POS0999 HIGHER CARDIOVASCULAR MORBIDITY SEEN IN MEN WITH LONGER DELAY TO THE DIAGNOSIS OF AXIAL SPONDYLOARTHRITIS

Background

Diagnostic delay in axial spondyloarthritis (axSpA) is a well-defined feature of the disease, despite increased awareness. Morbidity and mortality are higher in axSpA than the general population1. Much of this excess burden is due to increased comorbidity. However, the association between delayed diagnosis and increased comorbidity in this population is unknown.

Objectives

(1)Examine the relationship between delayed diagnosis and comorbidity in a large cohort of well characterised individuals with axSpA

(2)Assess the impact of sex on the relationship between diagnostic delay and comorbidity.

Methods

The Ankylosing Spondylitis Registry of Ireland (ASRI), a descriptive epidemiological study of the Irish axSpA population, provided the cohort for this study. A standardised clinical assessment was performed on each patient. Delay to diagnosis was calculated as age at diagnosis minus age at symptom onset. Comorbidities were considered as any condition present in addition to axial SpA, excluding extra-musculoskeletal manifestations (EMM). SPSS was used for statistical analysis, with appropriate tests used for normally and non-normally distributed data.

Results

Of the 913 included patients, 659 (72%) were male and mean age was 46 years (SD 13). Detailed baseline clinical and demographic characteristics are outlined in Table 1. Median delay to diagnosis was 5 (2, 12) years. Comorbidity was present in 37% (n=341) of the cohort, with hypertension the most prevalent (see Figure 1).

Table 1.

Baseline demographic and clinical characteristics

VariableAge, mean (SD)45.8 (12.6)Female, n (%)254 (27.8)Caucasian, n (%)819 (96.5)Ever Smoker, n (%)*527 (57.7)HLA-B27 positive, n (%)631 (89.9)Disease duration, median (25th,75th)17.1 (9.5, 27.8)Delay to diagnosis, median (25th, 75th)5.0 (2.0, 12.0)AAU, n (%)308 (34.4)PsO, n (%)150 (16.7)IBD, n (%)96 (10.7)Biologic use, n (%)628 (68.5)BASMI, mean (SD)3.6 (2.1)BASFI, mean (SD)3.4 (2.9)BASDAI, mean (SD)3.9 (2.4)HAQ, median (25th, 75th)0.38 (0.0, 0.9)

The median delay to diagnosis was significantly longer in those with ≥1 comorbidity compared to those with none (7 v 5 years, p<0.01). Hypertension (6 v 5 years, p=0.1) and cerebrovascular disease (10 v 5 years, p=0.03) were associated with a significantly longer delay to diagnosis, with a similar trend seen in those with hyperlipidaemia (7 v 5 years, p=0.09) and ischaemic heart disease (10 v 5 years, p=0.07). The delay to diagnosis was also longer in those that currently (7 v 5 years, p=0.03) or ever smoked (6 v 5 years, p<0.01). The delay to diagnosis was significantly longer in those with depression (9 v 5, p<0.05). The presence of EMM did not contribute to a delay to diagnosis, and there was no association with any categories of medication.

There was no significant difference in the median delay to diagnosis between females (5 v 6 years) for males. However, there were differences in the relationship between delay to diagnosis and the pattern of comorbidities between sexes. There was a significantly (p<0.05) longer delay to diagnosis in men with cerebrovascular disease (12 v 6 years), ischaemic heart disease (10 v 6 years) and diabetes (10 v 6 years), which wasn’t evident in females. Depression was associated with a longer delay to diagnosis in males (10 v 6 years, p<0.05), but not females (6 v 5 years, p=0.5).

Conclusion

Delay to diagnosis of axSpA was associated with a higher prevalence of comorbidities. This was particularly evident in men, with higher cardiovascular morbidity in those with a longer delay to diagnosis. Further research is needed to determine if shortening the delay to diagnosis would reduce the burden of cardiovascular morbidity.

References

[1]Chaudhary et al. All-Cause and Cause-Specific Mortality in Psoriatic Arthritis and Ankylosing Spondylitis: A Systematic Review and Meta-Analysis. Arthritis Care Res. 2021 Nov 17 (online).

Disclosure of Interests

None declared

POS1001 CURRENT SMOKING IS ASSOCIATED WITH LOWER RISK OF UVEITIS AND PERIPHERAL ARTHRITIS IN MALES WITH AXIAL SPONDYLOARTHRITIS

Background

The associations between smoking and extra-axial manifestations of axial spondyloarthritis (axSpA) are inadequately described. Previous observational studies have demonstrated smoking as protective against some but not other manifestations. However, the impact of sex on these associations is unknown.

Objectives

Using a large descriptive epidemiological dataset, we performed a sex-stratified analysis of the association between smoking status and extra-axial manifestations in axSpA.

Methods

This study was carried out within the framework of ASRI (Ankylosing Spondylitis Registry of Ireland), a descriptive epidemiological study of the axSpA population of Ireland. A standardised clinical assessment was performed on each patient, collecting demographic and clinical data. Smoking status was characterised as current, previous or never. The number of cigarettes per day, plus number of years smoking was also collected. Data on the following extra-axial manifestations was collected: arthritis, enthesitis, dactylitis, acute anterior uveitis (AAU), psoriasis (PsO), inflammatory bowel disease (IBD). Standardised measures of disease severity were also collected. Separate logistic regression models were used to define the association between extra-axial manifestations and smoking, controlling for potential confounders. SPSS was used for statistical analysis.

Results

Smoking data was available for 913 out of the 917 axSpA individuals with data in ASRI (mean age 46 (SD 13) years, disease duration 19 (SD 12) years, 72% male, 97% Caucasian). Twenty eight percent (n=259) were current smokers, 29% (n=268) were past smokers and 42% (n=386) were never smokers. Of the current smokers, the mean number of cigarettes per day was 12 (SD 7) and number of years smoking was 22 (SD 12). Thirty one percent had peripheral arthritis, 7% had dactylitis, 18% had enthesitis, 34% had AAU, 17% had psoriasis and 11% had IBD.

Current smokers had a significantly lower prevalence of arthritis and uveitis than past or non-smokers (see Table 1). A sex-stratified analysis was performed. There was no association between smoking status and any extra-axial manifestation in females. However, current smoking was associated with lower prevalence of arthritis in males compared to past or non-smokers (22% v 36% v 42%, p=0.002). A similar pattern was seen for uveitis, where male current smokers had a lower prevalence than non-smokers (24% v 38%, p=0.01). In contrast, psoriasis was more prevalent in men who were current smokers compared to non-smokers (18% v 12%, p=0.01), with no difference seen in females. There was no association with number of cigarettes smoked or number of years smoking.

