A qualitative study examining newly diagnosed breast cancer patients' experiences of participating in the Alberta Moving Beyond Breast Cancer (AMBER) prospective cohort study

BACKGROUND

Decisions to participate in cancer trials are associated with uncertainty, distress, wanting to help find a cure, the hope for benefit, and altruism. There is a gap in the literature regarding research examining participation in prospective cohort studies. The aim of this study was to examine the experiences of newly diagnosed women with breast cancer participating in the AMBER Study to identify potential strategies to support patients' recruitment, retention, and motivation.

METHODS

Newly diagnosed breast cancer patients were recruited from the Alberta Moving Beyond Breast Cancer (AMBER) cohort study. Data were collected using semi-structured conversational interviews with 21 participants from February to May 2020. Transcripts were imported into NVivo software for management, organization, and coding. Inductive content analysis was undertaken.

RESULTS

Five main concepts associated with recruitment, retention, and motivation to participate were identified. These main concepts included: (1) personal interest in exercise and nutrition; (2) investment in individual results; (3) personal and professional interest in research; (4) burden of assessments; (5) importance of research staff.

CONCLUSIONS

Breast cancer survivors participating in this prospective cohort study had numerous reasons for participating and these reasons could be considered in future studies to enhance participant recruitment and retention. Improving recruitment and retention in prospective cancer cohort studies could result in more valid and generalizable study findings that could improve the care of cancer survivors.

Effects of a Computerized Prescriber Order Entry System on Pharmacist Prescribing

Background

In Alberta, pharmacists are eligible to obtain additional prescribing authority (APA). At the University of Alberta Hospital, a transition was made from a paper-based prescriber order entry system to a computerized prescriber order entry (CPOE) system.

Objectives

The primary objective was to quantify any change in pharmacist prescribing after CPOE implementation. The secondary objective was to compare the paper-based and CPOE systems in terms of drug schedule, order type, medication class, and the pharmacist's area of clinical practice.

Methods

A retrospective comparative review of pharmacist orders was completed using 2-week periods of data from each of the paper-based order entry system and the CPOE system, spaced 1 year apart (in January 2019 and January 2020).

Results

Pharmacists prescribed a mean of 3.76 (95% confidence interval 1.97-5.96) more orders per day within the CPOE system than in the paper-based system (p < 0.001). Schedule I medications accounted for a higher proportion of pharmacists' prescriptions in the CPOE system than in the paper-based system (77.7% versus 70.5%, p < 0.001). In terms of order type, discontinuation orders accounted for a much higher proportion of pharmacists' orders in the CPOE system than in the paper-based order entry system (58.0% versus 19.8%, p < 0.001).

Conclusions

This study showed that a CPOE system resulted in more use of APA by pharmacists, with schedule I medications accounting for a higher proportion of pharmacists' prescriptions. With the CPOE system, pharmacists used their prescribing privileges to discontinue a higher proportion of orders than was the case with the paper-based system. Therefore, the CPOE system is a potential facilitator of pharmacist prescribing.

P-739 Social and treatment characteristics of women with Uterine Fibroid (UF) with/without Heavy Menstrual Bleeding (HMB), in a commercially insured US population

Study question

Are there differences in patient’s social demographic, clinical and treatment characteristics among patients diagnosed with HMB and/or UF?

Summary answer

Baseline characteristics were similar across all UF-status defined-groups. Differences were observed in education, net-worth and 12-monthfollow-up characteristics. Nearly 60% were prescribed pain meds pre-diagnosis.

