Epidemiological insights into the burden of feline upper respiratory tract infections in Queensland RSPCA shelters

INTRODUCTION

Feline upper respiratory tract infection (FURTI) is a severe problem in animal shelters where there is high turnover of populations and compromised immunity. This retrospective cohort study explores associations of potential animal-based and environmental-based factors with the risk of FURTI, where a previously modelled infection classification is used as the outcome of interest. The study type is a retrospective cohort and the measures of association include Odds Ratios and conditional predictions.

OBJECTIVES

To gain epidemiological insights into variation in FURTI using retrospective data from one of Australia's leading animal shelters.

METHODS

We stratified FURTI by admission and environmental variables. Predicted infection status, obtained using a machine-learning classifier trained on clinical text (accuracy 0.95 [CI 0.92, 0.97]), was used as the outcome of interest. Prior assumptions were represented by a causal framework or a direct acyclic graph (DAG), which informed creation of multiple Bernoulli models with an observational and prior component.

RESULTS

We analysed 43,431 feline entries over 8 years. Males were 1.24 (95% CI 1.19 to 1.31) times more likely than females to be classified as positive, while already desexed animals were only 0.68 (95% CI 0.60 to 0.72) as likely to be classified as positive compared to those not desexed on entry. Cats (>4 months) were twice as likely (95% CI 1.91 to 2.09) as kittens (0-4 months) to be classified positive. Animals entering the shelter as seized by the inspectorate (n = 415) were more likely to be classified positive compared to animals from other sources. Predicted infection probability increased in winter and showed a linear pattern with how full the shelter was.

CONCLUSION

This study estimates the association between animal and environmental variables of interest and FURTI classification status, thus better interpreting the distribution of disease as predicted by a previously uninterpretable model. This analysis gives much needed insight into the types of changes in an animal's environment that can impact final animal outcomes.

Current evidence for non-pharmaceutical, non-surgical treatments of canine osteoarthritis

Osteoarthritis is a progressive degenerative disease process that affects a significant proportion of the canine population, impacting these animals' quality of life. Currently, there is no cure and treatment consists of managing the clinical signs of pain and reduced mobility. There are many treatments for canine osteoarthritis and in this review we discuss the evidence base behind non-pharmaceutical, non-surgical treatments of this disease. These treatments include weight management, nutraceuticals, acupuncture, physiotherapies such as therapeutic exercise, hydrotherapy as well as other therapeutic modalities including photobiomodulation therapy, electromagnetic field therapy and others.

An update on mobility assessment of dogs with musculoskeletal disease

Mobility impairments associated with musculoskeletal diseases, such as osteoarthritis and degenerative joint disease, affect approximately 200,000 dogs annually and pose a notable challenge to canine health and welfare. Osteoarthritis causes the remodelling of synovial joints, alongside inflammation and impaired mechanical function which can be extremely debilitating. Secondary osteoarthritis commonly affects dogs and can be exacerbated by previous joint abnormalities, such as patellar luxation or cranial cruciate ligament rupture. Although musculoskeletal diseases can affect dogs of any age, the early subtle signs of gait abnormalities are perhaps missed by owners, thus, dogs may be in the latter stages of osteoarthritis progression when they are presented to veterinarians. Dogs showing subtle signs of gait abnormalities must be presented to veterinary practices for acute diagnosis to prevent long-term deterioration. Musculoskeletal diseases, such as osteoarthritis and degenerative joint disease, are commonly diagnosed via visible radiographic changes. However, veterinarians can use a combination of subjective and objective clinical scoring systems, such as clinical metrology instruments and gait assessment in conjunction with radiography to aid their diagnosis and longitudinal monitoring of musculoskeletal diseases. These scoring systems may be more sensitive to earlier signs of mobility impairments in dogs, ultimately, promoting increased canine health and welfare by enabling pain reduction, improvement of muscle strength and preservation of joint function. Current canine mobility scoring systems available to veterinarians will be discussed in turn throughout this review for implementation into clinical practice.

The impact of COVID-19 public health measures on attendance and overdose at supervised injecting facilities in Australia

OBJECTIVES

The COVID-19 pandemic disrupted service provision of harm reduction and drug treatment services for people who inject drugs in many countries. The two supervised injecting facilities (SIFs) in Sydney and Melbourne were differentially impacted by the pandemic, requiring local procedural changes in each service. We aimed to examine the impact of pandemic responses (including restrictions on movement, known as 'lockdowns') on service use and key parameters such as client reports of drug injected and recorded overdose rates.

STUDY DESIGN

Time series analysis of weekly client visits and monthly overdoses occurring at each service.

