Baseline characteristics of people experiencing homelessness with a recent drug overdose in the PHOENIx pilot randomised controlled trial

BACKGROUND

Drug-related deaths in Scotland are the highest in Europe. Half of all deaths in people experiencing homelessness are drug related, yet we know little about the unmet health needs of people experiencing homelessness with recent non-fatal overdose, limiting a tailored practice and policy response to a public health crisis.

METHODS

People experiencing homelessness with at least one non-fatal street drug overdose in the previous 6 months were recruited from 20 venues in Glasgow, Scotland, and randomised into PHOENIx plus usual care, or usual care. PHOENIx is a collaborative assertive outreach intervention by independent prescriber NHS Pharmacists and third sector homelessness workers, offering repeated integrated, holistic physical, mental and addictions health and social care support including prescribing. We describe comprehensive baseline characteristics of randomised participants.

RESULTS

One hundred and twenty-eight participants had a mean age of 42 years (SD 8.4); 71% male, homelessness for a median of 24 years (IQR 12-30). One hundred and eighteen (92%) lived in large, congregate city centre temporary accommodation. A quarter (25%) were not registered with a General Practitioner. Participants had overdosed a mean of 3.2 (SD 3.2) times in the preceding 6 months, using a median of 3 (IQR 2-4) non-prescription drugs concurrently: 112 (87.5%) street valium (benzodiazepine-type new psychoactive substances); 77 (60%) heroin; and 76 (59%) cocaine. Half (50%) were injecting, 50% into their groins. 90% were receiving care from Alcohol and Drug Recovery Services (ADRS), and in addition to using street drugs, 90% received opioid substitution therapy (OST), 10% diazepam for street valium use and one participant received heroin-assisted treatment. Participants had a mean of 2.2 (SD 1.3) mental health problems and 5.4 (SD 2.5) physical health problems; 50% received treatment for physical or mental health problems. Ninety-one per cent had at least one mental health problem; 66% had no specialist mental health support. Participants were frail (70%) or pre-frail (28%), with maximal levels of psychological distress, 44% received one or no daily meal, and 58% had previously attempted suicide.

CONCLUSIONS

People at high risk of drug-related death continue to overdose repeatedly despite receiving OST. High levels of frailty, multimorbidity, unsuitable accommodation and unmet mental and physical health care needs require a reorientation of services informed by evidence of effectiveness and cost-effectiveness. Trial registration UK Clinical Trials Registry identifier: ISRCTN 10585019.

Pharmacist and Homeless Outreach Engagement and Non-medical Independent prescribing Rx (PHOENIx): a study protocol for a pilot randomised controlled trial

INTRODUCTION

The number of people experiencing homelessness (PEH) is increasing worldwide. Systematic reviews show high levels of multimorbidity and mortality. Integrated health and social care outreach interventions may improve outcomes. No previous studies have targeted PEH with recent drug overdose despite high levels of drug-related deaths and few data describe their health/social care problems. Feasibility work suggests a collaborative health and social care intervention (Pharmacist and Homeless Outreach Engagement and Non-medical Independent prescribing Rx, PHOENIx) is potentially beneficial. We describe the methods of a pilot randomised controlled trial (RCT) with parallel process and economic evaluation of PEH with recent overdose.

METHODS AND ANALYSIS

Detailed health and social care information will be collected before randomisation to care-as-usual plus visits from a pharmacist and a homeless outreach worker (PHOENIx) for 6-9 months or to care-as-usual. The outcomes are the rates of presentations to emergency department for overdose or other causes and whether to progress to a definitive RCT: recruitment of ≥100 participants within 4 months, ≥60% of patients remaining in the study at 6 and 9 months, ≥60% of patients receiving the intervention, and ≥80% of patients with data collected. The secondary outcomes include health-related quality of life, hospitalisations, treatment uptake and patient-reported measures. Semistructured interviews will explore the future implementation of PHOENIx, the reasons for overdose and protective factors. We will assess the feasibility of conducting a cost-effectiveness analysis.

ETHICS AND DISSEMINATION

The study was approved by South East Scotland National Health Service Research Ethics Committee 01. Results will be made available to PEH, the study funders and other researchers.

TRIAL REGISTRATION NUMBER

ISRCTN10585019.

Is the Performance of a Periodontal Prediction Model for Identification of Diabetes affected by Participants' Characteristics?

OBJECTIVE

To evaluate whether the diagnostic accuracy of a novel periodontal prediction model (PPM) for identification of adults with diabetes varies according to participants' characteristics.

BASIC RESEARCH DESIGN

The study was carried out among 250 adults attending primary care clinics in Riyadh (Saudi Arabia). The study adopted a case-control approach, where diabetes status was first ascertained, and data collection carried out afterwards using questionnaires and periodontal examinations. Variations in the performance of the PPM by demographic (sex and age), socioeconomic (education) and behavioural factors (smoking status and last dental visit) were evaluated using receiver-operating characteristic (ROC) regression.