What is known already

Uterine leiomyomas (or fibroids) are benign neoplasm that affect women of reproductive age1. In the US, treatment for UF is individualized, dependent on size and location of the fibroids, patient profile, symptom severity and type of diagnosis. Patients may be diagnosed with HMB before UF (HMB-UF), diagnosed with UF first and then HMB (UF-HMB), diagnosed with only HMB (HMB-Only) or UF only (UF-Only). Previous studies indicated that the majority (70%) of women received no prescription medications regardless of surgery status and 40% had pain at time of diagnosis.2,3

Study design, size, duration

Our retrospective real-world observational study included 295,400 women across four cohorts between 10/1/2012 -12/31/2020. The majority (96,961; 44%) had HMB-Only, 46,763 (21%) UF-Only, 35,421 (16%) HMB-UF, and 40,806 (19%) UF-HMB. Patients required 12 months continuous enrollment before index date (earlier of HMB or UF diagnosis date based on cohorts) and 12-months of follow-up unless hysterectomy was observed before 12 months. Surgical and pharmacologic agents explored were based on ACOG guidelines for UF.

Participants/materials, setting, methods

Optum® Socio-Economic Status claims database was used to identify newly diagnosed women 18-55 years old with UF and/or HMB claims, without history of conservative/radical surgery or non-dermatological cancers.

Descriptive analyses were performed for patients’ social demographics and treatment characteristics during pre- and post-index period.

Main results and the role of chance

Across all cohorts,

During the 12-month follow-up, nearly 80% of patients used at least 1 prescribed pain medication compared to nearly 60% at baseline. The increase in pain medication use was mainly driven by increase in NSAIDs, opioids, analgesics, and anti-migraine in all cohorts except HMB-O (Opioids: baseline 24-30% to follow up 41-55%; NSAIDs: 20-21% to 44-53%; analgesics: 6-8% to 19%-33%; anti-migraine: 8-11% to 16-29%).

Limitations, reasons for caution

True incidence of index claims are difficult to estimate. Over-the-counters medications or claims made outside the study period are not captured. Pain medication may be unrelated to UF-associated pain.

Findings only reflect the commercially insured population and may not be generalizable. Claims data provide limited clinical profile and prescribing rationales.

Wider implications of the findings

The majority of the patients in these cohorts experienced pain and were prescribed opioids. Determining the link between the use of pain medication and symptoms of UF and HMB is important, as pain medications do not address HMB.

Trial registration number

Not applicable

Contrasting impacts of mixed nonionic surfactant micelles on plant growth in the delivery of fungicide and herbicide

HYPOTHESIS

Nonionic alkyl ethoxylate surfactants are widely used in agrochemicals to facilitate the permeation of systemic herbicides and fungicides across the plant waxy film. Industrial grade surfactants are often highly mixed and how the mixing affects their interactions with pesticides and wax films remains largely unexplored. A better understanding could enable design of mixed nonionic surfactants for herbicides and fungicides to maximize their efficiency and reduce wastage whilst controlling their impact on plant wax films.

EXPERIMENT

In this study, nonionic surfactants with general structure n-oxyethylene glycol monododecyl ether (C₁₂E_n) were used to form surfactant mixtures with the same average ethoxylate numbers but different hydrophilic-lipophilic balance (HLB) values. Their mixed micellar systems were then used to solubilize a herbicide diuron (DN) and a fungicide cyprodinil (CP), followed by plant wax solubilization upon contact with wax films. These processes were monitored by ¹H NMR and SANS.

FINDING

Pesticide solubilization made surfactant micelles effectively more hydrophobic but subsequent wax dissolution caused pesticide release and the restoration of the micellar amphiphilicity. Nonionic surfactants with lower HLBs form larger nanoaggregates, show enhanced wettability, and have better ability to solubilize and permeate pesticides across the wax film, but may cause significant damage to plant growth. These observations help explain why herbicides applied on weeds would benefit from surfactants with lower HLB values while fungicides require surfactants with HLBs to balance between delivery efficiency and potential phytotoxicity risks.

