Cross-sectional survey of SARS-CoV-2 testing at US airports and one health department’s proactive management of travelers

Background

Many health departments and private enterprises began offering SARS-CoV-2 testing to travelers at US airports in 2020. Persons with positive SARS-CoV-2 test results who have planned upcoming travel may be subject to US federal public health travel restrictions.

We assessed availability of testing for SARS-CoV-2 at major US airports. We then describe the management of cases and close contacts at Denver International Airport’s testing site.

Methods

We selected 100 US airports. Online surveys were conducted during November–December 2020 and assessed availability of testing for air travelers, flight crew, and airport employees. Respondents included health department (HD) staff or airport directors.

We analyzed testing data and management practices for persons who tested positive and their close contacts at one airport (Denver International) from 12/21/2020 to 3/31/2021.

Results

Among the 100 selected airports, we received information on 77 airports; 38 (49%) had a testing site and several more planned to offer one (N = 7; 9%). Most sites began testing in the fall of 2020. The most frequently offered tests were RT-PCR or other NAAT tests (N = 28).

Denver International Airport offered voluntary SARS-CoV-2 testing. Fifty-four people had positive results among 5724 tests conducted from 12/21/2020 to 3/31/2021 for a total positivity of < 1%. Of these, 15 were travelers with imminent flights. The Denver HD issued an order requiring the testing site to immediately report cases and notify airlines to cancel upcoming flight itineraries for infected travelers and their traveling close contacts, minimizing the use of federal travel restrictions.

Conclusions

As of December 2020, nearly half of surveyed US airports had SARS-CoV-2 testing sites. Such large-scale adoption of airport testing for a communicable disease is unprecedented and presents new challenges for travelers, airlines, airports, and public health authorities. This assessment was completed before the US and other countries began enforcing entry testing requirements; testing at airports will likely increase as travel demand returns and test requirements for travel evolve.

Lessons from Denver demonstrate how HDs can play a key role in engaging airport testing sites to ensure people who test positive for SARS-CoV-2 immediately before travel do not travel on commercial aircraft.

What can Europe learn from HCP knowledge and attitudes towards hepatitis A vaccination in the US?

Background

An estimated &gt;100 million new hepatitis A (hepA) infections occur annually worldwide. Centres for disease control and prevention reported 38795 hepA cases in the US since 2016, and 4475 outbreak-confirmed cases in Europe between 2016-2018. HepA outbreaks resulted mainly from person-to-person contact, especially among homeless, illegal drug users (IDU) and men who have sex with men (MSM). In 2020, we surveyed US health care providers (HCPs) to understand their knowledge and attitudes towards hepA vaccination in these populations at higher risk of infection and complications.

Methods

This was a cross-sectional, web-based survey of 400 HCPs (primary care providers, nurse practitioners, gastroenterologists, internal medicine and infectious disease specialists [IDs], emergency room physicians [ERs]) who had recommended and/or administered hepA vaccines to ≥ 19-year-olds.

Results

85% of 371 HCPs reported recommending hepA vaccine to homeless, 87% of 393 to IDU and 83% of 397 to MSM, although vaccination may not actually occur after recommendation. Results varied by specialty, 16% fewer ERs than IDs reported recommending the vaccine in these at-risk populations. Moreover, 64%, 75% and 71% of all (400) HCPs reported extremely important that homeless, IDU and MSM, respectively, get vaccinated for hepA, while 6%, 7% and 8% of all HCPs reported this as slightly, or not important. Reasons for not recommending hepA vaccine to homeless, IDU and MSM included uncertainty on guidelines (reported by 22/56, 24/50 and 29/66 HCPs, respectively) and low risk of infection (reported by 20/56, 30/50 and 27/66 HCPs, respectively).

Conclusions

Despite recent hepA outbreaks and strengthened recommendations for vaccination in at-risk populations, knowledge gaps persist among US HCPs. This survey may motivate European countries to reinforce national hepA vaccination recommendations and, in parallel, consider efforts to raise vaccination awareness.

