Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Climate change adaptation in conflict-affected countries: A systematic assessment of evidence

People affected by conflict are particularly vulnerable to climate shocks and climate change, yet little is known about climate change adaptation in fragile contexts. While climate events are one of the many contributing drivers of conflict, feedback from conflict increases vulnerability, thereby creating conditions for a vicious cycle of conflict. In this study, we carry out a systematic review of peer-reviewed literature, taking from the Global Adaptation Mapping Initiative (GAMI) dataset to documenting climate change adaptation occurring in 15 conflict-affected countries and compare the findings with records of climate adaptation finance flows and climate-related disasters in each country. Academic literature is sparse for most conflict-affected countries, and available studies tend to have a narrow focus, particularly on agriculture-related adaptation in rural contexts and adaptation by low-income actors. In contrast, multilateral and bilateral funding for climate change adaptation addresses a greater diversity of adaptation needs, including water systems, humanitarian programming, and urban areas. Even among the conflict-affected countries selected, we find disparity, with several countries being the focus of substantial research and funding, and others seeing little to none. Results indicate that people in conflict-affected contexts are adapting to climate change, but there is a pressing need for diverse scholarship across various sectors that documents a broader range of adaptation types and their results.

0534 Cognitive Behavioral Therapy for Perinatal Insomnia: Effects on Postpartum Depressive Symptoms

Introduction

Poor sleep during pregnancy is a risk for postpartum depression. Using data from an RCT of CBT-I for insomnia disorder during pregnancy, we examined whether improvement in insomnia reduced postpartum depression symptom severity. We hypothesized that better response to treatment during pregnancy would result in lower depressive symptom severity during the postpartum.

Methods

Pregnant women (N=179; gestation age 18-30 weeks) with insomnia disorder were randomized to CBT-I or an active control (CTRL) therapy (5 sessions during pregnancy, one at 6 weeks postpartum). Women with depressive disorders and those using prescription medications that impact sleep were excluded. The Insomnia Severity Index (ISI) and the Edinburgh Postpartum Depression Scale (EPDS) were administered at baseline, during pregnancy, and at 8, 18, and 30 weeks postpartum. The Perinatal Risk Questionnaire (PRQ) was administered at baseline. Included in the analyses were women who provided data for at least one of three postpartum assessments (62 in CBT-I; 55 in CTRL).

Results

Mixed effects models revealed that lower ISI following the pregnancy treatment phase (p < .001) and greater reduction in ISI during pregnancy (p = .053) predicted overall lower EPDS scores during postpartum; but these effects did not differ significantly between treatment arms. Average postpartum EPDS scores, which were low overall, were higher in women with ISI score at or above the median of 9 (6.6±3.9), compared to those below the median (3.5±3.3). Compared to CTRL, participants in the CBT-I condition were nearly twice likely to have ISI scores below the median following the pregnancy treatment phase (29.1% versus 56.5%). Although higher PRQ scores were associated with overall higher postpartum EPDS (p=.0026), PRQ did not moderate postpartum EPDS trajectories.

Conclusion

We have previously shown that CBT-I is effective for antenatal insomnia, which is a risk for postpartum depression. Our current findings suggest that improving insomnia in pregnancy may reduce the risk for postpartum depression. Limitations include a small sample and missing data during the postpartum follow-up. A larger study among women specifically at risk for postpartum depression could help identify patient related factors that predict therapeutic benefits of CBT-I on postpartum depression.

Support

NR013662

0499 Predictors of Session Attendance in a RCT for CBT-I for Perinatal Insomnia

Introduction

Cognitive behavioral therapy for insomnia (CBT-I) is recommended as the first-line treatment for chronic insomnia disorder. However, early treatment dropout can negatively impact the success of treatment. In order to design effective strategies to reduce attrition we need to understand predictors of dropout. In this work, we focus on predictors of treatment session attendance among pregnant women in a randomized controlled trial of CBT-I.

Methods

Participants were 87 pregnant women with insomnia disorder (mean age=32.5, SD=5.1 years) who were enrolled in a randomized controlled trial of CBT-I and were randomized to the CBT-I arm (5 sessions). We did not include women who did not complete treatment due to early labor. The Insomnia Severity Index (ISI) and Edinburgh Postnatal Depression Scale (EPDS) and demographic questionnaires (age, income, and educational background) were administered at screening.

