Exploring dimensions of quality-of-life in survivors of stroke with communication disabilities - a brief report

BACKGROUND

People with communication disabilities post-stroke have poor quality-of-life.

OBJECTIVES

We aimed to explore the association of self-reported communication disabilities with different dimensions of quality-of-life between 90 and 180 days post-stroke.

METHODS

Cross-sectional survey data were obtained between 90 and 180 days post-stroke from registrants in the Australian Stroke Clinical Registry recruited from three hospitals in Queensland. The usual follow-up survey included the EQ5D-3L. Responses to the Hospital Anxiety and Depression Scale, and extra questions (e.g. communication disabilities) were also collected. We used χ² statistics to determine differences.

RESULTS

Overall, 244/647 survivors completed the survey. Respondents with communication disabilities (n = 72) more often reported moderate to extreme problems in all EQ5D-3L dimensions, than those without communication disabilities (n = 172): anxiety or depression (74% vs 40%, p < .001), pain or discomfort (58% vs 39%, p = .006), self-care (46% vs 18%, p < .001), usual activities (77% vs 49%, p < .001), and mobility (68% vs 35%, p < .001). Respondents with communication disabilities reported less fatigue (66% vs 89%, p < .001), poorer cognitive skills (thinking) (16% vs 1%, p < .001) and lower social participation (31% vs 6%, p < .001) than those without communication disabilities.

CONCLUSIONS

Survivors of stroke with communication disabilities are more negatively impacted across different dimensions of quality-of-life (as reported between 90 and 180 days post-stroke) compared to those without communication disabilities. This highlights the need for timely and on-going comprehensive multidisciplinary person-centered support.

683 A Quality Improvement Project (QIP) To Increase Compliance with Peri-Operative Antibiotic Guidelines in Colorectal Surgery (CS)

Introduction

In CS, the correct use of antibiotics is important in order to reduce the risk of surgical site and intra-abdominal infections, whilst balancing risks from overuse of antibiotics. The Commissioning for Quality and Improvement (CQUIN) of 2019/20 identified that antibiotic prophylaxis guideline compliance could be enhanced in CS. This QIP aimed to improve local CS antibiotic prophylaxis and extension guideline compliance.

Method

In December 2019, an educational session was held to highlight the details of the local guideline and prescribing discrepancies. A3 posters of the guideline were created for accessible reference in operating theatres. Perioperative antibiotic prescription data from all colorectal elective cases in January 2020 were extracted and analysed using descriptive methods.

Results

Out of 93 cases in the sample, 70 (75.3%) were compliant with the prophylaxis guideline. However, metronidazole was commonly used in perianal surgery, which is not recommended. 13 cases required extension of the antibiotic course, of which seven were compliant (53.8%). The main issues included: use of agents and course durations which were not indicated; and a lack of antibiotic switch after a pause in therapy.

Conclusions

To further improve compliance with antibiotic guidelines, targeting historic practice, increasing awareness, and making systemic change is required for the next cycle.

3D collagen architecture induces a conserved migratory and transcriptional response linked to vasculogenic mimicry

The topographical organization of collagen within the tumor microenvironment has been implicated in modulating cancer cell migration and independently predicts progression to metastasis. Here, we show that collagen matrices with small pores and short fibers, but not Matrigel, trigger a conserved transcriptional response and subsequent motility switch in cancer cells resulting in the formation of multicellular network structures. The response is not mediated by hypoxia, matrix stiffness, or bulk matrix density, but rather by matrix architecture-induced β1-integrin upregulation. The transcriptional module associated with network formation is enriched for migration and vasculogenesis-associated genes that predict survival in patient data across nine distinct tumor types. Evidence of this gene module at the protein level is found in patient tumor slices displaying a vasculogenic mimicry (VM) phenotype. Our findings link a collagen-induced migration program to VM and suggest that this process may be broadly relevant to metastatic progression in solid human cancers.

Extracellular matrix plays a central role in driving cancer development. Here the authors using an in vitro approach show that confining collagen architectures induce fast and persistent cell migration and the formation of multicellular network structures linked to vascular mimicry observed in tumours from patients.

Are energy and protein requirements met in hospital?

BACKGROUND

Malnutrition is a problem within hospitals, which impacts upon clinical outcomes. The present audit assesses whether a hospital menu meets the energy and protein standards recommended by the British Dietetic Association's (BDA) Nutrition and Hydration Digest and determines the contribution of oral nutrition supplements (ONS) and additional snacks.

METHODS

Patients in a UK South West hospital were categorised as 'nutritionally well' or 'nutritionally vulnerable' in accordance with their Malnutrition Universal Screening Tool score. Energy and protein content of food selected from the menu ('menu choice'), menu food consumed ('hospital intake') and total food consumed including snacks ('overall intake') were calculated and compared with the standards.