Funding

GlaxoSmithKline Biologicals SA

Key messages

Education on hepatitis A vaccination recommendations in at-risk populations is needed. Health care providers’ vaccination knowledge plays a critical role to control the hepatitis A outbreak in the US and preventing hepatitis A in Europe.

POS1060 A PROSPECTIVE, LONGITUDINAL STUDY TO EVALUATE REAL-WORLD PATIENT EXPERIENCES AND TREATMENT SATISFACTION WITH SECUKINUMAB FOR PSORIATIC ARTHRITIS

Background:

Psoriatic arthritis (PsA) is an inflammatory disease that impairs quality of life. Despite therapeutic advances, up to a third of patients do not respond or are unable to sustain a treatment response. Thus, data on patient treatment experience in PsA is critical.

Objectives:

To assess real-world experiences of patients with PsA treated with secukinumab.

Methods:

This is an ongoing 12-month, prospective, longitudinal, web-based survey study of patients with PsA initiating secukinumab. Patient demographics and medical history are collected at baseline using a rheumatologist case report form. Patient experience data are collected at baseline, 3, 6, 9, and 12 months by patient surveys. The primary endpoint is change in the Psoriatic Arthritis Impact of Disease 12-item questionnaire (PsAID12) from baseline to 3 months. In addition, this study will explore other changes at 3 months, including PsA symptoms, treatment satisfaction with secukinumab, and other patient-reported outcome measures. Baseline and available month 3 data from patients enrolled to date were analyzed descriptively.

Results:

Baseline demographic and medical history data were available for 72 patients; 32 (44.4%) were male, 59 (81.9%) were White, and 15 (20.8%) reported modifying their diet because of PsA. The mean (SD) time since symptom onset (n = 29) and since PsA diagnosis (n = 53) was 56.3 (45.6) and 34.4 (44.7) months, respectively. More than half of the patients who started treatment with secukinumab were biologic experienced (38/62; 61.3%). Primary and secondary loss of effectiveness were the main reasons for previous biologic discontinuation (Table 1). At 3 months (n = 49), the mean (SD) PsAID12 change from baseline was –1.8 (1.8) points. Additionally, 24.5% of patients reported their PsA symptoms to be “much better,” 40.8% reported “moderately better,” and 32.7% “a little better” compared with baseline; none reported “no change” or worsened symptoms. On a scale of 1-10, patients rated their overall satisfaction with secukinumab treatment at month 3 with a mean (SD) score of 6.8 (2.1). Patients were also highly satisfied with their symptom improvement, speed to symptom improvement, and the mode and frequency of secukinumab administration (Table 1).

Table 1.

Summary of Prior PsA Treatment and Treatment Satisfaction with Secukinumab at Month 3

Physician-reported treatment characteristicsBaseline measure(N = 62)Most recent PsA biologic prior to secukinumab, n (%)n = 31Adalimumab12 (38.7)Certolizumab pegol8 (25.8)Etanercept6 (19.4)Infliximab, including -dyyb3 (9.7)Golimumab1 (3.2)Unknown/not sure1 (3.2)Primary reasons for discontinuing previous PsA biologic treatment, n (%)an = 30Primary and secondary loss of effectiveness25 (83.3)Disease progression6 (20.0)Worsening of or new comorbidities1 (3.3)How the medication was taken2 (6.7)Adverse effects/intolerance4 (13.3)Otherb1 (3.3)Patient-reported treatment satisfaction with secukinumab, mean (SD)cMonth 3 (N = 49)Symptom improvement6.7 (2.3)Speed of symptom improvement6.9 (2.0)Dose frequency7.4 (1.9)cMethod of administration7.2 (1.5)Ease of use8.2 (1.5)Side effects, if any7.9 (1.9)Patient support services by manufacturer8.3 (1.7)

PsA, psoriatic arthritis.

a Rheumatologists may list > 1 reason. Data tabulated based on the number of case report forms received from rheumatologists at analysis cutoff (n = 30).

b Other reasons included availability of new treatment, patient request, or family history of disease.

c n = 48.