Development and Reliability of a 7×15m Repeated On-Ice Sprint Test for Female Ice Hockey Players

The purpose of this investigation was to design and examine the reliability of a 7×15m repeated on-ice skating sprint test for female ice hockey players. Seventeen women (X̄ ± SD age, height and body mass = 21 ± 2 years, 166.2 ± 6.4 cm and 61.9 ± 7.7 kg, respectively) completed 7 consecutive on-ice sprints of 15m repeated every 15s. Two trials of the test were performed on the same day and then repeated on a different day approximately 1 week later for a total of 4 trials. The fastest 15m time, mean time for 7 sprints and total sprint time collapsed across all 4 trials was 2.96 ± 0.12s, 3.05 ± 0.13s and 21.35 ± 0.89s, respectively. There were no significant differences between trials for any variable. Typical error (TE), coefficient of variation (%CV) and intra-class coefficients (ICC) for the fastest 15m time, mean of 7 sprints, and total time were ICC = 0.77, TE = 0.06s and %CV = 2.1; ICC = 0.91; TE = 0.04s and %CV = 1.4; and, ICC = 0.91; TE = 0.29 and %CV = 1.4 for all 4 trials, respectively. Players in the forward position had a faster mean 15m time and lower total time compared to those in the defensive position (p < 0.05). These findings show that a 7×15m repeated on-ice sprint test for varsity women ice hockey players was reliable. It was also found that forwards had a better mean of 7 sprint time and faster total time compared to players in the defensive position.

What happens when pesticides are solubilised in binary ionic/zwitterionic-nonionic mixed micelles?

HYPOTHESIS

Surfactants have been widely used as adjuvants in agri-sprays to enhance the solubility of pesticides in foliar spray deposits and their mobility through leaf cuticles. Previously, we have characterised pesticide solubilisation in nonionic surfactant micelles, but what happens when pesticides become solubilised in anionic, cationic and zwitterionic and their mixtures with nonionic surfactants remain poorly characterised.

EXPERIMENTS

To facilitate characterisations by SANS and NMR, we used nonionic surfactant hexaethylene glycol monododecyl ether (C₁₂E₆), anionic sodium dodecylsulphate (SDS), cationic dodecyltrimethylammonium bromide (DTAB) and zwitterionic dodecylphosphocholine (C₁₂PC) as model adjuvant systems to solubilise 3 pesticides, Cyprodinil (CP), Azoxystrobin (AZ) and Difenoconazole (DF), representing different structural features. The investigation focused on the influence of solubilisates in driving changes to the micellar nanostructures in the absence or presence of electrolytes. NMR and NOESY were applied to investigate the solubility and location of each pesticide in the micelles. SANS was used to reveal subtle changes to the micellar structures due to pesticide solubilisation with and without electrolytes.

FINDINGS

Unlike nonionic surfactants, the ionic and zwitterionic surfactant micellar structures remain unchanged upon pesticide solubilisation. Electrolytes slightly elongate the ionic surfactant micelles but have no effect on nonionic and zwitterionic surfactants. Pesticide solubilisation could alter the structures of the binary mixtures of ionic/zwitterionic and ionic/nonionic micelles by causing elongation, shell shrinkage and dehydration, with the exact alteration being determined by the molar ratio in the mixture.

How does substrate hydrophobicity affect the morphological features of reconstituted wax films and their interactions with nonionic surfactant and pesticide?

HYPOTHESIS

Surfactants are widely used in agri-sprays to improve pesticide efficiency, but the mechanism underlying their interactions with the surface wax film on plants remains poorly understood. To facilitate physical characterisations, we have reconstituted wheat cuticular wax films onto an optically flat silicon substrate with and without octadecyltrimethoxysilane modification to control surface hydrophobicity.

EXPERIMENTS

Imaging techniques including scanning electron microscopy (SEM) unravelled morphological features of the reconstituted wax films similar to those on leaves, showing little impact from the different substrates used. Neutron reflection (NR) established that reconstituted wax films were comprised of an underlying wax film decorated with top surface wax protrusions, a common feature irrespective of substrate hydrophobicity and highly consistent with what was observed from natural wax films. NR measurements, with the help of isotopic H/D substitutions to modify the scattering contributions of the wax and solvent, revealed different wax regimes within the wax films, illustrating the impact of surface hydrophilicity on the nanostructures within the wax films.

