older typical drugs. The launch of the first long-acting atypical antipsychotic is an interesting new advance that may benefit many patients with schizophrenia. Psychosocial interventions, particularly family-based therapies, as well as cognitive behavioural and compliance therapies, when used alongside antipsychotics, have been shown to reduce relapse rates dramatically and to assist in social reintegration. In addition, forging collaborative alliances with patients and their carers can help to demystify schizophrenia and empower patients to take responsibility for their illness.

CONSENSUS STATEMENT

This article outlines a consensus reached by a panel of leading UK healthcare professionals working with schizophrenia brought together to discuss long-term management strategies.