Results

Logistic regression analyses were conducted to identify predictors of number of CBT-I sessions attended during pregnancy. A logistic regression model that included clinical predictors found that the ISI and EPDS were not significant predictors of session attendance. A logistic regression model that included demographic predictors (income, education, and age) was significant (F(3,76)=6.49, p<0.001) with an R² of .204. Independently, income was not a significant predictor (β =.15, p=.32), but education (β =-.21, p<.05) and age (β =-.48, p<.01) were significant predictors of fewer sessions attended. Dropping income from the model, there was a significant age by education effect (β =1.39, p<.05). Among participants with less than a college degree, those who were younger had attended fewer sessions during pregnancy. Among those who completed a college education and above, number of sessions attended did not differ by age.

Conclusion

Pregnant women with insomnia who were randomized to receive CBT-I were more likely to withdraw early from treatment if they were younger and had less than a college education. Further research that focuses on increasing attendance in CBT-I treatment among pregnant women needs to develop strategies to increase retention in this vulnerable population.

Support

NR013662

Predicting delivery of a small-for-gestational-age infant and adverse perinatal outcome in women with suspected pre-eclampsia

OBJECTIVE

To evaluate the test performance of 47 biomarkers and ultrasound parameters for the prediction of delivery of a small-for-gestational-age (SGA) infant and adverse perinatal outcome in women presenting with suspected pre-eclampsia.

METHODS

This was a prospective, multicenter observational study in which 47 biomarkers and ultrasound parameters were measured in 397 women with a singleton pregnancy presenting with suspected preterm pre-eclampsia between 20 + 0 and 36 + 6 weeks' gestation, with the objective of evaluating them as predictors of subsequent delivery of a SGA infant and adverse perinatal outcome. Women with confirmed pre-eclampsia at enrollment were excluded. Factor analysis and stepwise logistic regression were performed in two prespecified groups stratified according to gestational age at enrollment. The primary outcome was delivery of a SGA infant with a birth weight < 3^rd customized centile (SGA-3), and secondary outcomes were a SGA infant with a birth weight < 10^th customized centile and adverse perinatal outcome.

RESULTS

In 274 women presenting at 20 + 0 to 34 + 6 weeks' gestation, 96 (35%) delivered a SGA-3 infant. For prediction of SGA-3, low maternal placental growth factor (PlGF) concentration had a sensitivity of 93% (95% CI, 84-98%) and negative predictive value (NPV) of 90% (95% CI, 76-97%) compared with a sensitivity of 71% (95% CI, 58-82%) and a NPV of 79% (95% CI, 68-87%) for ultrasound parameters (estimated fetal weight or abdominal circumference < 10^th centile). No individual biomarker evaluated had a better performance than did PlGF, and marker combinations made only small improvements to the test performance. Similar results were found in 123 women presenting between 35 + 0 and 36 + 6 weeks' gestation.

CONCLUSION

In women presenting with suspected preterm pre-eclampsia, measurement of PlGF offers a useful adjunct for identifying those at high risk of delivering a SGA infant, allowing appropriate surveillance and timely intervention. © 2017 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Scottish survey of learning disability psychiatrists

Aims and Method

A survey was undertaken to determine the working arrangements of learning disability psychiatrists in Scotland. A questionnaire was sent to each of the 15 NHS providers of learning disabilities services in Scotland. Results were converted to the equivalent of whole time equivalent (WTE) consultant.

Results

The results showed a wide range in the level of psychiatric staffing throughout services. The median consultant learning disability psychiatrist in Scotland covers a catchment population of 160 000 and works with 0.65 WTE non-consultant career-grade psychiatrists and 0.68 WTE training-grade psychiatrists. They are responsible for a median of 3.7 assessment and treatment beds, no rehabilitation beds, no day hospital places, 23 long-stay beds, 0.6 respite beds and 0.7 forensic beds. At the time of the survey, 15.6% of consultant posts were vacant.