RESULTS

In total, 93 patients were included. For 'nutritionally well' patients (n = 81), energy and protein standards were met by 11.1% and 33.3% ('menu choice'); 7.4% and 22.2% ('hospital intake'); and 14.8% and 28.4% ('overall intake'). For 'nutritionally vulnerable' patients (n = 12), energy and protein standards were met by 0% and 8.3% ('menu choice'); 0% and 8.3% ('hospital intake'); and 8.3% and 16.7% ('overall intake'). Ten percent of patients consumed ONS. Patients who consumed hospital snacks (34%) were more likely to meet the nutrient standards (P ≤ 0.001).

CONCLUSIONS

The present audit demonstrated that most patients are not meeting the nutrient standards recommended by the BDA Nutrition and Hydration Digest. Recommendations include the provision of energy/protein-dense snacks, as well as menu, offering ONS where clinically indicated, in addition to training for staff. A food services dietitian is ideally placed to lead this, forming a vital link between patients, caterers and clinical teams.

Laparoscopic ventral mesh rectopexy in the management of solitary rectal ulcer syndrome: a cause for optimism?

AIM

The treatment of solitary rectal ulcer syndrome (SRUS) is notoriously difficult. Laparoscopic ventral mesh rectopexy (LVMR) is a nonresectional technique for patients with full thickness external rectal prolapse and internal prolapse with obstructed defaecation syndrome (ODS), features associated in the pathogenesis of SRUS. Our aim was to assess the short- and long-term efficacy of LVMR in treating SRUS.

METHOD

Forty-eight patients with SRUS who underwent LVMR over a 15-year period (December 1996 to July 2012) were identified from a prospectively maintained electronic database.

RESULTS

Forty-eight patients, 38 (79%) women, median age 43 (18-80) years, median body mass index 26 (21-40) kg/m(2) underwent LVMR for SRUS after initial biofeedback. The median follow-up was 33 months (95% CI 31-55, range 1-186 months); 52% were followed for more than 3 years and 13 (27%) for more than 5 years. Five (10%) had relapsed following a response to stapled transanal rectal resection (STARR; 10 additional patients have had a continued response to STARR). Eleven (23%) had intermittent reducible external prolapse. Epithelial ulcer healing was reported in all patients at 3 months. The ODS scores improved by 68% (P < 0.0001) and quality of life (QoL; Birmingham Bowel and Urinary Symptoms Questionnaire-22) scores improved by 45% (P < 0.0001). There was a significant improvement in bowel visual analogue scale (VAS) scores at 3 and 12 months (P = 0.0007). Sustained improvement in QoL and VAS scores was maintained at 2 years and continued in the 52% followed up for between 3 and 15 years. There were four (8%) symptomatic ODS recurrences: posterior rectal wall prolapse successfully treated by STARR (3) and one symptom free for 2 years following a temporary loop ileostomy. There were two recurrences (4%).

CONCLUSION

LVMR appears to provide a sustained improvement in QoL, VAS and patient satisfaction in patients with SRUS. Morbidity, recurrence and safety profiles are low.

Faster pulmonary oxygen uptake kinetics in children vs adults due to enhancements in oxygen delivery and extraction

This study aimed to examine if the faster pulmonary oxygen uptake (VO2p) phase 2 in children could be explained by increased O2 availability or extraction at the muscle level. For that purpose, O2 availability and extraction were assessed using deoxyhemoglobin (HHb) estimated by near-infrared spectroscopy during moderate-intensity constant load cycling exercise in children and young adults. Eleven prepubertal boys and 12 men volunteered to participate in the study. They performed one maximal graded exercise to determine the power associated with the gas exchange threshold (GET) and four constant load exercises at 90% of GET. VO2p and HHb were continuously monitored. VO2p , HHb, and estimated capillary blood flow (Qcap) kinetics were modelled after a time delay and characterized by the time to achieve 63% of the amplitude (τ) and by mean response time (MRT: time delay + τ), respectively. Mean values of τ for VO2p (P < 0.001), of MRT for HHb (P < 0.01) and of MRT for Qcap (P < 0.001) were significantly shorter in children. Faster VO2p kinetics have been shown in children; these appear due to both faster O2 extraction and delivery kinetics as indicated by faster HHb and Qcap kinetics, respectively.

Medium-term results of stapled transanal rectal resection (STARR) for obstructed defecation and symptomatic rectal-anal intussusception

AIM

Stapled transanal rectal resection (STARR) is an increasingly accepted treatment for obstructed defaecation syndrome (ODS) associated with internal rectal prolapse (IRP) and rectocoele. The aim of this study is to evaluate the medium to long-term outcomes of STARR for ODS.

METHOD

The intermediate-term results of STARR used over a 9-year period were reviewed from the analysis of a prospectively maintained database. Patients were followed for a median period of 98 (95% CI 85-112, range 5-386) weeks.