METHODS

Administrative client data from the two SIFs (Sydney data from 1 January 2018 to 30 April 2022; Melbourne data from 1 July 2018 to 30 April 2022) were examined using interrupted time series analyses with lockdown dates in each state entered as interruption terms. We analysed weekly SIF visits overall and by drug type, and monthly rates of opioid overdose at each service.

RESULTS

Lockdowns resulted in decreased visits to both services. The number of weekly client visits decreased during the first national lockdown for both the Sydney (trend change = -57.9; 95% CI [-109.4, -6.4]) and Melbourne SIF (near sig trend change = -54.8 [-110.8, 1.05]). Trends in visit numbers increased after lockdowns were lifted in each city; however, visits in Sydney have not returned to the numbers recorded prior to the pandemic. Visits to the Melbourne SIF related to heroin use declined at each lockdown (trend 1 = -42.7 [-81.5, -3.9]; trend 2 = -56.1 [-94.6, -17.7]; trend 3 = -33.8 [-67.4, -0.2]); heroin visits to the Sydney SIF declined during the first lockdown and remained low (trend = -55.6 [-82.8, -28.3]). Methamphetamine visits to the Sydney SIF fluctuated, surpassing heroin visits at several timepoints. Rates of monthly opioid overdoses at both services declined immediately following the start of the first lockdown (Sydney = -16.6 [-26.1, -6.8]; Melbourne = -6.4 [-8.7, -4.1]), with increasing trends recorded at the end of the final lockdown in each jurisdiction (Sydney = 2.8 [0.6, 5.0]; Melbourne = 1.3 [0.72, 3.2]).

CONCLUSIONS

Public health restrictions related to the COVID-19 pandemic were associated with reduced client visits to, and overdoses in, Australian SIFs. Variations were noted in the drugs injected, likely reflecting changes in local drug markets. Shifts to other drugs during these periods were evident: methamphetamine in Sydney; co-injection of heroin and diphenhydramine in Melbourne.

Management of vagus nerve simulation therapy in the peri-operative period: Guidelines from the Association of Anaesthetists: Guidelines from the Association of Anaesthetists

Vagus nerve stimulation is a well-established treatment option for patients with drug-resistant epilepsy and has an expanding range of other clinical indications. Side effects of vagus nerve stimulation therapy include: cough; voice changes; vocal cord adduction; rarely, obstructive sleep apnoea; and arrhythmia. Patients with implanted vagus nerve stimulation devices may present for unrelated surgery and critical care to clinicians who are unfamiliar with their function and safe management. These guidelines have been formulated by multidisciplinary consensus based on case reports, case series and expert opinion to support clinicians in the management of patients with these devices. The aim is to provide specific guidance on the management of vagus nerve stimulation devices in the following scenarios: the peri-operative period; peripartum period; during critical illness; and in the MRI suite. Patients should be aware of the importance of carrying their personal vagus nerve stimulation device magnet with them at all times to facilitate urgent device deactivation if necessary. We advise that it is generally safer to formally deactivate vagus nerve stimulation devices before general and spinal anaesthesia. During periods of critical illness associated with haemodynamic instability, we also advise cessation of vagus nerve stimulation and early consultation with neurology services.

POS0298 UNDERSERVED POPULATIONS IDENTIFY BARRIERS AND PROPOSE SOLUTIONS FOR SELF-MANAGING ARTHRITIS AND CHRONIC CONDITIONS

Background:

Underserved populations, such as ethnic minorities, low-income adults, and Indigenous people living with arthritis are more likely to have lower health literacy, higher rates of multi-morbidity, and face challenges in accessing care1-3. Self-management support (SMS) can help to mitigate the impacts of living with arthritis4. However, we require a more in-depth understanding of the daily barriers underserved communities face in living with arthritis in order to develop effective SMS that can meaningfully improve well-being and quality of life.

Objectives:

The study objective was to bring together underserved people living with arthritis to identify common barriers they face in taking care of their conditions in daily life, and to identify their solutions to the identified challenges.

Methods:

A team of researchers from several universities, nurse practitioners, physicians, policy makers, an arthritis consumer-patient leader and our community partners (Multi-lingual Orientation Service Association for Immigrant Communities and the Portland Hotel Society Community Services Society) engaged in a Community-based Participatory and Concept Mapping (CM) study5-7 where participants from underserved communities identified major barriers they face in managing arthritis, agreed on key themes that emerged, and determined priorities for actions. This involved three key CM activities: 1) brainstorming ideas; 2) sorting and rating ideas; and 3) analyzing and interpreting concept maps8. Data was collected through face-to-face interviews and prioritized and interpreted in workshop settings.

Results:

Sixty-three individuals who were ethnic minorities, immigrants, refugees, low-income, over 65, and/or housing insecure and living with arthritis identified 35 common barriers and made recommendations in the areas of financial difficulties, social services, access to health services, quality of health services, lack of knowledge, and mental health. Additional funding has been sought through Community-University Engagement Support Funding to enable our community partners to prioritize the recommendations in their communities, and to develop mechanisms for implementation using already existing community structures, processes, and services.

