Prevalence and factors associated with gender incongruence in French healthcare professionals: results from a nationwide survey

OBJECTIVES

The objective of this study was to explore gender incongruence among French healthcare professionals and its associated factors.

STUDY DESIGN

Nationwide online cross-sectional survey.

METHODS

Healthcare professionals were recruited from May 2, 2021, to June 30, 2021, through social networks, professional networks, and email invitations. A multivariate regression model was used to analyze the association between gender incongruence and socio-demographic, professional, mental health, and addiction behavior factors.

RESULTS

The study included 10,325 healthcare professionals, indicating a prevalence of gender incongruence at 2.6% (95% confidence interval [CI]: 2.3-2.9%). In multivariate analyses, we found that healthcare professionals with gender incongruence, when compared to their counterparts, exhibited the following characteristics: they were more frequently male (adjusted odds ratio [aOR] = 1.88, 95% CI: [1.42-2.48], p < 0.001), less frequently physicians (aOR = 0.18, 95%CI: [0.11-0.29], p < 0.001), health executives (aOR = 0.51 [0.34-0.77], p = 0.001), nurses (aOR = 0.47, 95%CI: [0.33-0.68], p < 0.001), and other allied professionals (aOR = 0.33, 95%CI [0.23-0.49], p < 0.001) than nurse assistants, they consumed antidepressants more frequently (aOR = 1.52, 95%CI: [1.02-2.26], p = 0.041) and were more likely to be tobacco smokers (aOR = 1.34 (1.02-1.77), p = 0.035). We did not observe any significant associations with age, hazardous drinking, sustained bullying at the work place, or sexual-orientation-based discrimination (all p > 0.05).

CONCLUSIONS

Gender incongruence should be taken into account at the management, colleague, or institution levels. We found that the professionals reporting gender incongruence consumed more antidepressants and smoked more, which may indicate a certain level of distress that warrants further investigation.

PROTOCOL REGISTRATION

IRB n°C08/21.01.06.93911, CNIL. The protocol was published DOI: 10.1016/j.encep.2021.06.001.

TRIAL AND PROTOCOL REGISTRATION

The protocol was published DOI: 10.1016/j.encep.2021.06.001.

"Work with us… to make it more accessible". What women with intellectual disabilities want from infant-feeding health resources: an exploratory study

BACKGROUND

More women with intellectual disabilities are becoming mothers but fewer are known to breastfeed compared with other women. Women with intellectual disabilities are entitled to accessible antenatal and infant feeding information, yet are rarely asked for their views on available resources. This article reports on the final stage of a UK project exploring how women with intellectual disabilities are supported to make infant feeding decisions. The wider project includes a scoping review and interviews with healthcare professionals, here we focus on the voices of the women themselves.

METHODS

Four women with an intellectual disability participated in a focus group where they were asked to give their views on the accessibility of currently available infant feeding resources and on alternative representations of infant feeding. All were interested in women's health issues, including infant feeding. Photo-elicitation was used to gather views on videos, bespoke 'Easy Read' material and several alternative representations of infant feeding. A transcription of the discussion was thematically analysed whilst a critical visual analysis was undertaken of the women's preferred images/resources. The study took place in Bristol, UK, during 2022.

RESULTS

Two themes were identified from the group discussion: 'The desire for choice' and 'How easy is 'Easy Read'?' The desire for choice was expressed in terms through agreements and disagreements about preferred imagery, differing tastes, and reasons for these preferences. We identified a challenge to 'Easy Read' as a default standard and concerns that some forms of 'Easy Read' can confuse rather than inform. Critical visual analysis identified the importance of the story and social setting of the preferred infant feeding image.

CONCLUSIONS

Findings suggest a need for a suite of resources, avoiding the one-size-fits-all approach, including people with an intellectual disability at every stage of the design and production process. Resources should recognise and embrace differences in terms of understanding, visual literacy and cultural taste, as well as being freely available to support women with intellectual disabilities to make informed infant feeding decisions. An accessible film was co-produced, to disseminate the findings from all three stages of the completed project.

Ecological and evolutionary drivers of phenotypic and genetic variation in the European crabapple [Malus sylvestris (L.) Mill.], a wild relative of the cultivated apple

BACKGROUND AND AIMS

Studying the relationship between phenotypic and genetic variation in populations distributed across environmental gradients can help us to understand the ecological and evolutionary processes involved in population divergence. We investigated the patterns of genetic and phenotypic diversity in the European crabapple, Malus sylvestris, a wild relative of the cultivated apple (Malus domestica) that occurs naturally across Europe in areas subjected to different climatic conditions, to test for divergence among populations.

METHODS

Growth rates and traits related to carbon uptake in seedlings collected across Europe were measured in controlled conditions and associated with the genetic status of the seedlings, which was assessed using 13 microsatellite loci and the Bayesian clustering method. Isolation-by-distance, isolation-by-climate and isolation-by-adaptation patterns, which can explain genetic and phenotypic differentiation among M. sylvestris populations, were also tested.

KEY RESULTS

A total of 11.6 % of seedlings were introgressed by M. domestica, indicating that crop-wild gene flow is ongoing in Europe. The remaining seedlings (88.4 %) belonged to seven M. sylvestris populations. Significant phenotypic trait variation among M. sylvestris populations was observed. We did not observe significant isolation by adaptation; however, the significant association between genetic variation and the climate during the Last Glacial Maximum suggests that there has been local adaptation of M. sylvestris to past climates.

CONCLUSIONS

This study provides insight into the phenotypic and genetic differentiation among populations of a wild relative of the cultivated apple. This might help us to make better use of its diversity and provide options for mitigating the impact of climate change on the cultivated apple through breeding.