RESULTS

Three hundred and forty-four (234 woman) patients of median age 54 (19-90) years underwent STARR over a 9-year period. Preoperative symptoms included pelvic pain (93%), incomplete evacuation (90%), urgency (74%), a sensation of obstruction (65%) and rectal digitation (27%). Thirteen had the solitary rectal ulcer syndrome. Of 326 patients with follow-up data, 249 (76%) were followed beyond 1 year and 149 (43%) beyond 2 years. The ODS score improved [14.6 ± 5.4 pre vs 1.6 ± 3.1 post (P < 0.0001)] as did the faecal incontinence (FI) score [3.5 ± 3.3 pre vs 0.4 ± 1.3 post (P < 0.0001)]. Fifteen (4.3%) patients reported deterioration in FI, and 11 (3.2%) experienced new onset minor incontinence. Urgency was 72% at 8 weeks, 20% at 16 weeks, 11.5% at 52 weeks and 5% at 1.5 years. None of the 29 patients followed beyond 4 years reported urgency. Urgency was unrelated to sex, age or preoperative ODS symptoms (Mantel-Cox log-rank). Recurrent symptoms of ODS occurred in 4.9%. Eighty-one per cent of patients were highly satisfied with STARR and would recommend or have it again.

CONCLUSION

STARR was successful for the treatment of selected patients with ODS and IRP. Postoperative faecal urgency rapidly decreases with time. It is not possible to predict who will develop urgency.

VO2 slow component is independent from critical power

The aim of this study was to determine whether the amplitude of the V˙O (2) slow component was dependent from Critical Power (CP; the slope of the linear time - distance relationship) in individuals matched for V˙O (2) peak. 30 moderately-trained endurance athletes completed a maximal graded exercise test, 2 randomly ordered constant power tests at 90 and 100% of peak power output (PPO), and 2 constant duration test of 6 min at 30% of the difference between CP and PPO. Afterwards, participants were ranked according to their relative CP (%PPO; a direct measure of aerobic endurance). The median third was excluded to form a low aerobic endurance group (LEG) and a high aerobic endurance group (HEG). A t-test revealed no difference between LEG and HEG in peak oxygen consumption, but a large difference in their relative CP (p<0.001, effect size=3.2). A' (2) was similar between groups (626 ± 96 and 512 ± 176 ml, corresponding to 26 ± 4 and 24 ± 8% of end exercise oxygen consumption, respectively; NS) and was not associated with relative CP (r=0.10; NS). These results suggest that increasing CP probably extends the range of exercise intensities over which the V˙O (2) slow component does not develop, but does not decrease the amplitude of this phenomenon once it occurs.

Risk factors for encephalitis from West Nile Virus: a matched case-control study using hospitalized controls

We conducted a case-control study to determine risk factors for developing encephalitis among West Nile virus cases when compared with age-, gender and race/ethnicity-matched hospitalized controls. In the multivariable conditional logistic regression analysis, we identified the following independent risk factors associated with being an encephalitis case: hypertension (OR 4.0; P = 0.005), immunosuppressing conditions (OR 5.6; P = 0.001) and cardiovascular disease (OR = 28.3; P < 0.001). Individuals with these comorbidities should be targeted for education on protecting themselves from mosquito exposures.

Evaluation of a radiographer-provided barium enema service

AIM

Radiographers performed and reported 5516 double contrast barium enemas (RDCBEs) over 4 years to October 2001. This study was undertaken to assess the accuracy of RDCBE and the sensitivity for diagnosing colorectal cancer (CRC).

METHOD

A total of 224 consecutive outpatient RDCBEs were reported; normal (C1), diverticulosis (C2), diverticulosis with filling defect (C3), diverticulosis & other pathology (C4) and abnormal (C5). RDCBEs were then reported by a radiologist (AL, NS) and the two reports compared. Of 450 CRCs, 153 had undergone DCBE; 152 RDCBEs. Reports were analysed to establish concurrence between radiographer and radiologist and final CRC diagnosis.

RESULTS

By category: C1 - 37%, C2 - 31%, C3 - 21%, C4 - 11%, C5 - 0%. C4s included polyps (50%), cancer (12.5%), disrupted anastomosis (8%) and colitis (4%). There was no discrepancy between RDCBE and radiologist reports. Radiology and CRC diagnosis agreed in 145 of 152 DCBEs. There were three exclusions: DCBEs occurred outside the study period (2), one only with raised possibility of malignancy. Of eight remaining RDCBEs, seven were false negatives and one false positive. Sensitivity score for RDCBE was 94.5%. Double reporting by a radiologist did not improve sensitivity.

CONCLUSION

RDCBEs are as accurate as those performed by radiologists and have a very high sensitivity for CRC. In a time of ever increasing demands for complex staging investigations for CRC and interventional radiology, the ACPGBI needs to reconsider its guidelines on radiographers not only performing but also reporting DCBE.