RESULTS

The PPM including 3 periodontal parameters (missing teeth, percentage of sites with pocket depth ≥6mm and mean pocket depth) had an area under the ROC curve (AUC) of 0.69 (95% Confidence Interval: 0.61-0.78), which dropped to 0.64 (95% CI: 0.53-0.75) after adjustment for covariates. Larger variations in performance were found by participants' sex, age and education, but not by smoking status or last dental visit. The PPM performed better among male (adjusted AUC: 0.76; 95% CI: 0.53 to 0.99), younger (0.67; 95% CI: 0.50 to 0.84) and less educated participants (0.76; 95% CI: 0.60, 0.92).

CONCLUSIONS

The diagnostic accuracy of a novel periodontal prediction model to identify individuals with diabetes varied according to participants' characteristics. This study highlights the importance of adjusting for covariates on studies of diagnostic accuracy.

Setting up and maximising the usage of an Urgent Dental Care Centre in Blackpool. Sharing our experiences

An integrated Urgent Dental Care Centre with Tier 2 Oral Surgery support was set up in Blackpool starting 24^th March 2020. This was in reaction to the COVID-19 pandemic. In the first month 1433 patients had telephone consultations and 713 extractions were performed. The challenges surrounding set up and continuity of care are discussed.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Can multiphase CT scan distinguish between papillary renal cell carcinoma type 1 and type 2?

OBJECTIVE

To investigate the utility of multiphase computed tomography (CT) and percutaneous renal mass biopsy (PRMB) in differentiating between papillary renal cell carcinoma (pRCC)-Type 1 and -Type 2, as emerging data have suggested differential enhancement patterns in different renal tumor histologies.

MATERIAL AND METHODS

Retrospective analysis of 51 patients (23 pRCC-Type 1/28 pRCC-Type 2) who underwent multiphase CT followed by surgery from July 2011 to April 2016 was performed. Data were analyzed between subgroups based on histology. Multiphase CT was analyzed for tumor size, and attenuation [Hounsfield Units (HU)]. Change in HU (ΔHU) was calculated between noncontrast (NC), corticomedullary (CM), nephrographic (N), and delayed (D) phases. Subset analysis was carried out on patients who underwent PRMB prior to surgery.

RESULTS

There was no difference in median tumor size (pRCC-Type 1 2.8 vs. pRCC-Type 2 2.6 cm, p=0.832). In addition to tumor size being similar between groups, distribution of tumor stages between groups was also similar (p=0.651). Greater proportion of high-grade tumors (III/IV) was noted in pRCC-Type 2 (42.9% vs. 8.7%) (p=0.011). There was no difference in HU values for NC (p=0.961), CM (p=0.118), N (p=0.277), and D (p=0.256) phases, and in ΔHU between CM-NC (p=0.278), N-NC (p=0.316), and D-NC (p=0.103). Thirteen patients underwent percutaneous biopsy, 11 of whom had diagnostic samples. Examination of 10/11 (90.9%) samples accurately predicted correct histology, and of 6/11 (54.5%) samples correctly identified high-vs. low-grade histology.

CONCLUSION

Our findings suggest substantial overlap of CT findings, despite pRCC-Type 2 having greater proportion of high-grade tumors. Utility of CT is limited in the differentiation between pRCC subtypes. Patients with suggested pRCC on CT imaging being considered for a non-extirpative strategy should undergo PRMB for risk stratification.

Cassava flour slurry as a low-cost alternative to commercially available gel for obstetrical ultrasound: a blinded non-inferiority trial comparison of image quality

OBJECTIVE

To evaluate the quality of ultrasound images obtained with cassava flour slurry (CFS) compared with conventional gel in order to determine objectively whether CFS could be a true low-cost alternative.

DESIGN

Blinded non-inferiority trial.

SETTING

Obstetrical ultrasound unit in an academic medical centre.

POPULATION OR SAMPLE

Women with a singleton pregnancy, undergoing anatomy ultrasounds.

METHODS

Thirty pregnant women had standard biometry measures obtained with CFS and conventional gel. Images were compared side-by-side in random order by two blinded sonologists and rated for image resolution, detail and total image quality using a 10-cm visual analogue scale. Ratings were compared using paired t-tests. Participant and sonographer experience was measured using five-point Likert scales.

MAIN OUTCOME MEASURES

Image resolution, detail, and total image quality. Participant experience of gel regarding irritation, messiness, and ease of removal.

