Safety and care of no fasting prior to catheterization laboratory procedures: a non-inferiority randomized control trial protocol (SCOFF trial)

Aims

Cardiac catheterization procedures are typically performed with local anaesthetic and proceduralist guided sedation. Various fasting regimens are routinely implemented prior to these procedures, noting the absence of prospective evidence, aiming to reduce aspiration risk. However, there are additional risks from fasting including patient discomfort, intravascular volume depletion, stimulus for neuro-cardiogenic syncope, glycaemic outcomes, and unnecessary fasting for delayed/cancelled procedures.

Methods and results

This is an investigator-initiated, multicentre, randomized trial with a prospective, open-label, blinded endpoint (PROBE) assessment based in New South Wales, Australia. Patients will be randomized 1:1 to fasting (6 h solid food and 2 h clear liquids) or to no fasting requirements. The primary outcome will be a composite of hypotension, hyperglycaemia, hypoglycaemia, and aspiration pneumonia. Secondary outcomes will include patient satisfaction, contrast-induced nephropathy, new intensive care admission, new non-invasive or invasive ventilation requirement post procedure, and 30-day mortality and readmission.

Conclusions

This is a pragmatic and clinically relevant randomised trial designed to compare fasting verse no fasting prior to cardiac catheterisation procedures. Routine fasting may not reduce peri-procedural adverse events in this setting.

A Systematic Review of Glaucoma Diagnosis in Prevalence Studies and Quality of Reporting

PRCIS

This systematic review has revealed that variable definitions of glaucoma continue to be used in prevalence studies, despite the introduction of the International Society of Geographic and Epidemiologic Ophthalmology (ISGEO) criteria.

PURPOSE

To systematically review diagnostic criteria and examinations performed in glaucoma prevalence studies over time and determine the quality of reporting. Accurate estimates of glaucoma prevalence are crucial to inform resource allocation. However, diagnosis of glaucoma comprises inherently subjective examinations and the cross-sectional nature of prevalence studies precludes monitoring for progression.

METHODS

A systematic review of PubMed, Embase, Web of Science, and Scopus was performed to examine diagnostic protocols used by glaucoma prevalence studies and evaluate uptake of the ISGEO criteria, introduced in 2002 to standardize glaucoma diagnosis in prevalence studies. Detection bias and compliance with the Strengthening Reporting of Observational Studies in Epidemiology (STROBE) guidelines were evaluated.

RESULTS

Ten thousand five hundred forty-four articles were identified. After deduplication, 5589 articles were screened, yielding 136 articles pertaining to 123 studies. An absence of data in many countries was identified. Ninety-two percent of studies stated diagnostic criteria, and 62% used the ISGEO criteria since their publication. Weaknesses of the ISGEO criteria were identified. Temporal variations in the performance of various examinations were observed, including heterogeneity in angle assessment. Mean STROBE compliance was 82% (range 59-100%); 72 articles had a low risk of detection bias, 4 had a high risk, and 60 had some concerns.

CONCLUSION

Heterogeneous diagnostic definitions persist in glaucoma prevalence studies, despite introduction of the ISGEO criteria. Standardization of criteria remains imperative and the development of new criteria represent a valuable opportunity to achieve this goal. In addition, methods of determining diagnoses are poorly reported, suggesting a need for improvement in study conduct and reporting. Accordingly, we propose the Reporting of quality Of GlaUcoma Epidemiological Studies (ROGUES) Checklist. We have also identified a need for further prevalence studies in regions with limited data and to update Australian angle closure glaucoma prevalence. Design and reporting of future studies can be informed by this review's insights into diagnostic protocols previously used.

Protocol paper for SMART OPS: Shared decision-making Multidisciplinary Approach - a Randomised controlled Trial in the Older adult Population considering Surgery

INTRODUCTION

The Australian population presenting with surgical pathology is becoming older, frailer and more comorbid. Shared decision-making is rapidly becoming the gold standard of care for patients considering high-risk surgery to ensure that appropriate, value-based healthcare decisions are made. Positive benefits around patient perception of decision-making in the immediacy of the decision are described in the literature. However, short-term and long-term holistic patient-centred outcomes and cost implications for the health service require further examination to better understand the full impact of shared decision-making in this population.

METHODS

We propose a novel multidisciplinary shared decision-making model of care in the perioperative period for patients considering high-risk surgery in the fields of general, vascular and head and neck surgery. We assess it in a two arm prospective randomised controlled trial. Patients are randomised to either 'standard' perioperative care, or to a multidisciplinary (surgeon, anaesthetist and end-of-life care nurse practitioner or social worker) shared decision-making consultation. The primary outcome is decisional conflict prior to any surgical procedure occurring. Secondary outcomes include the patient's treatment choice, how decisional conflict changes longitudinally over the subsequent year, patient-centred outcomes including life impact and quality of life metrics, as well as morbidity and mortality. Additionally, we will report on healthcare resource use including subsequent admissions or representations to a healthcare facility up to 1 year.

ETHICS AND DISSEMINATION

This study has been approved by the Hunter New England Human Research Ethics Committee (2019/ETH13349). Study findings will be presented at local and national conferences and within scientific research journals.

TRIAL REGISTRATION NUMBER

ACTRN12619001543178.

Medicine treatment of glaucoma in Australia 2012-2019: prevalence, incidence and persistence

Objective

Medical therapy can halt or significantly slow the progression of glaucoma if medicines are used in accordance with the guidelines. We used dispensing claims for a 10% sample of all Australians dispensed publicly subsidised glaucoma medicines to determine the prevalence and incidence of glaucoma medicine treatment and to examine treatment persistence between July 2012 and June 2019.