Laparoscopic ventral rectopexy, posterior colporrhaphy and vaginal sacrocolpopexy for the treatment of recto-genital prolapse and mechanical outlet obstruction

OBJECTIVE

Whilst trans-abdominal fixation +/- resection offers better functional results and lower recurrence than perineal procedures, mesh rectopexy is complicated by constipation. Laparoscopic autonomic nerve-sparing, ventral rectopexy allows correction of the underlying abnormalities of the rectum, vagina, bladder and pelvic floor.

METHOD

A prospective database was used to audit our 7-year experience of this technique. The recto-vaginal septum was mobilized anteriorly to the pelvic floor avoiding nerve damage. A prolene mesh was sutured to the ventral rectum, posterior vagina and vaginal fornix and secured to the sacral promontory. Patients were assessed with questionnaires and Cleveland Clinic scores.

RESULTS

Eighty patients, six males, median age 59 years (range 31-90) underwent laparoscopic prolapse surgery between Jan 1997 and Dec 2005; 55% had full thickness prolapse and 46% rectal anal intussusception. Five had a solitary rectal ulcer. A total of 58% had undergone previous surgery; hysterectomy 33%, posterior colporrhaphy 15%, posterior rectopexy 6%, Delorme's rectal mucosectomy 5% and Birch colposuspension 3%. Half (54%) were incontinent (mean Wexner score 11, range 2-17) and 31% reported symptoms of obstructed defecation; seven had slow transit constipation and underwent resection. The median operative time was 125 min (range 50-210) with one conversion. Median time to diet was 12 h and median length of stay 3 days (1-12). No patient has developed recurrent full thickness prolapse at a median follow-up of 54 months (30-96). Incontinence improved in 39 of 43 patients (91%); median post-operative Wexner score 1 (0-9). Obstructed defecation resolved in 20 of 25 patients (80%). Pelvic pain resolved in all but one. Complications occurred in 21%; faecal impaction 4%, wound infection 2%, bleeding 2%, leak 1%, chest infection 1%, retention 1%. Three developed minor evacuatory difficulties and two, urinary stress incontinence.

CONCLUSION

Laparoscopic ventral rectopexy is safe with relatively low morbidity. In the medium-term, it provides good results for prolapse and associated symptoms of incontinence and obstructed defecation.

V·O2 Kinetics during Supramaximal Exercise: Relationship with Oxygen Deficit and 800-m Running Performance

The aim of this study was to compare .VO2 kinetics of highly- versus recreationally-trained subjects during a constant velocity test of supramaximal intensity. Eighteen trained male subjects were recruited to one of two groups: highly trained (HT, n = 8, .VO(2max) = 70.1 +/- 6.5 ml . min (-1) . kg (-1)) and recreationally trained (RT, n = 10, .VO(2max) = 63.2 +/- 6.4 ml . min (-1) . kg (-1)). All subjects performed an incremental test to exhaustion for the determination of .VO(2max) and peak treadmill velocity (PTV), two constant velocity tests at 110 % of PTV to determine .VO2 kinetics and oxygen deficit (O(2)def), and a 800-m time trial to determine running performance (mean velocity over the distance, V (800 m)). We found significant differences between HT and RT for the on-transient of the .VO2 response (tau, 24.7 +/- 3.3 and 30.9 +/- 7.0 s, respectively), the amplitude of the .VO2 response (60.0 +/- 5.0 and 53.5 +/- 5.7 ml . min (-1) . kg (-1), respectively) and V (800 m) (6.27 +/- 2.1 and 5.45 +/- 0.38 m . s (-1), respectively). O(2)def (24.6 +/- 2.7 and 27.7 +/- 7.8 ml . kg (-1), respectively) and the gain of the .VO2 response (193 +/- 14 and 194 +/- 13 ml . kg (-1) . m (-1), respectively) were similar between groups. tau was associated with O(2)def (r = 0.90, p < 0.05), but not with V (800 m) (r = 0.30, p > 0.05). It was concluded that HT subjects exhibited faster on-kinetics and higher amplitude than their RT counterparts. The higher amplitude was not thought to reflect any difference in underlying physiological mechanisms. The faster tau, whose exact mechanisms remain to be elucidated, may have practical implications for coaches.

Assessment of Maximal Aerobic Power and Critical Power in a Single 90-s Isokinetic All-Out Cycling Test

The purpose of this study was to establish the validity of a 90-s all-out test for the estimation of maximal oxygen uptake (V.O (2max)) and submaximal aerobic ability as represented by critical power. We hypothesized that the fall in power output by the end of the 90-s all-out test (end power) would represent the exhaustion of anaerobic work capability, and as such, would correspond with the critical power. Sixteen active individuals (mean +/- SD: 30 +/- 6 years; 69.6 +/- 9.9 kg) carried out a series of tests: (i) an incremental ramp test to determine V.O (2max), (ii) three fixed-work rate trials to exhaustion to determine critical power, and (iii) two 90-s all-out tests to measure end power and peak V.O (2). End power (292 +/- 65 W) was related to (r=0.89) but was significantly higher (p<0.01) than critical power (264 +/- 50 W). The mean +/- 95 % limits of agreement (29 +/- 65 W) were too low to use these variables interchangeably. The peak V.O (2) in the 90-s trial was significantly lower than the V.O (2max) (3435 +/- 682 ml x min (-1) vs. 3929 +/- 784 ml x min (-1); p<0.01); mean +/- 95 % limits of agreement was equal to 495 +/- 440 mL x min (-1). The 90-s all-out test cannot, therefore, assess both V.O (2max) and critical power in adult performers. The duration of all-out exercise required to allow V.O (2) to attain its maximum is longer than 90 s.