Clinical Implications

Service provision appears to be variable across Scotland. The implications of this may warrant closer scrutiny.

Free Fluid Accumulation following Blunt Abdominal Trauma: Potential for Expansion of the Fast Protocol

Objective

To determine sites of free intra-peritoneal fluid collection following blunt abdominal trauma, with a view to refinement of the Focused Assessment by Sonography for Trauma (FAST) protocol.

Methods

This was a retrospective observational study of CT scans of subjects who had suffered blunt abdominal trauma and had free intra-peritoneal fluid detected on CT scan within 24 hours. The depth from the skin and amount of fluid at 14 abdominal sites were determined.

Results

CT scans of 105 patients were examined: 68 (64.8%) were male, mean age 36.7±18.4 years, mean injury severity score 25.4±11.6. Fluid collected most commonly at three sites: right mid-axillary line at the level of the xiphisternum (52 patients, 49.5%), lateral margin of the right rectus muscle at the level of the anterior superior iliac spine (49 patients, 46.7%) and right mid-axillary line at the level of the umbilicus (40 patients, 38.1%). Mean depth of fluid at these sites were 3.6, 3.6 and 4.2 cm, respectively.

Conclusions

Free fluid collects commonly in the area of the right iliac fossa following blunt abdominal trauma. The inclusion of this site in the FAST protocol may increase the ultrasonographic detection of free fluid in the acute trauma setting.

Statistical modelling studies examining the dimensional structure of psychopathology experienced by adults with intellectual disabilities: Systematic review

Diagnosing mental ill-health using categorical classification systems has limited validity for clinical practice and research. Dimensions of psychopathology have greater validity than categorical diagnoses in the general population, but dimensional models have not had a significant impact on our understanding of mental ill-health and problem behaviours experienced by adults with intellectual disabilities. This paper systematically reviews the methods and findings from intellectual disabilities studies that use statistical methods to identify dimensions of psychopathology from data collected using structured assessments of psychopathology. The PRISMA framework for systematic review was used to identify studies for inclusion. Study methods were compared to best-practice guidelines on the use of exploratory factor analysis. Data from the 20 studies included suggest that it is possible to use statistical methods to model dimensions of psychopathology experienced by adults with intellectual disabilities. However, none of the studies used methods recommended for the analysis of non-continuous psychopathology data and all 20 studies used statistical methods that produce unstable results that lack reliability. Statistical modelling is a promising methodology to improve our understanding of mental ill-health experienced by adults with intellectual disabilities but future studies should use robust statistical methods to build on the existing evidence base.

Information and Communication Technology: Design, Delivery, and Outcomes from a Nursing Informatics Boot Camp

Information and communication technology (ICT) is integral in today’s healthcare as a critical piece of support to both track and improve patient and organizational outcomes. Facilitating nurses’ informatics competency development through continuing education is paramount to enhance their readiness to practice safely and accurately in technologically enabled work environments. In this article, we briefly describe progress in nursing informatics (NI) and share a project exemplar that describes our experience in the design, implementation, and evaluation of a NI educational event, a one-day boot camp format that was used to provide foundational knowledge in NI targeted primarily at frontline nurses in Alberta, Canada. We also discuss the project outcomes, including lessons learned and future implications. Overall, the boot camp was successful to raise nurses’ awareness about the importance of informatics in nursing practice.

Diagnostic accuracy of placental growth factor and ultrasound parameters to predict the small-for-gestational-age infant in women presenting with reduced symphysis-fundus height

OBJECTIVES

To assess the diagnostic accuracy of placental growth factor (PlGF) and ultrasound parameters to predict delivery of a small-for-gestational-age (SGA) infant in women presenting with reduced symphysis-fundus height (SFH).

METHODS

This was a multicenter prospective observational study recruiting 601 women with a singleton pregnancy and reduced SFH between 24 and 37 weeks' gestation across 11 sites in the UK and Canada. Plasma PlGF concentration < 5(th) centile, estimated fetal weight (EFW) < 10(th) centile, umbilical artery Doppler pulsatility index > 95(th) centile and oligohydramnios (amniotic fluid index < 5 cm) were compared as predictors for a SGA infant < 3(rd) customized birth-weight centile and adverse perinatal outcome. Test performance statistics were calculated for all parameters in isolation and in combination.