Conclusion:

Most patients were biologic experienced and reported primary or secondary loss of effectiveness as the main reason for discontinuation of their previous biologic. Patients reported overall symptom improvement and satisfaction with secukinumab treatment at 3 months after initiation.

Disclosure of Interests:

M Elaine Husni Consultant of: AbbVie, Amgen, Janssen, Novartis, Eli Lilly, UCB, and Regeneron, Michael Bozyczko Employee of: National Psoriasis Foundation, Daniel Wolin Employee of: RTI Health Solutions, Carolyn Sweeney Employee of: RTI Health Solutions, Eric Davenport Employee of: RTI Health Solutions, Steven Hass Employee of: Novartis, Esther Yi Employee of: Novartis, Peter Hur Employee of: Novartis, Linda Grinnell-Merrick Consultant of: AbbVie, Amgen (previously Celgene), Novartis, Pfizer, and Regeneron.

Outbreak of Tattoo-associated Nontuberculous Mycobacterial Skin Infections

BACKGROUND

On 29 April 2015, the Florida Department of Health in Miami-Dade County (DOH Miami-Dade) was notified by a local dermatologist of 3 patients with suspected nontuberculous mycobacterial (NTM) infection after receiving tattoos at a local tattoo studio.

METHODS

DOH Miami-Dade conducted interviews and offered testing, described below, to tattoo studio clients reporting rashes. Culture of clinical isolates and identification were performed at the Florida Bureau of Public Health Laboratories. Characterization of NTM was performed by the Centers for Disease Control and Prevention and the US Food and Drug Administration (FDA), respectively. Whole-genome sequencing (WGS) and single-nucleotide polymorphism (SNP) analyses were used to construct a phylogeny among 21 Mycobacterium isolates at the FDA.

RESULTS

Thirty-eight of 226 interviewed clients were identified as outbreak-associated cases. Multivariate logistic regression revealed that individuals who reported gray tattoo ink in their tattoos were 8.2 times as likely to report a rash (95% confidence interval, 3.1-22.1). Multiple NTM species were identified in clinical and environmental specimens. Phylogenetic results from environmental samples and skin biopsies indicated that 2 Mycobacterium fortuitum isolates (graywash ink and a skin biopsy) and 11 Mycobacterium abscessus isolates (5 from the implicated bottle of graywash tattoo ink, 2 from tap water, and 4 from skin biopsies) were indistinguishable. In addition, Mycobacterium chelonae was isolated from 5 unopened bottles of graywash ink provided by 2 other tattoo studios in Miami-Dade County.

CONCLUSIONS

WGS and SNP analyses identified the tap water and the bottle of graywash tattoo ink as the sources of the NTM infections.

The Overseas Registration Examination of the General Dental Council

The Overseas Registration Examination is a route to entry to the UK Dentists Register for dentists who have qualified outside the European Economic Area. The role of the examination is to protect the public by ensuring that such dentists meet minimum standards of competence. Candidates invest considerable time and resource in attempting the examination. For these reasons it is essential that the examination is both robust and fair. This paper describes the fundamental principles of assessment underpinning the design of the examination and the steps taken by the General Dental Council's ORE Advisory Group to assure its ongoing quality.

Secukinumab demonstrates greater sustained improvements in daily activities and personal relationships than ustekinumab in patients with moderate-to-severe plaque psoriasis: 52-week results from the CLEAR study

Background

Psoriasis can greatly impact patients’ lives by influencing clothing worn as well as by impairing sexual functioning. Secukinumab, a human monoclonal antibody selectively neutralizing interleukin‐17A, has demonstrated good efficacy and safety in the treatment of moderate‐to‐severe psoriasis and psoriatic arthritis with a rapid onset of action and sustained response.