Supporting women with learning disabilities in infant feeding decisions: UK health care professionals' experiences

Women with learning disabilities are less likely to breastfeed than other women. They may find it hard to understand or learn feeding techniques or know that they have infant feeding choices. This population may be supported during their pregnancies by a range of professionals with differing priorities and responsibilities towards both the mother and the baby. This puts considerable pressure on health care professionals including, but not limited to, midwives, infant feeding specialists, health visitors and learning disability nurses. Those who support women with learning disabilities through their journey into motherhood have a responsibility to ensure the women in their care have the information they need to make decisions about a range of issues, including infant feeding. In the absence of dedicated lactation consultants, this is one of many issues to be discussed within time-limited appointments. Little is known about the experience of supporting women with learning disabilities to make infant feeding decisions from the point of view of health professionals. Using a qualitative descriptive research design, we conducted online, semistructured interviews with seven UK health professionals about their experience of supporting women with learning disabilities in infant feeding. Thematic analysis identified three themes: the importance of health professionals' having unconditional, positive regard; the need for an individualised approach to supporting women to make infant-feeding decisions; and being part of the support network. This suggests that women with learning disabilities can make and put into practice infant feeding decisions if they have access to the right support at the right time.

Coronal STIR MRI sequences in unexplained limping in children under 6 years old: A single-center retrospective study of 130 cases

INTRODUCTION

Limping is a common presenting symptom in young children. Clinical examination backed up by laboratory analysis, standard radiography, and/or ultrasound may fail to determine the diagnosis, and limping may prove persistent, requiring repeated consultation. Magnetic resonance imaging (MRI) can suggest the etiology or provide welcome reassurance when normal. We advocate the use of MRI in cases of persistent unexplained limping in young children. The study hypothesis was that coronal short TI inversion recovery (STIR) MRI has good negative predictive value (NPV) in unexplained limping in children under 6 years of age.

MATERIAL AND METHOD

Coronal STIR MRI sequences were analyzed in 130 children younger than 6 years (84 boys, 46 girls) during the period April 2007 to May 2017. They extended from the lower thoracic spine down to the feet. Agreement was analyzed between the radiologist's initially suggested diagnosis and the pediatric orthopedic specialist's final diagnosis.

RESULTS

Overall, 49 scans were normal (37.7%) and 81 abnormal (62.3%). The mean age at MRI was 32.3 months. Coronal STIR MRI had 98% NPV. There was 99.2% agreement between the radiologist's diagnosis and the final diagnosis.

DISCUSSION

The recently reported contribution of STIR MRI in bone and joint infections was extended to unexplained limping.

CONCLUSION

First-line MRI with coronal STIR sequences improved the diagnostic efficacy, thanks to its speed and relative lack of movement artifacts.

Supporting women with learning disabilities in infant feeding decisions: A scoping review

Mothers with learning disabilities face many challenges during the perinatal period including preparing for and establishing infant feeding. Evidence shows that women with learning disabilities are less likely to breastfeed than other mothers. A scoping review was undertaken using Arksey and O'Malley's methodology to understand what is known about how women with learning disabilities can be supported to make infant feeding decisions, particularly in relation to the use of appropriate and accessible images. An additional aim was to understand what further research is needed to achieve sustainable improvements to policy and practice in this area. A comprehensive search of fourteen electronic databases was undertaken to look for both published and grey literature. Initial searches, after removal of duplicates, resulted in 467 primary research articles plus 22 items of grey literature. Following a systematic process, three published papers and six items of grey literature were identified which met inclusion and exclusion criteria, five of which were resources. Little is known about the acceptability of existing resources, specifically in relation to the use of visual images. A synthesis of the grey literature and a thematic analysis of published literature was conducted and confirmed that women with learning disabilities need tailored support with infant feeding, including accessible resources and that there is a need for more in‐depth research in this area. There is a high level of agreement about the importance of using easily read visual images within these resources, but little evaluation of the types of imagery used or their aesthetic histories.

Women with learning disabilities need tailored support with infant feeding, including accessible resources.

Little is known about the acceptability of existing resources on infant feeding to women with learning disabilities, specifically in relation to the use of visual images.

We found a small number of existing resources, which are similar in approach but not always easy to access.

The different disciplinary backgrounds of the researchers enabled us to consider the needs of mothers with learning disabilities alongside the history of visual representations of learning disability.

974 Paget-Schroetter Syndrome in A Young Fitness Enthusiast with A Negative D-Dimer. Highlighting the Balance Between Clinical Suspicion and Diagnostic Modalities

This case illustrates an athletic 22-year-old, who presented to the hospital with a 3-week history of spontaneous right arm ache, discolouration and swelling. His blood tests were normal, with a negative D-dimer (&lt;150ng/ml). He underwent a CT venogram for suspicion of venous obstruction which was unremarkable. However due to a high clinical suspicion, an ultrasound doppler was performed. This identified the presence of axillary-subclavian thrombosis which in conjunction with other clinical and radiological parameters confirmed the diagnosis of Paget-Schroetter Syndrome (PSS). Our patient was commenced on anticoagulation as the venous obstruction was suspected to be sub-acute with clinical suggestion of collateral formation. Unfortunately, his symptoms failed to resolve over a 6-month period, and he underwent an elective right rib resection with right subclavian bypass using the great saphenous vein with good outcome post-operatively.