RESULTS

Of the 601 women recruited, 592 were analyzed. For predicting delivery of SGA < 3(rd) centile (n = 78), EFW < 10(th) centile had 58% sensitivity (95% CI, 46-69%) and 93% negative predictive value (NPV) (95% CI, 90-95%), PlGF had 37% sensitivity (95% CI, 27-49%) and 90% NPV (95% CI, 87-93%); in combination, PlGF and EFW < 10(th) centile had 69% sensitivity (95% CI, 55-81%) and 93% NPV (95% CI, 89-96%). The equivalent receiver-operating characteristics (ROC) curve areas were 0.79 (95% CI, 0.74-0.84) for EFW < 10(th) centile, 0.70 (95% CI, 0.63-0.77) for low PlGF and 0.82 (95% CI, 0.77-0.86) in combination.

CONCLUSIONS

For women presenting with reduced SFH, ultrasound parameters had modest test performance for predicting delivery of SGA < 3(rd) centile. PlGF performed no better than EFW < 10(th) centile in determining delivery of a SGA infant.

Fractionated stereotactic radiotherapy for acoustic neuromas: long-term outcomes

AIMS

Acoustic neuromas are rare, benign intracranial tumours. There are a variety of treatment options, with no clear optimal management strategy and wide variation in treated outcomes. We report the outcomes from a 15 year cohort of patients treated at our centre using fractionated stereotactic radiotherapy (52.5 Gy in 25 fractions).

MATERIALS AND METHODS

We analysed a retrospective case series. Patients were identified from patient records and a retrospective review of case notes and imaging reports was undertaken. We assessed tumour response using RECIST criteria and recorded toxicity. Progression-free survival was estimated using the Kaplan-Meier method. The study was conducted according to the STROBE guidelines.

RESULTS

In total, 93 patients were identified; 83 patients had follow-up data, with a median follow-up period of 5.7 years. The overall control rate using RECIST criteria was 92%. Data on complications were available for 90 patients, with six (7%) experiencing a reduction in hearing, one (1%) developing trigeminal nerve dysfunction and one (1%) a deterioration in facial nerve function. Other toxicities included four (4%) patients who developed hydrocephalus, requiring the placement of a shunt and one (1%) patient who developed radiation brainstem necrosis. After further evaluation this patient was deemed to have been treated within acceptable dose constraints.

CONCLUSION

These data suggest that a good control rate of acoustic neuromas is achievable using fractionated stereotactic radiotherapy to a dose of 52.5 Gy in 25 fractions. Toxicity is considered acceptable but the episode of radiation brainstem necrosis remains of concern and is the subject of further work.

Effects of shift length on quality of patient care and health provider outcomes: systematic review

BACKGROUND

Healthcare providers work increasingly under a variety of shift work systems to cover the continuous care required by patients. However, the effects of shift work on patient and provider outcomes in healthcare settings has not been systematically evaluated.

OBJECTIVE

To identify and analyse the available evidence on the effect of shift length (8-h vs 12-h shifts) on quality of patient care and healthcare provider outcomes.

METHODS

Systematic searching of eight online databases, key governmental/organisational websites and academic journals with ancestry search of relevant articles (limited to articles published in English and Spanish).

RESULTS

Of 562 articles that were retrieved from 20 446 titles identified through database and manual searches, 27 satisfied the inclusion criteria, of which 15 were rejected because of low methodological quality. The 12 final studies included cross-sectional/survey (7), before-after (3) and prospective cohort (2) designs. The main primary outcomes evaluated were: (1) quality of patient care and (2) healthcare provider outcomes. The results were equivocal. With respect to the effect of shift length on quality of patient care, two studies found that errors and near errors were associated with working longer shifts, and another study reported decreased patient complications and length of stay with longer shifts. Specific healthcare provider outcomes such as health complaints, well-being, drug and alcohol consumption, stress and job satisfaction were mostly evaluated by single studies and therefore there was insufficient evidence from which to draw conclusions.