Table 1.

Association between smoking status and extra-axial manifestations in axSpA.

AxSpA cohortCurrent smokerPast smokerNon-smokerArthritis30.9%22.4%a35.5%b33.3%bDactylitis6.7%5.5%a6.7% a7.4% aEnthesitis18.1%17.4% a16.2% a19.9% aUveitis34.3%27.4%a35.0%b38.6%bPsoriasis16.7%18.5% a19.3% a13.8% aInflammatory bowel disease10.7%9.9% a13.2% a9.5% a

Different subscript letters denote significant (p<0.05) differences between groups. Significant values highlighted in bold.

There was no association between smoking status and disease severity by subjective or objective measures, either for the cohort as a whole or by sex.

When compared to non- or ex-smokers and controlled for potential confounders including sex, age, biologic use, the association remained only between current smokers and lower risk of uveitis (OR 0.68, 95% CI 0.49 to 0.96) and arthritis (OR 0.62, 95% CI 0.43 to 0.88), in separate logistic regression models. The association between current smoking and increased prevalence of psoriasis in males did not remain significant once controlled for confounders (OR 1.10, 96% CI 0.73 to 1.65).

Conclusion

We demonstrated that current smoking is independently associated with a lower risk of uveitis and arthritis in males with axSpA, but not females. More research is needed to further investigate this paradoxical finding.

Disclosure of Interests

None declared

POS0995 EFFECT OF SEX IN CO-EXISTENT FIBROMYALGIA AND ENTHESITIS IN SPONDYLOARTHRITIS: ANCILLARY ANALYSIS OF THE ASAS-PerSpA STUDY

Background:

Enthesitis is a common feature of axial spondyloarthropathy (axSpA) and psoriatic arthritis (PsA). Up to 25% of individuals with axSpA and PsA have a co-existing diagnosis of fibromyalgia syndrome (FMS). The anatomic overlap between tender points in FMS and sites of entheses is a challenge when differentiating between active SpA and FMS. Literature investigating the co-existence of enthesitis and FMS in individuals with SpA is sparse, in particular the effect of sex. The ASAS Peripheral involvement in Spondyloarthritis (PerSpA) study aims to characterize peripheral musculoskeletal in individuals with SpA across the world.

Objectives:

(1)To characterise the co-existence of enthesitis and FMS in individuals with SpA.

(2)To explore the effect of sex on the presence of FMS and enthesitis.

Methods:

All individuals from the cross-sectional multinational ASAS-PerSpA study with a diagnosis of axSpA, peripheral SpA (pSpA) or PsA according to their rheumatologist were included. The Fibromyalgia Rapid Screening Tool (FiRST) was used to make the diagnosis of FMS. The baseline descriptive and clinical differences between sexes were performed using T-tests and crosstabs. Sex-stratified comparisons within the following categories were conducted using chi-square analysis and ANOVA as appropriate: (1) enthesitis & fibromyalgia; (2) enthesitis only; (3) fibromyalgia only; (4) neither.

Results:

Baseline characteristics of the 4465 included patients are outlined in Table 1, stratified by sex. Enthesitis occurred in 44% (n=1984) of the population and was more common in females than males (48% vs 42%, p<0.01). The majority affected had intermittent episodes of enthesitis (55%, n=1088), with the Achilles tendon and plantar fascia the two most common sites in both sexes. Enthesitis was more often confirmed on imaging in females than males (44% v 35%, p<0.01). The most common treatment for enthesitis was non-steroidal anti-inflammatories (97%, n=1318), with no difference when stratified by sex. FMS occurred in 19% (n=775) of patients and was more common in females than males (28% vs 13%, p<0.01).

Table 1.

Participant characteristics, stratified by sex. Values are mean (SD), median (25th, 75th) or n (%). P-values are independent T-tests or Mann-Whitney as appropriate.

VariableTotalMaleFemaleP valueN446527241741Age, years45 (14)43 (14)46 (13)<0.01Disease duration, years11 (6, 20)12 (6, 21)11 (5, 19)0.01Delay to diagnosis, years3 (1, 9)3 (1, 9)3 (1, 10)0.11HLA-B27 positive2066 (66)1457 (73)609 (54)<0.01Radiographic sacroiliitis2517 (61)1788 (70)729 (46)<0.01Sacroiliitis on MRI1817 (65)1128 (68)689 (60)<0.01axSpA ASAS criteria2910 (65)1953 (72)957 (55)<0.01pSpA ASAS criteria555 (12)250 (9)305 (18)<0.01CASPAR criteria1043 (23)508 (19)535 (31)<0.01BMI, kg/m226 (23, 29)26 (23, 29)26 (23, 30)0.24Axial involvement3428 (76.8)2243 (82.3)1185 (68.1)<0.01Peripheral involvement2541 (56.9)1404 (51.5)1137 (65.3)<0.01Enthesitis1984 (44.4)1149 (42.2)835 (48.0)<0.01Uveitis738 (17)482 (18)256 (15)0.01Psoriasis1212 (27)615 (23)597 (34)<0.01Inflammatory bowel disease275 (6)150 (6)125 (7)0.02

Enthesitis and FMS occurred together in 10% of the cohort, was more common in women than men (see Figure 1) and was associated with a significantly (p<0.01) longer delay to diagnosis of 1.8 years and a higher BMI of 2.1 kg/m2 than people with enthesitis only. Objective confirmation of enthesitis was similar in those with and without FMS (38% vs 38%, p=0.92).

The presence of FMS added to the burden of disease in those with enthesitis as assessed by BASDAI (6.4 vs 3.6, p<0.01) and ASDAS-CRP (3.5 vs 2.5, p<0.01), with no difference between sexes (p>0.05).

Conclusion:

In this large cross-sectional multinational analysis, FMS affected 19% of individuals with SpA. The co-existence of enthesitis and FMS occurred in 16% of females compared to 6% of males. The presence of FMS increased the burden of disease in those with enthesitis, as assessed by BASDAI and ASDAS-CRP, with no difference between men and women.