Methods

We estimated incidence and prevalence per 10 000 population for Australian financial years (1 July to 30 June). We defined prevalence as at least one dispensing of any glaucoma medicine and incidence as a dispensing of any glaucoma medicine with no previous dispensing during the preceding 12 months. We estimated duration of treatment for a cohort initiating glaucoma medicines and used Kaplan-Meier methods to estimate the proportion of people persisting on treatment at 6, 12, 18 and 36 months after initiation. We stratified analyses by the number of repeats prescribed at initiation, age, sex and medicine class.

Results

Prevalence remained stable over the study period at around 180/10 000 people/year; incidence was also stable around 36/10 000/year. Among 34 900 people initiating glaucoma medicines, 37.0% remained on treatment at 6 months from initiation, 29.8% at 12 months and 19.2% at 36 months. Median duration of treatment was 13.2 months (IQR: 2.5—not reached) for people initiating prostaglandin analogues and less than 3 months for those initiating other medicine classes.

Conclusion

Prevalence and incidence of glaucoma treatment have not changed in Australia over the past decade. Persistence to treatment increased with age but remained poor throughout the study period.

Differentiation of Autoimmune Pancreatitis from Pancreatic Cancer Remains Challenging

BACKGROUND

Autoimmune pancreatitis (AIP) is an uncommon form of chronic pancreatitis. Whilst being corticosteroid responsive, AIP often masquerades radiologically as pancreatic neoplasia. Our aim is to appraise demographic, radiological and histological features in our cohort in order to differentiate AIP from pancreatic malignancy.

METHODS

Clinical, biochemical, histological and radiological details of all AIP patients 1997-2016 were analysed. The initial imaging was re-reviewed according to international guidelines by three blinded independent radiologists to evaluate features associated with autoimmune pancreatitis and pancreatic cancer.

RESULTS

There were a total of 45 patients: 25 in type 1 (55.5%), 14 type 2 (31.1%) and 6 AIP otherwise not specified (13.3%). The median (IQR) age was 57 (51-70) years. Thirty patients (66.6%) were male. Twenty-six patients (57.8%) had resection for suspected malignancy and one for symptomatic chronic pancreatitis. Three had histologically proven malignancy with concurrent AIP. Two patients died from recurrent pancreatic cancer following resection. Multidisciplinary team review based on radiology and clinical history dictated management. Resected patients (vs. non-resected group) were older (64 vs. 53, p = 0.003) and more frequently had co-existing autoimmune pathologies (22.2 vs. 55.6%, p = 0.022). Resected patients also presented with less classical radiological features of AIP, which are halo sign (0/25 vs. 3/17, p = 0.029) and loss of pancreatic clefts (18/25 vs. 17/17, p = 0.017). There were no differences in demographic features other than age.

CONCLUSION

Despite international guidelines for diagnosing AIP, differentiation from pancreatic cancer remains challenging. Resection remains an important treatment option in suspected cancer or where conservative treatment fails.

Racial Differences in Accepting Pegfilgrastim Onpro Kit (On-Body Injector) Use Among Cancer Patients

Background

1.1.Neulasta Onpro kit eliminates need for additional clinic visit after chemotherapy. Given the racially diverse population in our institution, we investigated acceptance of Onpro kit among patients on chemotherapy.

Research Design and Methods

1.2.Single-institution, retrospective review conducted in patients with GI tumors who received Onpro kit within 1 hour of completion of systemic chemotherapy from Jan 2014 through Jan 2018. Clinic/nursing notes and pharmacy records were reviewed to identify patients who refused Onpro kit and to discern reasons for refusal, including racial reason.

Results

1.3.Total 238 orders for kit were voided amongst 68 patients (Caucasian 41; African American 7; Spanish 3; Asian 17). Overall, 15/68 patients refused kit (22%) of these 87% were Asian. The reasons for refusal included dislike of bulky attachment to skin, request to place kit on stomach instead of arm, trepidation over unwitnessed administration of drug, fear of reaction, disposal at home, fear of pain, lack of confirmation of proper dose administration, and need for MRI.

Conclusions

1.4.While Onpro kit is an attractive alternative, 22% of patients with voided orders, mainly of Asian race, declined its application. We believe the current study represents the first look at important racial differences in accepting Onpro kit. Consideration of patients' cultural heritage, race, ethnicity and education may facilitate communication between physicians and patients to achieve optimal cancer care.

Measured and perceived indices of fluid balance in professional athletes. The use and impact of hydration assessment strategies

BACKGROUND

To determine athletes perceived and measured indices of fluid balance during training and the influence of hydration strategy use on these parameters.

METHODS

Thirty-three professional rugby union players completed a 120 minute training session in hot conditions (35°C, 40% relative humidity). Pre-training hydration status, sweat loss, fluid intake and changes in body mass (BM) were obtained. The use of hydration assessment techniques and players perceptions of fluid intake and sweat loss were obtained via a questionnaire.

RESULTS

The majority of players (78%) used urine colour to determine pre-training hydration status but the use of hydration assessment techniques did not influence pre-training hydration status (1.025 ± 0.005 vs. 1.023 ± 0.013 g^.ml^-1, P = .811). Players underestimated sweat loss (73 ± 17%) to a greater extent than fluid intake (37 ± 28%) which resulted in players perceiving they were in positive fluid balance (0.5 ± 0.8% BM) rather than the measured negative fluid balance (-1.0 ± 0.7% BM). Forty-eight percent of players used hydration monitoring strategies during exercise but no player used changes in BM to help guide fluid replacement.

CONCLUSION

Players have difficulty perceiving fluid intake and sweat loss during training. However, the use of hydration monitoring techniques did not affect fluid balance before or during training.

Ulcerative Colitis Treatment Patterns and Cost of Care

OBJECTIVES

To examine treatment patterns, dosing, health care resource utilization, and cost of tumor necrosis factor inhibitors (TNFi), adalimumab (ADA) and infliximab (IFX), among patients enrolled in US Humana insurance plans who have been diagnosed with ulcerative colitis (UC).