CONCLUSIONS

Methodological quality of the studies generally was low and results equivocal with insufficient evidence to determine the effects of shift length on quality of patient care and healthcare provider outcomes. Clearly, robust well-designed studies are needed to examine the effect of shift length on patient and healthcare provider outcomes.

Foreign-body ingestion: characteristics and outcomes in a lower socioeconomic population with predominantly intentional ingestion

BACKGROUND

Previous reports of foreign-body ingestions focused primarily on accidental ingestions.

OBJECTIVE

To describe the characteristics and management of foreign-body ingestions, with predominantly intentional ingestion, in a lower socioeconomic status population.

DESIGN

A retrospective case series.

SETTING

An urban county hospital.

PATIENTS

Patients >/=17 years old, with foreign-body ingestions between 2000 and 2006.

MAIN OUTCOME MEASUREMENTS

Characteristics of ingestion cases, endoscopic extraction, need for surgery, and complications.

RESULTS

Among 262 cases, 92% were intentional, 85% involved psychiatric patients, and 84% occurred in patients with prior ingestions. The time from ingestion to presentation was >48 hours in 168 cases (64%). The overall success rate for endoscopic extraction was 90% (165/183 cases). Surgery was performed in 30 cases (11%) and was more common for objects beyond the pylorus versus objects above the pylorus (16/43 [37%] vs 10/151 [7%], respectively) and in cases with a greater delay from ingestion to presentation (25/168 [15%] if >48 hours vs 4/77 [5%] if </=48 hours) and from presentation to intervention (15/40 [38%] if >48 hours vs 14/165 [8%] if </=48 hours). Perforation occurred in 16 cases (6%), with 6 perforations noted after endoscopy.

LIMITATION

A retrospective review of medical records.

CONCLUSIONS

Foreign-body ingestions in an urban county hospital occurred primarily in psychiatric patients who had repeated episodes of intentional ingestions. Endoscopic extraction was unsuccessful in 10% of cases. Long delays from ingestion to presentation and intervention may account for relatively high rates of surgery and perforation. Strategies to prevent ingestions and delays in endoscopic management are needed in this population.

Long-term survival of patients with unresectable hepatocellular carcinoma treated with transcatheter arterial chemoinfusion

BACKGROUND

Transcatheter arterial chemoembolization (TACE) has become one of the most common treatments for unresectable hepatocellular carcinoma. Published studies of TACE report a 5-16% risk of serious complications. Compared with TACE, transcatheter arterial chemoinfusion (TACI) may have similar efficacy and fewer side effects.

AIM

To examine the clinical outcomes of TACI.

METHODS

We performed a retrospective cohort study of 345 consecutive TACI cases in 165 patients performed at a single United States medical center between 1998 and 2002. Primary outcomes were tumour response and survival rates.

RESULTS

Only seven patients were hospitalized for more than 24 h after the procedure, and only three patients had worsening of liver function within 30 days of TACI. Survival was significantly poorer for patients with tumour-node-metastasis (TNM) IV compared to those with TNM I-III and also for patients with Child's class B/C vs. A. Following adjustment for age, gender, ethnicity and aetiology of liver diseases, independent predictors of poor survival were Child's class B/C [Hazard Ratio (HR) = 1.69, P = 0.024] and TNM IV staging (HR = 1.63, P = 0.014).

CONCLUSIONS

TACI appears to be safe and effective for unresectable hepatocellular carcinoma with TNM stage I-III; randomized controlled trials are needed to compare TACI to TACE.

Comparison of renal allograft outcomes in combined liver-kidney transplantation versus subsequent kidney transplantation in liver transplant recipients: Analysis of UNOS Database

BACKGROUND

There may be an allograft-enhancing effect by the liver on the renal allograft in the setting of simultaneous combined liver-kidney transplantation (CLKT) from the same donor. This study was performed to investigate whether an existing liver allograft could protect a kidney allograft from immunologic injury due to histoincompatibility in liver transplant recipients who received sequential kidney transplantation (KALT).

METHODS

Using the United Network for Organ Sharing database covering January 1996 to December 2003, outcomes of 352 KALT were compared to 1,136 CLKT. Incidence of acute and chronic rejection and rejection-free renal graft survival was compared between two groups.