Disclosure of Interests:

Gillian Fitzgerald: None declared, Sinead Maguire Grant/research support from: Recipient of Gilead Inflammation Fellowship, Finbar Barry O’Shea: None declared, Clementina López-Medina: None declared, Maxime Dougados: None declared, Nigil Haroon Speakers bureau: Received honorarium from AbbVie, Eli Lilly, Jannsen, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, Jannsen, Novartis, UCB, Grant/research support from: AbbVie, Eli Lilly, Jannsen, Novartis, UCB.

Metabolic syndrome in polycystic ovary syndrome: a systematic review, meta-analysis and meta-regression

Women with polycystic ovary syndrome (PCOS) have increased risk of metabolic syndrome. The relative contribution of clinical, demographic or biochemical factors to metabolic syndrome in PCOS is not known. A literature search was conducted in MEDLINE, CINAHL, EMBASE and clinical trial registries. Of 4530 studies reviewed, 59 were included in the systematic review and 27 in the meta-analysis and meta-regression. In good and fair quality studies, women with PCOS had an overall increased prevalence of metabolic syndrome (odds ratio, OR 3.35, 95% confidence interval, CI 2.44, 4.59). Increased prevalence of metabolic syndrome occurred in overweight or obese women with PCOS (OR 1.88, 95% 1.16, 3.04) but not in lean women (OR 1.45, 95% CI 0.35, 6.12). In meta-regression analyses, the markers of metabolic syndrome diagnostic criteria (waist circumference, high-density lipoprotein cholesterol, triglyceride, blood pressure), BMI, glucose tolerance (2-hr oral glucose tolerance test) and surrogate markers of insulin resistance (HOMA-IR) but not markers of reproductive dysfunction (sex hormone binding globulin, testosterone, PCOS phenotypes) contributed significantly to the heterogeneity in the prevalence of metabolic syndrome. Women with PCOS have increased risk of metabolic syndrome which was associated with obesity and metabolic features but not with indices of hyperandrogenism.

Water availability moderates N2 fixation benefit from elevated [CO2 ]: A 2-year free-air CO2 enrichment study on lentil (Lens culinaris MEDIK.) in a water limited agroecosystem

Increased biomass and yield of plants grown under elevated [CO₂ ] often corresponds to decreased grain N concentration ([N]), diminishing nutritional quality of crops. Legumes through their symbiotic N₂ fixation may be better able to maintain biomass [N] and grain [N] under elevated [CO₂ ], provided N₂ fixation is stimulated by elevated [CO₂ ] in line with growth and yield. In Mediterranean-type agroecosystems, N₂ fixation may be impaired by drought, and it is unclear whether elevated [CO₂ ] stimulation of N₂ fixation can overcome this impact in dry years. To address this question, we grew lentil under two [CO₂ ] (ambient ~400 ppm and elevated ~550 ppm) levels in a free-air CO₂ enrichment facility over two growing seasons sharply contrasting in rainfall. Elevated [CO₂ ] stimulated N₂ fixation through greater nodule number (+27%), mass (+18%), and specific fixation activity (+17%), and this stimulation was greater in the high than in the low rainfall/dry season. Elevated [CO₂ ] depressed grain [N] (-4%) in the dry season. In contrast, grain [N] increased (+3%) in the high rainfall season under elevated [CO₂ ], as a consequence of greater post-flowering N₂ fixation. Our results suggest that the benefit for N₂ fixation from elevated [CO₂ ] is high as long as there is enough soil water to continue N₂ fixation during grain filling.

Giant Cell Arteritis Presenting as an Ischaemic Upper Limb

Aim To present an interesting case of giant cell arteritis presenting as ischaemic upper limb. Methods Data was collected from the patient’s chart and from radiology and laboratory systems in our institution. Results The patient had a temporal artery biopsy confirming the diagnosis of temporal arteritis. This was successfully treated with high dose steroids leading to resolution of symptoms in the arm. Conclusion Arteritis is an important consideration to consider in patients who present with limb ischaemia as it is a reversible cause which can be treated effectively.

Benefits of increasing transpiration efficiency in wheat under elevated CO2 for rainfed regions

Higher transpiration efficiency (TE) has been proposed as a mechanism to increase crop yields in dry environments where water availability usually limits yield. The application of a coupled radiation and TE simulation model shows wheat yield advantage of a high-TE cultivar (cv. Drysdale) over its almost identical low-TE parent line (Hartog), from about -7 to 558 kg/ha (mean 187 kg/ha) over the rainfed cropping region in Australia (221-1,351 mm annual rainfall), under the present-day climate. The smallest absolute yield response occurred in the more extreme drier and wetter areas of the wheat belt. However, under elevated CO₂ conditions, the response of Drysdale was much greater overall, ranging from 51 to 886 kg/ha (mean 284 kg/ha) with the greatest response in the higher rainfall areas. Changes in simulated TE under elevated CO₂ conditions are seen across Australia with notable increased areas of higher TE under a drier climate in Western Australia, Queensland and parts of New South Wales and Victoria. This improved efficiency is subtly deceptive, with highest yields not necessarily directly correlated with highest TE. Nevertheless, the advantage of Drysdale over Hartog is clear with the benefit of the trait advantage attributed to TE ranging from 102% to 118% (mean 109%). The potential annual cost-benefits of this increased genetic TE trait across the wheat growing areas of Australia (5 year average of area planted to wheat) totaled AUD 631 MIL (5-year average wheat price of AUD/260 t) with an average of 187 kg/ha under the present climate. The benefit to an individual farmer will depend on location but elevated CO₂ raises this nation-wide benefit to AUD 796 MIL in a 2°C warmer climate, slightly lower (AUD 715 MIL) if rainfall is also reduced by 20%.

Engaging the public in healthcare decision-making: results from a Citizens' Jury on emergency care services

BACKGROUND

Policies addressing ED crowding have failed to incorporate the public's perspectives; engaging the public in such policies is needed.

OBJECTIVE

This study aimed at determining the public's recommendations related to alternative models of care intended to reduce crowding, optimising access to and provision of emergency care.

METHODS

A Citizens' Jury was convened in Queensland, Australia, to consider priority setting and resource allocation to address ED crowding. Twenty-two jurors were recruited from the electoral roll, who were interested and available to attend the jury from 15 to 17 June 2012. Juror feedback was collected via a survey immediately following the end of the jury.