Conclusion:

Persons living with arthritis in diverse underserved communities face significant health and social inequities, including lack of access to basic life necessities such as food, housing, employment, and safety, which creates barriers to self-managing arthritis and other chronic conditions in daily life. SMS for these communities needs to address these social and environmental barriers shaping capacity for self-management, and ultimately, quality of life and well-being.

References:

[1]Ackerman I, Busija L. Access to self-management education, conservative treatment and surgery for arthritis according to socioeconomic status. Best Pr Res Clin Rheumatol. 2012;26(5):561–83.

[2]Shadmi E. Multimorbidity and equity in health. Int J Equity Heal. 2013;12(59):59.

[3]Foster M, Kendall E, Dickson P, Chaboyer W, Hunter B, Gee T. Participation and chronic disease self-management: are we risking inequitable resource allocation? Aust J Prim Health. 2003;9(3):132–40.

[4]Brady T, Anderson L, Kobau R. Chronic disease self-management support: public health perspectives. Front Public Heal. 2015;2(234).

[5]Trochim W. An introduction to concept mapping for planning and evaluation. Eval Progr Plann. 1989;12(1):1–16.

[6]Anderson L, Day K, Vandenberg A. Using a concept map as a tool for strategic planning: the healthy brain initiative. Prev Chronic Dis. 2011;8(5):A117.

[7]Petrucci C, Quinlan K. Bridging the research practice gap: concept mapping as a mixed methods strategy in practice-based research and evaluation. J Soc Serv Res. 2007;34(2):25–42.

[8]Kane M, Trochim W. Concept mapping for planning and evaluation. Thousand Oaks (CA): SAGE Publications; 2007.

Disclosure of Interests:

None declared

B-vitamin nutrition in the pea aphid-Buchnera symbiosis

Various insects that utilize vitamin-deficient diets derive a supplementary supply of these micronutrients from their symbiotic microorganisms. Here, we tested the inference from genome annotation that the symbiotic bacterium Buchnera aphidicola in the pea aphid Acyrthosiphon pisum provides the insect with vitamins B₂ and B₅ but no other B-vitamins. Contrary to expectation, aphid survival over five days of larval development on artificial diets individually lacking each B-vitamin not synthesized by Buchnera was not significantly reduced, despite significantly lower carcass B₁, B₃, B₆ and B₇ concentrations in the aphids on diets lacking each of these B-vitamins than on the vitamin-complete diet. Aphid survival was, however, significantly reduced on diet containing low concentrations (≤0.2 mM) or no pantothenate (B₅). Complementary transcriptome analysis revealed low abundance of the sense-transcript, but high abundance of the antisense transcript, of the Buchnera gene panC encoding the enzyme mediating the terminal reaction in pantothenate synthesis. We hypothesize that metabolic constraints or antisense transcripts may reduce Buchnera-mediated production of pantothenate, resulting in poor aphid performance on pantothenate-free diets. The discrepancy between predictions from genome data and empirical data illustrates the need for physiological study to test functional inferences made from genome annotations.

OP0307 A NOVEL TARGETED APPROACH TO ACHIEVE IMMUNE SYSTEM RESET: CD45-TARGETED ANTIBODY DRUG CONJUGATES AMELIORATE DISEASE IN PRECLINICAL AUTOIMMUNE DISEASE MODELS AND ENABLE AUTO-HSCT

Background:

Resetting the immune system through autologous hematopoietic stem cell transplant (autoHSCT) is a highly effective treatment in selected patients with autoimmune diseases. AutoHSCT can induce long-term remission with 80% progression free survival in multiple sclerosis patients (Muraro 2017, Burt 2019). Use of autoHSCT in scleroderma patients has achieved superior outcomes in two randomized studies compared to standard of care (Tyndall 2014, Sullivan 2018). These impressive results are achieved by a combination of the eradication of autoreactive immune effector cells and re-establishment of self-tolerance, i.e., immune system reset. However, only a small fraction of eligible patients undergo autoHSCT, largely due to toxicity associated with current conditioning protocols.

Objectives:

As part of our goal to enable more patients to benefit from immune system reset, we have generated novel anti-human CD45 ADCs that cross react with nonhuman primates (NHP) and an anti-mouse CD45 ADC to model the approach in mouse models of AID.