The distance – time relationship over a century of running Olympic performances: A limit on the critical speed concept

We analyse the evolution of the slope (critical speed) and the y-intercept (anaerobic distance capacity) of the linear distance-time relationship over a century of Olympic running performances. The distance-time relationship of each Olympic Games (1920-2004) was plotted using the performances in the 800-, 1500- and 5000-m track events. Values for critical speed and anaerobic distance capacity were determined by linear modelling. Mean performances for the 800, 1500 and 5000 m were 104.9 +/- 1.5 s (1.4%), 217.2 +/- 2.8 s (1.3%) and 808.9 +/- 18.4 s (2.3%), respectively. Critical speed improved during the first three-quarters of the twentieth century to reach a plateau in 1984. This is in accordance with the literature (Peronnet & Thibault, 1989) and suggests that "human aerobic endurance" has improved within the century (+13.4%) and tends to stabilize. Anaerobic distance capacity was highly variable over the century (coefficient of variation = 9.4%) and did not show a linear improvement over the years as has previously been suggested (Peronnet & Thibault, 1989). This could be due to an artefact in the application of the two-parameter model to only three Olympic performances. A limitation to the use of this linear mathematical model to fit physiological data may have been demonstrated.

Oxygen uptake kinetics during supra VO2max treadmill running in humans

Accurate classification of VO2 kinetics is essential to correctly interpret its control mechanisms. The purpose of this study was to examine VO2 kinetics in severe and supra-maximal intensity running exercise using two modelling techniques. Nine subjects (mean +/- S.D: age, 27 +/- 7 years; mass, 69.8 +/- 9.0 kg; VO2max, 59.1 +/- 1.8 mL x kg x min(-1)) performed a series of "square-wave" exercise transitions to exhaustion at running speeds equivalent to 80% of the difference between the VO2 at LT and VO2max (delta), and at 100%, 110% and 120% VO2max. The VO2 response was modelled with an exponential model and with a semi-logarithmic transformation, the latter assuming a certain steady state VO2. With the exponential model there was a significant reduction in the "gain" of the primary component in supra-maximal exercise (167 +/- 5 mL x kg(-1) x km(-1) at 80% delta to 142 +/- 5 mL x kg(-1) x km(-1) at 120% VO2max, p = 0.005). The time constant of the primary component also reduced significantly with increasing intensity (17.8 +/- 1.1 s at 80% delta to 12.5 +/- 1.2 s at 120% VO2max, p < 0.05). However, in contrast, using the semi-log model, the time constant significantly increased with intensity (30.9 +/- 13.5 s at 80% delta to 72.2 +/- 23.9 s at 120% VO2max, p < 0.05). Not withstanding the need for careful interpretation of mathematically modelled data, these results demonstrate that neither the gain nor the time constant of the VO2 primary component during treadmill running are invariant across the severe and supra-maximal exercise intensity domains when fit with an exponential model. This suggests the need for a reappraisal of the VO2/work rate relationship in running exercise.

Reproducibility of variables derived from a 90 s all-out effort isokinetic cycling test

AIM

The aim of this study was to examine the reliability of the power output profile obtained from a 90 s all-out isokinetic cycling test.

METHODS

Within a 10 day period, 16 participants (-x+/-s: age 30.1+/-6.4 years; body mass 69.2+/-10.6 kg) performed an incremental VO2 max ramp test and two 90 s all-out efforts on an isokinetic cycle ergometer. Peak power (PP), mean power (MP), end power (EP) and fatigue index (FI) were determined.

RESULTS

There were no significant differences between tests for MP, EP and FI values (P > 0.05) but PP was higher on the second test (P = 0.003). Ratio limits of agreement suggested that a repeated measurement might be expected in 95% of cases to be between 0.92 to 1.21 times the initial PP measurement and 0.97 to 1.07 times the initial MP measurement. The 95% limits of agreement for EP and fatigue were -23 to +33 W (1.8+/-9.7% of the mean) and -6.5% to 8.8% (2+/-7.6% of the mean), respectively.

CONCLUSIONS

The 90 s all-out test appears to be a reliable test for given aspects of the physiological profile, with the exception of PP.