FINDINGS

It was observed from both spectroscopic ellipsometry and NR measurements that wax films formed on the hydrophobic substrate were more robust and durable against attack by nonionic surfactant C₁₂E₆ solubilised with pesticide Cyprodinil (CP) than films coated on the bare hydrophilic silica. Thus, the former could be a more feasible model for studying the wax-surfactant-pesticide interactions.

The influence of energy metabolism on postpartum weight retention

BACKGROUND

Profiling postpartum energy metabolism may assist in optimizing weight management following childbirth.

OBJECTIVES

The aims of this study were to profile total energy expenditure (TEE), resting energy expenditure (REE), exercise energy expenditure, sleep energy expenditure, and respiratory quotient in women at 3 and 9 mo postpartum (3M-PP, 9M-PP, respectively), and to examine the association between energy metabolism and postpartum weight retention (PPWR).

METHODS

In this cohort study, 1-h REE (measured in a whole body calorimetry unit, WBCU) and body composition (BC, measured by dual-energy X-ray absorptiometry) were measured at 3M-PP and 9M-PP (n = 49). Cardiorespiratory fitness [measured by the predicted maximal volume of oxygen consumption (p$\dot{V}$O2 max), n = 47] and 24-h TEE (WBCU, n = 43) were assessed only at 9M-PP. Women were stratified as high (>4.8 kg) or low (≤ 4.8 kg) weight retainers. Two-way mixed repeated-measures ANOVA and longitudinal regression models were applied. Linear regression was used to generate an equation at 3M-PP from the BC data, to predict the REE at 9M-PP.

RESULTS

The fat mass at 3M-PP was positively associated with PPWR at 3M-PP (mean ± SE β: 0.09 ± 0.03; P = 0.005) and 9M-PP (β: 0.11 ± 0.04; P = 0.008), and negatively associated with REE at 3M-PP (β: -0.16 ± 0.02; P < 0.001) and TEE at 9M-PP (β: -0.15 ± 0.03; P < 0.001). REE was negatively associated with PPWR (β: -0.74; 95% CI: -1.29, -0.19; P = 0.0087). REE was 2 kcal/kg higher in low- vs. high-retainers at 3M-PP, and REE and TEE were both 4 kcal/kg higher in low- vs. high-retainers at 9M-PP. Low-retainers demonstrated an increase in REE greater than expected for changes in BC. PPWR was negatively associated with TEE (β: -0.08 ± 0.02; P = 0.0009) and p$\dot{V}$O2 max (β: -0.02 ± 0.01; P = 0.047); p$\dot{V}$O2 max was 7 mL · kg-1 · min-1 higher in low- vs. high-retainers (P = 0.047).

CONCLUSIONS

Energy metabolism, BC, and cardiorespiratory fitness may be associated with weight regulation and its trajectory during the postpartum period. This provides the foundation for future strategies to promote appropriate postpartum weight management.

Deep tubewell microbial water quality and access in arsenic mitigation programs in rural Bangladesh