PSS is a rare manifestation of venous thoracic outlet syndrome (TOS) commonly seen in young, healthy, athletic individuals. Despite the high effectiveness of D-Dimers in ruling out acute thrombotic process and the accuracy of dedicated CT angiography in excluding vascular thrombotic events, both tests proved inconclusive in this particular case. This latter observation highlights the importance of the clinical context, and risk profiling in guiding results interpretation.

Inducing a long-term potentiation in the dentate gyrus is sufficient to produce rapid antidepressant-like effects

Recent hypotheses propose that one prerequisite to obtain a rapid antidepressant (AD) effect would reside in processes of synaptic reinforcement occurring within the dentate gyrus (DG) of the hippocampus independently from neurogenesis. However, to date no relationship has been established between an increased DG synaptic plasticity, and rapid AD-like action. To the best of our knowledge, this study shows for the first time that inducing a long-term potentiation (LTP) within the DG by stimulating the perforant pathway (PP) is sufficient to induce such effects. Thus, Sprague-Dawley rats having undergone a successful LTP displayed a significant reduction of immobility when passed acutely 3 days thereafter in the forced swimming test (FST). Further, in a longitudinal paradigm using the pseudo-depressed Wistar-Kyoto rat strain, LTP elicited a decrease of FST immobility after only 2 days, whereas the AD desipramine was not effective before 16 days. In both models, the influence of LTP was transient, as it was no more observed after 8-9 days. No effects were observed on the locomotor activity or on anxiety-related behavior. Theta-burst stimulation of a brain region anatomically adjacent to the PP remained ineffective in the FST. Immunoreactivity of DG cells for phosphorylated histone H3 and doublecortin were not modified three days after LTP, indicating a lack of effect on both cell proliferation and neurogenesis. Finally, depleting brain serotonin contents reduced the success rate of LTP but did not affect its subsequent AD-like effects. These results confirm the 'plastic DG' theory of rapid AD efficacy. Beyond, they point out stimulations of the entorhinal cortex, from which the PP originates, as putative new approaches in AD research.

ACL reconstruction in 11 children using the Clocheville surgical technique: Objective and subjective evaluation

INTRODUCTION

The over-the-top position of the femoral metaphyseal tunnel during extraphyseal ligament reconstruction of the anterior cruciate ligament (ACL) according to Clocheville may be responsible for negative anisometry. Until now, the follow-up of children operated using this pediatric technique was limited to screening for iatrogenic epiphysiodesis and the search for postoperative clinical instability. The objective of this study was to measure residual laxity using objective tests, to quantify muscle recovery, and to evaluate the quality of life of these patients in terms of the sports activities.

MATERIAL AND METHODS

Eleven patients with a mean age of 13.5years were seen at a mean 2.1years of follow-up. They underwent objective clinical tests (GNRB(®) arthrometer and CON-TREX(®) dynamometer) as well as subjective questionnaires (IKDC and KOOS).

RESULTS

No significant difference was found between the healthy knee and the operated knee for either the GNRB(®) at 134N (P=0.79) or at 200N (P=0.98). The CON-TREX(®) system allowed us to measure a median percentage of quadriceps recovery of 80.7% (range, 52.2-114.5) in terms of muscle power (60°/s) and 81.2% (range, 51.6-109.6) for muscle response (180°/s). The median subjective IKDC score was 94.73/100 (range, 73.68-98.93); 72.7% of the patients resumed competitive sports.

DISCUSSION

This study's lack of statistical power did not show a significant difference in terms of residual laxity at rest of GNRB(®) transplants, while a mean differential of +0.4mm was observed. Although pediatric transphyseal ligament reconstruction techniques are increasingly used, the Clocheville technique remains, in our opinion, an attractive surgical alternative in the youngest subjects, with no major risk of iatrogenic epiphysiodesis even though it is theoretically anisometric.

LEVEL OF EVIDENCE

IV.

Clinical experience with a highly purified factor IX concentrate in patients undergoing surgical operations

The haemostatic efficacy of a new highly purified factor IX concentrate, prepared by metal chelate affinity chromatography, was assessed in 13 patients with haemophilia B undergoing a variety of surgical operations. Four of the patients had developed post-operative thromboembolic complications following previous operations, when treated with a prothrombin complex concentrate. None of the patients in the present series developed any evidence of post-operative thrombotic complications. Effective haemostasis was achieved in all patients, with the exception of a surgical bleed in one case, and late post-operative bleeding in a second patient when the factor IX activity fell below 20iu/dl. The product is treated with a solvent-detergent process that destroys lipid-enveloped viruses, while the affinity chromatography process during manufacture removes in excess of 4 log10 of a non-lipid-enveloped virus. In follow-up studies, none of the patients has shown evidence of fresh infection from the concentrate, when assessed by virological markers. It is concluded that this high-purity concentrate (tradenane 'Replenine') is effective for the treatment of patients with haemophilia B who undergo surgical operations.

L5S1 spondylolisthesis in children and adolescents

The precise etiology of childhood and adolescent spondylolisthesis (SPL) remains undetermined, but would seem to be multifactorial, deriving from anthropological adaptations of spinal sagittal balance combined with microtraumatic, genetic and dysplastic factors. Description of sagittal parameters not only lends weight to etiopathogenetic hypotheses, but also seeks to improve the classification of severity so as to optimize treatment according to clinical and radiological presentation. Thus, surgery should not only stabilize the lumbosacral junction by solid fusion but also correct pelvic abnormalities so as to restore overall sagittal balance in the long-term, without requiring spinal, pelvic or sub-pelvic compensation and with the lowest possible energy cost. Methods are still under debate; surgical technique, whether instrumental or not and whether aiming at in situ fusion or to correct lumbosacral deformity, all incur neurological risk of which child and family should be informed. Only long-term follow-up of functional results on quality-of-life scales, combined with radiological results for surgery aiming at lumbosacral angle correction, will be able to demonstrate superiority over in situ fusion surgery.