Validity of the two-parameter model in estimating the anaerobic work capacity

The curvature of the power-time (P-t) relationship (W') has been suggested to be constant when exercising above critical power (CP) and to represent the anaerobic work capacity (AWC). The aim of this study was to compare W' to (1) the total amount of work performed above CP (W (90s)') and (2) the AWC, both determined from a 90s all-out fixed cadence test. Fourteen participants (age 30.5 +/- 6.5 years; body mass 67.8 +/- 10.3 kg), following an incremental VO(2max) ramp protocol, performed three constant load exhaustion tests set at 103 +/- 3, 97 +/- 3 and 90 +/- 2% P-VO(2max) to calculate W' from the P-t relationship. Two 90s all-out efforts were also undertaken to determine W (90s)' (power output-time integral above CP) and AWC (power output-time integral above the power output expected from the measured VO(2)). W' (13.6 +/- 1.3 kJ) and W (90s)' (13.9 +/- 1.1 kJ; P = 0.96) were not significantly different but were lower than AWC (15.9 +/- 1.2 kJ) by 24% (P = 0.03) and 17%, respectively (P = 0.04). All these variables were correlated (P < 0.001) but great extents of disagreement were reported (0.2 +/- 6.4 kJ between W' and W (90s)', 2.3 +/- 7.2 kJ between W' and AWC, and 2.1 +/- 4.3 kJ between W (90s)' and AWC). The underestimation of AWC from both W' and W (90s)' can be explained by the aerobic inertia not taking into consideration when determining the two latter variables. The low extents of agreement between W', W (90s)' and AWC mean the terms should not be used interchangeably.

Externalising deep brain electrodes: an increased risk of infection?

It is the practice in many centres to externalise deep brain electrodes in functional neurosurgery to confirm efficacy of therapy prior to full implantation of the pacemaker. It has been a concern that such practice might lead to an increased rate of infection. We report a retrospective study of the rates of infection in two major centres where all electrodes are externalised in one centre and directly implanted in the other. We have not found an increased rate of infection as a result of externalisation and feel, particularly in pain patients, that doing so can lead to significant cost savings by avoiding ineffective implantations.

Oxygen Uptake-Work Rate Relationship During Two Consecutive Ramp Exercise Tests

The performance of prior high intensity constant work rate (CWR) exercise significantly influences the gain of the fundamental oxygen uptake (VO2) response during subsequent high intensity CWR exercise. The purpose of the present study was to investigate whether equivalent effects could be elicited in the second of two bouts of exhaustive ramp exercise. We therefore hypothesised that a prior bout of exhaustive ramp exercise would increase the VO2-work rate (DeltaVO2/DeltaWR) slope during subsequent ramp exercise. Nine healthy males performed two ramp exercise tests to exhaustion on an electrically braked cycle ergometer separated by a 10-min period of cycling at 20 W. Pulmonary VO2 was measured breath-by-breath throughout both tests, and the mean response time (MRT) and the DeltaVO2/DeltaWR slope for exercise below the gas exchange threshold (GET) (S1), above the GET (S2), and over the S1 + S2 region (ST) were determined. Paired t-tests were used to analyse the data with significance accepted at p < 0.05. Blood [lactate] was higher at the onset of the second ramp test compared to the first (mean +/- SEM 1.2 +/- 0.1 vs. 6.2 +/- 0.7 mM; p < 0.01), but baseline VO2 was not significantly different between tests (0.93 +/- 0.05 vs. 0.99 +/- 0.06 L. min (-1)). The MRT (42 +/- 4 vs. 40 +/- 5 s) did not differ between tests, but the DeltaVO2/DeltaWR slope was steeper in the second ramp test for S2 (9.1 +/- 0.4 vs. 9.8 +/- 0.5 ml. min (-1). W (-1); p < 0.01) and ST (9.0 +/- 0.4 vs. 9.6 +/- 0.5 ml. min (-1). W (-1); p < 0.05). The demonstration that prior ramp exercise increases the DeltaVO2/DeltaWR slope during subsequent ramp exercise is consistent with the results of previous CWR studies and indicates that exercise economy is sensitive to the prior activity of the engaged muscles.

Post-herpetic trigeminal neuralgia treated with deep brain stimulation

Post-herpetic neuralgic affects up to 20% of patients after an attack of trigeminal Herpes Zoster infection. Past medical and surgical treatments have been unrewarding. We report the successful treatment of such a case with deep brain stimulation into the region of the contralateral periventricular grey area (PVG) and ventral posterior lateral thalamic nucleus (VPL).

Prevalence of hepatitis B and C infection in a methadone clinic population: implications for hepatitis B vaccination

AIMS

To examine the HBV and HCV markers of injecting drug users on methadone maintenance, and the feasibility of vaccination at the drug clinic.

METHODS

Systematic serological testing of patients for hepatitis B and C was undertaken, and free hepatitis B vaccination was offered via arranged clinic appointments.