Methods:

The human-targeted CD45-ADC is an affinity-matured mAb that targets an epitope present on all human CD45 isoforms, is cross-reactive with NHP CD45, and is conjugated to a payload that efficiently kills both quiescent and cycling cells. This ADC is engineered to eliminate Fc-mediated effector function, enable site-specific conjugation of linker/payload, and enable rapid clearance. This ADC was evaluated in vitro and in vivo in hNSG and NHPs. The murine tool ADC specifically targets the CD45.2 isoform of mouse CD45, and is also engineered to eliminate effector function, allow for site-specific conjugation of linker payload, and be rapidly cleared. The payload for this murine tool ADC is potent and preferentially kills dividing cells. This ADC was tested for the ability to enable immune reset and ameliorate autoimmune disease in multiple disease models.

Results:

The anti-human CD45-ADC showed efficient killing of human HSCs and human and cyno PBMC, including CD3+cells from healthy donors and patients with MS. In hNSG, single doses of the CD45-ADC were well-tolerated and led to substantial depletion of human cells. In NHPs, single doses of CD45-ADC were well tolerated and depleted both peripheral lymphocytes and HSCs. Administration of a single dose of anti-human CD45-ADC to hNSGs with sclerodermatous xenoGVHD resulted in depletion of human T cells and resolution of symptoms. A single-dose of the anti-mouse CD45-ADC enabled full myeloablation and complete durable donor chimerism with congenic HSCT at 16 weeks. In a murine immunization model of MS, MOG-induced EAE, a single dose of the CD45-ADC followed by congenic HSCT prior to disease onset enabled full donor chimerism, significantly delayed disease onset and reduced disease severity. We are generating additional data in an adoptive transfer model of EAE to confirm and extend these results. In a murine model of arthritis, therapeutic treatment with a single dose of the CD45-ADC followed by congenic HSCT enabled complete donor chimerism and halted disease progression, comparable to with the effects of an anti-TNFα antibody. The ADC is being further evaluated in a model of type 1 diabetes and those data will be presented. These data demonstrate that CD45-ADC conditioning followed by congenic HSCT is sufficient for full myeloablation and immune reset.

Conclusion:

These results demonstrate that targeted immune depletion with a single dose of CD45-ADC can enable auto-HSCT and immune reset in multiple AID indications without toxic side effects. Targeted conditioning with CD45-ADC may represent a better tolerated approach for removing disease-causing cells as part of immune reset through auto-HSCT and enable more patients to benefit.

Disclosure of Interests:

Geoffrey Gillard Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Jennifer Proctor Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Sharon Hyzy Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Oliver Mikse Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Tahirih Lamothe Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Sean McDonough Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Nicholas Clark Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Rahul Palchaudhuri Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Anjali Bhat Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Melissa Brooks Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Ganapathy Sarma Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Prashant Bhattarai Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Pranoti Sawant Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Brad Pearse Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Charlotte McDonagh Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Tony Boitano Shareholder of: Magenta, Employee of: Magenta, Michael Cooke Shareholder of: Magenta, Employee of: Magenta

Whole-Genome Sequence of "Candidatus Liberibacter solanacearum" Strain R1 from California

The draft whole-genome sequence of "Candidatus Liberibacter solanacearum" strain R1, isolated from and maintained in tomato plants in California, is reported. The R1 strain has the genome size of 1,204,257 bp, G+C content of 35.3%, 1,101 predicted open reading frames, and 57 RNA genes.

An evaluation of the potential drug interaction between warfarin and levothyroxine

BACKGROUND

Drug interaction references report that initiation of levothyroxine potentiates the effects of warfarin, and recommend more frequent International Normalized Ratio (INR) monitoring, but the mechanism is not well understood.

OBJECTIVE

To assess the impact of levothyroxine initiation on INR response.

PATIENTS/METHODS

A retrospective, self-controlled study was performed on patients aged ≥ 18 years receiving chronic warfarin therapy who were started on levothyroxine between 1 January 2006 and 30 June 2013, and who were followed for 90 days prior to and after levothyroxine initiation. The included patients had at least one elevated thyroid-stimulating hormone laboratory value in the pre-period, continuous warfarin therapy for 100 days prior to levothyroxine initiation, no purchases of medications known to interact with warfarin, no procedures requiring warfarin interruption, and no bleeding or thromboembolic event during the study period. The primary outcome was a comparison of the warfarin dose/INR ratio recorded before the initiation of levothyroxine with the ratio recorded during the post-period after two consecutive INRs with no warfarin dose change.

RESULTS

One hundred and two patients were included in the primary outcome. The mean warfarin dose/INR ratios in the pre-period and post-period were equivalent (P = 0.825). Although the mean warfarin dose was numerically lower in the post-period than in the pre-period, this difference did not reach statistical significance (P = 0.068).

CONCLUSION

No difference in the mean warfarin dose/INR ratio before and after initiation of levothyroxine was detected. The results suggest that there is not a clinically significant interaction between warfarin and levothyroxine, and so additional monitoring may not be necessary.