Objective

This analysis using the CLEAR study, a phase 3b double‐blind study comparing the efficacy and safety of secukinumab vs. ustekinumab in adults with moderate‐to‐severe plaque psoriasis, evaluated the treatment effects on patient's daily activities and personal relationships.

Methods

Impact on daily activities (interference with home/shopping/garden, and influence on clothes worn) and impact on personal relationships (problems with partner/others, and sexual difficulties) as well as their corresponding subscales were selected from the Dermatology Life Quality Index scale and evaluated for patients treated with secukinumab vs. ustekinumab from the CLEAR study. Treatment differences in mean scores and proportions of responders (score = 0, indicating no impact) were evaluated through 52 weeks. Time to response was evaluated through Week 16.

Results

Significant differences between secukinumab and ustekinumab were observed for daily activities and personal relationships at Week 16 and sustained through Week 52 (Week 52 response rates for daily activities: 82.9% vs. 73.5%, including interference with home/shopping/garden: 88.5% vs. 78.2%, and influence on clothes worn: 85.6% vs. 74.4%; personal relationships: 86.1% vs. 73.7%, including problems with partner/others: 86.6% vs. 74.8%, and sexual difficulties: 88.5% vs. 74.3%; all P < 0.01). The median time to response was 4 weeks for secukinumab vs. 8 weeks for ustekinumab for daily activities and personal relationships (both P < 0.05).

Conclusion

Secukinumab treatment helps patients with moderate‐to‐severe plaque psoriasis have a more normal life faster when compared to ustekinumab, by providing greater and sustained improvement in clothing choice and sexual functioning.

Index cholecystectomy in a rural hospital: it can be done

BACKGROUND

Index cholecystectomy (IC) refers to an operation during a patient's first hospital admission with symptomatic gallstone (GS) disease. There are proven reductions in cost, hospital bed days and GS-related complications while awaiting elective surgery. IC has not been universally adopted, particularly in smaller centres where logistics can present a barrier. The aim of this paper is to describe the introduction of routine IC at Hastings Hospital and the effects in terms of waiting time until surgery; GS-related re-presentations and complications while awaiting surgery; operative complications and overall hospital stay.

METHODS

Data were collected for all patients who underwent cholecystectomy in the year following the introduction of IC (2015/2016). The results were compared with data from the year 2009/2010.

RESULTS

A total of 259 cholecystectomies were performed over the 2015/2016 study period compared with 186 in the 2009/2010 study period. The IC rate increased from 9.89% in 2009 to 75.4% in 2015 (P < 0.001). The incidence of GS pancreatitis whilst waiting for surgery reduced from six in 2009 compared with one in 2015 (P = 0.046). The operative complications were similar in both groups. Total hospital stay was also similar.

CONCLUSION

The study shows that it is possible to perform IC in a rural setting reducing complications of waiting and in particular, rates of GS-related pancreatitis were significantly reduced. It can be done safely with an accommodating acute on-call system.

Production of gold nanoparticles by electrode-respiring Geobacter sulfurreducens biofilms

The goal of this work was to synthesize gold nanoparticles (AuNPs) using electrode-respiring Geobacter sulfurreducens biofilms. We found that AuNPs are generated in the extracellular matrix of Geobacter biofilms and have an average particle size of 20nm. The formation of AuNPs was verified using TEM, FTIR and EDX. We also found that the extracellular substances extracted from electrode-respiring G. sulfurreducens biofilms reduce Au³⁺ to AuNPs. From FTIR spectra, it appears that reduced sugars were involved in the bioreduction and synthesis of AuNPs and that amine groups acted as the major biomolecules involved in binding.

Accuracy of frozen sections for breast cancer sentinel lymph node biopsies within a peripheral New Zealand hospital

AIM

Intra-operative frozen section is a commonly-used technique for evaluating sentinel lymph node biopsies in breast cancer to determine the need for an axillary node dissection (AND). Frozen section does have drawbacks, including cost and uncertainty around operating time. In addition, recent studies have questioned the benefit of AND in certain cases. The aim of this study was therefore to evaluate the accuracy of frozen section at our institution.