The objective of this paper is to determine whether deep tubewells installed through arsenic mitigation efforts in rural Bangladesh provide better drinking water microbial quality compared to shallow tubewells. We conducted a stratified random cross-sectional survey of 484 households to assess microbial contamination of deep tubewell water at source and at point of use (POU) compared to shallow tubewell water using the Compartment Bag Test. In addition, we measured storage time, distance, travel time and ownership status among both sets of users to assess deep tubewell efficacy and under what conditions they offer poorer or better water quality. Differences in tubewell characteristics were compared using non-parametric Mann-Whitney U tests and two-proportion Z-tests. Prevalence ratios of microbial contamination stratified by water quality, storage time and distance to tubewells and ownership were estimated using unadjusted Mantel-Haenszel tests. There was no significant difference in microbial contamination between shallow and deep tubewells at source. The presence of POU water microbial contamination in storage containers in deep tubewell households was 1.11 times the prevalence in shallow tubewell storage containers (95% CI = 0.97-1.27). Deep tubewell users stored water longer and walked significantly farther to obtain water compared to shallow tubewell users. Among deep tubewell households, those residing farther away from the source were 1.24 times as likely to drink contaminated water from storage containers compared to those located nearby (95% CI = 1.04-1.48). Our findings suggest that deep tubewells have comparable water quality to shallow tubewells at source, but increasing distance from the household exacerbates risk of microbial contamination at POU.

Lipid remodeling and an altered membrane-associated proteome may drive the differential effects of EPA and DHA treatment on skeletal muscle glucose uptake and protein accretion

In striated muscle, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have differential effects on the metabolism of glucose and differential effects on the metabolism of protein. We have shown that, despite similar incorporation, treatment of C₂C₁₂ myotubes (CM) with EPA but not DHA improves glucose uptake and protein accretion. We hypothesized that these differential effects of EPA and DHA may be due to divergent shifts in lipidomic profiles leading to altered proteomic profiles. We therefore carried out an assessment of the impact of treating CM with EPA and DHA on lipidomic and proteomic profiles. Fatty acid methyl esters (FAME) analysis revealed that both EPA and DHA led to similar but substantials changes in fatty acid profiles with the exception of arachidonic acid, which was decreased only by DHA, and docosapentanoic acid (DPA), which was increased only by EPA treatment. Global lipidomic analysis showed that EPA and DHA induced large alterations in the cellular lipid profiles and in particular, the phospholipid classes. Subsequent targeted analysis confirmed that the most differentially regulated species were phosphatidylcholines and phosphatidylethanolamines containing long-chain fatty acids with five (EPA treatment) or six (DHA treatment) double bonds. As these are typically membrane-associated lipid species we hypothesized that these treatments differentially altered the membrane-associated proteome. Stable isotope labeling by amino acids in cell culture (SILAC)-based proteomics of the membrane fraction revealed significant divergence in the effects of EPA and DHA on the membrane-associated proteome. We conclude that the EPA-specific increase in polyunsaturated long-chain fatty acids in the phospholipid fraction is associated with an altered membrane-associated proteome and these may be critical events in the metabolic remodeling induced by EPA treatment.

Structural Features of Reconstituted Cuticular Wax Films upon Interaction with Nonionic Surfactant C12E6

The interaction of nonionic surfactant hexaethylene glycol monododecyl ether (C₁₂E₆) with a reconstituted cuticular wheat wax film has been investigated by spectroscopic ellipsometry and neutron reflection (NR) to help understand the role of the leaf wax barrier during pesticide uptake, focusing on the mimicry of the actions adjuvants impose on the physical integrity and transport of the cuticular wax films against surfactant concentration. As the C₁₂E₆ concentration was increased up to the critical micelle concentration (CMC = 0.067 mM), an increasing amount of surfactant mass was deposited onto the wax film. Alongside surface adsorption, C₁₂E₆ was also observed to penetrate the wax film, which is evident from the NR measurements using fully protonated and chain-deuterated surfactants. Furthermore, surfactant action upon the model wax film was found to be physically reversible below the CMC, as water rinsing could readily remove the adsorbed surfactant, leaving the wax film in its original state. Above the CMC, the detergency action of the surfactant became dominant, and a significant proportion of the wax film was removed, causing structural damage. The results thus reveal that both water and C₁₂E₆ could easily penetrate the wax film throughout the concentration range measured, indicating a clear pathway for the transport of active ingredients while the removal of the wax components above the CMC must have enhanced the transport process. As the partial removal of the wax film could also expose the underlying cutaneous substrate to the environment and undermine the plant's health, this study has a broad implication to the roles of surfactants in crop care.