[Peroneal nerve palsy in children: Uncommon diagnosis of a proximal tibiofibular synovial cyst]

Compression of the common peroneal nerve by synovial cysts of the tibiofibular joint is a rare disease. Two macroscopic forms may be encountered: extraneural cysts and intraneural cysts. In a review of the literature, we found only three pediatric cases of common peroneal nerve palsy due to extraneural cysts and about 60 cases reported in adults. Taking advantage of the clinical history of two children operated in our department for this disease, we describe this uncommon entity, which must be diagnosed and treated rapidly. Even in the presence of severe clinical and electrophysiological symptoms, a full clinical recovery is possible, as observed in these two children. However, follow-up is needed because recurrence is possible.

Effective interprofessional simulation training for medical and midwifery students

Introduction

Good interprofessional teamworking is essential for high quality, efficient and safe clinical care. Undergraduate interprofessional training has been advocated for many years to improve interprofessional working. However, few successful initiatives have been reported and even fewer have formally assessed their educational impact.

Methods

This was a prospective observational study of medical and midwifery students at a tertiary-level maternity unit. An interprofessional training module was developed and delivered by a multiprofessional faculty to medical and midwifery students, including short lectures, team-building exercises and practical simulation-based training for one obstetric (shoulder dystocia) and three generic emergencies (sepsis, haemorrhage, collapse). Outcome measures were interprofessional attitudes, assessed with a validated questionnaire (UWE Interprofessional Questionnaire) and clinical knowledge, measured with validated multiple-choice questions.

Results

Seventy-two students participated (34 medical, 38 midwifery). Following training median interprofessional attitude scores improved in all domains (p<0.0001), and more students responded in positive categories for communication and teamwork (69-89%, p=0.004), interprofessional interaction (3-16%, p=0.012) and interprofessional relationships (74-89%, p=0.006). Scores for knowledge improved following training for medical students (65.5% (61.8-70%) to 82.3% (79.1-84.5%) (median (IQR)) p<0.0001) and student midwives (70% (64.1-76.4%) to 81.8% (79.1-86.4%) p<0.0001), and in all subject areas (p<0.0001).

Conclusions

This training was associated with meaningful improvements in students' attitudes to teamwork, and knowledge acquisition. Integrating practical tasks and teamwork training, in authentic clinical settings, with matched numbers of medical and non-medical students can facilitate learning of both why and how to work together. This type of training could be adopted widely in undergraduate healthcare education.

Astroglial Control of the Antidepressant-Like Effects of Prefrontal Cortex Deep Brain Stimulation

Although deep brain stimulation (DBS) shows promising efficacy as a therapy for intractable depression, the neurobiological bases underlying its therapeutic action remain largely unknown. The present study was aimed at characterizing the effects of infralimbic prefrontal cortex (IL-PFC) DBS on several pre-clinical markers of the antidepressant-like response and at investigating putative non-neuronal mechanism underlying DBS action. We found that DBS induced an antidepressant-like response that was prevented by IL-PFC neuronal lesion and by adenosine A₁ receptor antagonists including caffeine. Moreover, high frequency DBS induced a rapid increase of hippocampal mitosis and reversed the effects of stress on hippocampal synaptic metaplasticity. In addition, DBS increased spontaneous IL-PFC low-frequency oscillations and both raphe 5-HT firing activity and synaptogenesis. Unambiguously, a local glial lesion counteracted all these neurobiological effects of DBS. Further in vivo electrophysiological results revealed that this astrocytic modulation of DBS involved adenosine A₁ receptors and K⁺ buffering system. Finally, a glial lesion within the site of stimulation failed to counteract the beneficial effects of low frequency (30 Hz) DBS. It is proposed that an unaltered neuronal–glial system constitutes a major prerequisite to optimize antidepressant DBS efficacy. It is also suggested that decreasing frequency could heighten antidepressant response of partial responders.

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The antidepressant effect of prefrontal cortex DBS was prevented by neuronal lesion and adenosine A₁ receptor antagonists.

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DBS rapidly increased hippocampal mitosis, cortical oscillations, raphe 5-HT firing activity and synaptogenesis.

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Local glial lesions prevented the neurobiological effects of DBS in a frequency-dependent manner.

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Although deep brain stimulation (DBS) is a promising therapy for patients with treatment-resistant depression, the neurobiological bases underlying its therapeutic action remain largely unknown. Here, we demonstrated that DBS produced a robust antidepressant-like effect that was associated with a fast induction of markers of the antidepressant-like response. Unambiguously, the effects of high-frequency, but not low-frequency, DBS were counteracted by a glial lesion within the site of stimulation. Thus, it is proposed that an unaltered neuronal–glial system constitutes a major prerequisite to optimize antidepressant DBS efficacy. It is also suggested that decreasing frequency of DBS could heighten antidepressant response of partial responders.

Minimally invasive harvesting of nonvascularized fibular graft in children

Using a nonvascularized fibular graft is part of the therapeutic arsenal for filling bone loss defects. It is conventionally performed by open surgery. The authors propose a minimally invasive technique for harvesting a free fibular graft. The fibula was removed subperiosteally by two or three small incisions in five patients with a mean age of nine years and nine months. The mean surgical time was 21 min and 40.5% of the length of the fibula was harvested. At the donor site, we found no removal-related complications, regeneration of the fibula was observed in 80% of cases, and the cosmetic result was considered excellent by all patients with a mean 4.3 years follow-up. This minimally invasive technique is simple and fast, with very low morbidity in our experience.