RESULTS

The jury considered that all patients attending the ED should be assessed with a minority of cases diverted for assistance elsewhere. Jurors strongly supported enabling ambulance staff to treat patients in their homes without transporting them to the ED, and allowing non-medical staff to treat some patients without seeing a doctor. Jurors supported (in principle) patient choice over aspects of their treatment (when, where and type of health professional) with some support for patients paying towards treatment but unanimous opposition for patients paying to be prioritised. Most of the jurors were satisfied with their experience of the Citizens' Jury process, but some jurors perceived the time allocated for deliberations as insufficient.

CONCLUSIONS

These findings suggest that the general public may be open to flexible models of emergency care. The jury provided clear recommendations for direct public input to guide health policy to tackle ED crowding.

Response of wheat growth, grain yield and water use to elevated CO2 under a Free-Air CO2 Enrichment (FACE) experiment and modelling in a semi-arid environment

The response of wheat crops to elevated CO2 (eCO2 ) was measured and modelled with the Australian Grains Free-Air CO2 Enrichment experiment, located at Horsham, Australia. Treatments included CO2 by water, N and temperature. The location represents a semi-arid environment with a seasonal VPD of around 0.5 kPa. Over 3 years, the observed mean biomass at anthesis and grain yield ranged from 4200 to 10 200 kg ha-1 and 1600 to 3900 kg ha-1 , respectively, over various sowing times and irrigation regimes. The mean observed response to daytime eCO2 (from 365 to 550 μmol mol-1 CO2 ) was relatively consistent for biomass at stem elongation and at anthesis and LAI at anthesis and grain yield with 21%, 23%, 21% and 26%, respectively. Seasonal water use was decreased from 320 to 301 mm (P = 0.10) by eCO2 , increasing water use efficiency for biomass and yield, 36% and 31%, respectively. The performance of six models (APSIM-Wheat, APSIM-Nwheat, CAT-Wheat, CROPSYST, OLEARY-CONNOR and SALUS) in simulating crop responses to eCO2 was similar and within or close to the experimental error for accumulated biomass, yield and water use response, despite some variations in early growth and LAI. The primary mechanism of biomass accumulation via radiation use efficiency (RUE) or transpiration efficiency (TE) was not critical to define the overall response to eCO2 . However, under irrigation, the effect of late sowing on response to eCO2 to biomass accumulation at DC65 was substantial in the observed data (~40%), but the simulated response was smaller, ranging from 17% to 28%. Simulated response from all six models under no water or nitrogen stress showed similar response to eCO2 under irrigation, but the differences compared to the dryland treatment were small. Further experimental work on the interactive effects of eCO2 , water and temperature is required to resolve these model discrepancies.

Rising CO2 concentration altered wheat grain proteome and flour rheological characteristics

Wheat cv. H45 was grown under ambient CO2 concentration and Free Air CO2 Enrichment (FACE; e[CO2], ∼550 μmol CO2 mol(-1)). The effect of FACE on wheat grain proteome and associated changes in the flour rheological properties was investigated. A comparative proteomic analysis was performed using 2-D-DIGE followed by MALDI/TOF-MS. Total grain protein concentration was decreased by 9% at e[CO2]. Relative abundance of three high molecular weight glutenin sub units (HMW-GS) were decreased at e[CO2]. In contrast, relative abundance of serpins Z1C and 1-Cys peroxiredoxin was increased at e[CO2]. Elevated [CO2] also decreased the bread volume (by 11%) and dough strength (by 7%) while increased mixing time. However, dough extensibility and dough stability were unchanged at elevated [CO2]. These findings suggest that e[CO2] has a major impact on gluten protein concentration which is associated lower bread quality at e[CO2].

Increasing CO2 threatens human nutrition

Dietary deficiencies of zinc and iron are a substantial global public health problem. An estimated two billion people suffer these deficiencies, causing a loss of 63 million life-years annually. Most of these people depend on C3 grains and legumes as their primary dietary source of zinc and iron. Here we report that C3 grains and legumes have lower concentrations of zinc and iron when grown under field conditions at the elevated atmospheric CO2 concentration predicted for the middle of this century. C3 crops other than legumes also have lower concentrations of protein, whereas C4 crops seem to be less affected. Differences between cultivars of a single crop suggest that breeding for decreased sensitivity to atmospheric CO2 concentration could partly address these new challenges to global health.

"In somno securitas" anaesthetists' noise exposure in Orthopaedic operating theatres

Excessive noise exposure can have adverse effects on the health and performance of healthcare providers. Irish statutory regulations limit daily workplace noise exposure to 87 A-weighted decibels [dB(A)]. The World Health Organisation recommends noise levels remain under 35 dB(A) in patient treatment rooms. We measured anaesthetists' noise exposure during elective orthopaedic surgery. The mean and maximum sound levels were 63.0 (SD 4.26) and 92.8 dB(A) respectively. Noise was louder than 65 dB(A) 22.2% of the time and louder than 80 dB(A) less than 1% of the time. Staff conversation and metal instruments were responsible for 29.5% and 19.9% of peaks louder than 65 dB(A) respectively. Sound levels recorded were lower than recognised levels associated with hearing loss. Sound regularly exceeded World Health Organisation (WHO) recommended levels for patient comfort and safety. Anaesthetists need to be aware of the influence of environmental noise on clinical practice.

Health care system in Saudi Arabia: an overview

The government of Saudi Arabia has given high priority to the development of health care services at all levels: primary, secondary and tertiary. As a consequence, the health of the Saudi population has greatly improved in recent decades. However, a number of issues pose challenges to the health care system, such a shortage of Saudi health professionals, the health ministry's multiple roles, limited financial resources, changing patterns of disease, high demand resulting from free services, an absence of a national crisis management policy, poor accessibility to some health care facilities, lack of a national health information system, and the underutilization of the potential of electronic health strategies. This paper reviews the historical development and current structure of the health care system in Saudi Arabia with particular emphasis on the public health sector and the opportunities and challenges confronting the Saudi health care system.

Diet–tissue discrimination factors of carbon and nitrogen stable isotopes in blood of Snowy Owl (Bubo scandiacus)

Analysis of carbon (13C/12C) and nitrogen (15N/14N) stable isotope ratios (hereafter δ13C and δ15N, respectively) in animal tissues is a powerful tool in food-web studies. However, isotopic ratios of prey are not transmitted directly to a consumer, as a diet–tissue discrimination factor (denoted Δ) occurs between sources and consumer’s tissues. An accurate assessment of the diet of a consumer with stable isotopes thus requires that the Δ13C and Δ15N of the studied species are known. Our aim was to establish Δ13C and Δ15N values in the Snowy Owl ( Bubo scandiacus (L., 1758)). Moreover, we assessed the potential effect of ethanol preservation of blood samples on δ13C and δ15N values. We kept four captive adult Snowy Owls on a pure diet of mice for ≥6 weeks. We then collected mouse muscle and blood samples from the owls and analyzed their δ13C and δ15N values. Δ13C and Δ15N values (mean ± SE) for owl blood were +0.3‰ ± 0.2‰ and +1.9‰ ± 0.1‰, respectively. These values are the first discrimination factors ever reported in Strigiformes and are lower, for Δ15N, than those obtained in terrestrial carnivores and other bird species, including falcons. Preservation in ethanol did not significantly affect δ13C and δ15N values.