Structural features of reconstituted wheat wax films

Cuticular waxes are essential for the well-being of all plants, from controlling the transport of water and nutrients across the plant surface to protecting them against external environmental attacks. Despite their significance, our current understanding regarding the structure and function of the wax film is limited. In this work, we have formed representative reconstituted wax film models of controlled thicknesses that facilitated an ex vivo study of plant cuticular wax film properties by neutron reflection (NR). Triticum aestivum L. (wheat) waxes were extracted from two different wheat straw samples, using two distinct extraction methods. Waxes extracted from harvested field-grown wheat straw using supercritical CO₂ are compared with waxes extracted from laboratory-grown wheat straw via wax dissolution by chloroform rinsing. Wax films were produced by spin-coating the two extracts onto silicon substrates. Atomic force microscopy and cryo-scanning electron microscopy imaging revealed that the two reconstituted wax film models are ultrathin and porous with characteristic nanoscale extrusions on the outer surface, mimicking the structure of epicuticular waxes found upon adaxial wheat leaf surfaces. On the basis of solid–liquid and solid–air NR and ellipsometric measurements, these wax films could be modelled into two representative layers, with the diffuse underlying layer fitted with thicknesses ranging from approximately 65 to 70 Å, whereas the surface extrusion region reached heights exceeding 200 Å. Moisture-controlled NR measurements indicated that water penetrated extensively into the wax films measured under saturated humidity and under water, causing them to hydrate and swell significantly. These studies have thus provided a useful structural basis that underlies the function of the epicuticular waxes in controlling the water transport of crops.

Differences in Blood Pressure in Infants After General Anesthesia Compared to Awake Regional Anesthesia (GAS Study-A Prospective Randomized Trial)

BACKGROUND

The General Anesthesia compared to Spinal anesthesia (GAS) study is a prospective randomized, controlled, multisite, trial designed to assess the influence of general anesthesia (GA) on neurodevelopment at 5 years of age. A secondary aim obtained from the blood pressure data of the GAS trial is to compare rates of intraoperative hypotension after anesthesia and to identify risk factors for intraoperative hypotension.

METHODS

A total of 722 infants ≤60 weeks postmenstrual age undergoing inguinal herniorrhaphy were randomized to either bupivacaine regional anesthesia (RA) or sevoflurane GA. Exclusion criteria included risk factors for adverse neurodevelopmental outcome and infants born at <26 weeks of gestation. Moderate hypotension was defined as mean arterial pressure measurement of <35 mm Hg. Any hypotension was defined as mean arterial pressure of <45 mm Hg. Epochs were defined as 5-minute measurement periods. The primary outcome was any measured hypotension <35 mm Hg from start of anesthesia to leaving the operating room. This analysis is reported primarily as intention to treat (ITT) and secondarily as per protocol.

RESULTS

The relative risk of GA compared with RA predicting any measured hypotension of <35 mm Hg from the start of anesthesia to leaving the operating room was 2.8 (confidence interval [CI], 2.0-4.1; P < .001) by ITT analysis and 4.5 (CI, 2.7-7.4, P < .001) as per protocol analysis. In the GA group, 87% and 49%, and in the RA group, 41% and 16%, exhibited any or moderate hypotension by ITT, respectively. In multivariable modeling, group assignment (GA versus RA), weight at the time of surgery, and minimal intraoperative temperature were risk factors for hypotension. Interventions for hypotension occurred more commonly in the GA group compared with the RA group (relative risk, 2.8, 95% CI, 1.7-4.4 by ITT).

CONCLUSIONS

RA reduces the incidence of hypotension and the chance of intervention to treat it compared with sevoflurane anesthesia in young infants undergoing inguinal hernia repair.