RESULTS

We found no significant difference between perceived image quality obtained with CFS (mean = 6.2, SD = 1.2) and commercial gel (mean = 6.4, SD = 1.2) [t (28) = -1.1; P = 0.3]. Images were not rated significantly differently for either reviewer in any measure, any standardized image or any view of a specific anatomic structure. All five sonographers rated CFS as easy to obtain clear images and easy for patient and machine cleanup. Only one participant reported itching with CFS.

CONCLUSIONS

CFS produces comparable image quality to commercial ultrasound gel. The dissemination of these results and the simple CFS recipe could significantly increase access to ultrasound for screening, monitoring and diagnostic purposes in resource-limited settings.

FUNDING

This study was internally funded by our department.

TWEETABLE ABSTRACT

Low-cost homemade cassava flour slurry creates images equal to commercial ultrasound gel, improving access.

Protein biomarker of cell proliferation determines survival to discharge in cases of equine large colon volvulus

BACKGROUND

Progenitor cells play critical roles in epithelial repair following ischaemic injury. Protein biomarkers have been used to identify intestinal progenitor cell subpopulations. This study aims to determine if a critical number of intestinal progenitor cells can predict tissue viability and survival to discharge of large colon volvulus (LCV) cases.

OBJECTIVES

The objectives were to 1) identify intestinal progenitor cell subpopulations using biomarkers: proliferating cell nuclear antigen (PCNA), sex determining region Y box 9 (SOX9), phospho-histone H3 (PHH3) and Ki-67, 2) define cut-off values for critical numbers of positive cells and 3) determine if survival to discharge is associated with cut-off values.

STUDY DESIGN

Retrospective cohort study.

METHODS

Adult horses admitted to the Farm and Equine Veterinary Medical Center at NC State's Veterinary Hospital and Peterson and Smith Equine Hospital between 2006 and 2016 that underwent an exploratory coeliotomy with a diagnosis of LCV of ≥360 degrees, had pelvic flexure biopsy and that recovered from general anaesthesia were selected for inclusion in the study. Immunohistochemical analyses were performed and positive cells were counted. Optimal cut-off values were determined using receiver operator curves. A Fisher's exact test was used to associate cut-off values with survival to discharge.

RESULTS

In this study, 23 cases of LCV ≥360° were included. Of 23 horses, 13 (57%) survived to discharge. A cut-off value of <2.1 PHH3 positive cells per crypt correctly predicted death with 100% sensitivity (95% CI; 69.15-100%) and 84.62% specificity (95% CI; 54.55-98.08%). LCV cases with <2.1 PHH3 positive cells per crypt were 96.6 times more likely to die (95% CI; 4.14-2255 and P < 0.0001). Biomarkers PCNA, SOX9 and Ki-67 did not predict short-term survival.

MAIN LIMITATIONS

The population size was small.

CONCLUSIONS

PHH3 immunohistochemical analysis may assist in more accurate prediction of survival to hospital discharge of LCV cases. The summary is available in Spanish - see Supporting Information.

A Tool for Investigating Asthma and COPD Exacerbations: A Newly Manufactured and Well Characterised GMP Wild-Type Human Rhinovirus for Use in the Human Viral Challenge Model

Background

Human Rhinovirus infection is an important precursor to asthma and chronic obstructive pulmonary disease exacerbations and the Human Viral Challenge model may provide a powerful tool in studying these and other chronic respiratory diseases. In this study we have reported the production and human characterisation of a new Wild-Type HRV-16 challenge virus produced specifically for this purpose.

Methods and Stock Development

A HRV-16 isolate from an 18 year old experimentally infected healthy female volunteer (University of Virginia Children’s Hospital, USA) was obtained with appropriate medical history and consent. We manufactured a new HRV-16 stock by minimal passage in a WI-38 cell line under Good Manufacturing Practice conditions. Having first subjected the stock to rigorous adventitious agent testing and determining the virus suitability for human use, we conducted an initial safety and pathogenicity clinical study in adult volunteers in our dedicated clinical quarantine facility in London.

Human Challenge and Conclusions

In this study we have demonstrated the new Wild-Type HRV-16 Challenge Virus to be both safe and pathogenic, causing an appropriate level of disease in experimentally inoculated healthy adult volunteers. Furthermore, by inoculating volunteers with a range of different inoculum titres, we have established the minimum inoculum titre required to achieve reproducible disease. We have demonstrated that although inoculation titres as low as 1 TCID₅₀ can produce relatively high infection rates, the optimal titre for progression with future HRV challenge model development with this virus stock was 10 TCID₅₀. Studies currently underway are evaluating the use of this virus as a challenge agent in asthmatics.