Monopolar-probe monitoring during spinal surgery with expandable prosthetic ribs

BACKGROUND

Intraoperative monitoring (IOM) has been proven to decrease the risk of neurological injury during scoliosis surgery. The vertical expandable prosthetic titanium rib (VEPTR) is a device that allows spinal growth. However, injuries to the spinal cord and brachial plexus have been reported after VEPTR implantation in 2 and 5% of patients, respectively. Simultaneous monitoring of these two structures requires the use of multiple time-consuming and complex methods that are ill-suited to the requirements of paediatric surgery, particularly when repeated VEPTR lengthening procedures are needed. We developed a monopolar stimulation method derived from Owen's monitoring technique. This method is easy to implement, requires only widely available equipment, and allows concomitant monitoring of the spinal cord and brachial plexus. The primary objective of this study was to assess the reliability of our technique for brachial plexus monitoring by comparing the stability of neurogenic mixed evoked potentials (NMEPs) at the upper and lower limbs.

HYPOTHESIS

We hypothesised that the coefficients of variation (CVs) of NMEPs were the same at the upper and lower limbs.

MATERIAL AND METHODS

Twelve VEPTR procedures performed in 6 patients between 1st January 2012 and 1st September 2014 were monitored using a monopolar stimulating probe. NMEPs were recorded simultaneously at the upper and lower limbs, at intervals of 150 s. The recording sites were the elbow over the ulnar nerve and the popliteal fossa near the sciatic nerve. Wilcoxon's test for paired data was used to compare CVs of the upper and lower limb NMEPs on the same side.

RESULTS

Mean CV of NMEP amplitude at the lower limbs was 16.34% on the right and 16.67% on the left; corresponding values for the upper limbs were 18.30 and 19.75%, respectively. Mean CVs of NMEP latencies at the lower limbs were 1.31% on the right and 1.19% on the left; corresponding values for the upper limbs were 1.96 and 1.73%. The risk of type I error for a significant difference between the upper and lower limbs was 0.5843 on the right and 0.7312 on the left for NMEP amplitudes and 0.7618 on the right and 0.4987 on the left for NMEP latencies.

CONCLUSION

Using an epidural active electrode and a sternal return electrode allows simultaneous stimulation of the cervical spinal cord and brachial plexus roots. The NMEPs thus obtained are as stable (reliable) at the upper limbs as at the lower limbs. This easy-to-implement method allows simultaneous monitoring of the upper and lower limbs. It seems well suited to VEPTR procedures.

LEVEL OF EVIDENCE

IV, retrospective single-centre non-randomised study.

Isolated meniscal injuries in paediatric patients: outcomes after arthroscopic repair

BACKGROUND

The management of isolated meniscal tears in paediatric patients is poorly standardised, and few published data are available. Nevertheless, there is widespread agreement that meniscectomy, even when partial, produces poor outcomes including the premature development of osteoarthritis.

HYPOTHESIS

Arthroscopic repair of isolated meniscal tears in paediatric patients yields good outcomes and should be attempted routinely.

MATERIALS AND METHODS

We retrospectively assessed 19 arthroscopic repair procedures performed between 2006 and 2010 by a single surgeon in 17 patients with a mean age of 14 years. In every case, the knee was stable and the meniscus normal before the meniscal tear, which was the only injury. Mean follow-up was 22 months. In all 19 cases, the evaluation included a physical examination, pre-operative magnetic resonance imaging (MRI), and determination of the Tegner and Lysholm scores. Post-operative MRI was performed in 10 cases.

RESULTS

The outcome was good in 12/17 (70%) patients with significant improvements in the mean Tegner score, from 3.9 to 7.1, and mean Lysholm score, from 55.9 to 85.4, between the pre-operative and post-operative assessments. The clinical outcomes were not significantly associated with time to arthroscopic repair, gender, lesion site, or lesion type. Neither was any correlation demonstrated between clinical outcomes and meniscal healing as assessed by MRI.

DISCUSSION

The known poor outcomes after meniscectomy in paediatric patients, the results of our study, and previously published data support routine arthroscopic repair of isolated meniscal tears in this age group, regardless of the site and type of injury. In addition, in asymptomatic patients, clinical follow-up is sufficient and post-operative MRI unnecessary.

LEVEL OF EVIDENCE

Level IV. Retrospective study.

Current Products and Practices

Personal Digital Assistants (PDAs) have certain advantages over conventional diaries and are thought of as the 'electronic filofax'. They can be backed up, used for personal and professional organization, integrated with mobile phones for email and Internet access, image storage, logbook functions and audit. They are limited when used for desktop functions. This article attempts to highlight the current advantages and disadvantages of PDAs for use in orthodontics, and provides some guidance to those who are considering the purchase of such a device.

Measurement and control systems for an imaging electromagnetic flow metre

Electromagnetic flow metres based on the principles of Faraday's laws of induction have been used successfully in many industries. The conventional electromagnetic flow metre can measure the mean liquid velocity in axisymmetric single phase flows. However, in order to achieve velocity profile measurements in single phase flows with non-uniform velocity profiles, a novel imaging electromagnetic flow metre (IEF) has been developed which is described in this paper. The novel electromagnetic flow metre which is based on the 'weight value' theory to reconstruct velocity profiles is interfaced with a 'Microrobotics VM1' microcontroller as a stand-alone unit. The work undertaken in the paper demonstrates that an imaging electromagnetic flow metre for liquid velocity profile measurement is an instrument that is highly suited for control via a microcontroller.