METHODS

All patients who had a sentinel node biopsy for breast cancer in the Hawke's Bay District Health Board region over a 1-year period were included in the study. Results of intra-operative frozen section were compared to routine paraffin histological analysis.

RESULTS

Eighty patients were eligible. Eighteen had a positive frozen section. There were two false negatives. The sensitivity of frozen section for metastases was 90%, specificity was 100%, and the false negative rate was 2.5%.

CONCLUSIONS

The accuracy of frozen section section for sentinel lymph node biopsies in breast cancer at Hawke's Bay District Health Board is acceptable by international standards. However, as further evidence against axillary node dissections in those with sentinel node positive disease mounts, their use in the future may be limited.

Dysfunctional metacognition and drive for thinness in typical and atypical anorexia nervosa

BACKGROUND

Anorexia nervosa is complex and difficult to treat. In cognitive therapies the focus has been on cognitive content rather than process. Process-oriented therapies may modify the higher level cognitive processes of metacognition, reported as dysfunctional in adult anorexia nervosa. Their association with clinical features of anorexia nervosa, however, is unclear. With reclassification of anorexia nervosa by DSM-5 into typical and atypical groups, comparability of metacognition and drive for thinness across groups and relationships within groups is also unclear. Main objectives were to determine whether metacognitive factors differ across typical and atypical anorexia nervosa and a non-clinical community sample, and to explore a process model by determining whether drive for thinness is concurrently predicted by metacognitive factors.

METHODS

Women receiving treatment for anorexia nervosa (n = 119) and non-clinical community participants (n = 100), aged between 18 and 46 years, completed the Eating Disorders Inventory (3(rd) Edition) and Metacognitions Questionnaire (Brief Version). Body Mass Index (BMI) of 18.5 kg/m(2) differentiated between typical (n = 75) and atypical (n = 44) anorexia nervosa. Multivariate analyses of variance and regression analyses were conducted.

RESULTS

Metacognitive profiles were similar in both typical and atypical anorexia nervosa and confirmed as more dysfunctional than in the non-clinical group. Drive for thinness was concurrently predicted in the typical patients by the metacognitive factors, positive beliefs about worry, and need to control thoughts; in the atypical patients by negative beliefs about worry and, inversely, by cognitive self-consciousness, and in the non-clinical group by cognitive self-consciousness.

CONCLUSIONS

Despite having a healthier weight, the atypical group was as severely affected by dysfunctional metacognitions and drive for thinness as the typical group. Because metacognition concurrently predicted drive for thinness in both groups, a role for process-oriented therapy in adults is suggested. Implications are discussed.

Acute hypercortisolism: what can the surgeon offer?

Rapid onset or acute hypercortisolism is a rare critical illness requiring emergency management. The majority of patients will have underlying malignancy with surgery an obvious choice in the minority with resectable disease. For those with unresectable disease, medical management alone has been the traditional approach. However, this often proves inadequate raising interest in the role of surgery as palliation in this setting. Patient selection, timing of surgery and optimal surgical technique are areas of current controversy with little literature available to provide answers. Decisions regarding management of patients with acute hypercortisolism are complex, and these patients are best managed in a subspecialized setting.

Assessment of trace elements and legacy contaminant concentrations in California mussels (Mytilus spp.): relationship to land use and outfalls

NOAA's Mussel Watch Program funded a regional pilot project in California that characterized contaminants associated with various land uses in conjunction with state, federal and private partners. Herein we assess the magnitude and distribution of trace elements and persistent organic contaminants in indigenous mussels with respect to land use, presence of outfalls and a subset of California Areas of Special Biological Significance (ASBS). We detected significant differences among the land use categories for the majority of trace elements and legacy contaminants measured. There was no significant difference between sites with and without outfalls. PCBs and PAHs were significantly lower in sites within ASBS boundary compared to other sites. The findings of this study will help fine tune future regional and national assessments as well as guide development of resource management and remediation activities and programs.