METHODS

This retrospective cohort study identified the first pharmacy or medical claim for ADA or IFX (from January 1, 2007, to December 31, 2014) in patients with continuous enrollment for 6 months or more preindex and 12 months or more postindex, with one or more UC diagnosis claim 6 months pre- or postindex. TNFi discontinuation was defined as a therapy gap of 56 days or more for ADA and 112 days or more for IFX. TNFi switch was defined as nonindex TNFi initiation. Health care resource utilization and costs were characterized quarterly according to treatment patterns.

RESULTS

The study population comprised 295 patients: mean age 50.9 years, 50.5% females, and 61.7% in southern United States. At the index date, 17% of patients received ADA and 83% received IFX. Treatment discontinuation was observed in 52% of ADA and 45% of IFX users through 12 months postindex (mean time 19 and 22 weeks, respectively). Among discontinuers, 46% of ADA and 68% of IFX users did not restart/switch TNFi. ADA and IFX showed mean times to switch of 18 and 30 weeks, respectively. TNFi discontinuers had the lowest mean quarterly total health care cost ($3,935) versus patients who initiated/switched TNFi ($15,004). Nevertheless, discontinuers had higher UC-related hospitalization versus patients receiving therapy.

CONCLUSIONS

Approximately half of ADA and IFX users discontinued, with approximately half of discontinuers not restarting/switching therapies. Further investigation of treatment patterns and outcomes after TNFi discontinuation is required.

Tofacitinib for induction and maintenance therapy of Crohn's disease: results of two phase IIb randomised placebo-controlled trials

OBJECTIVE

Tofacitinib is an oral, small-molecule Janus kinase inhibitor that is being investigated for IBD. We evaluated the efficacy and safety of tofacitinib for induction and maintenance treatment in patients with moderate-to-severe Crohn's disease (CD).

DESIGN

We conducted two randomised, double-blind, placebo-controlled, multicentre phase IIb studies. Adult patients with moderate-to-severe CD were randomised to receive induction treatment with placebo, tofacitinib 5 or 10 mg twice daily for 8 weeks. Those achieving clinical response-100 or remission were re-randomised to maintenance treatment with placebo, tofacitinib 5 or 10 mg twice daily for 26 weeks. Primary endpoints were clinical remission at the end of the induction study, and clinical response-100 or remission at the end of the maintenance study.

RESULTS

180/280 patients randomised in the induction study were enrolled in the maintenance study. At week 8 of induction, the proportion of patients with clinical remission was 43.5% and 43.0% with 5 and 10 mg twice daily, respectively, compared with 36.7% in the placebo group (p=0.325 and 0.392 for 5 and 10 mg twice daily vs placebo). At week 26 of maintenance, the proportion of patients with clinical response-100 or remission was 55.8% with tofacitinib 10 mg twice daily compared with 39.5% with tofacitinib 5 mg twice daily and 38.1% with placebo (p=0.130 for 10 mg twice daily vs placebo). Compared with placebo, the change in C-reactive protein from baseline was statistically significant (p<0.0001) with 10 mg twice daily after both induction and maintenance treatments.

CONCLUSIONS

Primary efficacy endpoints were not significantly different from placebo, although there was evidence of a minor treatment effect. No new safety signals were observed for tofacitinib.

TRIAL REGISTRATION NUMBERS

NCT01393626 and NCT01393899.

Tofacitinib as Induction and Maintenance Therapy for Ulcerative Colitis

BACKGROUND

Tofacitinib, an oral, small-molecule Janus kinase inhibitor, was shown to have potential efficacy as induction therapy for ulcerative colitis in a phase 2 trial. We further evaluated the efficacy of tofacitinib as induction and maintenance therapy.

METHODS

We conducted three phase 3, randomized, double-blind, placebo-controlled trials of tofacitinib therapy in adults with ulcerative colitis. In the OCTAVE Induction 1 and 2 trials, 598 and 541 patients, respectively, who had moderately to severely active ulcerative colitis despite previous conventional therapy or therapy with a tumor necrosis factor antagonist were randomly assigned to receive induction therapy with tofacitinib (10 mg twice daily) or placebo for 8 weeks. The primary end point was remission at 8 weeks. In the OCTAVE Sustain trial, 593 patients who had a clinical response to induction therapy were randomly assigned to receive maintenance therapy with tofacitinib (either 5 mg or 10 mg twice daily) or placebo for 52 weeks. The primary end point was remission at 52 weeks.

RESULTS

In the OCTAVE Induction 1 trial, remission at 8 weeks occurred in 18.5% of the patients in the tofacitinib group versus 8.2% in the placebo group (P=0.007); in the OCTAVE Induction 2 trial, remission occurred in 16.6% versus 3.6% (P<0.001). In the OCTAVE Sustain trial, remission at 52 weeks occurred in 34.3% of the patients in the 5-mg tofacitinib group and 40.6% in the 10-mg tofacitinib group versus 11.1% in the placebo group (P<0.001 for both comparisons with placebo). In the OCTAVE Induction 1 and 2 trials, the rates of overall infection and serious infection were higher with tofacitinib than with placebo. In the OCTAVE Sustain trial, the rate of serious infection was similar across the three treatment groups, and the rates of overall infection and herpes zoster infection were higher with tofacitinib than with placebo. Across all three trials, adjudicated nonmelanoma skin cancer occurred in five patients who received tofacitinib and in one who received placebo, and adjudicated cardiovascular events occurred in five who received tofacitinib and in none who received placebo; as compared with placebo, tofacitinib was associated with increased lipid levels.

CONCLUSIONS

In patients with moderately to severely active ulcerative colitis, tofacitinib was more effective as induction and maintenance therapy than placebo. (Funded by Pfizer; OCTAVE Induction 1, OCTAVE Induction 2, and OCTAVE Sustain ClinicalTrials.gov numbers, NCT01465763 , NCT01458951 , and NCT01458574 , respectively.).