Predicting freedom from clinical events in non-ST-elevation acute coronary syndromes: the Global Registry of Acute Coronary Events

OBJECTIVE

To identify patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) with a low likelihood of any adverse in-hospital event.

DESIGN, SETTING AND PATIENTS

Data were analysed from 24 097 patients with NSTEMI or unstable angina included in the Global Registry of Acute Coronary Events (January 2001 to September 2007).

MAIN OUTCOME MEASURES

In-hospital events were myocardial infarction, arrhythmia, congestive heart failure or shock, major bleeding, stroke or death. Two-thirds of the patients were randomly chosen for model development and the remainder for model validation. Multiple logistic regression identified predictors of freedom from an in-hospital event, and a Freedom-from-Event score was developed.

RESULTS

Of the 16 127 patients in the model development group, 19.1% experienced an in-hospital adverse event. Fifteen factors independently predicted freedom from an adverse event: younger age; lower Killip class; unstable angina presentation; no hypotension; no ST deviation; no cardiac arrest at presentation; normal creatinine; decreased pulse rate; no hospital transfer; no history of diabetes, heart failure, peripheral arterial disease, or atrial fibrillation; prehospital use of statins, and no chronic warfarin. In the validation group, 18.6% experienced an adverse event. The model discriminated well between patients experiencing an in-hospital event and those who did not in both derivation and validation groups (c-statistic = 0.77 in both). Patients in the three lowest risk deciles had a very low in-hospital mortality (<0.5%) and an uncomplicated clinical course (>93% event-free in hospital). The model also predicted freedom from postdischarge events (death, myocardial infarction, stroke; c-statistic = 0.77).

CONCLUSIONS

The GRACE Freedom-from-Event score can predict the in-hospital course of NSTE-ACS, and identifies up to 30% of the admitted population at low risk of death or any adverse in-hospital event.

Using dried blood spots stored on filter paper to measure cholinesterase activity in wild avian species

Birds of prey that are poisoned by cholinesterase inhibitors (e.g. organophosphate and carbamate insecticides) are often cared for at animal shelters, rehabilitation centres and wildlife diagnostic facilities. Plasma cholinesterase (ChE) activity is a recognized method of assessing exposure to these insecticides, but standard blood-handling protocols are difficult to follow in non-laboratory settings. The primary objective of this study was to expand upon a method for storing human blood on filter paper without the need for complicated equipment or refrigeration, and to test its utility for measurement of ChE activity in avian blood. ChE activity from whole blood, plasma, and dried blood spots was analysed from 169 wild birds and comparisons made among sample types. ChE activity measured in whole blood haemolysates and dried blood spots were significantly correlated (r = 0.74, p < 0.001), as was ChE activity measured in plasma and dried blood spots (r = 0.68, p < 0.001). This study demonstrated that monitoring pesticide exposure in birds could be conducted using elementary blood sampling, preserving and shipping techniques.

Life under stress: the probiotic stress response and how it may be manipulated

The continuing expansion of interest in probiotic bacteria has led to an increase in manufactured Functional Foods and medicines containing these bacteria. Given the intestinal origin of these microorganisms, the challenges these sensitive bacteria face in order to be in a highly viable state throughout processing, storage and gastrointestinal transit to the site of action in the human gut are enormous. These bacteria encounter stresses including temperature, acid, bile, exposure and osmotic and oxidative stress in both product matrices and during gastrointestinal transit. However, like all bacteria, probiotic bacteria retain a broad arsenal of molecular mechanisms to combat the often lethal environmental stresses encountered during processing and following ingestion. A comprehensive appreciation of these mechanisms should inevitably lead to the design and manufacture of probiotic cultures, which retain greater viability through to the target site in the intestine. This review attempts to catalogue the cellular processes available to probiotic bacteria to facilitate survival in stressful conditions, and to speculate on how manipulation of these cellular systems can lead to production of designer strains with enhanced viability in food systems and efficacy following ingestion.

Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the Global Registry of Acute Coronary Events

OBJECTIVE

To assess whether sex differences exist in the angiographic severity, management and outcomes of acute coronary syndromes (ACS).

METHODS

The study comprised 7638 women and 19 117 men with ACS who underwent coronary angiography and were included in GRACE (Global Registry of Acute Coronary Events) from 1999-2006. Normal vessels/mild disease was defined as <50% stenosis in all epicardial vessels; advanced disease was defined as >or=one vessel with >or=50% stenosis.

RESULTS

Women were older than men and had higher rates of cardiovascular risk factors. Men and women presented equally with chest pain; however, jaw pain and nausea were more frequent among women. Women were more likely to have normal/mild disease (12% vs 6%, p<0.001) and less likely to have left-main and three-vessel disease (27% vs 32%, p<0.001) or undergo percutaneous coronary intervention (65% vs 68%, p<0.001). Women and men with normal and mild disease were treated less aggressively than those with advanced disease. Women with advanced disease had a higher risk of death (4% vs 3%, p<0.01). After adjustment for age and extent of disease, women were more likely to have adverse outcomes (death, myocardial infarction, stroke and rehospitalisation) at six months compared to men (odds ratio 1.24, 95% confidence interval 1.14 to 1.34); however, sex differences in mortality were no longer statistically significant.

CONCLUSIONS

Women with ACS were more likely to have cardiovascular disease risk factors and atypical symptoms such as nausea compared with men, but were more likely to have normal/mild angiographic coronary artery disease. Further study regarding sex differences related to disease severity is warranted.