Adrenal incidentalomas: management in British district general hospitals

INTRODUCTION

Adrenal incidentalomas have become a common clinical dilemma with the increasing use and resolution of cross sectional imaging modalities.

OBJECTIVES

This retrospective observational study examined the management of adrenal incidentalomas in district general hospitals in Northumbria and adherence to current guidelines.

MATERIALS AND METHODS

We searched 4028 abdominal CT scans performed in Northumbria between 1 January and 31 December 2010. All patients with an incidental adrenal lesion were identified and their clinical records reviewed.

RESULTS

75 patients with adrenal incidentalomas were identified. Of these, only 13 (17%) were referred for specialist review with a further two patients undergoing additional evaluation by the primary medical team; 80% received no biochemical investigation or follow-up. Comorbidity may have affected the decision in a proportion, but 36 of 62 patients (58%) had no comorbidities precluding additional evaluation. In contrast, all patients reviewed by an endocrine specialist were appropriately investigated and managed, the majority conservatively, with three requiring adrenalectomy for phaeochromocytoma or cortisol secreting adenomas. In the patients with an incidentaloma, comorbidities which may be attributable to autonomous adrenal cortisol or aldosterone release were higher than regional averages, suggesting possible undiagnosed functional tumours.

CONCLUSIONS

The management of adrenal incidentalomas in British district general hospitals in Northumbria shows poor adherence to guidelines. Adherence was significantly better in those patients managed by an endocrine specialist. We suggest a pathway for the management and referral process.

Introduction of sacral neuromodulation for the treatment of faecal incontinence

INTRODUCTION

Faecal incontinence (FI) is a condition that impairs quality of life and ability to function socially. Over the last 15 years a promising new therapy (sacral neuromodulation, SNM) has been introduced which has been associated with marked improvement in many incontinence symptoms.

AIMS

To assess the early results of SNM in Auckland in terms of improved continence in those undergoing implantation of a permanent stimulator, and determine whether these results are comparable to overseas data.

METHODS

Patients who met the criteria for SNM; severe faecal incontinence, failure to respond to other measures including biofeedback, dietary modification, and appropriate surgical intervention were offered this treatment. After an initial bowel diary, patients underwent lead placement connected to an external stimulator and only those who responded had an implanted stimulator placed. Results were assessed by repeated bowel diary, QoL scores and continence scores.

RESULTS

Of 29 patients who had initial percutaneous stimulation, 27 showed adequate improvement and went on to permanent implanted stimulator. Of these, results were available on 26. The median number of FI episodes per week preoperatively was 7.25. The median post implantation was one. FI episodes improved following SNM by a mean of 12.21 episodes per week (95% confidence interval 4.91 to 19.51, p value=0.002). For those with longer follow up the initial improvement was sustained. There was a mean follow up time of 10.7 months (range 1 to 30 months).

CONCLUSION

Early results are encouraging, with a significant improvement in faecal incontinence following SNM. The results in Auckland in terms of improvement in symptom severity and quality of life are significant and comparable to other centres. SNM offers a good alternative for patients with end-stage FI.

Maternal and adolescent temperament as predictors of maternal affective behavior during mother-adolescent interactions

This study examined maternal and early adolescent temperament dimensions as predictors of maternal emotional behavior during mother-adolescent interactions. The sample comprised 151 early adolescents (aged 11-13) and their mothers (aged 29-57). Adolescent- and mother-reports of adolescent temperament and self-reports of maternal temperament were collected. Mother-adolescent dyads participated in event-planning and problem-solving interactions, which were coded for frequency of aggressive, dysphoric, and positive interpersonal maternal behavior. Analyses indicated that adolescents who are higher in temperamental Negative Affectivity and lower in Effortful Control are generally exposed to more frequent aggressive and less frequent positive interpersonal maternal behavior. Furthermore, mothers lower in Effortful Control engaged in more frequent dysphoric behavior toward their adolescent. Given the associations between parental emotional behavior and the development of adolescent emotion regulation, these findings suggest that temperamental dispositions, particularly of early adolescents, may influence their ongoing socialization of emotion regulation skills, and thus their emotional well being.