Direct and Indirect Effects of Tofacitinib on Treatment Satisfaction in Patients with Ulcerative Colitis

BACKGROUND AND AIMS

This mediation modelling analysis evaluated direct and indirect effects of tofacitinib, an oral, small molecule Janus kinase inhibitor under investigation for ulcerative colitis, on patient treatment satisfaction.

METHODS

Data from an 8-week randomized Phase 2 trial [NCT00787202] in adults with moderate-to-severe, active ulcerative colitis receiving twice-daily tofacitinib 0.5-15mg [n=146] or placebo [n=48] were analysed in patient-reported [n=149] and clinician-reported [n=170] outcomes-based mediation models. Binary predictor variable: Treatment [pooled active treatment vs placebo]. Eventual dependent variable: Week 8 patient treatment satisfaction [measured on a five-point Likert scale]. Mediators of treatment effect on satisfaction: Week 8 Inflammatory Bowel Disease Questionnaire domains [Bowel Symptoms, Emotional Health, Social Function and Systemic Symptoms] and Mayo scale domains [Stool Frequency, Rectal Bleeding, Physician's Global Assessment and Endoscopic Disease Activity] for patient-reported and clinician-reported models, respectively.

RESULTS

Overall tofacitinib indirect effect on satisfaction via Inflammatory Bowel Disease Questionnaire domains was 40.5% [p<0.05] and via Mayo scale domains was 84.0% [p<0.01] for patient-reported and clinician-reported models, respectively. Bowel function had the most important indirect effect: of the total tofacitinib effect on satisfaction, 32.4% [p=0.05] was indirectly mediated via Bowel Symptoms; and 30.0% [p=0.04] via Stool Frequency. In total, 59.5% [p<0.01] and only 16.0% [p=0.56] of tofacitinib's effect on satisfaction was unrelated to Inflammatory Bowel Disease Questionnaire and Mayo scale domains in the patient-reported and clinician-reported models, respectively.

CONCLUSIONS

Bowel function is an important factor for patient treatment satisfaction with tofacitinib. Treatment effect on patient satisfaction was almost completely mediated via improvement in Mayo scale domains.

Efficacy and safety of an interleukin 6 monoclonal antibody for the treatment of systemic lupus erythematosus: a phase II dose-ranging randomised controlled trial

Objectives

This phase II trial evaluated the efficacy and safety of an interleukin (IL) 6 monoclonal antibody for systemic lupus erythematosus (SLE).

Methods

Patients with active disease were randomised to placebo or PF-04236921 10 mg, 50 mg or 200 mg, subcutaneously, every 8 weeks with stable background therapy. SLE Responder Index (SRI-4; primary end point) and British Isles Lupus Assessment Group-based Composite Lupus Assessment (BICLA) were assessed at week 24. Post hoc analysis identified an enriched population based upon planned univariate analyses.

Results

183 patients received treatment (placebo, n=45; 10 mg, n=45; 50 mg, n=47; 200 mg, n=46). The 200 mg dose was discontinued due to safety findings and not included in the primary efficacy analysis. The SRI-4 response rates were not significant for any dose compared with placebo; however, the BICLA response rate was significant for 10 mg (p=0.026). The incidence of severe flares was significantly reduced with 10 mg (n=0) and 50 mg (n=2) combined versus placebo (n=8; p<0.01). In patients with greater baseline disease activity (enriched population), the SRI-4 (p=0.004) and BICLA (p=0.012) response rates were significantly different with 10 mg versus placebo. Four deaths (200 mg, n=3; 10 mg, n=1) occurred. The most frequently reported adverse events included headache, nausea and diarrhoea.

Conclusions

PF-04236921 was not significantly different from placebo for the primary efficacy end point in patients with SLE. Evidence of an effect with 10 mg was seen in a post hoc analysis. Safety was acceptable for doses up to 50 mg as the 200 mg dose was discontinued due to safety findings.

Trial registration number

NCT01405196; Pre-results.

City Challenge: Sustainable Process or Temporary Gesture?

In this paper, the processes of governance within the UK government's recent urban policy initiative, City Challenge, are explored. This initiative targets the involvement, through “partnership”, of residents of “areas of concentrated disadvantage” in the processes of programme formulation and delivery. Underlying this is the objective of “incorporating” neighourhood residents in ‘mainstream’ political and economic life. In this paper, that objective is set in the context of contemporary conditions in such neighbourhoods. Experiences of the early stages of two City Challenge programmes are then discussed, in order to assess the character of the partnerships which are evolving. The two examples vary significantly in their style and in the strategy of the local authority, as well as in the characteristics of the areas. It is argued that, although central government's influence over the style of the programmes remains pervasive, the strategy of the local authority and the struggles by the participants in the partnerships have a significant influence on the content and style of the programmes. Further, the style of the programmes affects the balance of power within the programme and the terms of incorporation of the various partnerships in governance processes.

Comparing the effectiveness of selective laser trabeculoplasty with topical medication as initial treatment (the Glaucoma Initial Treatment Study): study protocol for a randomised controlled trial

Background

Glaucoma is the leading cause of irreversible blindness in the world. Estimated to affect 60 million people worldwide, this figure is expected to rise to 80 million by 2020. Untreated, glaucoma leads to visual decay and eventually to blindness, and can significantly reduce quality of life. First-line treatment in patients with primary open-angle glaucoma and exfoliative glaucoma is topical medical therapy with ocular hypotensives as eye drops. However, eye drops have several disadvantages including cost, possible local and systemic side effects, and adherence and perseverance issues. Randomised controlled trials have demonstrated that selective laser trabeculoplasty is equally as effective in lowering intraocular pressure as eye drops. However, the impact of these two treatment modalities from the patient and economic perspectives has not been adequately determined. Thus, it remains unclear whether topical medical therapy or selective laser trabeculoplasty should be recommended as first-line treatment for glaucoma.