Trial Registration

ClinicalTrials.gov NCT02522832

Regionally dependent neuromuscular functions of motilin and 5-HT₄ receptors in human isolated esophageal body and gastric fundus

BACKGROUND

Motilin agonists promote human gastric motility and cholinergic activity, but excitatory and inhibitory actions are reported in the esophagus. The effect of 5-HT₄ agonists in esophagus is also unclear. Perhaps the use of drugs with additional actions explains the variation. The aim, therefore, was to examine how motilin and prucalopride, selective motilin and 5-HT₄ receptor agonists, modulate neuromuscular functions in human esophagus and gastric fundus.

METHODS

Electrical field stimulation (EFS) evoked nerve-mediated contractions of circular and longitudinal muscle from human esophageal body and circular muscle from gastric fundus.

KEY RESULTS

In esophageal circular muscle EFS evoked brief contraction, followed by another contraction on termination of EFS, each prevented by atropine. Nitric oxide synthase inhibition facilitated contraction during EFS and the overall contraction became monophasic. In esophagus longitudinal muscle and gastric fundus, EFS evoked cholinergically mediated, monophasic contractions, attenuated by simultaneous nitrergic activation. Motilin (100-300 nM) reduced esophagus circular muscle contractions during EFS, unaffected by L-NAME or apamin. Motilin 300 nM also reduced EFS-evoked contractions of longitudinal muscle. Similar concentrations of motilin facilitated cholinergic activity in the fundus and increased baseline muscle tension. Prucalopride facilitated EFS-evoked contractions in esophagus (tested at 30 μM) and fundus (0.1-30 μM).

CONCLUSIONS & INFERENCES

Selective motilin and 5-HT₄ agonists have different, region-dependent abilities to modulate human esophageal and stomach neuromuscular activity, exemplified by weak inhibition (motilin) or excitation (5-HT₄) in esophageal body and excitation for both in stomach. In different patients with motility dysfunctions, motilin and 5-HT₄ agonists may reduce gastro-esophageal reflux in different ways.

Using debate to teach pharmacy students about ethical issues

OBJECTIVE

To create, implement, and evaluate debate as a method of teaching pharmacy undergraduate students about ethical issues.

DESIGN

Debate workshops with 5 hours of contact with student peers and facilitators and 5 hours of self-study were developed for second-year pharmacy students. Student development of various skills and understanding of the topic were assessed by staff members and student peers.

ASSESSMENT

One hundred fifty students completed the workshops. The mean score for debating was 25.9 out of 30, with scores ranging from 23.2 to 28.7. Seventy percent of students agreed that the debates were a useful teaching method in the degree program.

CONCLUSION

A series of workshops using debates effectively delivered course content on ethical issues and resulted in pharmacy students developing skills such as teamwork, peer assessment, communication, and critical evaluation. These findings suggest that pharmacy students respond favorably to a program using debates as a teaching tool.

Epilepsy health consumer groups and charities; how representative of patients are they? The results of a pilot study

PURPOSE

In the United Kingdom all health care providers are encouraged to consult with user groups. The submissions of charities and patient advocacy groups to NICE and SIGN are considered reflective of the patient groups they purport to represent, yet little is known about how representative they are. This pilot study was designed to ascertain how many patients attending a hospital based epilepsy clinic were members of such advocacy groups.

METHODS

Patients were asked to complete a brief 9-question questionnaire before they left the clinic.

RESULTS

One hundred and twenty-five questionnaires were distributed, of which 101 were returned. Seventeen percent of patients were members of advocacy groups, with several being members of more than one charity/group. Only seven percent of the respondents had ever been contacted by an advocacy group to canvass their opinions. Seventy percent of patients questioned stated they thought a frank discussion with their physician, or specialist nurse was more likely to influence patient services. Patients with long duration of disease and taking multiple anti-epileptic drugs were more likely to be members of charity/advocacy groups.

CONCLUSIONS

As patient charities in the U.K. are often in receipt of public funds, and actively seek to influence public policy this raises the question of whether they should be required to consult more widely with the people they claim to represent.

Facilitating the quality of care in a specialist Pacific ophthalmic nursing workforce

BACKGROUND

Sufficient, appropriately trained health personnel need to be retained in the workforce, and their performance maintained, to achieve quality care. Mid-level ophthalmic personnel in Western Pacific Island Countries and Territories (WPICT) are no exception.

AIM

The study aims to assess influences on the quality of care provided by specialist mid-level ophthalmic personnel in WPICT and devise strategies to train, retain and maintain performance of these personnel.

METHODS

A situational assessment employed a checklist and semi-structured interviews with specialist mid-level ophthalmic personnel, nursing bodies and Ministry of Health representatives from seven WPICT. A selective literature review guided strategies to address the issues identified.