RESULTS

Hepatitis B serology was obtained in 163 of the 220 clinic patients. 85 (52.1%) patients had evidence of hepatitis B exposure, and 3 (1.8%), of previous vaccination. Positive hepatitis B markers were associated with increasing age (p=0.004), and the duration of injecting prior to treatment (p=0.008). Hepatitis B and C serology was obtained for 153 patients, with 76 (49.7%) having evidence of dual exposure. 164 (84.1%) of 195 patients were positive for antibody to hepatitis C. Completion of the vaccine course was lower than anticipated (36.5% of HBV negative patients).

CONCLUSIONS

The high rates of hepatitis B exposure in injecting drug users on methadone treatment confirm the need for hepatitis B vaccination, particularly in view of their endemic hepatitis C infection. Monitoring of this group for the development of chronic liver disease and hepatocellular carcinoma is recommended. Routine cost-free vaccination of patients on entering drug treatment, using a rapid vaccination schedule, may improve compliance.

The vitamin D3 analog, ILX-23-7553, enhances the response to adriamycin and irradiation in MCF-7 breast tumor cells

Ionizing radiation and the anthracycline antibiotic, Adriamycin, generally fail to promote a primary apoptotic response in experimental breast tumor cell lines. Similarly, the primary response of breast tumor cells to vitamin D3 (1,25(OH)2D3) and vitamin D3 analogs such as EB 1089 is growth inhibition. Previous studies have demonstrated that pretreatment of MCF-7 breast tumor cells with vitamin D3 or EB 1089 can increase sensitivity to both Adriamycin and irradiation.

PURPOSE

The capacity of the vitamin D3 analog, ILX 23-7553, to enhance the antiproliferative and cytotoxic effects of Adriamycin or irradiation and to promote apoptosis in MCF-7 breast tumor cells was assessed in the present study.

RESULTS

Pretreatment of MCF-7 cells with ILX 23-7553 followed by Adriamycin or irradiation decreased viable cell numbers by 97% and 93%, respectively. Cell numbers were reduced by 56%, 74% and 75% by ILX 23-7553, Adriamycin and irradiation alone. Pretreatment with ILX 23-7553 also shifted the dose response curve for clonogenic survival, increasing sensitivity to Adriamycin 2.5-fold and sensitivity to radiation fourfold. In addition, ILX 23-7553 pretreatment conferred sensitivity to Adriamycin- or irradiation-induced DNA fragmentation and resulted in morphological changes indicative of apoptotic cell death in MCF-7 cells. Statistical analysis demonstrated that ILX 23-7553 interacts additively and not synergistically with both Adriamycin and irradiation.

CONCLUSIONS

ILX 23-7553 enhances the effects of Adriamycin and irradiation in MCF-7 breast tumor cells by decreasing viable cell numbers, reducing clonogenic survival and inducing apoptotic cell death. Current studies are focused on elucidating the mechanisms underlying the induction of apoptosis as well as understanding the nature of the interactions between ILX 23-7553 and Adriamycin or irradiation.

Counselling for alcohol problems in primary care in Forth Valley--an innovative approach?

OBJECTIVE

To explore the implications of establishing a voluntary sector provided alcohol counselling service within a Primary Care setting in Forth Valley Health Board area, and to evaluate the potential of such a project.

DESIGN

Analysis of routinely held information and postal questionnaire survey.

SETTING

North and South Local Health Care Co-operatives, Forth Valley Primary Care NHS Trust in conjunction with Central Scotland Council on Alcohol (CSCA).

SUBJECTS

Users of counselling service and local general practitioners.

RESULTS

General practitioners referred a total of 349 people with 284 attending for counselling. Survey of a sample of 80 service users achieved a 45% response rate. Of those who responded a majority (89%) said that the health centre location was an important factor in their ability to use and therefore benefit from the service. Accessibility, quality and confidentiality of the counselling service were important factors determining ability to attend and benefit from counselling. The survey of local general practitioners achieved a 69% response. The majority (96%) of general practitioners reported the service to be either extremely valuable or very helpful. General Practitioners listed 3 major benefits as confidentiality, accessibility and cost effectiveness. A significant minority of general practitioners (24%) reported that they were unaware that the service existed. Compared with other routine CSCA counselling services people's reported alcohol consumption was some 18% higher in those referred to the primary care based counselling service. At review, four weeks later, the average reported alcohol consumption had decreased considerably. People using the counselling service reported that the service helped them reduce their alcohol consumption, improve their general health and their personal relationships.

CONCLUSION

This project has demonstrated that a voluntary sector agency can work closely and successfully with primary care services in establishing counselling services for those with alcohol problems. Early evaluation would point towards success in terms of reducing reported levels of drinking and improved health. Local general practitioners indicated their support for continued development of this type of service provision.