Age-specific incidence rates for breast cancer in carriers of BRCA1 mutations from Norway

Incidence rates of breast cancer among women with a BRCA1 mutation vary according to their reproductive histories and country of residence. To measure cancer incidence, it is best to follow-up cohort of healthy women prospectively. We followed up a cohort of 675 women with a BRCA1 mutation who did not have breast or ovarian cancer before inclusion and who had a normal clinical examination and mammography at first visit. After a mean of 7.1 years, 98 incident cases of breast cancer were recorded in the cohort. Annual cancer incidence rates were calculated, and based on these, a penetrance curve was constructed. The average annual cancer risk for the Norwegian women from age 25 to 70 was 2.0%. Founder mutations had lower incidence rate (1.7%) than less frequent mutations (2.5%) (p = 0.03). The peak incidence (3.1% annual risk) was observed in women from age 50 to 59. The age-specific annual incidence rates and penetrance estimate were compared with published figures for women from North America and from Poland. The risk of breast cancer to age 70 was estimated to be 61% for women from Norway, compared with 55% for women from Poland and 69% for women from North America.

A randomised control trial to determine if use of the iResus© application on a smart phone improves the performance of an advanced life support provider in a simulated medical emergency

This study sought to determine whether using the Resuscitation Council UK's iResus© application on a smart phone improves the performance of doctors trained in advanced life support in a simulated emergency. Thirty-one doctors (advanced life support-trained within the previous 48 months) were recruited. All received identical training using the smart phone and the iResus application. The participants were randomly assigned to a control group (no smart phone) and a test group (access to iResus on smart phone). Both groups were tested using a validated extended cardiac arrest simulation test (CASTest) scoring system. The primary outcome measure was the overall cardiac arrest simulation test score; these were significantly higher in the smart phone group (median (IQR [range]) 84.5 (75.5-92.5 [64-96])) compared with the control group (72 (62-87 [52-95]); p=0.02). Use of the iResus application significantly improves the performance of an advanced life support-certified doctor during a simulated medical emergency. Further studies are needed to determine if iResus can improve care in the clinical setting.

Evaluation of a single-use intubating videoscope (Ambu aScope ™) in three airway training manikins for oral intubation, nasal intubation and intubation via three supraglottic airway devices

We compared the Ambu aScope™ with a conventional fibrescope in two simulated settings. First, 22 volunteers performed paired oral and nasal fibreoptic intubations in three different manikins: the Laerdal Airway Trainer, Bill 1 and the Airsim (a total of 264 intubations). Second, 21 volunteers intubated the Airway Trainer manikin via three supraglottic airways: classic and intubating laryngeal mask airways and i-gel (a total of 66 intubations). Performance of the aScope was good with few failures and infrequent problems. In the first study, choice of fibrescope had an impact on the number of user-reported problems (p=0.004), and user-assessed ratings of ease of endoscopy (p<0.001) and overall usefulness (p<0.001), but not on time to intubate (p=0.19), or ease of railroading (p=0.72). The manikin chosen and route of endoscopy had more consistent effects on performance: best performance was via the nasal route in the Airway Trainer manikin. In the second study, the choice of fibrescope did not significantly affect any performance outcome (p=0.3), but there was a significant difference in the speed of intubation between the devices (p=0.02) with the i-gel the fastest intubation conduit (mean (SD) intubation time i-gel 18.5 (6.8) s, intubating laryngeal mask airway = 24.1 (11.2) s, classic laryngeal mask airway = 31.4 (32.5) s, p=0.02). We conclude that the aScope performs well in simulated fibreoptic intubation and (if adapted for untimed use) would be a useful training tool for both simulated fibreoptic intubation and conduit-assisted intubation. The choice of manikin and conduit are also important in the success of such training. This manikin study does not predict performance in humans and a clinical study is required.

Pulmonary zygomycosis in solid organ transplant recipients in the current era

Fifty-eight solid organ transplant recipients with zygomycosis were studied to assess the presentation, radiographic characteristics, risks for extra-pulmonary dissemination and mortality of pulmonary zygomycosis. Pulmonary zygomycosis was documented in 31 patients (53%) and developed a median of 5.5 months (interquartile range, 2-11 months) posttransplantation. In all, 74.2% (23/31) of the patients had zygomycosis limited to the lungs and 25.8% (8/31) had lung disease as part of disseminated zygomycosis; cutaneous/soft tissue (50%, 4/8) was the most common site of dissemination. Pulmonary disease presented most frequently as consolidation/mass lesions (29.0%), nodules (25.8%) and cavities (22.6%). Patients with disseminated disease were more likely to have Mycocladus corymbifer as the causative pathogen. The mortality rate at 90 days after the treatment was 45.2%. In summary, pulmonary zygomycosis is the most common manifestation in solid organ transplant recipients with zygomycosis, and disseminated disease often involves the cutaneous/soft tissue sites but not the brain.