RESULTS

Appropriate training allows nurses to fulfill a mid-level role in WPICT as specialist ophthalmic nurses. Resources generally do not restrict practice. Nursing structures have generally failed to support professionalism: scope and conditions of service, clinical supervision, career structures, professional recognition and opportunities for continuing professional development are rudimentary. Ophthalmic nurses were dissatisfied with the lack of specialty recognition, career progression and salary increase. Regional and local strategies tailored to each country have been devised to establish sustainable processes for support.

CONCLUSION

Salary was a major cause of dissatisfaction. It should be addressed along with professional recognition and related processes. Without professional support, specialist and advanced cadres within nursing may cease to exist, nurses' performance may be affected or they may leave. Specialist ophthalmic nursing, recognized, situated within and properly supported by nursing structures can provide a model for specialist clinical care for other specialties and in other countries.

Who needs antipsychotic medication in the earliest stages of psychosis? A reconsideration of benefits, risks, neurobiology and ethics in the era of early intervention

In recent years, early intervention services have attempted to identify people with a first episode of psychosis as early as possible, reducing the duration of untreated psychosis and changing the timing of delivery of interventions. The logic of early intervention is based partly on accessing people in a more treatment responsive stage of illness in which psychosocial damage is less extensive, and partly on remediating a putatively active process of neuroprogression that leads to pathophysiological, symptomatic and structural changes, hence improving symptomatic and functional outcomes. However, as in other areas of health care, earlier identification of new patients may mean that different treatment approaches are indicated. The corollary of early detection is that the sequence and complexion of treatment strategies for first episode psychosis has been revaluated. Examples include the minimal effective dosage of antipsychotic medication and the content of psychosocial interventions. With the substantial reductions of DUP now seen in many early psychosis services, based on clinical staging and stepped care principles, it is even possible that the immediate introduction of antipsychotic medication may not be necessary for all first episode psychosis cases, but that potentially safer interventions, which may be more acceptable to many patients, such as comprehensive psychosocial intervention, may constitute effective treatment at least for a subgroup of patients. In this paper, we review this theoretical background and describe a randomised controlled trial currently underway at the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne designed to test outcomes for first episode psychosis patients in response to two different treatments: intensive psychosocial intervention plus antipsychotic medication versus intensive psychosocial intervention plus placebo. This is a theoretically and pragmatically novel study in that it will provide evidence as to whether intensive psychosocial intervention alone is sufficient for a subgroup of first episode psychosis patients in a specialised early intervention service, and provide a test of the heuristic clinical staging model. By experimentally manipulating duration of untreated psychosis, the study will also provide a methodologically strong test of the effect of delaying the introduction of antipsychotic medication, as well as helping to disentangle the effects of antipsychotic medications and the putative neurobiological processes associated with brain changes and symptom profiles in the early phase of psychotic disorders. The study has been carefully crafted to satisfy critical ethical demands in this challenging research domain.

The effect of preoperative weight loss and body mass index on postoperative outcome in patients with esophagogastric carcinoma

Studies have shown that weight loss is associated with adverse outcomes in all treatment modalities for esophagogastric carcinoma. Because of the increased prevalence of obesity and the effectiveness of perioperative nutrition, a number of patients are now obese or have normal body mass index (BMI) at the time of treatment. We investigated the relationship between weight loss, BMI, and outcome of surgery for patients with esophagogastric carcinoma. Data were collected over a 38-month period for all patients diagnosed with operable esophagogastric cancer at two UK centers. All patients underwent resection by a single Consultant Upper Gastrointestinal Surgeon and the use of perioperative jejunal feeding was universal. Ninety-three patients (57 male) underwent esophagogastric resection; 48 had no preoperative weight loss (34 with a BMI > 25 and 14 with a BMI < 25). Forty-five patients had preoperative weight loss (20 with BMI > 25 and 25 with BMI < 25). There was no significant difference in complication rates, median hospital stay, or mortality between the four groups. A significantly higher number of patients displaying preoperative weight loss were found to have stage III disease, but difference in survival of up to 3 years did not reach statistical significance on multivariate analysis. Preoperative weight loss and low BMI did not significantly influence the complication rate, perioperative mortality rate, length of hospital stay, or short-term prognosis. We conclude that preoperative weight loss can not be reliably used as an independent predictor of poor outcome in patients undergoing surgery for esophagogastric carcinoma. However, patients with preoperative weight loss and low BMI are more likely to have advanced disease.

Psychosocial response in emergency situations ? the nurse's role

BACKGROUND

It is critical to ensure that nurses have the skills and knowledge to respond effectively and to contribute to the psychosocial recovery of survivors of emergencies, particularly as an increasing proportion of the population is at risk of being exposed to a catastrophe. Over a decade ago it was reported that 16% of the world's population was at risk of experiencing some kind of catastrophic event. That has now risen with a total of 16% vulnerable to flood alone worldwide (Ministry of Health 2005). In the first semester of 2005, there were 174 natural disasters affecting 86 countries, resulting in the deaths of 5967 people, affecting a total of 60 million with an estimated damage of $6.3 billion (US$) (Centre for Research on the Epidemiology of Disasters 2005).