Sentinel lymph node biopsy experience in Taranaki: a prospective audit in a provincial New Zealand hospital

AIM

Sentinel lymph node biopsy has been rapidly incorporated into the management of early stage invasive breast cancer. The aim of this study was to review the adoption of sentinel lymph node biopsy at a provincial centre in New Zealand and compare markers of performance against established standards.

METHODS

The Taranaki Breast Database was created in 2002 and prospectively records data from all breast cancer patients in the Taranaki area. Data on all patients undergoing sentinel lymph node biopsy were retrieved and the results reviewed.

RESULTS

Between October 2002 and August 2007, 152 sentinel lymph node biopsies were undertaken in 151 patients. The initial 49 patients (training set) also underwent routine axillary clearance as part of an initial audit on the accuracy of sentinel lymph node biopsy. A sentinel node was identified in 97% of patients (93% including the training set) and a mean of two nodes per biopsy were removed. Metastatic nodal disease was identified in 40 of 152 (26%) of biopsies of which nine were micrometastases. In the training set there was a false negative rate for nodal spread of 5% (two of 40) and a 92% negative predictive value.

CONCLUSIONS

The performance of sentinel lymph node biopsy in Taranaki is comparable to international centres. Adoption of this technique as routine may spare many Taranaki women the morbidity of axillary clearance, without jeopardising safety.

Cholecystectomy deferral in patients with endoscopic sphincterotomy

BACKGROUND

Cholecystectomy is not required in up to 64% of patients who adopt a wait-and-see policy after endoscopic clearance of common bile duct stones. Although reports of retrospective cohort series have shown a higher mortality among patients who defer cholecystectomy, it is not known if this is due to the patients' premorbid health status or due to the deferral of cholecystectomy. Randomised clinical trials of prophylactic cholecystectomy versus wait-and-see have not had sufficient power to demonstrate differences in survival.

OBJECTIVES

To evaluate the beneficial and harmful effects of cholecystectomy deferral (wait-and-see) versus elective (prophylactic) cholecystectomy in patients who have had an endoscopic biliary sphincterotomy.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Controlled Trials Register (CENTRAL) in The Cochrane Library, MEDLINE (1966 to 2007), EMBASE (1980 to 2007), and Science Citation Index Expanded without language restrictions until April 2007.

SELECTION CRITERIA

Randomised clinical trials comparing patients whose gallbladder was left in-situ after endoscopic sphincterotomy (wait-and-see group) versus patients who had cholecystectomy with either endoscopic sphincterotomy or common bile duct exploration (prophylactic cholecystectomy group), irrespective of blinding, language, or publication status.

DATA COLLECTION AND ANALYSIS

We assessed the impact of a wait-and-see policy on mortality. Secondary outcomes assessed were the incidence of biliary pain, cholangitis, pancreatitis, need for cholangiography, need for cholecystectomy, and the rate of difficult cholecystectomy. We pooled data using relative risk with fixed-effect and random-effects models.

MAIN RESULTS

We included 5 randomised trials with 662 participants out of 93 publications identified through the literature searches. The number of deaths was 47 in the wait-and-see group (334 patients) compared to 26 in the prophylactic cholecystectomy group (328 patients) for a 78% increased risk of mortality (RR 1.78, 95% CI 1.15 to 2.75, P = 0.010). The survival benefit of prophylactic cholecystectomy was independent of trial design, inclusion of high risk patients or inclusion of any one of the five trials. Patients in the wait-and-see group had higher rates of recurrent biliary pain (RR 14.56, 95% CI 4.95 to 42.78, P < 00001), jaundice or cholangitis (RR 2.53, 95% CI 1.09 to 5.87, P = 0.03), and of repeat ERCP or other forms of cholangiography (RR 2.36, 95% CI 1.29 to 4.32, P = 0.005). Cholecystectomy was eventually performed in 35% (115 patients) of the wait-and-see group.