External quality assessment of human neutrophil antigen (HNA)-specific antibody detection and HNA genotyping from 2000 to 2012

Since 2000, Quality Assurance (QA) exercises for the detection and identification of granulocyte antibodies and DNA typing for human neutrophil antigens (HNA) have been distributed within the International Granulocyte Immunobiology Workshops, which are linked to International Society of Blood Transfusion. The exercises were standardised at the outset to enable laboratory performance to be monitored. Between 2000 and 2012, nine exercises were distributed to 20 laboratories. Overall, 45 examples of 42 unique samples containing defined granulocyte reactive antibodies were distributed for serological analysis together with 20 samples for HNA genotyping. The level of satisfactory serological performance was initially set at 50% and later increased to 70%, while the 'cut-off' for HNA genotyping was set at 100% after 2008. Failure to achieve the minimum score in the QA exercises in consecutive years resulted in temporary exclusion. In 2000, the 15 participating laboratories had a mean score of 56.1% for serological analysis and 13 laboratories attempted HNA-1a and -1b genotyping, while 11 attempted HNA-1c typing. Steady improvements in proficiency for serological testing and HNA typing occurred in subsequent exercises. In 2012, the mean score for serology was 88.5% and 12/13 laboratories scored 100% for HNA-1a, -1b, -1c, -3a, -3b, -4a, -4bw, -5a and -5bw genotyping. These QA exercises have provided an invaluable tool to monitor and improve the standard of granulocyte immunology investigations for participating laboratories, thereby enhancing performance for both clinical investigations and donor screening programmes to reduce the incidence of TRALI.

Determination of human neutrophil antigen-1, -3, -4 and -5 allele frequencies in English Caucasoid blood donors using a multiplex fluorescent DNA-based assay

BACKGROUND AND OBJECTIVES

A number of DNA-based methods to genotype the alleles coding for HNA have been described, but all require the separate amplification and analysis of each allele. The aim was to develop a DNA-based method for simultaneous detection of HNA-1, HNA-3, HNA-4 and HNA-5 alleles.

MATERIALS AND METHODS

An allele-specific primer extension method was used in combination with magnetic beads from Luminex technology. PCR-sequence-specific primers (SSP) was used to resolve the presence of the HNA-1b allele in samples assigned by the Luminex bead assay as HNA-1a/-1b/-1c or HNA-1b/-1c. HNA allele frequencies were determined in a panel of 140 randomly selected English Caucasoid blood donors.

RESULTS

HNA allelic types were compared with historical results, and 100% concordance was found. Only eight of the 97 samples used in the validation required additional testing by PCR-SSP. Allele frequencies were determined in the blood donor population as follows: 0·318 for HNA-1a, 0·668 for HNA-1b, 0·014 for HNA-1c, 0·768 for HNA-3a, 0·232 for HNA-3b, 0·882 for HNA-4a, 0·118 for HNA-4b, 0·736 for HNA-5a and 0·264 for HNA-5b.

CONCLUSION

A multiplex Luminex bead assay for the simultaneous detection of HNA-1, HNA-3, HNA-4 and HNA-5 alleles is described that enables rapid typing of donors to support HNA alloimmunized patients who require HNA-compatible blood products.

An International reference reagent for the detection of anti-human neutrophil antigen-1a

BACKGROUND AND OBJECTIVES

Testing for neutrophil antibodies has become more common as awareness of transfusion-related acute lung injury (TRALI) has increased. However, unlike other areas of blood cell antibody testing, there are no certified reference reagents available with which laboratories can determine the sensitivity of detection of their assays. This report describes the production and evaluation of a freeze-dried preparation of human plasma, code 09/284, containing anti-human neutrophil antigen-1a (anti-HNA-1a) for use as a minimum sensitivity reagent.

MATERIALS AND METHODS

One-millilitre of aliquots of plasma containing anti-HNA-1a were freeze-dried in glass ampoules. To characterize the material, 24 laboratories took part in an international collaborative study. The participants evaluated doubling dilutions of the material using their in-house routine assays and recorded the highest dilution in which the antibody could be detected.

RESULTS

When diluted 1 in 4, most laboratories were able to detect the anti-HNA-1a in the material, and the participants agreed that this was an appropriate level to set as the minimum sensitivity required.

CONCLUSIONS

In October 2011, the WHO Expert Committee on Biological Standardization approved the material 09/284 as an International Reference Reagent for the detection of anti-HNA-1a.

An environment-dependent interatomic potential for silicon carbide: calculation of bulk properties, high-pressure phases, point and extended defects, and amorphous structures

An interatomic potential has been developed to describe interactions in silicon, carbon and silicon carbide, based on the environment-dependent interatomic potential (EDIP) (Bazant et al 1997 Phys. Rev. B 56 8542). The functional form of the original EDIP has been generalized and two sets of parameters have been proposed. Tests with these two potentials have been performed for many properties of SiC, including bulk properties, high-pressure phases, point and extended defects, and amorphous structures. One parameter set allows us to keep the original EDIP formulation for silicon, and is shown to be well suited for modelling irradiation-induced effects in silicon carbide, with a very good description of point defects and of the disordered phase. The other set, including a new parametrization for silicon, has been shown to be efficient for modelling point and extended defects, as well as high-pressure phases.

Recommendations of the ISBT Working Party on Granulocyte Immunobiology for leucocyte antibody screening in the investigation and prevention of antibody-mediated transfusion-related acute lung injury

BACKGROUND

Transfusion-related acute lung injury (TRALI) is currently one of the most common causes of transfusion-related major morbidity and death. Among the many TRALI mediators, leucocyte antibodies have been identified as important triggers of severe TRALI.