Subtractive screening for probiotic properties of lactobacillus species from the human gastrointestinal tract in the search for new probiotics

In the search for new probiotics, 61 Lactobacillus spp. isolates, belonging to 12 species and isolated as dominant lactic acid bacteria from the feces of healthy humans, were subjected to a subtractive system of in vitro analyses, which included desirable and undesirable traits. Twenty-four isolates were able to grow in 2% bovine bile, of which 13 grew in acidified broth at pH 3.5 in acidified cysteine-containing MRS broth. Intrinsic resistance to certain antimicrobial agents (cefoxitin, metronidazole, vancomycin) was observed in most isolates, but atypical resistances to erythromycin, clindamycin, or tetracycline were also found in 5 strains. Undesirable traits such as alpha-chymotrypsin or N-acetyl-beta-glucosaminidase activities were not detected, but low beta-glucuronidase and moderate beta-glucosidase activities were recorded in 2 strains. Two Lactobacillus gasseri and 2 Lactobacillus paracasei selected strains inhibited several intestinal pathogens in an agar spot test, including strains of Escherichia coli, Listeria monocytogenes, Salmonella typhimurium, and Staphylococcus aureus. They also adhered to human Caco-2 and HT-29 epithelial cells in a manner comparable to Lactobacillus rhamnosus strain GG, and were unable to degrade pig gastric mucin in a plate assay. Together, these results suggest these 4 strains to be good probiotic candidates, concluding that the subtractive screening devised in this work could be a valuable tool in large-scale surveys for probiotics.

Salmonella enterica phage-resistant mutant colonies display an unusual phenotype in the presence of phage Felix 01

AIMS

To investigate irregular colony morphology formation in Salmonella enterica serovar Typhimurium DPC6046 in the presence of a lytic phage, Felix 01.

METHODS AND RESULTS

Phage-resistant derivatives of the parent strain DPC6046 were isolated which exhibited an irregular colony morphology. These were subjected to viability studies by using confocal scanning laser microscopy and live/dead BacLight stain to evaluate the cell viability within the colony. The phenomenon was also observed with other S. enterica serotypes tested which were normally sensitive to phage Felix. In the case of strain DPC6046, dead cells were clearly evident at the irregular edges of the phage-resistant colonies in locations where the cell density was lower. This colony morphology was not apparent with two other Salmonella phages tested.

CONCLUSIONS

These findings support the hypothesis that the unusual morphology is due to reversion to phage sensitivity and consequent cell death within the colony as it forms.

SIGNIFICANCE AND IMPACT OF THE STUDY

The irregular colony morphology observed is peculiar to phage Felix. The confocal scanning laser microscopy methodology allowed the basis for the irregular morphology to be elucidated.

Sequence analysis of the plasmid genome of the probiotic strain Lactobacillus paracasei NFBC338 which includes the plasmids pCD01 and pCD02

Lactobacillus paracasei NFBC338 is a probiotic strain that was isolated from the human gastrointestinal tract (GIT) and contains a plasmid genome of 80kb. Using a shotgun sequencing approach, two of the plasmids, pCD01 (19,882bp) and pCD02 (8554bp) have been completely sequenced, and four contiguous sequences (Contigs) have been assembled. Bioinformatic analysis of pCD01 revealed that it contains 23 putative open reading frames (ORFs) and that it contains regions characterised by potential replication functions and multidrug resistance (MDR). In contrast, the content of pCD02 is mainly cryptic, although, it does contain two insertion sequence (IS) elements. Indeed, up to 17% of the entire plasmid genome encodes putative transposable elements. In addition, there are a number of interesting ORFs distributed over the four Contigs that show significant homology to genes such as those involved in adherence and biotin metabolism, which may prove beneficial to Lb. paracasei NFBC338 under certain environmental conditions. This study provides a novel insight into the rich plasmid complement of this probiotic Lactobacillus strain, which may potentially be exploited as the basis for development of improved genetic tools for probiotic lactobacilli.

Microbial contamination of dental unit water systems

INTRODUCTION

Dental unit water systems (DUWS) may serve as a reservoir for biofilms that contribute to high numbers of bacteria in the water used during dental treatment. These microbes are predominantly harmless but potentially pathogenic organisms can also be present in the biofilm. This may pose a potential health risk for patients and dental personnel.

AIM

to determine the microbial levels of DUWS in dental practices.

MATERIALS AND METHOD

A cross-sectional study of water and tubing samples from 30 general dental practices (15 health board and 15 private surgeries) was undertaken as part of a pan-European investigation of the microbial qualitative and quantitative aspects of DUWS.

RESULTS

Microbial loads ranged from 100 to 104 cfu ml-1 and exceeded the European guidelines for drinking water in many cases. The available evidence suggested the presence of isolates most likely belonging to families of aquatic and soil bacteria. It was not possible to draw distinct conclusions correlating microbial loads with dental unit parameters, including age of the unit, water source and chemistry and presence or absence of anti-retraction devices. Opportunistic or true pathogens were not detected. Yeasts were observed in samples from three units although further analysis confirmed that these were not Candida albicans. A decontamination strategy applied to one of the units eliminated the yeasts completely.

CONCLUSIONS

Dental practitioners must be knowledgeable regarding microbial contamination and biofilm formation in dental unit waterlines. There is a need for development of European evidence-based guidelines and reliable control regimes for microbial contamination of DUWS.

Improved survival of Lactobacillus paracasei NFBC 338 in spray-dried powders containing gum acacia

AIMS

To assess the protective effect of gum acacia (GA) on the performance of Lactobacillus paracasei NFBC 338 during spray-drying, subsequent storage and exposure of the culture to porcine gastric juice.

METHODS AND RESULTS

For these studies, Lact. paracasei NFBC 338 was grown in a mixture of reconstituted skim milk (10% w/v) and GA (10% w/v) to mid log phase and spray-dried at outlet temperatures between 95 and 105 degrees C. On spray drying at the higher air outlet temperature of 100-105 degrees C, the GA-treated culture displayed 10-fold greater survival than control cells. Probiotic lactobacilli in GA-containing powders also survived dramatically better than untreated cultures during storage at 4-30 degrees C for 4 weeks. A 20-fold better survival of the probiotic culture in GA-containing powders was obtained during storage at 4 degrees C while, at 15 and 30 degrees C, greater than 1000-fold higher survival was obtained. Furthermore, the viability of probiotic lactobacilli in GA-containing powders was 100-fold higher when exposed to porcine gastric juice over 120 min compared with the control spray-dried culture.

CONCLUSIONS

The data indicate that GA has applications in the protection of probiotic cultures during drying, storage and gastric transit.

SIGNIFICANCE AND IMPACT OF THE STUDY

Gum acacia treatment for the manufacture of probiotic-containing powders should result in more efficient probiotic delivery to the host gastrointestinal tract.