AIM

To describe the nursing contribution to the psychosocial recovery of survivors of emergencies during the emergency preparedness and planning stage and in promoting recovery over the longer term.

METHODS

Data for this article was sourced from relevant literature including World Health Organization policy and guidelines regarding mental health in emergencies. IMPLICATIONS FOR EDUCATION, TRAINING AND PRACTICE: It is vital that nurses realize they are too vulnerable to the effects of an emergency situation and that steps can be taken to protect nurses from enduring psychosocial effects.

Nurses at the forefront of innovation

BACKGROUND

This paper is based on a presentation given by the author at the 23rd Quadrennial ICN Congress and 7th International Regulation Congress in Taipei in May 2005.

AIM

Nurses worldwide are engaged in innovative practice on a daily basis. In most health systems across the world, nurses provide up to 80% of primary health care and are therefore well positioned to provide critically needed innovative solutions to many global health challenges. The aim of this paper is to increase awareness of the importance and value of innovations in nursing; provide an improved understanding of the contribution nurses make to innovation in health care; and increase understanding of the importance of creating environments that inspire innovation and help shape practice in new and improved ways.

DESIGN

This paper explores the concept of innovation, the inherent set of characteristics that need to be present in order for innovations to succeed, and the barriers that impede innovation from occurring.

CONCLUSION

There are numerous examples of successful innovations worldwide that are developed and implemented by nurses, some of which are described in this paper. The paper concludes that organizations need to have a support climate that encourages creativity and innovation to occur.

Safety of enfuvirtide in combination with an optimized background of antiretrovirals in treatment-experienced HIV-1-infected adults over 48 weeks

BACKGROUND

Antiretroviral tolerability is a critical factor contributing to treatment outcome. The T-20 Versus Optimized Background Regimen Only (TORO) studies assessed the safety and efficacy of enfuvirtide in treatment-experienced HIV-1-infected patients.

METHODS

A total of 997 patients were randomized at a 2:1 ratio to an optimized background antiretroviral regimen plus enfuvirtide (n = 663) or an optimized background regimen alone (control group; n = 334). Control patients could switch to enfuvirtide on virologic failure.

RESULTS

In total, 26.5% of patients randomized to enfuvirtide and 36.6% to the control group discontinued study treatment before week 48; the percentage of patients withdrawn for safety reasons (including adverse events [AEs], deaths, and laboratory abnormalities) was 14.0% in the enfuvirtide group and 11.6% in the control group. Injection site reactions (ISRs) occurred in 98% of enfuvirtide patients and led to treatment discontinuation in 4.4%. Treatment-related (defined as possibly, probably, or remotely) AE rates per 100 patient-years were lower with enfuvirtide (96.2) than in the control group (149.9); diarrhea, nausea, and fatigue, the most frequently reported AEs, were significantly less frequent with enfuvirtide than in the control group. Pneumonia was significantly more frequent in patients treated with enfuvirtide (6.7 vs. 0.6 events per 100 patient-years), although the incidence was within expected ranges for this population. Lymphadenopathy was also higher in enfuvirtide-treated patients (7.1 vs. 1.2 events per 100 patient-years) for control patients.

CONCLUSION

The addition of enfuvirtide to an optimized background regimen does not exacerbate AEs commonly associated with antiretrovirals. ISRs limited treatment in <5% of patients.

Latent adenoviral infection induces production of growth factors relevant to airway remodeling in COPD

Previous studies showed an association between latent adenoviral infection with expression of the adenoviral E1A gene and chronic obstructive pulmonary disease (COPD). The present study focuses on how the adenoviral E1A gene could alter expression of growth factors by human bronchial epithelial (HBE) cells. The data show that connective tissue growth factor (CTGF) and transforming growth factor (TGF)-β1 mRNA and protein expression were upregulated in E1A-positive HBE cells. Upregulation of CTGF in this in vitro model was independent of TGF-β secreted into the growth medium. Comparison of E1A-positive with E1A-negative HBE cells showed that both expressed cytokeratin but only E1A-positive cells expressed the mesenchymal markers vimentin and α-smooth muscle actin. We conclude that latent infection of epithelial cells by adenovirus E1A could contribute to airway remodeling in COPD by the viral E1A gene, inducing TGF-β1 and CTGF expression and shifting cells to a more mesenchymal phenotype.

Anorectal sepsis

Anorectal sepsis is a common cause of hospital admission, presenting with abscess or fistula formation. This article discusses the aetiology of acute anorectal sepsis and its management.