Investigation of Positional Differences in Fitness of Male University Ice Hockey Players and the Frequency, Time Spent and Heart Rate of Movement Patterns during Competition

Background:  Men’s university ice hockey has received little scientific attention over the past 30 years, a time in which the traits of the players and the demands of the game have evolved.  Objectives: This study compared the physiological characteristics of university ice hockey players and examined the frequency and duration of the different movement patterns and heart rate (HR) responses during competition. Methods: Twenty male ice hockey players from the same team ( age ± SD = 22±2 years) underwent a fitness evaluation and were filmed and HR monitored during regular season games. Results: Forwards and defense had similar fitness and only differed on % fatigue index and peak heart during on-ice sprinting (P<0.05). Defense stood, glided and skated backwards more than forwards and forwards skated at a moderate intensity and glided forward more than defense (P<0.05). All players spent the majority of game time gliding forward (60% of the time) followed by skating forward at a moderate intensity (17%) and standing with little movement (9%). Average HR during the game reached 96 and 92 % and peak HR was 100 and 96 % of maximum in forwards and defense, respectively. Conclusions: Male university hockey players present with a high level of physical fitness in a variety of categories with few differences between forwards and defense. Movement patterns during games suggest that players are performing low to moderate intensity on-ice activities the majority of the time. Paradoxically, HR continues to climb to near maximum during on ice shifts.

The effect of selection history on extinction risk during severe environmental change

Environments rarely remain the same over time, and populations are therefore frequently at risk of going extinct when changes are significant enough to reduce fitness. Although many studies have investigated what attributes of the new environments and of the populations experiencing these changes will affect their probability of going extinct, limited work has been directed towards determining the role of population history on the probability of going extinct during severe environmental change. Here, we compare the extinction risk of populations with a history of selection in a benign environment, to populations with a history of selection in one or two stressful environments. We exposed spores and lines of the green alga Chlamydomonas reinhardtii from these three different histories to a range of severe environmental changes. We found that the extinction risk was higher for populations with a history of selection in stressful environments compared to populations with a history of selection in a benign environment. This effect was not due to differences in initial population sizes. Finally, the rates of extinction were highly repeatable within histories, indicating strong historical contingency of extinction risk. Hence, information on the selection history of a population can be used to predict their probability of going extinct during environmental change.

Non-ionic surfactant phase diagram prediction by recursive partitioning

A model has been designed to predict the phase which forms in water for a non-ionic surfactant, at a given concentration and temperature. The full phase diagram is generated by selecting enough data points to cover the region of interest. The model estimates the probability for each one of 10 possible phases and selects the one with the highest likelihood. The probabilities are based on the recursive partitioning of a dataset of 10 000 known observations. The model covers alkyl chain length and branching, ethoxylate head length and number, and end capping of one or more of the ethoxylate chains. The relationship between chemical structure, shape and phase behaviour is discussed.This article is part of the themed issue 'Soft interfacial materials: from fundamentals to formulation'.

Final-year dental students' opinions of their training in medical emergency management

The management of medical emergencies is clearly of vital importance in dental practice. The starting point of training in this area is the undergraduate dental degree programme. The aim of this study was to examine the opinions of final-year dental students at Newcastle School of Dental Sciences in relation to their undergraduate training in medical emergency management. Overall the responses were positive but the need for further practical training in the use of emergency drugs and equipment was highlighted.

Speed and efficiency in walking and wheeling with novel stimulation and bracing systems after spinal cord injury: a case study

To compare various novel and conventional systems for locomotion, a 25-year-old man was studied with motor complete spinal cord injury at the T4/5 level. He used various devices in the community, and changes in speed, physiological cost index (PCI), and oxygen consumption were measured periodically. Speed was fastest with a conventional manual wheelchair (nearly 120 m/min in a 4-min test). Speed was about 30% less, but the PCI was lowest (highest efficiency) using functional electrical stimulation (FES) of the quadriceps and hamstring muscles to propel a novel wheelchair. He walked with knee-ankle-foot orthoses (KAFO) at much lower speed (8.8 m/min) and higher PCI. He walked with an alternating gait using a new stance-control KAFO with FES. The speed was still slow (5 m/min), but he prefers the more normal-looking gait and uses it daily. Walking with FES and ankle-foot orthoses (AFO) was slowest (3.5 m/min) and had the highest PCI. In conclusion, the leg-propelled wheelchair provides a more efficient method of locomotion. A new stance-controlled KAFO with FES may provide a more acceptable walking system, but must be tested on other subjects.