STUDY DESIGN AND METHODS

These recommendations were compiled by experts of the ISBT Working Party on Granulocyte Immunobiology, based on the results obtained in eight international granulocyte immunology workshops, their personal experiences and on published study results.

RESULTS

Leucocyte antibody screening has to include the detection of human leucocyte antigen (HLA) class I, class II and human neutrophil alloantigen antibodies using established and validated techniques. HLA class I antibody detection should be restricted to antibodies clinically relevant for TRALI. To avoid unnecessary workload, TRALI diagnosis should be assessed by consultation with the reporting clinician and thorough exclusion of transfusion-associated circulatory overload/cardiac insufficiency. In patients diagnosed with TRALI having donors with detectable leucocyte antibodies, evidence of leucocyte incompatibility should be provided by either cross-matching or typing of patient for cognate antigen.

CONCLUSION

Leucocyte antibody screening for the immunological clarification of TRALI cases as well as for identification of potentially alloimmunized blood donors is feasible and can be performed in a reasonable and quality assured manner. This practice can contribute to the prevention of antibody-mediated TRALI.

A modified rapid monoclonal antibody-specific immobilization of platelet antigen assay for the detection of human platelet antigen (HPA) antibodies: a multicentre evaluation

BACKGROUND

The monoclonal antibody-specific immobilization of platelet antigens (MAIPA) assay is the cornerstone technique for the detection and identification of human platelet antigen (HPA) antibodies. However, the original technique described by Kiefel and colleagues requires approximately 8 h adding to diagnostic delay. Moreover, proficiency exercises indicate that there are substantial variations in the MAIPA protocol, and that these may account for interlaboratory differences in sensitivity and specificity.

STUDY DESIGN AND METHODS

A review of current MAIPA assay protocols from six laboratories together with performance in quality-assessment schemes identified several key variables potentially affecting the assay results. An optimized protocol was derived and assay time reduced to 5 h. The modified rapid MAIPA (MR-MAIPA) assay was evaluated using 61 samples with a range of HPA antibodies typically encountered in cases of fetomaternal alloimmune thrombocytopenia (n = 22), post-transfusion purpura (n = 8), platelet refractoriness (n = 7) and other platelet immune conditions (n = 24). The sensitivity of the assay was assessed using three international standards and the recombinant HPA-1a antibody CamTran007. The results obtained were compared with the original findings obtained with the local MAIPA assays. In addition, four different glycoprotein IIb/IIIa capture monoclonal antibodies were evaluated for their effect on assay sensitivity.

RESULTS

Complete concordance was found between the original MAIPA results and those obtained with the new assay when testing a selected panel of clinical samples. The modified assay had nanogram level sensitivity for the detection of HPA-1a antibodies and titration of HPA-1a and HPA-5b antibody sensitivity standards yielded end-points equal to or greater than the mean recorded in international workshops.

CONCLUSION

The MR-MAIPA assay offers improved turnaround for the detection of HPA antibodies without loss of sensitivity.

Early immunologic and virologic responses to highly active antiretroviral therapy and subsequent disease progression among HIV-infected injection drug users

We examined the prevalence and prognostic value of early responses to highly active antiretroviral therapy (HAART) among community-based injection drug users (IDUs) in Baltimore. Virologic (HIV RNA <1000 copies/ml) and immunologic (CD4 >500 cells/ul or increase of 50 cells/ul from the pre-HAART level) responses were examined in the 1st year of HAART initiation. Cox regression was used to examine the effect of early response on progression to new AIDS diagnosis or AIDS-related death. Among 258 HAART initiators, 75(29%) had no response, 53(21%) had a virologic response only, 38(15%) had an immunologic response only and 92(36%) had a combined immunologic and virologic response in the first year of therapy. Poorer responses were observed in those who were older, had been recently incarcerated, reported injecting drugs, had not had a recent outpatient visit and had some treatment interruption within the 1st year of HAART. In multiple Cox regression analysis, the risk of progression was lower in those with combined virologic and immunologic response than in non-responders, (relative hazard [RH], 0.32; 95% confidence interval [CI], 0.17-0.60). Those with discordant responses had reduced risk of progression compared to non-responders but experienced faster progression than those with a combined response, although none of these differences was statistically significant. Early discordant and non response to HAART was common, often occurred in the setting of injection drug use and treatment interruption and was associated with poorer survival. Interventions to reduce treatment interruptions and to provide continuity of HIV care during incarceration among IDUs are needed to improve responses and subsequent survival.

Lack of clinical efficacy of rituximab in the treatment of autoimmune neutropenia and pure red cell aplasia: implications for their pathophysiology

We describe 11 patients with severe refractory autoimmune cytopenias treated with the anti-CD20 monoclonal antibody rituximab. Six patients had autoimmune neutropenia (AIN), two had pure red cell aplasia (PRCA), one had AIN and autoimmune haemolytic anaemia, one had AIN and immune thrombocytopaenia purpura (ITP) and one had PRCA and ITP. Rituximab was administered at a dose of 375 mg/m(2) as an intravenous infusion weekly for 4 weeks. Six of eight patients with AIN and all three patients with PRCA did not respond. Two patients died: one with resistant AIN and autoimmune haemolytic anaemia died of pneumocytis pneumonia infection, and one with PRCA and ITP died of an acute exacerbation of bronchiectasis. Rituximab in AIN and PRCA appears to be less effective than Campath-1H when compared to historical data from our group. This supports the hypothesis that T cells may be important in the pathophysiology of AIN and PRCA.