Conjugated linoleic acid biosynthesis by human-derived Bifidobacterium species

AIMS

To assess strains of Lactobacillus, Lactococcus, Pediococcus and Bifidobacterium for their ability to produce the health-promoting fatty acid conjugated linoleic acid (CLA) from free linoleic acid.

METHODS AND RESULTS

In this study, strains of Lactobacillus, Lactococcus, Pediococcus and Bifidobacterium were grown in medium containing free linoleic acid. Growth of the bacteria in linoleic acid and conversion of the linoleic acid to CLA was assessed. Of the bacteria assessed, nine strains of Bifidobacterium produced the c9, t11 CLA isomer from free linoleic acid. The t9, t11 CLA isomer was also produced by some strains, but at much lower concentrations.

CONCLUSIONS

The production of CLA by bifidobacteria exhibited considerable interspecies variation. Bifidobacterium breve and B. dentium were the most efficient CLA producers among the range of strains tested, with B. breve converting up to 65% linoleic acid to c9, t11 CLA when grown in 0.55 mg ml(-1) linoleic acid. Strains also varied considerably with respect to their sensitivity to linoleic acid.

SIGNIFICANCE AND IMPACT OF THE STUDY

The production of CLA by probiotic bifidobacteria offers a possible mechanism for some health-enhancing properties of bifidobacteria and provides novel opportunities for the development of functional foods.

Identification of a phosphofructokinase-encoding gene from Streptococcus thermophilus CNRZ1205--a novel link between carbon metabolism and gene regulation?

In order to isolate genes encoding so-called Two-Component Regulatory Systems from the lactic acid bacterium Streptococcus thermophilus, a cloning strategy was employed based on suppression of the alkaline phosphatase-negative phenotype displayed by the Escherichia coli strain ANCC22. Several suppressing clones were obtained which were shown to produce alkaline phosphatase activity. Sequence analysis of four of these clones revealed the presence of overlapping DNA inserts representing two ORFs, designated pfkT and pykT, whose deduced protein products exhibit significant similarity to phosphofructokinases and pyruvate kinases, respectively, from a variety of bacteria. A plasmid bearing pfkT was shown to complement a phosphofructokinase-negative mutant of E. coli, showing that this gene indeed specifies phosphofructokinase activity. It was shown that suppression of the alkaline phosphatase-negative phenotype of E. coli ANCC22 due to the presence of pfkT is caused by modulation of the intracellular level of acetyl phosphate.

Level of maternal antibody required to protect neonates against early-onset disease caused by group B Streptococcus type Ia: a multicenter, seroepidemiology study

Because of the difficulty of conducting efficacy trials of vaccines against group B streptococcus (GBS), the licensure of these vaccines may have to rely on studies that measure vaccine-induced antibody levels that correlate with protection. This study estimates the level of maternal antibody required to protect neonates against early-onset disease (EOD) caused by GBS type Ia. Levels of maternal serum IgG GBS Ia antibodies, measured by ELISAs in 45 case patients (neonates with EOD caused by GBS Ia) and in 319 control subjects (neonates colonized by GBS Ia but without EOD) born at > or =34 weeks gestation were compared. The probability of developing EOD declined with increasing maternal levels of IgG GBS Ia antibody (P = .03). Neonates whose mothers had levels of IgG GBS Ia antibody > or =5 microg/mL had an 88% lower risk (95% confidence interval, 7%-98%) of developing type-specific EOD, compared with those whose mothers had levels < 0.5 microg/mL. A vaccine that induces IgG GBS Ia antibody levels > or =5 microg/mL in mothers can be predicted to confer a high degree of type-specific immunity to EOD to their infants.

In vitro selection criteria for probiotic bacteria of human origin: correlation with in vivo findings

The enteric flora comprises approximately 95% of the total number of cells in the human body and can elicit immune responses while protecting against microbial pathogens. However, the resident bacterial flora of the gastrointestinal tract may also be implicated in the pathogenesis of diseases such as inflammatory bowel disease (ulcerative colitis and Crohn disease). The objectives of the Probiotic Research Group based at University College Cork were to isolate and identify lactic acid bacteria exhibiting beneficial probiotic traits, such as bile tolerance in the absence of deconjugation activity, acid resistance, adherence to host epithelial tissue, and in vitro antagonism of pathogenic microorganisms or those suspected of promoting inflammation. To isolate potentially effective probiotic bacteria, we screened the microbial population adhering to surgically resected segments of the gastrointestinal tract (the environment in which they may subsequently be reintroduced and required to function). In total, 1500 bacterial strains from resected human terminal ilea were assessed. From among these organisms, Lactobacillus salivarius subsp. salivarius strain UCC118 was selected for further study. In mouse feeding trials, milk-borne L. salivarius strain UCC118 could successfully colonize the murine gastrointestinal tract. A human feeding study conducted in 80 healthy volunteers showed that yogurt can be used as a vehicle for delivery of strain UCC118 to the human gastrointestinal tract with considerable efficacy in influencing gut flora and colonization. In summary, we developed criteria for in vitro selection of probiotic bacteria that may reflect certain in vivo effects on the host such as modulation of gastrointestinal tract microflora.

Market potential for probiotics

"Functional foods" as a marketing term was initiated in Japan in the late 1980s and is used to describe foods fortified with ingredients capable of producing health benefits. This concept is becoming increasingly popular with consumers because of a heightened awareness of the link between health, nutrition, and diet. Food manufacturers are enthusiastic about developing such products because the added ingredients give increased value to food. The global market for functional foods in the coming years is predicted to grow rapidly. Although Japan currently accounts for about one-half of this market, the fastest rate of growth is expected to be in the United States. Probiotic products represent a strong growth area within the functional foods group and intense research efforts are under way to develop dairy products into which probiotic organisms such as Lactobacillus and Bifidobacterium species are incorporated. Such probiotic foods may modulate gut microbial composition, thereby leading to improved gut health, for example, through improved tolerance to lactose in lactose-intolerant individuals or improved resistance to pathogenic bacteria. Large numbers of viable microorganisms are likely to be required in the food product, which should be consumed regularly to experience the health effect. The probiotic market, especially dairy products such as yogurts and fermented milks, has experienced rapid growth in Europe. The long-term exploitation of probiotics as health promoters is dependent on several factors, including sound, scientifically proven clinical evidence of health-promoting activity; accurate consumer information; effective marketing strategies; and, above all, a quality product that fulfills consumer expectations.