A heterocycle-forming double michael reaction. [5 + 1] annulation route to highly substituted and functionalized piperidines

[reaction: see text]. Nitrogen-containing tethered diacids, easily prepared by reductive alkylation of diethyl aminomalonate or ethyl cyanoglycinate, undergo double Michael reactions with 3-butyn-2-one to give highly functionalized and substituted piperidines (pipecolic acid derivatives) with surprisingly high stereoselectivity. The heterocyclic double Michael adducts can be induced to undergo further cyclizations to give a variety of azabicyclic and diazabicyclic compounds.

Retroviral transduction of human periodontal cells with a temperature-sensitive SV40 large T antigen

The periodontal ligament (PDL) is considered to contain subpopulations of cells responsible for the development, repair and regeneration of the periodontium. Cell cultures have been used as model systems in order to understand the complex cellular and biochemical events underlying these processes. In order to obtain long-term cultures of these cells that can be cloned and characterized, primary cultures of PDL and gingival cells were infected with an amphotropic retroviral construct encoding a temperature-sensitive SV40 large T antigen (tsT). After selection for drug resistance, the cells expressed the T antigen and proliferated at 34 degrees C for more than 40 passages. However, when the T antigen was inactivated by incubation at 39 degrees C, the cultures became growth-arrested and the granularity of the cells increased, possibly as a result of differentiation. Reverse transcribed-polymerase chain reaction and flow cytometry showed that the tsT-transduced cells expressed a number of soft and hard connective-tissue antigens, including osteocalcin, osteonectin, osteopontin, collagen type I and alkaline phosphatase. Moreover, incubation of the transduced PDL cells at 39 degrees C was found to upregulate the expression of osteocalcin, osteopontin and collagen type I, but downregulate osteonectin. At this temperature, the presence of the dexamethasone downregulated type I collagen, while vitamin D3 had no effect on the expression of any of the antigens examined. Under all culture conditions, antigen expression was far higher in the transduced PDL cells than the gingival cells. The findings thus show that growth of the tsT-transduced PDL and gingival cells is temperature-dependent and that the presence of the T antigen increases their lifespan but does not ablate the expression of certain of their characteristic phenotypic and functional features.

The relationship between life-events and periodontitis. A case-control study

This case-control study (n = 100 dental patients, matched for age and sex) investigated the role of life-events in periodontitis. Data collected included life events, tobacco use, oral health behaviours and socio-demographics. The results of conditional simple logistic regression analysis showed that periodontitis was associated with the negative impact of life-events (p < 0.01), the number of negative life-events (p < 0.05), high levels of dental plaque (p < 0.01), tobacco smoking (p < 0.01) and being unemployed (p < 0.05). These associations remained statistically significant after adjusting for oral health behaviour and socio-demographic variables, but not tobacco smoking (p > 0.05). Marital status became statistically significant after adjusting for the other variables (p < 0.05). A model is suggested to explain the pathways through which life events may affect periodontal health. It was concluded that psychosocial factors and oral health risk behaviours cluster together as important determinants of periodontitis.

A comparative study of cefepime and ceftazidime in the treatment of community-acquired lower respiratory tract infections

Antibiotic treatment for community-acquired pneumonia must target Gram-positive pathogens, especially frequently isolated organisms such as Streptococcus pneumoniae. The severity of community-acquired pneumonia is often related to underlying factors. Occasionally it may be complicated by staphylococcal or Gram-negative bacillary infection. We have compared the safety and efficacy of cefepime 1 g bd with ceftazidime 1 g tds as empirical treatment in adults with community-acquired lower respiratory tract infections (LRTIs). One hundred and thirty-one patients with moderate to severe LRTIs were randomized to two treatment groups: 87 received cefepime and 44 received ceftazidime. The treatment groups were comparable with regard to sex, age and treatment duration. Of the 116 pathogens isolated, 57 were Gram-positive (46 strains of S. pneumoniae) and 59 were Gram-negative (33 strains of Haemophilus influenzae). Of the 111 patients evaluated, clinical cure rates were 87% (65/75) in the cefepime group and 86% (31/36) in the ceftazidime group. Pathogen eradication rates were 95% (74/78 and 36/37, respectively) in both groups. Both drugs were well tolerated and the incidence of adverse events in each group was comparable. Cefepime 2 g per day (1 g bd) was as safe and effective as ceftazidime 3 g per day (1 g tds) in the treatment of community-acquired LRTIs.