Cardiovascular risk in women with polycystic ovarian syndrome (PCOS)

AIMS

Studies have suggested that polycystic ovary syndrome (PCOS) is associated with increased cardiovascular risk. The aim of this study was to examine cardiovascular risk profiles in women with PCOS compared with healthy age and weight matched control subjects using novel biochemical and biophysical markers.

METHODS

After ethics committee approval, 11 women with PCOS and 12 controls were recruited (mean age, 32; SD, 6.5 years; mean body mass index (BMI), 33.1; SD, 5.9 kg/m2). Serum was analysed for lipid and lipoprotein profile (total and high density lipoprotein cholesterol, triglycerides, apolipoprotein B-100, apolipoprotein A1, lipoprotein (a)), and sialic acid, fibrinogen, homocysteine, and C reactive protein (CRP) concentrations. Endothelial function was also assessed by a standard venous occlusion plethysmography technique to measure reactive hyperaemic forearm blood flow (RH), and expressed as per cent increase from baseline.

RESULTS

There were no significant differences in glucose, lipid, or lipoprotein concentrations between the two groups. Furthermore, sialic acid (PCOS: mean, 70.5; SD, 149 mg/litre; controls: mean, 71.3; SD, 112 mg/litre), fibrinogen (PCOS: mean, 3.1; SD, 1.0 g/litre; controls: mean, 3.3; SD, 0.7 g/litre), CRP (PCOS: mean, 4.6; SD, 4.2 mg/litre; controls: mean, 5.41 SD, 5.5 mg/litre), and RH (PCOS: mean, 158.7; SD, 135.5%; controls: mean, 200.1; SD, 114.2%) were similar.

CONCLUSIONS

There were no differences in surrogate markers of the processes linked to enhanced cardiovascular risk between patients with PCOS and weight matched controls.

Lactate and Ventilatory Thresholds Reflect the Training Status of Professional Soccer Players Where Maximum Aerobic Power is Unchanged

The aim of this study was to investigate maximum aerobic power (VO2 max) and anaerobic threshold (AT) as determinants of training status among professional soccer players. Twelve professional 1st team British male soccer players (age: 26.2 ± 3.3 years, height: 1.77 ± 0.05 m, body mass: 79.3 ± 9.4 kg) agreed to participate in the study and provided informed consent. All subjects completed a combined test of anaerobic threshold (AT) and maximum aerobic power on two occasions: Test 1) following 5 weeks of low level activity at the end of the off-season and Test 2) immediately following conclusion of the competitive season. AT was assessed as both lactate threshold (LT) and ventilatory threshold (VT). There was no change in VO2 max between Test 1 and Test 2 (63.3 ± 5.8 ml·kg(-1)·min(-1) vs. 62.1 ± 4.9 ml·kg(-1)·min(-1) respectively), however, the duration of exercise tolerance (ET) at VO2 max was significantly extended from Test 1 to Test 2 (204 ± 54 vs. 228 ± 68 s respectively) (P<0.01). LT oxygen consumption was significantly improved in Test 2 versus Test 1 (P<0.01) VT was also improved (P<0.05). There was no significant difference in VO2 (ml·kg(-1)·min(-1)) corresponding to LT and VT. The results of this study show that VO2 max is a less sensitive indicator to changes in training status in professional soccer players than either LT or VT.

The uninsured and Medicaid Oregon tobacco user experience in a real world, phone based cessation programme

OBJECTIVE

To describe the experience of uninsured and Medicaid Oregon tobacco users who registered in Free & Clear (F&C), a telephone based cessation programme including five scheduled outbound calls.

DESIGN AND SETTING

Using a retrospective cohort design, 1334 (423 uninsured, 806 Medicaid, and 105 commercially insured) Oregon tobacco users who registered in F&C between 18 November 1998 and 28 February 2000 were identified and followed for 12 months post-registration; 648 (48.6%) were successfully contacted at 12 months. Information was collected from the F&C database. Unconditional logistic regression, adjusted for race and education, was used.

RESULTS

The seven day quit rate at 12 months, assuming non-respondents were smokers, was 14.8% (95% confidence interval (CI) 13.0 to 16.9). This rate was significantly higher among commercially insured participants (v Medicaid but not uninsured) and among participants who completed > or = 5 calls (v < 5 calls). The quit rate for those contacted at 12 months was 30.6% (95% CI 27.0% to 34.3%) and varied, however not significantly, by insurance and number of calls. After adjustment, respondents who completed > or = 5 calls were 60% more likely to quit tobacco (odds ratio (OR) 1.6, 95% CI 0.9 to 3.1), and uninsured respondents who completed > or = 5 calls were 70% more likely to quit tobacco (OR 1.7, 95% CI 0.9 to 3.5), relative to those who completed < 5 calls, but the difference was not significant.