RESULTS

Renal half-life of KALT allografts was shorter than CLKT group (6.6+/-0.9 vs. 11.7+/-1.3 years, P < 0.001). Incidence of chronic rejection in KALT group was higher than CLKT group (4.6 vs. 1.2%, P < 0.001). One and three-year rejection-free renal graft survival of KALT and CLKT groups were different (77% and 67% KALT vs. 85% and 78% CLKT, respectively; P < 0.001). Among human leukocyte antigen mismatched and sensitized patients, rejection-free renal graft survival of KALT group was inferior to the CLKT group (75% at 1 year and 61% 3 years vs. 86% at 1 year and 79% 3 years, P < 0.001).

CONCLUSION

Liver allograft provided renal graft immunoprotection if both organs are transplanted simultaneously (immunogenetic identity), but not for kidneys transplanted subsequently.

Localized reactive angioendotheliomatosis

We present a unique case of a woman with multiple painful dermal lesions localized to the left upper quadrant of the body. Histological investigation revealed microvascular thrombosis with capillary-wall proliferation. Further investigation revealed a very high anticardiolipin IgG titre and a left subclavian stenosis, presumably providing the reduced blood flow and relative hypoxia to allow microthromboses to occur in the presence of a thrombophilic tendency. Similar clinical and histological features have been reported in patients with the antiphospholipid syndrome and cases of reactive angioendotheliomatosis (RAE). This case represents a unique variant of RAE.

Haploinsufficiency of the mSds3 chromatin regulator promotes chromosomal instability and cancer only upon complete neutralization of p53

The mSin3 corepressor complex has been linked to diverse cancer signaling pathways through its capacity to regulate target gene expression via chromatin modification. mSds3, a cell essential gene, is a key component of the mSin3 complex serving to maintain its inherent histone deacetylase activity. mSds3 also serves an essential role in the establishment of pericentric heterochromatin, and genetic ablation of mSds3 results in chromosome missegregation. In contrast, mSin3A nullizygous cells show normal chromosome dynamics and cytogenetic profiles. The integral role of mSds3 in controlling chromosome segregation and mSin3-regulated transcriptional networks prompted efforts to determine the neoplastic impact of loss of one copy of mSds3 or mSin3A. In particular, we assessed whether loss of one copy of mSds3, alone or in combination with p53 mutation, results in aneuploidy and promotes a cancer-prone condition in the mouse. We observe that, in a p53 null background, loss of one mSds3 allele results in accelerated tumor onset and increased tumor burden. Notably, these mSds3(+/-) p53(-/-) tumors exhibit a more complex cytogenetic profile characterized by marked aneuploidy and centromeric associations. The presence of even one copy of p53 is sufficient to suppress the accelerated tumorigenesis in mSds3(+/-) mice, consistent with a key role for p53 in monitoring mitotic fidelity. These observations with Sds3 mutant mice contrast with mSin3A(+/-) p53(-/-) mice, which do not show an accelerated or increased tumor incidence relative to mSin3A(+/+)p53(-/-) controls, correlating with the absence of aneuploidy detected upon mSin3A genetic inactivation. This genetic study establishes that the capacity of mSds3 to cooperate with p53 deficiency in cancer predisposition relates to its specific role in chromosome segregation, rather than its central role in maintaining a functional mSin3A complex.

Early transoesophageal echocardiography (TOE) in cardiac arrest: a case study

We describe a case of abrupt cardiac arrest in an 80 year old woman. Emergent transoesophageal echocardiography (TOE) helped clarify the diagnosis of pulmonary embolism, and guide management and ongoing resuscitation. This case highlights the utility of TOE in the peri-arrest setting and in the diagnosis of massive pulmonary embolism. TOE can also be useful in providing prognostic information and determining the choice of therapeutic drug treatment and vasopressor support.