Methods/Design

This protocol describes an international, multi-centre, randomised controlled trial to determine the optimum first-line therapy for people with primary open-angle glaucoma and exfoliative glaucoma. This study will compare the effect of selective laser trabeculoplasty and topical medication with respect to patients’ generic and glaucoma-specific quality of life. The trial will also provide a detailed cost-effectiveness analysis and compare the clinical effectiveness with respect to the degree of intraocular pressure lowering and rates of treatment failure. Research coordinators in each centre will identify and recruit previously untreated patients with primary open-angle glaucoma and exfoliative glaucoma. Those who meet the eligibility criteria will be invited to enter a randomised controlled trial with either selective laser trabeculoplasty or topical ocular hypotensive therapy, according to a stepped regimen. Outcome assessment will be measured at 6 weeks and at 6, 12, and 24 months post-treatment. Regular clinic follow-ups will continue as clinically indicated between study outcome visits.

Discussion

The Glaucoma Initial Treatment Study is the first multi-centred RCT to determine the optimum first-line therapy for people with glaucoma. Our trial will have an unprecedented capacity to meaningfully transform the treatment and management of glaucoma in Australia and overseas.

Trial registration

ACTRN12611000720910; Date registered: 11 July 2011

Randomized trial of tofacitinib in active ulcerative colitis: analysis of efficacy based on patient-reported outcomes

Background

Tofacitinib, a novel, oral Janus kinase inhibitor, demonstrated a dose-dependent efficacy for induction of clinical response and remission in patients with active ulcerative colitis (UC). The objective of the current study was to determine the effect of tofacitinib on patient-reported outcomes (PROs).

Methods

Eligible patients (≥18 years of age) with a diagnosis of active UC (total Mayo score of 6-12 points and moderately-to-severely active disease on sigmoidoscopy) were randomized in a 2:2:2:3:3 ratio to receive oral tofacitinib 0.5 mg, 3 mg, 10 mg, or 15 mg, or placebo twice daily (BID) for 8 weeks. PROs were assessed by the Inflammatory Bowel Disease Questionnaire (IBDQ) and the Inflammatory Bowel Disease Patient-Reported Treatment Impact (IBD PRTI) survey.

Results

At Week 8, mean IBDQ total scores had improved relative to baseline across all five treatment groups (baseline range 123.2-134.5; Week 8 range 149.6-175.4). Improvement from baseline was significantly greater (P = 0.001) for tofacitinib 15 mg BID versus placebo. For tofacitinib 15 mg BID, most patients reported satisfaction or extreme satisfaction, definite preference for tofacitinib, and definite willingness to use tofacitinib again on the IBD PRTI at week 8. Patients achieving endoscopic remission (Mayo endoscopy score of 0) had significantly higher IBDQ scores and favorable PRTI scores than those not achieving endoscopic remission.

Conclusions

Short-term treatment with tofacitinib BID was associated with dose-dependent improvement in health-related quality of life and patient preferences for tofacitinib. The results complement previously reported efficacy and safety data for the Phase II study. (NCT 00787202, November 6, 2008).

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-015-0239-9) contains supplementary material, which is available to authorized users.

Circumferential resection margin (CRM) positivity after MRI assessment and adjuvant treatment in 189 patients undergoing rectal cancer resection

PURPOSE

The management of rectal cancer relies on accurate MRI staging. Multi-modal treatments can downstage rectal cancer prior to surgery and may have an effect on MRI accuracy. We aim to correlate the findings of MRI staging of rectal cancer with histological analysis, the effect of neoadjuvant therapy on this and the implications of circumferential resection margin (CRM) positivity following neoadjuvant therapy.

METHODS

An analysis of histological data and radiological staging of all cases of rectal cancer in a single centre between 2006 and 2011 were conducted.

RESULTS

Two hundred forty-one patients had histologically proved rectal cancer during the study period. One hundred eighty-two patients underwent resection. Median age was 66.6 years, and male to female ratio was 13:5. R1 resection rate was 11.1%. MRI assessments of the circumferential resection margin in patients without neoadjuvant radiotherapy were 93.6 and 88.1% in patients who underwent neoadjuvant radiotherapy. Eighteen patients had predicted positive margins following chemoradiotherapy, of which 38.9% had an involved CRM on histological analysis.

CONCLUSIONS

MRI assessment of the circumferential resection margin in rectal cancer is associated with high accuracy. Neoadjuvant chemoradiotherapy has a detrimental effect on this accuracy, although accuracy remains high. In the presence of persistently predicted positive margins, complete resection remains achievable but may necessitate a more radical approach to resection.

Review article: the aetiology, investigation and management of diarrhoea in the HIV-positive patient

BACKGROUND

Diarrhoea is a common presentation throughout the course of HIV disease.

AIM

To review the literature relating to aetiology, investigation and management of diarrhoea in the HIV-infected adult.

METHODS

The PubMed database was searched using major subject headings 'AIDS' or 'HIV' and 'diarrhoea' or 'intestinal parasite'. The search was limited to adults and to studies with >10 patients.

RESULTS

Diarrhoea affects 40-80% of HIV-infected adults untreated with antiretroviral therapy (ART). First-line investigation is by stool microbiology. Reported yield varies with geography and methodology. Molecular and immunological methods and special stains have improved diagnostic yield. Endoscopy is diagnostic in 30-70% of cases of pathogen-negative diarrhoea and evidence supports flexible sigmoidoscopy as a first line screening procedure (80-95% sensitive for CMV colitis), followed by colonoscopy and terminal ileoscopy. Radiology is useful to assess severity, distribution, complications and to diagnose HIV-related malignancies. Side effects and compliance with ART are important considerations in assessment. There is a good evidence base for many specific therapies, but optimal treatment of cryptosporidiosis is unclear and only limited data support symptomatic treatments.