Measurement of trihalomethanes in potable and recreational waters using solid phase micro extraction with gas chromatography-mass spectrometry

Solid phase micro extraction (SPME) was applied to the determination of selected trihalomethanes (THMs), chloroform, bromodichloromethane, dibromochloromethane, bromoform, in potable and recreational waters. The selected samples were environmentally significant due to mandatory limits imposed by regulatory agencies. Extraction of the analytes was performed using headspace SPME (fused silica fibre with a 100 microm poly(dimethylsiloxane coating) followed by thermal desorption at 220 degrees C and GC-MS analysis. A linear working range of 10-160 microg/l was established with relative standard deviations (%RSD) within the range, 0.9-19%. Limits of detection (LOD) were 1.0-2.8 microg/l. The highest THM concentration was 61.8 microg/l which was well within the proposed European Union directive of 100 microg/l. The total THMs determined in swimming pool waters ranged from 105-134 microg/l, with chloroform accounting for 84-86% of total THM.

Factors associated with decisions about clinical BRCA1/2 testing

Testing for mutations in BRCA1 and BRCA2 can provide important information about breast and ovarian cancer risk to a small but identifiable subgroup of women. Women who test positive for a BRCA1/2 mutation can pursue more aggressive cancer surveillance and prevention regimens. Among families with known mutations, women who test negative may avoid unnecessary interventions. Currently, little is known about the factors associated with the use of clinical BRCA1/2 testing. The objective of this study was to determine the factors associated with decisions about clinical BRCA1/2 testing among women undergoing clinical BRCA1/2 counseling through a retrospective cohort study of women who participated in a university-based clinic offering breast cancer risk assessment, genetic counseling, and BRCA1/2 testing between January 1996 and April 1998. From the 251 eligible women who responded to a follow-up survey, 125 (50%) had undergone or were undergoing BRCA1/2 testing, 86 (34%) had decided not to undergo testing, and 40 (16%) were undecided about testing. After multivariate adjustment, we found that women who chose to undergo BRCA1/2 testing were more likely to have a known familial mutation [odds ratio (OR), 7.46; 95% confidence interval (CI), 0.97-62.16], more likely to be Ashkenazi Jewish (OR, 6.37; 95% CI, 2.68-15.12), more likely to want cancer risk information for family members (OR, 1.93; 95% CI, 0.99-4.14), more likely to want information about ovarian cancer risk (OR, 1.69; 95% CI, 1.18-3.69), and less likely to be concerned about insurance or job discrimination (OR, 0.45; 95% CI, 0.21-0.94). These associations were also found in the subgroup of women with a predicted probability of a BRCA1 mutation of 25%. Our study suggests that approximately half of eligible women choose to undergo clinical BRCA1/2 testing after participating in counseling. Women who have the highest risk of carrying a mutation, and thus the greatest probability of gaining some useful information from the test results, are most likely to undergo testing. Women who undergo testing are also more interested in ovarian cancer risk information and less concerned about job and insurance discrimination.

Characterisation of whiskeys using solid-phase microextraction with gas chromatography-mass spectrometry

The application of solid-phase microextraction and gas chromatography-mass spectrometry to the detection of flavour volatiles present in Irish and Scottish whiskeys was investigated. A method was developed to characterise these volatiles which included the extraction, identification and quantification of 17 congeners which included fusel alcohols, acetates and esters. The method validation produced the optimum fibre [85 microm poly(acrylate)], extraction time (35 min), sample volume size (3 ml) and desorption time (5 min). The impact of salt on the absorption process was also studied. Characteristic profiles were determined for each whiskey and the flavour congeners were quantified using 4-methyl-2-pentanol as the internal standard. Calibration ranges were determined for each of the congeners with coefficients of linearity ranging from 0.993 (butan-1-ol) to 0.999 (ethyl laurate) and relative standard deviations ranging from 2.5% (2-methylbutan-1-ol) to 21% (furfural) at a concentration of 18.2 mg/l. Detection limits ranged from 0.1 mg/l (ethyl caprate) to 21 mg/l (butan-2-ol).

Intraosseous infusion devices: a comparison for potential use in special operations

OBJECTIVE

To determine which intraosseous (IO) devices were easy to learn to use, easy to use once the skill was obtained, and appropriate for the Special Operations environment.

METHODS

Thirty-one Navy SEAL corpsmen, Air Force pararescuemen, Army Special Forces, and Ranger medics, in a prospective, randomly assigned, cross-over study, tested four commercially available, Food and Drug Administration-cleared IO devices. The systems included the injection models First Access for Shock and Trauma (FAST, Pyng Medical) and Bone Injection Gun (Wais Medical, Kress USA Corporation) and the hand-driven threaded-needle SurFast (Cook Critical Care) and straight-needle Jamshidi needle (Baxter) models. The Special Operations medical care providers received a lecture regarding IO use, viewed videotapes of the injection models, and practiced with demonstration units in the classroom. Each participant then entered the cadaver lab where all four of the IO devices were placed in randomly assigned order. A poststudy questionnaire was then completed. The FAST was placed in the sternum, whereas the other units were placed in either medial proximal or distal medial tibia. Each participant was assessed for time, number of attempts, and success. The presence of marrow, extravasation, quality of flow, and security of needle were evaluated in combination to help determine success.

RESULTS

All four devices were believed to be easy to learn as well as easy to place. FAST was successful in 29 of 30 insertions (94%) with a placement time of 114 +/- 36 (mean +/- SD) seconds. The Bone Injection Gun was similarly successful (29 of 31 insertions, 94%) with a mean placement time of 70 +/- 33 seconds. This time was statistically significantly faster (p < 0.05) than that with FAST, but not with the other devices. Thirty of 31 SurFast placements (97%) were successful, on average taking 88 +/- 33 seconds to place. The Jamshidi needle also had 30 of 31 successful placements (97%) at an average 90 +/- 59 seconds. No one device was rated by the participants as significantly better than the others; however, the Bone Injection Gun did have 65% of participants rate it as first or second (closest was Jamshidi needle at 52%).

CONCLUSION

These IO devices were easy to teach and learn as well as easy to use. Insertion times compared favorably with peripheral intravenous catheter placement in the face of hemorrhage. All four devices can be appropriately used in the Special Operations environment and are reasonable alternatives when intravenous access cannot be gained. Although no device was rated higher than the others, particular features are desirable (low weight/size, simplicity, reusability, secure, clean, well protected).