Granulocyte transfusions for treating infections in patients with neutropenia or neutrophil dysfunction

BACKGROUND

Transfusions of granulocytes have a long history of usage in clinical practice to support and treat severe infection in high risk groups of patients with neutropenia or neutrophil dysfunction. However, there is considerable current variability in therapeutic granulocyte transfusion practice, and uncertainty about the beneficial effect of transfusions given as an adjunct to antibiotics on mortality.

OBJECTIVES

To determine the effectiveness of granulocyte transfusions compared to no granulocyte transfusions for treating infections in patients with neutropenia or disorders of neutrophil function in reducing mortality.

SEARCH STRATEGY

Randomised controlled trials (RCTs) were searched for in the Cochrane Central Register of Controlled Trials (CENTRAL) in 2003. Searching was also undertaken on the OVID versions of Medline and Embase using an RCT search filter strategy.

SELECTION CRITERIA

RCTs involving transfusions of granulocytes, given therapeutically, to patients with neutropenia or disorders of neutrophil dysfunction.

DATA COLLECTION AND ANALYSIS

Two reviewers completed data extraction independently. Relative risk (RR) with 95% confidence intervals (CI) using the random effects model were reported for dichotomous outcomes. Pre-specified subgroup analyses were done and reported eg granulocyte dose.

MAIN RESULTS

Eight parallel RCTs were included with 310 total analysed patient episodes. Different policies were applied for the schedule of transfusion, method of granulocyte procurement and process of donor selection including leucocyte compatibility. Each study used different criteria for neutropenia (range < 0.1 to < 1.0 x 10(9)/L) and definition of infection requiring treatment. For mortality, which was extracted from six trials, the summary RR = 0.64 in favour of transfusion (95% CI 0.33, 1.26), but with evidence of significant statistical heterogeneity (Chi-square 11.3 and I(2) = 56%). The data for the combined RR for mortality for the four studies transfusing higher granulocyte doses greater than 1x10(10) indicated a significant summary RR= 0.37 (95% CI 0.17, 0.82); Chi-square 3.9, I(2) 23%. Data on rates of reversal of infection could be extracted from four studies, and the combined RR was 0.94 (95% CI 0.71, 1.26), again with evidence of heterogeneity. In addition to the observed clinical diversity between all studies, uncertainty about the quantitative and qualitative analyses for these studies is compounded by methodological deficiencies.

AUTHORS' CONCLUSIONS

Currently, there is inconclusive evidence from RCTs to support or refute the generalised use of granulocyte transfusion therapy in the most common neutropenic patient populations, that is caused by myeloablative chemotherapy with or without haematopoietic stem cell support. Contemporary well designed prospective trials are required to evaluate the efficacy of this intervention in these patient populations and to establish definitively whether it has clinical benefit. In such studies, average numbers of collected granulocytes for adults should be (at least) greater than 1x10(10).

Low-fat high-fiber diet decreased serum and urine androgens in men

To validate our hypothesis that reduction in dietary fat may result in changes in androgen metabolism, 39 middle-aged, white, healthy men (50-60 yr of age) were studied while they were consuming their usual high-fat, low-fiber diet and after 8 wk modulation to an isocaloric low-fat, high-fiber diet. Mean body weight decreased by 1 kg, whereas total caloric intake, energy expenditure, and activity index were not changed. After diet modulation, mean serum testosterone (T) concentration fell (P < 0.0001), accompanied by small but significant decreases in serum free T (P = 0.0045), 5 alpha-dihydrotestosterone (P = 0.0053), and adrenal androgens (androstendione, P = 0.0135; dehydroepiandrosterone sulfate, P = 0.0011). Serum estradiol and SHBG showed smaller decreases. Parallel decreases in urinary excretion of some testicular and adrenal androgens were demonstrated. Metabolic clearance rates of T were not changed, and production rates for T showed a downward trend while on low-fat diet modulation. We conclude that reduction in dietary fat intake (and increase in fiber) results in 12% consistent lowering of circulating androgen levels without changing the clearance.

Testosterone metabolic clearance and production rates determined by stable isotope dilution/tandem mass spectrometry in normal men: influence of ethnicity and age

The metabolic clearance rate (MCRT) and production rate (PRT) of testosterone (T) were measured using constant infusion of trideuterated (d3) T and quantitating serum d3T by liquid chromatography-tandem mass spectrometry (LC-MS-MS). Serum unlabeled T (d0T) was measured by LC-MS-MS, and serum total T (d3T + d0T) was measured by RIA. Mean MCRR (measured by LC-MS-MS) in young white men (1272 +/- 168 liters/d) was not significantly different from young Asian men (1070 +/- 166 liters/d). Mean PRT was also not significantly different between the two ethnic groups (whites, 9.11 +/- 1.11 mg/d; Asians, 7.22 +/- 1.15 mg/d; P = 0.19 using d0T data). Both the mean MCRR (812 +/- 64 liters/d; P < 0.01) and the PRT (3.88 +/- 0.27 mg/d; P < 0.001) were significantly lower in middle-aged white men when compared with their younger counterparts. The mean MCRR and PRR calculated using serum total T or d0T data showed a diurnal variation, with levels at midday significantly higher than those measured in the evening in the young (MCRT, P < 0.01; PRT, P < 0.001) and to a lesser extent in the older men (MCRT, P < 0.05; PRT, P < 0.05 using total T and P < 0.001 using d0T data). We conclude that using LC-MS-MS to detect d3T in serum after constant infusion of stable isotope-labeled T allows the measurements of MCRT and PRT, which can be used to study androgen metabolism repeatedly after physiological or pharmacological interventions.