CONCLUSIONS

The immunological response to HIV infection and Antiretroviral therapy remains incompletely understood. Antiretroviral therapy regimens need to be optimised to suppress HIV while minimising side effects. Effective agents for management of cryptosporidiosis are lacking. There is an urgent need for enhanced regional diagnostic facilities in countries with a high prevalence of HIV. The ongoing roll-out of Antiretroviral therapy in low-resource settings will continue to change the aetiology and management of this problem, necessitating ongoing surveillance and study.

The use of hepatitis B core antibody-positive donor livers does not appear to have a deleterious effect on graft survival in liver transplantation for hepatitis C

INTRODUCTION

The use of hepatitis B core antibody-positive donor livers (HBcAb(+)) has steadily increased. According to a recent multivariate analysis of United Network for Organ Sharing (UNOS) data, there was no significant increase in the risk of using these donors. The increased risk among the hepatitis C virus (HCV)-positive subgroup noted in a univariate model disappeared upon multivariate analysis. However, deeper scrutiny may show that HCV-positive recipients may be at increased risk with HBcAb(+) donor livers, as they require simultaneous treatment with two antiviral regimens there may be deleterious interactions between the two viruses. Thus, the issue of HBcAb(+) donors for HCV-positive recipients merits more detailed analysis.

METHODS

Using UNOS registry data of all liver transplantations performed during the Model for End-Stage Liver Disease era from February 2002 through November 2007, we analyzed graft survival using Kaplan-Meier and Cox regression analyses.

RESULTS

Of the 12,543 HCV-positive recipients, 2,543 received HBcAb(-) livers and 853 received HBcAb(+) livers. While Kaplan-Meier analysis showed significantly lower graft survival among HCV-negative recipients of HBcAb(+) livers (P = .0001), there was no significant effect on graft survival among the HCV-positive population (P = .2). To detect an early effect in HCV-positive recipients, we examined 1-year graft survival, observing no significant difference (P = .3). To exclude a possible late effect, we examined graft survival in the HCV-positive population conditional upon surviving at least 1 year after transplantation; no significant difference was observed (P = .6). The elimination of potentially confounding codiagnoses, such as hepatitis B virus, alcoholism, acute graft failure, and hepatocellular cancer did not alter the findings. On univariate analysis, the lack of a significant effect persisted among the HCV population. However, the significant effect observed in the univariate model for the HCV-negative population became insignificant when combined with other risk factors in the multivariate model.

CONCLUSION

The use of HBcAb(+) livers in recipients with HCV did not appear to have a significant impact on graft survival.

Engineering polycrystalline Ni films to improve thickness uniformity of the chemical-vapor-deposition-grown graphene films

It has been shown that few-layer graphene films can be grown by atmospheric chemical vapor deposition using deposited Ni thin films on SiO(2)/Si substrates. In this paper we report the correlation between the thickness variations of the graphene film with the grain size of the Ni film. Further investigations were carried out to increase the grain size of a polycrystalline nickel film. It was found that the minimization of the internal stress not only promotes the growth of the grains with (111) orientation in the Ni film, but it also increases their grain size. Different types of SiO(2) substrates also affect the grain size development. Based upon these observations, an annealing method was used to promote large grain growth while maintaining the continuity of the nickel film. Graphene films grown from Ni films with large versus small grains were compared for confirmation.

When does the 'learning curve' of innovative interventions become questionable practice?

Demand for less invasive surgical intervention has increased in recent years resulting in surgeons occasionally being pressurised into adopting new techniques before evidence of safety and efficacy has been established. Unlike pharmaceutical research, most innovative surgical procedures enter surgical practice without regulatory oversight. This anomaly was recently highlighted in the 'Bristol Report' resulting in a recommendation that unproven therapies or surgical techniques be subjected to ethical overview or independent oversight. When a novel technique is introduced, the surgeon will find himself/herself gaining proficiency and experience on suitable patients. Hence the surgeon embarks on a 'learning curve'. A learning curve can be defined as a graphic representation showing the relationship between experience with a procedure and outcome. Studies demonstrate that learning curves generally 'flatten out' as experience increases, resulting in fewer complications and less of a need to convert to the standard procedure. In addition to lack of regulatory oversight, it is this learning curve that gives rise to many ethical and legal dilemmas. This paper considers the ethical issues relating to a surgeon's candour and clinical equipoise, the legal standard of care in a negligence action and the ethical and legal implications regarding risk disclosure during informed consent. The paper concludes by considering a more patient centred approach where new and innovative therapies are being considered in order to ensure good medical practice and avoid litigation for allegations of negligence or breach of human rights.

The heritability of optic disc parameters: a classic twin study

PURPOSE

To examine the roles of genetic and environmental factors in the optic disc in a classic twin study.

METHODS

Five hundred six pairs of twins were recruited to participate from the Twins U.K. Adult Twin Registry at St. Thomas' Hospital, London. Photographs of the optic disc were obtained, and the covariance of optic disc, cup, and rim areas within monozygotic (MZ) and dizygotic (DZ) pairs was compared, and genetic modeling techniques were used to determine the relative contributions of genes and environment to the variation in optic disc parameters in this population.

RESULTS

Mean optic disc, cup, and rim areas were 2.62 (range, 1.06-4.87), 0.98 (range, 0.25-4.72), and 1.64 (range, 1.43-6.16) mm(2), respectively. The MZ correlations were higher than those of DZ pairs for disc and cup areas (correlation coefficient, 0.73/0.81 and 0.41/0.50 for MZ and DZ twins, respectively). The correlation for optic rim was also higher in MZ (0.62) than in DZ (0.43) pairs. Modeling suggested heritability for the optic disc area of 0.73 and for the optic cup area of 0.66. The heritability of the rim area was lower at 0.34, with a significant shared environmental component of 0.27 and individual factors (including measurement error) explaining 39% of the variance of the rim area.