Osteogenic progenitor cells in rat bone marrow stromal populations exhibit self-renewal in culture

Marrow stromal cells are a heterogeneous population, comprising a variety of lineages including osteogenic cells. In the presence of ascorbic acid, sodium beta-glycerophosphate, and dexamethasone, rat bone marrow stromal cells form discrete nodules of mineralized, bonelike tissue. We used nodule formation by rat bone marrow stromal cells to assay for the self-renewal capacity of osteogenic progenitor cell populations. Cultures were subcultured every 5 days up to six times. Osteogenesis was assayed from second to sixth subcultures by counting the number and measuring the areas of mineralized nodules formed in cultures grown with 10(-8) mol/L dexamethasone. Nodule number and area decreased progressively between second and sixth subcultures. Alkaline phosphatase activity associated with individual cells and measured videodensitometrically decreased exponentially between the second and sixth subculture. The number of cells with alkaline phosphatase activity also decreased with progressive subculturing. The proportions of 3H-thymidine-labeled cells after continuous labeling from the beginning of the culture period showed 90% labeling for cells with alkaline phosphatase activity and fibroblastlike cells. Cultures labeled for only the first 3 days exhibited higher labeling of alkaline phosphatase-positive cells than fibroblastlike cells (P less than .05). Cultures that were flash-labeled at the end of the culture period demonstrated low labeling indices for cells with alkaline phosphatase activity and up to 10-fold higher labeling indices for fibroblastlike cells. Separate cultures treated with a cytocidal dose of high specific activity 3H-thymidine did not form nodules. These results indicate that osteogenic progenitor cells or another cell type required for nodules to develop must divide early in culture if nodule formation is to occur, and that osteoprogenitor cells express a limited capacity for self-renewal.

Primary lymphoma of the thyroid: clinical features, prognostic factors, and results of treatment

This study analyzes the results of 46 cases of biopsy-proven primary lymphoma of the thyroid, localized at diagnosis and treated at the Royal Marsden Hospital between 1948-1980. In all cases, disease was limited to the thyroid and cervical lymph nodes. There were 43 females and 3 males, with a mean age of 64.4 years (median 66 years; range 17-86). A short history (less than 3 months) of a neck mass and local compressive symptoms was the typical presentation. The majority of patients (91%) had adverse histologies, with diffuse histiocytic lymphomas being most common (78%). The overall crude 5-year survival rate was 40%, with 30% of patients surviving beyond 10 years. Disease-free and overall survival were virtually identical, indicating the ineffectiveness of salvage therapy. The important prognostic factors were: size of tumor, fixation, extra-capsular extension, and retrosternal involvement. Survival was not correlated with age, sex, histology, thyroid status, or stage of disease, as defined by the Ann Arbor classification. Patients who had total macroscopic removal of tumor had the highest rate of local control and long survival (p less than 0.005). No significant difference was seen between lobectomy, subtotal or total thyroidectomy, but 7 of 9 long-term survivors (58-129 months) have had total thyroidectomy. A radiotherapy dose to the tumor, of at least 40 Gy, was required to produce consistent local control in patients with unresected disease. The majority of patients who died had generalized disease. Only 52% of these patients were free of local recurrence. In view of the frequency of occult disseminated disease, adjuvant chemotherapy is one recommendation for patients with poor prognostic factors. For optimal local control, complete surgical eradication is recommended followed by high-dose local radiotherapy. The use of aggressive cytoreductive chemotherapy prior to radiotherapy is a possible alternative option which needs to be explored.

An assessment of the value of epithelial membrane antigen and other epithelial markers in solving diagnostic problems in tumour histopathology

Using standard immunohistological techniques on formalin-fixed paraffin-embedded sections, we have evaluated the role of epithelial membrane antigen in the histopathological diagnosis of tumours. Of the 70 samples examined, 22 were taken for staging purposes from patients known to have carcinoma and, in half these cases, malignant cells were seen which could not be identified with confidence by conventional means. Forty-eight tumours were stained in order to determine their histogenesis. Twenty-two of these were positive and 20 subsequently proved to be epithelial on follow-up studies, including six in which a diagnosis of non-epithelial malignancy had been made on conventional preparations. The distinction of anaplastic carcinoma from malignant lymphoma and of spindle-cell carcinoma from sarcoma were the most useful applications. One of the positive tumours was of germ cell origin and in one the histogenesis is still not clear. Comparison with carcinoembryonic antigen and pre-keratin showed that epithelial membrane antigen was the most sensitive marker of epithelial differentiation in formalin-fixed tissue. A combination of all three reagents, though, increases diagnostic accuracy and allows tentative suggestions to be made about the possible site of origin of a metastatic carcinoma.

Primary carcinoma of the trachea

Two cases of primary carcinoma of the trachea are described. Both patients were female and had smoked cigarettes for many years. One of the tumours was a squamous cell carcinoma and the other an oat cell carcinoma, the commonest and the rarest forms of tracheal cancer respectively. The diagnosis in the case of oat cell carcinoma was confirmed by electron-microscopic demonstration of neurosecretory granules, a unique observation at this site. Oat cell carcinoma of the trachea does not appear to have been recorded previously in a female.