Crop production in the high rainfall zones of southern Australia — potential, constraints and opportunities

Annual cropping has been expanding in the high rainfall zone of southern Australia. The higher rainfall and longer growing season compared with the traditional wheatbelt contribute to a much higher yield potential for major crops. Potential yields range from 5 to 8 t/ha for wheat and 3 to 5 t/ha for canola, although current crop yields are only about 50% of those potentials. The large yield gap between current and potential yields suggests that there is an opportunity to lift current yields. Both genetic constraints and subsoil constraints such as waterlogging, soil acidity, sodicity, and high soil strength contribute to the low yields. Waterlogging is a widespread hidden constraint to crop production in the region. Controlling waterlogging using a combination of raised beds and surface or subsurface drains is the first step to raise the productivity of the land. Increasing root growth into the subsoil remains a key to accessing more water and nutrients for high yield through early planting, deep ripping, liming and use of primer crops to ameliorate the subsoil. In order to realise the high yield potential, it is essential to achieve higher optimum dry matter at anthesis and high ear number through agronomic management, including early sowing with appropriate cultivars, a high seeding rate and application of adequate nitrogen along with other nutrients. Current cultivars of spring wheat may not fully utilise the available growing season and may have genetic limitations in sink capacity that constrain potential yield. Breeding or identification of long-season milling wheat cultivars that can fully utilise the longer growing season and with the ability to tolerate waterlogging and subsoil acidity, and with disease resistance, will give additional benefits. It is concluded that improving crop production in the high rainfall zone of southern Australia will require attention to overcoming soil constraints, particularly waterlogging, and the development of longer-season cultivars.

An evaluation of the FRIENDS programme: a cognitive behaviour therapy intervention to promote emotional resilience

AIMS

To evaluate the efficacy and acceptability of the FRIENDS programme.

METHODS

Uncontrolled before and after assessment of the FRIENDS programme, a 10 session cognitive behaviour therapy programme. A total of 213 children aged 9-10 years from six primary schools were studied.

MAIN OUTCOME MEASURES

Spence Children's Anxiety Scale, Culture Free Self-Esteem Questionnaire, qualitative assessment of acceptability.

RESULTS

End of programme data from 197 children (92.5% of eligible sample) showed significantly lower rates of anxiety (t = 2.95, df = 384) and significantly improved levels of self-esteem (t = 3.13, df = 386). Significant improvements were obtained in over half of those children with the most severe emotional problems. A total of 190 children (89.2%) completed a qualitative assessment of acceptability: 154 (81%) thought it was fun, 147 (77.4%) would recommend it to a friend; 137 (72.8%) thought they had learned new skills, and 78 (41.1%) had helped someone else with their new skills.

CONCLUSIONS

The FRIENDS programme appears to be an efficacious and acceptable way to promote emotional resilience (reduced anxiety and increased self-esteem) in primary school aged children, consistent with previous studies in Australia. Further controlled studies are needed to assess natural history of anxiety and self-esteem and whether benefits are maintained over time.

Knowledge and skill acquisition for critical care nursing practice

In many critical care units, extended orientation or education programs have been offered to prepare the registered nurse to work in this specialty area. Current shortages of nurses and less experienced nurses applying for critical care positions have augmented the need for educational programs. In the Edmonton region, a partnership between two public institutions led to the development and implementation of an innovative educational program. In this article, we describe challenges and strategies to prepare critical care nurses to integrate knowledge, and meet the standards and expectations of both partners. In particular, methods are described to achieve theoretical and clinical outcomes. This article contributes to the discussion and implementation to offer knowledge and skill acquisition for a novice critical care nurse.

The potential of emergency department injury surveillance data: an illustration using descriptive analysis of data in 0-4 year olds from the Bath injury surveillance system

OBJECTIVES

To illustrate the potential of injury surveillance data from an emergency department surveillance system.

SETTING

Bath clinical area.

METHODS

Data for children (0-4 years old) resident in Bath city in UK were recoded and analysed.

RESULTS

There were a total of 3144 attendances and 2300 unintentional injuries - equivalent to an attendance rate of 131/1000. There were 91 thermal injuries and 162 poisoning/ingestions. Descriptive information is presented on the circumstances and consequences.

CONCLUSION

The majority of unintentional injuries in 0-4 year olds occur in the home, which is a modifiable environment. Detailed information around the circumstances available from the Bath injury surveillance system allows better focus for prevention messages and priority setting.