CONCLUSIONS

The quit rates are similar to those reported in efficacy trials. The observed variation in quitting tobacco for respondents by number of calls completed and by insurance merits further investigation concentrating on increasing compliance with the call schedule, particularly for the uninsured.

Test performance indicators from a single soccer specific fitness test differentiate between highly trained and recreationally active soccer players

AIM

The aim of this study was to investigate whether a single soccer specific fitness test (SSFT) could differentiate between highly trained and recreationally active soccer players in selected test performance indicators.

METHODS

SUBJECTS

13 Academy Scholars (AS) from a professional soccer club and 10 Recreational Players (RP) agreed to participate in this study. Test 1--VO(2) max was estimated from a progressive shuttle run test to exhaustion. Test 2--The SSFT was controlled by an automated procedure and alternated between walking, sprinting, jogging and cruise running speeds. Three activity blocks (1A, 2A and 3A) were separated by 3 min rest periods in which blood lactate samples were drawn. The 3 blocks of activity (Part A) were followed by 10 min of exercise at speeds alternating between jogging and cruise running (Part B).

RESULTS

Estimated VO(2) max did not significantly differ between groups, although a trend for a higher aerobic capacity was evident in AS (p<0.09). Exercising heart rates did not differ between AS and RP, however, recovery heart rates taken from the 3 min rest periods were significantly lower in AS compared with RP following blocks 1A (124.65 b x min(-1) +/-7.73 and 133.98 b x min(-1) +/-6.63), (p<0.05) and 3A (129.91 b x min(-1) +/-10.21 and 138.85 b x min(-1) +/-8.70), (p<0.01). Blood lactate concentrations were significantly elevated in AS in comparison to RP following blocks 2A (6.91 mmol x l(-1) +/-2.67 and 4.74 mmol x l(-1) +/-1.28) and 3A (7.18 mmol x l(-1) +/-2.97 and 4.88 mmol x l(-1) +/-1.50), (p<0.05). AS sustained significantly faster average sprint times in block 3A compared with RP (3.18 sec +/-0.12 and 3.31 sec +/-0.12), (p<0.05).

CONCLUSION

The results of this study show that highly trained soccer players are able to sustain, and more quickly recover from, high intensity intermittent exercise.

Comprehensive management of pan-facial fractures

In the last 20 years, the management of pan-facial injuries has progressed to the point where immediate treatment using open reduction with rigid fixation is now the standard of care. After discussing the historical progression of treatments, the authors present a plan for treatment of craniofacial injuries based on the use of incisions that expose the four areas of the face: the frontal area, upper midface, lower midface and occlusion, and the basal mandibular area. According to the authors, five incisions permit access to the entire anterior craniofacial skeleton: the coronal, lower eyelid, upper and lower gingival-buccal-sulcus, and the preauricular-retromandibular. Through these incisions, the facial buttresses can be accessed to allow reduction and rigid fixation of facial fractures.

LAAM maintenance vs methadone maintenance for heroin dependence

BACKGROUND

LAAM and methadone are both full mu opiate agonists and have been shown to reduce dependence on heroin when given continuously under supervised dosing conditions. LAAM has a long duration of action requiring dosing every two or three days compared to methadone which requires daily dosing. LAAM is not as widely available internationally as methadone, and may be withdrawn from the market following ten cases of life-threatening cardiac arrhythmias and an association with QT prolongation.

OBJECTIVES

To compare the efficacy and acceptability of LAAM maintenance with methadone maintenance in the treatment of heroin dependence.

SEARCH STRATEGY

We searched MEDLINE (January 1966 to August 2000), PsycINFO (1887 to August 2000), EMBASE (January 1985 to August 2000), and the Cochrane Controlled Trials Register (Issue 2 2000). In addition we hand searched NIDA monographs until August 2000 and searched reference lists of articles.

SELECTION CRITERIA

All randomised controlled trials, controlled clinical trials and controlled prospective studies comparing LAAM and methadone maintenance for the treatment of heroin dependence and measuring outcomes of efficacy or acceptability were included.

DATA COLLECTION AND ANALYSIS

Data on retention in treatment, heroin use, side-effects and mortality were collected by two reviewers independently. A meta-analysis was performed using RevMan. Discrepancies were resolved by consensus.