AUTHORS' CONCLUSIONS

Prophylactic cholecystectomy should be offered to patients whose gallbladders remain in-situ after endoscopic sphincterotomy and common bile duct clearance.

Proteinase-activated receptor-2-mediated activation of stress-activated protein kinases and inhibitory kappa B kinases in NCTC 2544 keratinocytes

In this study we examined the regulation of the stress-activated protein (SAP) kinases and inhibitory kappa B kinases (IKKs) through stimulation of the novel G-protein-coupled receptor proteinase-activated receptor-2 in the human keratinocyte cell line NCTC2544. Trypsin and the peptide SLIGKV stimulated a time-dependent increase in both c-Jun N-terminal kinase and p38 mitogen-activated protein kinase activity. Trypsin also stimulated NF kappa B-DNA binding and the activation of the upstream kinases IKK alpha and -beta. Phorbol 12-myristate 13-acetate also strongly activated both SAP kinases and IKK isoforms, suggesting the potential for a protein kinase C-mediated regulatory mechanism underlying the effects of trypsin. Pre-incubation with selective protein kinase C (PKC) inhibitors GF109203X and Gö6983, or transfection of dominant negative (DN)-PKC alpha, abolished phorbol 12-myristate 13-acetate-mediated c-Jun N-terminal kinase activity, although it only partially inhibited the response to trypsin. In contrast, Gö6983 reduced trypsin-stimulated p38 mitogen-activated protein kinase activity to a greater extent than GF109203X, although DN-PKC alpha or PKC zeta had no substantial effect. Additionally, inhibitors of PKC partially reduced trypsin-stimulated IKK alpha activity but abolished that of IKK beta, whereas DN-PKC alpha but not DN-PKC zeta substantially reduced trypsin-stimulated Flag-IKK beta activity. This study shows for the first time proteinase-activated receptor-2-mediated stimulation of both SAP kinase and IKK signaling and differing roles for PKC isoforms in the regulation of each pathway.

The relationships between premilitary school record data and risk for posttraumatic stress disorder among Vietnam war veterans

The purpose of this study was to determine whether Vietnam veterans' risk for posttraumatic stress disorder (PTSD) was correlated with their premilitary school performance. The authors compared both primary and secondary school record data on hospitalized chemically dependent PTSD patients with those of both non-PTSD, chemically dependent and community controls. All participants were male Vietnam war combat veterans. The comparisons were made with MANCOVA analyses with the effects of combat and age differences between groups controlled. For the most part, primary-school grade point average, absenteeism, and tardiness data on three groups did not differ significantly. However, the mean secondary school grade points of the future PTSD patients were generally substantially lower than those of controls. Additionally, more secondary school absenteeism and tardiness were reported among future PTSD patients than in the controls. The groups did not differ significantly on number of extracurricular activities. Academic weakness, absenteeism, and tardiness in secondary school appear to be moderately strong predictors of vulnerability to PTSD after traumatization. It also supports the claim that chronic PTSD is, in part, the result of weaknesses present before exposure to trauma.

Measurement of moral development in medicine

The past two decades have been a time of heightened interest in the moral aspects of the practice of medicine. This interest has been reflected in medical education by the establishment of medical humanities programs in both preclinical and clinical education in many medical schools. It has also been reflected in the literature with a dramatic increase in journal articles on medical ethics as well as the development of medical ethics in textbooks. A number of journals have developed that are specifically devoted to medical ethics, including The Journal of Medical Ethics, The Journal of Medicine and Philosophy, The Journal of Medical Humanities, Theoretical Medicine, Cambridge Quarterly of Healthcare Ethics, just to name a few. The literature includes both theoretical foundations and conceptual analyses of particular issues as well as practical advice and general suggestions for how to implement programs in medical humanities.