CONCLUSIONS

This study has demonstrated that genetic effects were important in the determination of optic disc parameters in this twin population, with genetic factors explaining 73%, 66%, and 34% of the variation of optic disc, cup, and rim areas, respectively. Environmental factors also seemed to be important.

Myopia, Axial Length, and OCT Characteristics of the Macula in Singaporean Children

PURPOSE

The purpose of this study was to evaluate the associations between macular volume and thickness, as assessed by optic coherence tomography (OCT), with refraction and axial length (AL) in children.

METHODS

A total of 104 Chinese school children (51 girls and 53 boys) 11 to 12 years of age were randomly selected from one school during the 2005 examination in the Singapore Cohort Study of the Risk Factors for Myopia (SCORM). Cycloplegic autorefraction was performed to obtain refraction (defined as spherical equivalent [SE]) and ultrasound biometry performed to obtain the AL. Macular volume and thickness were then measured (StratusOCT3; Carl Zeiss Meditec, Dublin, CA).

RESULTS

Children with moderate myopia (SE at least -3.0 D) tended to have smaller total macular volume and thinner quadrant-specific macular thickness (except in the inferior and superior inner quadrants), followed by children with low myopia (-0.5<or=SE<-3.0 D), compared with children with no myopia (SE>-0.5 D). Total macular volume was positively associated with SE (beta=1.58, 95% CI, 0.84 to 2.32, standardized beta=0.14, P<0.001) and negatively associated with AL (beta=-1.20, 95% CI, -1.62 to -0.79, standardized beta=0.45, P<0.001) in multiple linear regression models controlling for age and gender.

CONCLUSIONS

In children, increasing axial myopia was associated with reduced macular volume and thickness. These findings suggest that early anatomic changes may be present in the retinas of children with axial myopia.

Patterns of glaucomatous visual field defects in an older population: the Blue Mountains Eye Study

This report aims to describe the frequency of different patterns of visual field loss in open-angle glaucoma (OAG). The Blue Mountains Eye Study examined 3654 persons (aged 49+) during 1992-1994. Humphrey supra-threshold visual fields were performed in 88.9%. Those classified as glaucoma suspects had 30-2 full-threshold fields (9.2%). Of OAG cases (n = 108) with field tests in both eyes (n = 97), unilateral defects were present in 49 (50.5%) and bilateral in 48 (49.5%). Advanced field loss was found in 16 (15.4%) subjects and in 22 (10.9%) eyes, with bilateral loss present in 6 (6.2%) cases. Of all eyes of OAG cases (n = 201), 49 (24.4%) had no defects, 52 (25.9%) upper, 61 (30.3%) lower, and 17 (8.5%) had combined upper and lower loss. Of the upper and lower cases (n = 113), the types of defects included nasal step (36), arcuate (26), nasal plus arcuate (26), and hemispherical defects (25). Of subjects with fields in at least one eye (n = 104), there was a similar proportion in the worse eye of upper defects (28.8%), lower (31.7%), and combined upper and lower (24.0%). Undiagnosed OAG was more frequent in unilateral (65.3%) than bilateral (34.7%) cases (P = 0.003). This study reports the pattern of typical glaucomatous field loss in an older Australian population.

Sensitivity and specificity of two glaucoma case-finding strategies for optometrists

Current best practice for primary open-angle glaucoma case-finding comprises history-taking, disc examination, intraocular pressure measurement and suprathreshold visual field analysis (SVFA). An alternative case-finding technique was formulated replacing SVFA with computerised quantitative disc assessment, using the Heidelberg retinal tomograph II (HRT II). Each approach was adopted by four optometrists who screened 29 POAG and 37 normal patients. Average sensitivities and specificities were similar in the two groups [sensitivity 71% (SVFA) vs 69% (HRT II); specificity 94% both groups]. Our inclusion of pre-perimetric glaucoma cases limited the sensitivity of the optometrists in this study. There was evidence to suggest that the optometrists tended to miss early changes at the optic disc such as disc haemorrhage, nerve fibre layer defects and subtle neuroretinal thinning.

Sites, jobs and portfolios: economic development discourses in the planning system

This paper focuses on the development and dissemination of policy discourses in the context of the English planning system. The discursive subject is the identification and justification for the allocation of large sites for economic development purposes. The way this discourse has been developed in two case study areas (the West Midlands and Lancashire) is summarised, drawing out the institutional contexts of discourse development, the functions of the discourses (persuasive, co-ordinative and justificatory), the different discursive levels which are affected by changes in the discourses, the ways in which discourses are disseminated and translated from one institutional arena to another and the institutional work that discourses perform.

Changes in referral practice, workload, and operative mortality after establishment of an endovascular abdominal aortic aneurysm program

PURPOSE

To determine the change in referral practice following establishment of an endovascular abdominal aortic aneurysm (AAA) program.

METHODS

A prospective audit of all elective admissions for AAA was established in January 1994 at the initiation of an endovascular AAA program. A comparison was made between this cohort and the elective AAA repairs performed between 1981 and 1993.

RESULTS

Since January 1994, 213 AAA patients (177 men; median age 73 years, range 54 to 88) have been referred for potential endovascular aneurysm repair. To date, 142 patients have undergone elective surgery (41 endovascular and 101 conventional). Between 1981 and 1993, 304 patients (255 men; median age 69 years, range 45 to 86) had elective aneurysm repair. Comparison of the two time periods has revealed significant increases in the number of tertiary referrals (41.8% versus 9.5%, p < 0.01), annual operations (50 versus 23, p < 0.05), and overall mortality (12% versus 6.7%, p < 0.05), the latter attended by a significant increase in cardiorespiratory comorbidity.

CONCLUSIONS

The higher elective AAA mortality rate since the establishment of an endovascular program reflects a change in referral practice and may be directly attributable to an increase in the number of high-risk patients. An endovascular AAA program has clinical and financial implications for the hospital concerned.