The patient inflating valve in anaesthesia and resuscitation breathing systems

Patient inflating valves combined with self-inflating bags are known to all anaesthetists as resuscitation devices and are familiar as components of draw-over anaesthesia systems. Their variants are also commonplace in transfer and home ventilators. However, the many variations in structure and function have led to difficulties in their optimal use, definition and classification. After reviewing the relevant literature, we defined a patient inflating valve as a one-way valve that closes an exit port to enable lung inflation, also permitting exhalation and spontaneous breathing, the actions being automatic. We present a new classification based on the mechanism of valve opening/closure; namely elastic recoil of a flexible flap/diaphragm, sliding spindle opened by a spring/magnet or a hollow balloon collapsed by external pressure. The evolution of these valves has been driven by the difficulties documented in critical incidents, which we have used along with information from modern International Organization for Standardization standards to identify 13 ideal properties, the top six of which are non-jamming, automatic, no bypass effect, no rebreathing or air entry at patient end, low resistance, robust and easy to service. The Ambu and the Laerdal valves have remained popular due to their simplicity and reliability. Two new alternatives, the Fenton and Diamedica valves, offer the benefits of location away from the patient while retaining a small functional dead space. They also offer the potential for greater use of hybrid continuous flow/draw-over systems that can operate close to atmospheric pressure. The reliable application of positive end-expiratory pressure/continuous positive airway pressure remains a challenge.

Clopidogrel dilemma for orthopaedic surgeons

BACKGROUND

Patients medicated with clopidogrel who require orthopaedic surgery present a particular challenge. Whether in an emergency or elective situation the orthopaedic surgeon must balance the risks of ceasing clopidogrel versus the risk of increased bleeding that dual antiplatelet therapy generates.

METHOD

This paper reviews the current published evidence regarding the risks of continuing clopidogrel, the risks of discontinuing clopidogrel and associated considerations such as venous thromboprophylaxis.

RESULTS

Little good quality evidence exists in regard to perioperative clopidogrel for orthopaedic surgery. Available evidence across non-cardiac and cardiac surgery were assessed and presented in regards to current practices, blood loss for orthopaedic operations, risks when continuing clopidogrel, risks of stopping clopidogrel and also the consideration of venous thromboembolism.

CONCLUSIONS

The patients at greatest risk, when discontinuing clopidogrel therapy, are those with drug eluting stents who may be at risk of stent thrombosis. Where possible, efforts should be made to continue clopidogrel therapy through the perioperative period, taking precautions to minimize bleeding. If the risk of bleeding is too high, antiplatelet therapy must be reinstated as soon as considered reasonable after surgery. In addition, patients on clopidogrel who sustain a fall or other general trauma need to be carefully assessed because of the possibility of occult bleeding, such as into the retroperitoneal space. Until more definitive evidence becomes available, this review aims to provide a guide for the orthopaedic surgeon in dealing with the difficult dilemma of the patient on clopidogrel therapy, recommending that orthopaedic surgeons take a team approach to assess the individual risks for all patients and consider continuation of clopidogrel therapy perioperatively where possible.

Oro-antral fistulae and fractured tuberosities

This paper, in discussing oro-antral fistulae and fractured tuberosities, aims to guide the dentist through the assessment and reduction of risk when removing maxillary molar teeth that are closely related to the maxillary sinus. However, complications are inevitable and the management of these will also be discussed.