MAIN RESULTS

Eighteen studies, (15 RCTs, 3 Controlled prospective studies) met the inclusion criteria for the review. Three were excluded from the meta-analysis due to lack of data on retention, heroin use or mortality. Cessation of allocated medication (11 studies, 1473 participants) was greater with LAAM than with methadone, (RR 1.36, 95%CI 1.07-1.73, p=0.001, NNT=7.7 (or 8)). Non-abstinence was less with LAAM (5 studies, 983 participants; RR 0.81, 95%CI 0.72-0.91, p=0.0003, NNT=9.1 (or 10)). In 10 studies (1441 participants) there were 6 deaths from a range of causes, 5 in participants assigned to LAAM (RR 2.28 (95%CI 0.59-8.9, p=0.2). other relevant outcomes, such as quality of life and criminal activity could not be analysed because of lack of information in the primary studies.

REVIEWER'S CONCLUSIONS

LAAM appears more effective than methadone at reducing heroin use. More LAAM patients than methadone ceased their allocated medication during the studies, but many transferred to methadone and so the significance of this is unclear. There was no difference in safety observed, although there was not enough evidence to comment on uncommon adverse events.

Acute opioid withdrawal in the emergency department: inadvertent naltrexone abuse?

From July 1999 it became evident that a rising number of heroin users were presenting to the Dandenong Hospital Emergency Department with a rapid onset, florid opioid withdrawal syndrome following the intravenous injection of what they had believed to be heroin. We suspect that the injected substance was in fact naltrexone. This paper describes two such cases and reviews the literature on naltrexone. Recommendations regarding the management of the acute opioid withdrawal syndrome are made.

Expressive language development of children exposed to cocaine prenatally: literature review and report of a prospective cohort study

It was hypothesized that prenatal exposure to cocaine and other substances would be related to delayed expressive language development. Speech and language data were available for 458 6-year olds (204 were exposed to cocaine). No significant univariate or multivariate differences by cocaine exposure group were observed. Classification and regression tree modeling was then used to identify language variable composites predictive of cocaine exposure status. Meaningful cut points for two language measures were identified and validated. Children with a type token ratio of less than 0.42 and with fewer than 97 word types were classified into a low language group. Low language children (n = 57) were more likely to be cocaine exposed (63.1%), with cocaine-exposed children 2.4 times more likely to be in the low language group compared with control children after adjustment for covariates. Prenatal cigarette, but not alcohol exposure, was also significantly related to expressive language delays.

Determinants of absconding by patients on acute psychiatric wards

Determinants of absconding by patients on acute psychiatric wards Absconding by patients from acute psychiatric wards is a high risk behaviour and has been linked to harm to self and others. Previous research on the characteristics of absconders has been overly reliant on officially generated statistics and small numbers of variables, limiting the conclusions that may be drawn. This paper reports on a prospective study of absconders from 12 acute admission wards in three English National Health Service Trusts over 5 months, compared to a control group matched for ward. Extensive data on absconder and control characteristics were collected from case records and from nursing staff. Absconders were significantly different from controls in many respects. Absconding is linked to other forms of non-compliant patient behaviour, e.g. medication refusal and involvement in violent incidents. Significant variations in the rates of absconding were found between different wards, and between different consultant psychiatrists. Predictive factors were identified by logistic regression. Study in the diverse fields of non-compliance should be brought together as these phenomena are likely to be interrelated. Further investigation is required to determine exactly what it is that consultant psychiatrists and ward nurses do that affects absconding rates.

Developing and communicating a long-term treatment plan for asthma

The treatment of asthma, according to current guidelines, requires complex treatment regimens that change as clinical conditions improve or deteriorate. We have developed a practical way to communicate long-term treatment plans in chart form in the primary care setting that is easy for patients to follow and use. The chart has been an important element in two interventions that have resulted in positive changes in health behavior and health outcomes in children with asthma. The plan provides recommendations for patients and families to make adjustments in medication based on changes in symptoms or peak expiratory air flow, or both, that are consistent with the Asthma Guidelines Expert Panel Report 2, 1997. The plan also indicates when the number and dosage of drugs should be increased or decreased and when emergency care should be sought, consistent with the Asthma Guidelines. By placing considerable control in the family's hands and by clearly delineating the conditions under which medicines can be reduced or discontinued, the physician provides incentives for families to adhere to the long-term treatment plan for asthma.

Psychiatric nursing and compulsory psychiatric care

Community psychiatric nurses (CPNs) have long been involved in the operations of the English Mental Health Acts. Research has shown that compulsory detention is not used uniformly or consistently. Rates of involuntary hospitalization are reported to vary widely across Europe, but there is some consensus on patient profiles. The ethnicity, social status and gender of the patient, the involvement of the police, the availability of care, problems caused to relatives, and the country and particular legislative system where these judgements take place, all influence who is compulsorily detained. This article reviews recent evidence from Europe and argues that involuntary psychiatric care can no longer be seen as entirely dependent on the symptoms and behaviour of the patient and that CPNs should be aware of and reflect upon these factors before invoking the detention process.