Surgical management of 671 abdominal aortic aneurysms: a 13 year review from a single centre

OBJECTIVE

To audit the results for abdominal aortic aneurysm (AAA) repair from a single centre over a 13 year period.

DESIGN

Retrospective survey.

SETTING

Vascular unit of a major teaching hospital.

MATERIALS

Six hundred and seventy-one consecutive patients divided into two groups: group A (1981-87) and group B (1988-93).

CHIEF OUTCOME MEASURES

Mortality rates, cause of death and major complications in patients undergoing elective, urgent and ruptured AAAs.

RESULTS

Elective repair was performed in 313 (47%) patients, urgent repair in 80 (12%) and emergency repair for rupture in 278 (41%). A vascular surgeon performed the procedure in 94% of patients. The overall mortality was 21 patients in the elective group (6.7%), 13 in the urgent group (16%) and 148 in the ruptured group (53%). Mortality rates have not fallen during the study period but more patients in group B had ischaemic heart disease. Sixty patients (9%) required further operative procedures on 66 occasions: 24 elective cases (8%), 8 urgent cases (10%) and 28 ruptured cases (10%). There were 23 deaths in these 60 patients (38%) who underwent re-operation (5 elective, 2 urgent and 16 ruptured). Major postoperative complications included cardiac events in 212 (32%) patients, respiratory failure in 202 (30%) and renal failure in 90 (13%). Major causes of death included cardiac disease in 67 patients (37%), cardiac disease with coagulopathy in 22 (12%) and cardiac disease with respiratory failure in 16 (9%). Logistic regression analysis showed that in the elective group, cardiac or renal failure were significantly associated with death; and in the ruptured group cardiac, respiratory or renal failure were significantly associated with death.

CONCLUSIONS

More high risk patients with ischaemic heart disease are undergoing AAA repair. Postoperative cardiac, respiratory or renal failure are significant causes of death in AAA patients.

Sex discrimination: how do we tell the difference between male and female faces?

People are remarkably accurate (approaching ceiling) at deciding whether faces are male or female, even when cues from hair style, makeup, and facial hair are minimised. Experiments designed to explore the perceptual basis of our ability to categorise the sex of faces are reported. Subjects were considerably less accurate when asked to judge the sex of three-dimensional (3-D) representations of faces obtained by laser-scanning, compared with a condition where photographs were taken with hair concealed and eyes closed. This suggests that cues from features such as eyebrows, and skin texture, play an important role in decision-making. Performance with the laser-scanned heads remained quite high with 3/4-view faces, where the 3-D shape of the face should be easiest to see, suggesting that the 3-D structure of the face is a further source of information contributing to the classification of its sex. Performance at judging the sex from photographs (with hair concealed) was disrupted if the photographs were inverted, which implies that the superficial cues contributing to the decision are not processed in a purely 'local' way. Performance was also disrupted if the faces were shown in photographic negatives, which is consistent with the use of 3-D information, since negation probably operates by disrupting the computation of shape from shading. In 3-D, the 'average' male face differs from the 'average' female face by having a more protuberant nose/brow and more prominent chin/jaw. The effects of manipulating the shapes of the noses and chins of the laser-scanned heads were assessed and significant effects of such manipulations on the apparent masculinity or femininity of the heads were revealed. It appears that our ability to make this most basic of facial categorisations may be multiply determined by a combination of 2-D, 3-D, and textural cues and their interrelationships.

Recognising facial surfaces

The extent to which faces depicted as surfaces devoid of pigmentation and with minimal texture cues ('head models') could be matched with photographs (when unfamiliar) and identified (when familiar) was examined in three experiments. The head models were obtained by scanning the three-dimensional surface of the face with a laser, and by displaying the surface measured in this way by using standard computer-aided design techniques. Performance in all tasks was above chance but far from ceiling. Experiment 1 showed that matching of unfamiliar head models with photographs was affected by the resolution with which the surface was displayed, suggesting that subjects based their decisions, at least in part, on three-dimensional surface structure. Matching accuracy was also affected by other factors to do with the view-points shown in the head models and test photographs, and the type of lighting used to portray the head model. In experiment 2 further evidence for the importance of the nature of the illumination used was obtained, and it was found that the addition of a hairstyle (not that of the target face) did not facilitate matching. In experiment 3 identification of the head models by colleagues of the people shown was compared with identification of photographs where the hair was concealed and eyes were closed. Head models were identified less well than these photographs, suggesting that the difficulties in their recognition are not solely due to the lack of hair. Women's heads were disproportionately difficult to recognise from the head models. The results are discussed in terms of their implications for the use of such three-dimensional head models in forensic and surgical applications.

Dimensioning an optical-fiber spread-spectrum multiple-access communication system

We examine the dimensioning of an optical-fiber-based spread-spectrum multiple-access communication system that utilizes the inherently broad spectrum of many types of semiconductor lasers and LED's as the spreading function.

Physiological and histopathological measurements on lungs of laboratory rats maintained under barrier and under conventional conditions

Measurements of goblet-cell activity in the trachea and bronchiolus and of respiratory mechanics were made on colonies of caesarian-derived rats maintained under strict barrier conditions and on animals derived from the same stock but kept under conventional conditions.

It was consistently found over a period of 10 months that no significant changes in goblet-cell activity occurred during a holding period of 6 weeks under conventional conditions. Furthermore, comparison of goblet-cell activity and respiratory mechanics in groups of rats held under barrier and conventional conditions were not significantly different after a holding period of 21 weeks.

It is concluded that for relatively short-term studies, particularly for inhalation work in which these parameters are used to assess irritancy, caesarian-derived rats can be maintained under conventional holding conditions without showing significant spontaneous changes in either structure or mechanical function of the lungs, provided there is no contact with older rats with lung disease.