Oxygen uptake kinetics during treadmill running in boys and men

The purpose of this study was to compare the kinetics of the oxygen uptake (VO(2)) response of boys to men during treadmill running using a three-phase exponential modeling procedure. Eight boys (11-12 yr) and eight men (21-36 yr) completed an incremental treadmill test to determine lactate threshold (LT) and maximum VO(2). Subsequently, the subjects exercised for 6 min at two different running speeds corresponding to 80% of VO(2) at LT (moderate exercise) and 50% of the difference between VO(2) at LT and maximum VO(2) (heavy exercise). For moderate exercise, the time constant for the primary response was not significantly different between boys [10.2 +/- 1.0 (SE) s] and men (14.7 +/- 2.8 s). The gain of the primary response was significantly greater in boys than men (239.1 +/- 7.5 vs. 167.7 +/- 5.4 ml. kg(-1). km(-1); P < 0.05). For heavy exercise, the VO(2) on-kinetics were significantly faster in boys than men (primary response time constant = 14.9 +/- 1.1 vs. 19.0 +/- 1.6 s; P < 0.05), and the primary gain was significantly greater in boys than men (209.8 +/- 4.3 vs. 167.2 +/- 4.6 ml. kg(-1). km(-1); P < 0.05). The amplitude of the VO(2) slow component was significantly smaller in boys than men (19 +/- 19 vs. 289 +/- 40 ml/min; P < 0.05). The VO(2) responses at the onset of moderate and heavy treadmill exercise are different between boys and men, with a tendency for boys to have faster on-kinetics and a greater initial increase in VO(2) for a given increase in running speed.

Effects of prior exercise and recovery duration on oxygen uptake kinetics during heavy exercise in humans

Prior heavy exercise (above the lactate threshold, LT) reduces the amplitude of the pulmonary oxygen uptake (VO2) slow component during heavy exercise, yet the precise effect of prior heavy exercise on the phase II VO2 response remains to be established. This study was designed to test the hypotheses that (1) prior heavy exercise increases the amplitude of the phase II VO2 response independently of changes in the baseline VO2 value and (2) the effect of prior exercise depends on the amount of external work done during prior exercise, irrespective of the intensity of the prior exercise. Nine subjects performed two 6 min bouts of heavy cycling exercise separated by 6 min baseline pedalling recovery (A), two 6 min heavy exercise bouts separated by 12 min recovery (6 min rest and 6 min baseline pedalling, B), and a bout of moderate exercise (below the LT) in which the same amount of external work was performed as during the prior heavy exercise, followed by 6 min heavy exercise (C). In both tests A and B, prior heavy exercise significantly increased the absolute VO2 amplitude at the end of phase II (by approximately 150 ml x min(-1)), and reduced the amplitude of the VO2 slow component by a similar amount. Following 12 min of recovery (B), baseline VO2, but not blood [lactate], had returned to pre-exercise levels, indicating that these effects occurred independently of changes in baseline VO2. Prior moderate exercise (C) had no effect on either the VO2 or blood [lactate] responses to subsequent heavy exercise. The VO2 response to heavy exercise was therefore dependent on the intensity of prior exercise, and the effects on the amplitudes of the phase II and slow VO2 components persisted for at least 12 min following prior heavy exercise.

Androstenetriol and androstenediol. Protection against lethal radiation and restoration of immunity after radiation injury

Androstenetriol (AET) and Androstenediol (AED) upregulate host immunity, leading to increased resistance against infections. AET augments IL-2, IL-3, IFN gamma levels, and counteracts hydrocortisone immune suppression. AET and AED at a dose of 0.75 mg/- and 8.0 mg/25-g mouse, protected 60 and 70%, respectively, of C57/BL/6J mice irradiated with a lethal dose. These hormones also protected mice irradiated with 6 Gy and infected with a coxsackievirus B4 LD50. AET significantly increased spleen lymphocyte numbers at 7, 14, and 21 days after a 6-Gy exposure. Fluorescent activated cell-sorter analysis of irradiated mice, spleen, and bone marrow showed that AET significantly augmented the myeloid precursor markers, CD11b/Mac-1, and B220 (pan B), as well as the absolute numbers of CD4+/CD8+ cells over the 21 days of testing. Overall, the data are consistent with AET/AED inducing a more rapid recovery of all hematopoietic precursors from the small number of surviving stem cells.

Hospital referrals to a hospice: timing of referrals, referrers' expectations, and the nature of referral information

Hospital referrals to Mary Potter Hospice were reviewed prior to the implementation of a new hospital palliative care support service. The hospital palliative care service aims to improve the communication between health professionals in the acute hospital and hospice, and to advise the hospital staff on its management of terminally ill patients. The purpose of this review was to provide baseline information that would assist the hospice with the planning and future evaluation of the new service. Information included the timing of the referrals, the type of referral information provided by hospital doctors, and their expectations of hospice care. One fifth of patients were referred near to death. While medical information was nearly always provided on referral, information on the psychological, spiritual and social dimensions of care was often absent. A third of hospital doctors expressed their expectation of the hospice as "to take over" the patient's care. This suggests the hospital palliative care support service should encourage health professionals to take a more active role in caring for dying patients. The findings are discussed in relation to the goals of the new hospital palliative care support service.